Physical therapists’ perception of workplace ethics in an evolving health-care delivery environment: a cross-sectional survey

Physical therapists are trained and obligated to deliver optimal health care and put patients first above all else. In the changing health-care environment, health-care organizations are grappling with controlling cost and increasing revenues. Moral distress may be created when physical therapists’ desire to provide optimal care conflicts with their organization’s goals to remain financially viable or profitable. Moral distress has been associated with low perception of ethical environment, professional burnout, and high turnover in organizations. This study identified groups who may be vulnerable to low perception of organizational ethical environment and identified self-reported strategies to remedy these perceptions. An ethics environment questionnaire was mailed to a random sample of 1200 physical therapists in Georgia. Respondents (n = 340) were analyzed by age, workplace setting, and position in organization. Therapists working in skilled nursing/assisted living environments scored the lowest on the questionnaire and voiced concerns regarding their ethical work environments. Owners and executives perceived their organizations to be more ethical than front-line clinicians. Respondent concerns included high productivity standards, aggressive coding/billing policies, decreased reimbursement, and increased insurance regulation. Possible solutions included more frequent communication between management and clinicians about ethics, greater professional autonomy, and increased training in business ethics and finance.     

Management of Mild-to-Moderate Osteoarthritis: A Study of the Primary Care Perspective

Abstract

Objectives: Examine the knowledge, attitudes, and practice patterns of primary care clinicians regarding the management of mild-to-moderate osteoarthritis (OA). Design: Case vignette-based survey. Methods: A survey was distributed to 251 physicians, physician assistants (PAs), and nurse practitioners (NPs) in the primary care setting. The survey assessed practice patterns in the management of patients with mild-to-moderate OA, as well as attitudes toward guidelines and future educational topics that may be of benefit to the clinician. Results: We found that primary care clinicians are most likely to treat mild-to-moderate OA with an oral nonsteroidal anti-inflammatory drug regimen. Patients with initial or recurrent OA were “very likely” to be recommended to a physical therapy maintenance program. Two-thirds of respondents claimed to be unfamiliar with Osteoarthritis Research Society International guidelines for OA management. Conclusion: This study reflects the need for further education for primary care physicians, NPs, and PAs on the management of OA.     

A proposal for a code of ethics for nurse practitioners

PURPOSE: To review established codes for health care professionals and standards of practice for the nurse practitioner (NP) and to utilize these codes and standards, general ethical themes, and a new ethical triangle to propose an ethical code for NPs. DATA SOURCES: Reviews of three generally accepted ethical themes (deontological, teleological, and areteological), the ethical triangle by Potter, the American Academy of Nurse Practitioners (AANP) standards of practice for NPs, and codes of ethics from the American Nurses Association (ANA) and the American Medical Association (AMA). CONCLUSIONS: A proposal for a code of ethics for NPs is presented. This code was determined by basic ethical themes and established codes for nursing, formulated by the ANA, and for physicians, formulated by the AMA. The proposal was also developed in consideration of the AANP standards of practice for NPs. IMPLICATIONS FOR PRACTICE: The role of the NP is unique in its ethical demands. The authors believe that the expanded practice of NPs presents ethical concerns that are not addressed by the ANA code and yet are relevant to nursing and therefore different than the ethical concerns of physicians. This proposal attempts to broaden NPs' perspective of the role that ethics should hold in their professional lives.     

The impact of ethics and work-related factors on nurse practitioners' and physician assistants' views on quality of primary healthcare in the United States

PurposeNurse practitioners (NPs) and physician assistants (PAs) provide primary care services for many American patients. Ethical knowledge is foundational to resolving challenging practice issues, yet little is known about the importance of ethics and work-related factors in the delivery of quality care. The aim of this study was to quantitatively assess whether the quality of the care that practitioners deliver is influenced by ethics and work-related factors.MethodsThis paper is a secondary data analysis of a cross-sectional self-administered mailed survey of 1,371 primary care NPs and PAs randomly selected from primary care and primary care subspecialties in the United States.ResultsEthics preparedness and confidence were significantly associated with perceived quality of care (p < 0.01) as were work-related characteristics such as percentage of patients with Medicare and Medicaid, patient demands, physician collegiality, and practice autonomy (p < 0.01). Forty-four percent of the variance in quality of care was explained by these factors.ConclusionsInvesting in ethics education and addressing restrictive practice environments may improve collaborative practice, teamwork, and quality of care.     

The impact of the nurse-physician professional relationship on nurses' experience of ethical dilemmas in effective pain management.

