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Use the following Ethics Inventory to evaluate your approach to ethical issues as a Family Nurse Practitioner (FNP) (from p. 118 of the Policy and Politics in Nursing and Health Care text):
Identify an ethical dilemma you would face as a Nurse Practitioner (NP) (refer to p. 314 in your text, Advanced Practice Nursing: An Integrative Approach, for examples).
Write a 900- to 1,050-word paper addressing the following:
Cite references to support your assignment.
Format your assignment according to APA guidelines.
The Spectrum of Political Competencies (Fig. 4.1) demonstrates the breadth and variety of political and policy competencies ranging from novice to more sophisticated levels, including running for elective office. Initial experiences in activism and advocacy as a student are available through the National Student Nurses Association (NSNA) Health Policy and Advocacy Committee. Participating in lobby days and observing skilled lobbyists negotiate with policymakers are great ways to sharpen one’s political skills. At these events, nurse lobbyists and citizen activists serve as role models to nurses and students by exhibiting effective networking strategies and influencer behaviors while lobbying policymakers on specific legislation. These activists (Fig. 4.2) also provide the inspiration and vision for what can be done if nurses work together toward shared goals. This is real-life learning, and it is a highly effective and practical way of developing political awareness and know-how.
refer to p. 314 in your text, Advanced Practice Nursing: An Integrative Approach, for examples).
Interprofessional ConflictThe second theme encountered is that most ethical dilemmas that occur in the health care setting are multidisciplinary in nature. Issues such as refusal of treatment, end-of-life decision making, cost containment, and confidentiality all have interprofessional elements interwoven in the dilemmas, so an interprofessional approach is necessary for successful resolution of the issue. Health care professionals bring varied viewpoints and perspectives into discussions of ethical issues (Hamric & Blackhall, 2007; Piers et al., 2011; Shannon, Mitchell, & Cain, 2002). These differing positions can lead to creative and collaborative decision making or to a breakdown in communication and lack of problem solving. Thus an interprofessional theme is necessary in the presentation and resolution of ethical problems.For example, a clinical nurse specialist (CNS) is facilitating a discharge plan for an older woman who is terminally ill with heart failure. The plan of care, agreed on by the interprofessional team, patient, and family, is to continue oral medications but discontinue intravenous inotropic support and all other aggressive measures. Just prior to discharge, the social worker laments to the CNS that medical coverage for the patient’s care in the skilled nursing facility will be covered by the insurer only if the patient has an intravenous line in place. The patient’s daughter wishes to take her mother home and provide care. The attending cardiologist determines that the patient can be discharged to her daughter’s home because she no longer requires skilled care; however, the bedside nurse is concerned that the patient’s need for physical assistance will overwhelm her daughter and believes that the patient is better off returning to the skilled nursing facility. The CNS engages the patient in a careful conversation about her condition and her preferences. Although each team member shares responsibility to ensure that the plan of care is consistent with the patient’s wishes and minimizes the cost burden to the patient, they differ in perspective and approach for how to achieve these goals. Such legitimate but differing perspectives from various team members can lead to ethical conflict.Multiple CommitmentsThe third theme that frequently arises when ethical issues in nursing practice are examined is the issue of balancing commitments to multiple parties. Nurses have numerous and, at times, competing fidelity obligations to various stakeholders in the health care and legal systems (Chambliss, 1996; Hamric, 2001). Fidelity is an ethical concept that requires persons to be faithful to their commitments and promises. For the APRN, these obligations start with the patient and family but also include physicians and other colleagues, the institution or employer, the larger profession, and oneself. Ethical deliberation involves analyzing and dealing with the differing and opposing demands that occur as a result of these commitments. An APRN may face a dilemma if encouraged by a specialist consultant to pursue a costly intervention on behalf of a patient, whereas the APRNS’s hiring organization has established cost containment as a key objective and does not support use of this intervention (Donagrandi & Eddy, 2000). In this and other situations, APRNs are faced with an ethical dilemma created by multiple commitments and the need to balance obligations to all parties.Another significant threat to ethical practice is the failure of APRNs to practice self-care. As noted in the Code of Ethics for Nurses (American Nurses Association [ANA], 2015), nurses owe the same duty to themselves that they do to their patients. For example, an APRN may receive a referral to see a patient late in the day. She will feel compelled to stay late and meet the patient’s needs, even if she has already worked well beyond a “normal” day. As a one-time event, this is laudable. When it becomes a pattern, particularly when the APRN is sacrificing personal time or family time, she puts herself at risk for long-term health consequences (Fox, Dwyer, & Ganster, 1993). Something as commonplace as interrupted sleep or lack of sleep contributes to a negative emotional state (Tempesta et al., 2010), which in turn may deplete self-control and lead to unethical behavior (Barnes, Schaubroeck, Huth, & Ghumman, 2011; Gino, Schweitzer, Mead, & Ariely, 2011).The general themes of communication, interprofessional conflict, and balancing multiple commitments are prevalent in most ethical dilemmas. Specific ethical issues may be unique to the specialty area and clinical setting in which the APRN practices.Ethical Issues Affecting