PART ll Competencies of Advanced Practice Nursing

The patient’s care in the skilled nursing facility will only be covered by the insurer if the patient has an IV in place. The attending cardiologist determines that the patient can be discharged to her daughter’s home because she no longer requires skilled care and the social worker agrees to proceed with this plan.

However, the CNS 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 scheduled nursing facility. 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 how to achieve these goals. Such legitimate but differing perspectives from various team members can lead to ethical conflict.

Multiple Commitments

The 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 com- mitments and promises. For the APN, these obligations start with the patient and family but also include physi- cians 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 APN may face a dilemma if encouraged by a specialist consultant to pursue a costly intervention on behalf of a patient, whereas the APN’s hiring organization has estab- lished cost containment as a key objective and does not support use of this intervention (Donagrandi & Eddy, 2000). In this and other situations, APNs are faced with an ethical dilemma created by multiple commitments and the need to balance obligations to all parties.

The general themes of communication, interdisciplinary 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 APN practices.Advanced Practice Nurse Assignment Papers.

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Ethical Issues Affecting Advanced Practice Nurses

Primary Care Issues

Situations in which personal values contradict professional responsibilities often confront 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 inter- fere with care were cited in one older study as frequently encountered ethical issues (Turner, Marquis, & Burman, 1996). Ethical problems related to insurance reimburse- ment, 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 APNs.

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. Advanced Practice Nurse Assignment Papers. 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 nurse practitioner (NP) known of this policy, the testing could have been scheduled on an outpatient basis with prior authorization from the insurance company and thus be 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 issues most often noted by NP respondents as causing moral dilemmas are those of being required to follow policies and procedures that infringe on personal values, needing to bend the rules to ensure appropriate patient care, and dealing with patients who have refused appropriate care.

Issues leading to moral distress 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. APNs in rural settings may have fewer resources than their col- leagues working in or near academic centers in which ethics committees, ethics consultants, and educational opportunities are more accessible.Advanced Practice Nurse Assignment Papers.

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). APNs must con- front 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 APN 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.