The aims of the current investigation were (1) to examine the ethical and professional conflicts experienced by Tasmanian registered nurses in attempting to provide optimal pain management, and (2) to examine nurse satisfaction with their professional relationship with physicians and with their level of involvement in pain management. A total of 1,015 registered nurses completed a 21-item survey examining ethical and professional conflicts encountered during patient pain management. Data also were gathered investigating nurse satisfaction with their involvement in and professional relationship with physicians during pain management. The respondents who felt adequately consulted by physicians were significantly more likely to instigate the consultation process than the respondents who felt that they were not adequately consulted by physicians about their patient's pain status. This was marked in relation to the need for increased pain relief medications. Nurses who did not feel adequately consulted by physicians were significantly more likely to experience ethical conflicts such as concerns about undermedication and patient reluctance to report pain. Nurses' concerns related to ethical conflicts concerning effective pain management are affected by their relationship with physicians. Education, for both nurses and physicians, concerning the role of the nurse in the workplace will help to ensure that these conflicts do not arise. Guidelines concerning the level of patient care at which consultation is necessary will ensure fewer conflicts and greater nurse satisfaction in the workplace.     

Physician Perceptions of Advanced Practice Providers on Hospitalist Teams

Little is known about physician perceptions of nurse practitioners (NPs) and physician assistants (PAs) on hospitalist teams and the factors that impact their perceptions. Academic physician hospitalists were surveyed to better understand those factors, focusing on NP/PA experience, training, and physician experience with NPs/PAs. Perceptions by hospitalist physicians of NPs/PAs were strongly positive. Notable findings include the perceived positive impacts of NPs/PAs on clinical care provided, practice efficiency, and physician satisfaction. Most respondents prefer working with NPs and PAs with multiple years of clinical experience, particularly those who have participated in training beyond NP/PA graduate programs of study.     

Perceptions of Nurse Practitioners as Clinical Leaders in the Military

Health care systems need leaders to address complex challenges. This presents an opportunity for nurse practitioners (NPs). The United States Army is already using NPs as leaders. This study addresses the following 2 research questions: What are Army primary care clinicians’ perceptions of NPs as clinical leaders? and Are there differences in these perceptions? In this study, we used a survey that captured clinicians’ perceptions of NP leadership. Overall, respondents favored NPs as clinical leaders. Over 65% agreed that NPs were qualified as leaders within the Army. This study suggests clinicians perceive NPs as qualified and effective leaders at high levels throughout primary care.     

Understanding healthcare professionals’ self-efficacy to resolve interprofessional conflict

Conflict within interprofessional healthcare teams, when not effectively resolved, has been linked to detrimental consequences; however, effective conflict resolution has been shown to enhance team performance, increase patient safety, and improve patient outcomes. Alarmingly, knowledge of healthcare professionals’ ability to resolve conflict has been limited, largely due to the challenges that arise when researchers attempt to observe a conflict occurring in real time. Research literature has identified three central components that seem to influence healthcare professional’s perceived ability to resolve conflict: communication competence, problem-solving ability, and conflict resolution education and training. The purpose of this study was to investigate the impact of communication competence, problem-solving ability, and conflict resolution education and training on healthcare professionals’ perceived ability to resolve conflicts. This study employed a cross-sectional survey design. Multiple regression analyses demonstrated that two of the three central components—conflict resolution education and training and communication competence—were found to be statistically significant predictors of healthcare professionals’ perceived ability to resolve conflict. Implications include a call to action for clinicians and academicians to recognize the importance of communication competence and conflict resolution education and training as a vital area in interprofessional pre- and post-licensure education and collaborative practice.     

Are Advanced Providers Prepared to Care for the Agricultural Population?

This article concerns a pilot project for continuing education regarding agricultural health. We surveyed nurse practitioners (NPs) and physician assistants (PAs) in a rural state regarding hazardous agricultural respiratory exposures and the diagnosis and treatment of related agricultural health conditions. Most respondents could not identify hazardous agricultural agents and exposure sources. Many could not correctly answer questions about the diagnosis and treatment of associated health conditions, and 71% were uncomfortable concerning agricultural-related health issues and care. We used findings to develop an evidence-based educational program to address deficits, and presented at state and national professional conferences.     