APRNsPrimary Care IssuesSituations in which personal values contradict professional responsibilities often confront nurse practitioners (NPs) in a primary care setting. Issues such as abortion, teen pregnancy, patient nonadherence to treatment, childhood immunizations, regulations and laws, and financial constraints that interfere with care were cited in one older study as frequently encountered ethical issues (Turner, Marquis, & Burman, 1996). Ethical problems related to insurance reimbursement, such as when implementation of a desired plan of care is delayed by the insurance authorization process or restrictive prescription plans, are an issue for APRNs. NPs practicing within a managed care environment often feel the necessity to balance the needs of patients against the organization’s interests (Ulrich, Soeken, & Miller, 2003). The problem of inadequate reimbursement can also arise when there is a lack of transparency regarding the specifics of services covered by an insurance plan. For example, a patient who has undergone diagnostic testing during an inpatient stay may later be informed that the test is not covered by insurance because it was done on the day of discharge. Had the patient and NP known of this policy, the testing could have been scheduled on an outpatient basis with prior authorization from the insurance company and thus have been a covered expense.Viens (1994) found that primary care NPs interpret their moral responsibilities as balancing obligations to the patient, family, colleagues, employer, and society. More recently, Laabs (2005) has found that the three issues most often noted by NPs as causing moral dilemmas are (1) being required to follow policies and procedures that infringe on personal values, (2) wanting to bend the rules to ensure appropriate patient care, and (3) dealing with patients who have refused appropriate care. Issues leading to moral distress in NPs included pressure to see an excessive number of patients, clinical decisions being made by others, and a lack of power to effect change (Laabs, 2005). Increasing expectations to care for more patients in less time are routine in all types of health care settings as pressures to contain costs escalate. APRNs in rural or ambulatory care settings often have fewer resources than their colleagues working in or near academic centers in which ethics committees, ethics consultants, and educational opportunities are more accessible.Issues of quality of life and symptom management traverse primary and acute health care settings. Pain relief and symptom management can be problematic for nurses and physicians (Oberle & Hughes, 2001). APRNs must confront the various and sometimes conflicting goals of the patient, family, and other health care providers regarding the plans for treatment, symptom management, and quality of life. The APRN is often the individual who coordinates the plan of care and thus is faced with clinical and ethical concerns when participants’ goals are not consistent or appropriate.Acute and Chronic Care IssuesIn the acute care setting, APRNs struggle with dilemmas involving pain management, end-of-life decision making, advance directives, assisted suicide, and medical errors (Shannon, Foglia, Hardy, & Gallagher, 2009). Rajput and Bekes (2002) identified ethical issues faced by hospital-based physicians, including obtaining informed consent, establishing a patient’s competence to make decisions, maintaining confidentiality, and transmitting health information electronically. APRNs in acute care settings may experience similar ethical dilemmas. Recent studies of moral distress have revealed that feeling pressured to continue aggressive treatments that respondents thought were not in the patients’ best interest or in situations in which the patient was dying, working with physicians or nurses who were not fully competent, giving false hope to patients and families, poor team communication, and lack of provider continuity were all issues that engendered moral distress (Hamric & Blackhall, 2007; Hamric et al., 2012). Emergency department NPs experience moral distress with poor patient care results related to inadequate staff communication and working with incompetent coworkers in their practice (Trautmann, Epstein, Rovnyak, & Snyder, 2015).APRNs bring a distinct perspective to collaborative decision making and often find themselves bridging communication between the medical team and patient or family. For example, the neonatal nurse practitioner (NNP) is responsible for the day-to-day medical management of the critically ill neonate and may be the first provider to respond in emergency situations (Juretschke, 2001). The NNP establishes a trusting relationship with the family and becomes aware of the values, beliefs, and attitudes that shape the family’s decisions. Thus the NNP has insight into the perspectives of the health care team and family. This “in-the-middle” position, however, can be accompanied by moral distress (Hamric, 2001), particularly when the team’s treatment decision carried out by the NNP is not congruent with the NNP’s professional judgment or values. Botwinski (2010) conducted a needs assessment of NNPs and found that most had not received formal ethics content in their education and desired more education on the management of end-of-life situations, such as delivery room resuscitation of a child on the edge of viability. Knowing the best interests of the infant and balancing those obligations to the infant with the emotional, cognitive, financial, and moral concerns that face the family struggling with a critically ill neonate is a complex undertaking. Care must be guided by an NNP and health care team who understand the ethical principles and decision making related to issues confronted in neonatal intensive care unit practice.Societal IssuesOngoing cost containment pressures in the health care sector have significantly changed the traditional practice of delivering health care. Goals of reduced expenditures and increased efficiency, although important, may compete with enhanced quality of life for patients and improved treatment and care, creating tension between providers and administrators, particularly as reimbursement changes from a procedure-based to a quality/value-based system. Studies suggest that changes in payment systems can lead to ethical challenges for providers.Ulrich and associates (2006) surveyed NPs and physician assistants to identify their ethical concerns in relation to cost containment efforts, including managed care. They found that 72% of respondents reported ethical concerns related to limited access to appropriate care and more than 50% reported concerns related to the quality of care. An earlier study of 254 NPs revealed that 80% of the sample perceived that to help patients, it was sometimes necessary to bend practice or institutional policies to provide appropriate care (Ulrich et al., 2003). Most respondents in this study reported being moderately to extremely ethically concerned with cost containment; more than 50% said that they were concerned that business decisions took priority over patient welfare and more than 75% stated that their primary obligation was shifting from the patient to the insurance plan. Although many hoped the passage of the Patient Protection and Affordable Care Act (ACA, 2010) would help with these concerns to some extent, the ethical tensions that underlie cost containment pressures and the business model orientation of health care delivery no doubt will continue. Changes in government leadership bring shifts in health care policy, and the 2016 election is a prime example. Ongoing attempts to repeal and replace the ACA have highlighted the complexity of the healthcare system and vividly underscore the ongoing debate about what constitutes “fair” distribution of resources, different conceptions of what is good, and a predisposition to seek power and advantage (Obama, 2017; Sorrell, 2012). Even as lawmakers debate how to address healthcare delivery, real life challenges such as the opiate epidemic will stress the system and pose more ethical challenges for advanced practice nurses ((Friedmann, Andrews & Humphreys, 2017).A survey of primary care providers—physicians, NPs, and physician assistants—indicates that overall, providers are more negative about the increased reliance on quality metrics and financial penalties to promote high performance (Commonwealth Fund and Henry J. Kaiser Family Foundation, 2015). It may be too soon to know for sure; however, history suggests ethical challenges will continue as the system of health care delivery evolves. While a number of myths surround the impact of patient satisfaction scores on reimbursement, the data suggest that patients are good discriminators of the care they receive. Ultimately, it is about communication and relationships, not simply acquiescing to what a patient says he or she wants (Siegrist, 2013).An example of how cost containment goals can create conflict is a situation in which an NP wishes to order a computed tomography scan to evaluate a patient complaining of abdominal pain. The NP knows that the patient has a history of diverticulosis resulting in abscess formation, and the current presentation with fever and abdominal tenderness justifies this testing; however, the insurance approval process takes a minimum of 24 hours. By sending the patient to the emergency room, the test can be done more quickly, but the patient will also face a long wait and a high co-pay if she does not require subsequent hospital admission. Limiting access to computed tomography scans is based on containing costs and avoiding unnecessary testing, which are two laudable goals. In this situation, the lengthy approval process means that the NP must make decisions about the treatment plan without important information. The pressure to alleviate the patient’s suffering in a timely manner may tempt the NP to advise the patient to go to the emergency room, which may result in a greater financial burden on the patient and may ultimately prove more expensive to the system. The availability of modern technology forces difficult choices, especially challenging providers to redefine “timely,” urgent, and emergent, and may cause providers to feel as though they are choosing between what is best for patients and what is best for organizations.Technologic advances, such as the rapidly expanding field of genetics, are also challenging APRNs (Caulfield, 2012; Harris, Winship, & Spriggs, 2005; Horner, 2004; Pullman & Hodgkinson, 2006). As Hopkinson and Mackay (2002) have noted, although the potential impact of mapping the human genome is immense, the challenge of how to translate genetic data rapidly into improvements in the prevention, diagnosis, and treatment of disease remains. To counsel patients effectively on the risks and benefits of genetic testing, APRNs need to stay current in this rapidly changing field. A helpful resource for this and other issues is the text by Steinbock, Arras, and London (2012) and a more recent article by Seibert (2014). As one example, genetic testing poses a unique challenge to the informed consent process. Direct-to-consumer marketing, with phrases such as “Your DNA has an incredible story!” by companies that provide genetic testing, projects an image of a cutting-edge, risk-free opportunity (https://www.23andme.com). Patients may feel pressured by family members to undergo or refuse testing, and they may require intensive counseling to understand the complex implications of such testing (Erlen, 2006). APRNs may be involved in posttest counseling, helping patients navigate such thorny issues as disclosure of test results to family members or potential future family members and what to do if the information makes its way to an employer or insurance company. Because genetic information is crucially linked to the concepts of privacy and confidentiality, and the availability of this information is increasing, it is inevitable that APRNs will encounter legal issues and ethical dilemmas related to the use of genetic data. The cost of genomic testing may effectively put this technology out of reach for disadvantaged populations. It will be important for the health care system to create a model that will ensure the sustainability of funding for genomic-guided interventions, their adoption and coverage by health insurance, and prioritization of genomic medicine research, development, and innovation (Fragoulakis, Mitropoulou, van Schaik, Maniadakis, & Patrinos, 2016).
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