Predictors of nurse practitioners' autonomy: effects of organizational,ethical, and market characteristics

PURPOSE: To identify the predictors of autonomy of nurse practitioners (NPs) affiliated directly and/or indirectly with managed-care systems (e.g., HMOs). DATA SOURCES: A mailed survey sent to a stratified random sample of 254 NPs certified and licensed to practice in the state of Maryland. The measures consisted of selected organizational characteristics; market factors of HMO penetration and percentage of client population enrolled in managed care; and factors of ethical concern, such as ethical ideology, ethics education, and autonomy. The County Surveyor Database was used to assess market penetration in the state. CONCLUSIONS: Although NPs were ethically concerned about their autonomy in a managed-care environment (70.2%), actual autonomy scores were high. The higher the percentage of HMO penetration, percentage of client population enrolled in managed care, and perceived ethical concern, the lower the perceived autonomy of NPs. IMPLICATIONS FOR PRACTICE: Findings may be used for future research to address the complexity of variables that influence the autonomous practice of NPs.     

Impact of ethics consultations in the intensive care setting: a randomized, controlled trial

OBJECTIVE: To determine the following: a) whether ethics consultations in the intensive care setting reduce nonbeneficial treatments, defined as days in the intensive care unit (ICU) and treatments delivered to those patients who ultimately fail to survive to hospital discharge; and b) whether physicians, nurses, social workers, and patients/families agree that ethics consultations in the ICU are beneficial in addressing treatment conflicts. DESIGN: Prospective, randomized, controlled trial of ethics consultations. SETTING: Medical and pediatric ICUs in a university medical center. PATIENTS: Seventy-four patients in whom value-based treatment conflicts arose during the course of treatment. INTERVENTIONS: The patients were randomly assigned to an intervention (ethics consultation offered) or nonintervention (ethics consultation not offered) arm of the trial. MEASUREMENTS: Medical data and ICU hospital days were compared between the intervention and control groups before and after the randomization. Likert scale and commentary responses were recorded to structured and open-ended interviews with the responsible physicians, nurses, social workers, and families of patients assigned to the intervention arm within 1 month after the patient's death or hospital discharge. Interviewees were asked whether ethics consultations helped with the following: a) to identify ethical issues; b) to analyze ethical issues; c) to resolve ethical issues; d) to educate about ethical issues; and e) to present personal views. MAIN RESULTS: There were no differences in overall mortality between the control patients and patients receiving ethics consultations. However, ethics consultations were associated with reductions in ICU hospital days and life-sustaining treatments in those patients who ultimately failed to survive to discharge. Also, ethics consultations were regarded favorably by most participants. CONCLUSIONS: Ethics consultations seem to be useful in resolving conflicts that may be inappropriately prolonging futile or unwanted treatments and are perceived to be beneficial.     

Barriers to rehabilitation after critical illness: a survey of multidisciplinary healthcare professionals caring for ICU survivors in an acute care hospital

BackgroundThere is scant literature on the barriers to rehabilitation for patients discharged from the intensive care unit (ICU) to acute care wards.ObjectivesThe objective of this study was to assess ward-based rehabilitation practices and barriers and assess knowledge and perceptions of ward clinicians regarding health concerns of ICU survivors.Methods, design, setting, and participantsThis was a single-centre survey of multidisciplinary healthcare professionals caring for ICU survivors in an Australian tertiary teaching hospital.Main outcome measuresThe main outcome measures were knowledge of post–intensive care syndrome (PICS) amongst ward clinicians, perceptions of ongoing health concerns with current rehabilitation practices, and barriers to inpatient rehabilitation for ICU survivors.ResultsThe overall survey response rate was 35% (198/573 potential staff). Most respondents (66%, 126/190) were unfamiliar with the term PICS. A majority of the respondents perceived new-onset physical weakness, sleep disturbances, and delirium as common health concerns amongst ICU survivors on acute care wards. There were multifaceted barriers to patient mobilisation, with inadequate multidisciplinary staffing, lack of medical order for mobilisation, and inadequate physical space near the bed as common institutional barriers and patient frailty and cardiovascular instability as the commonly perceived patient-related barriers. A majority of the surveyed ward clinicians (66%, 115/173) would value education on health concerns of ICU survivors to provide better patient care.ConclusionThere are multiple potentially modifiable barriers to the ongoing rehabilitation of ICU survivors in an acute care hospital. Addressing these barriers may have benefits for the ongoing care of ICU survivors.     

Ethics in Public Health Practice: A Survey of Public Health Nurses in Southern Louisiana

Abstract The present study was designed to help learn more about the ethical interests and concerns of public health nurses employed in state and local health departments. Self-administered postal questionnaires were mailed to 41 public health nurses employed at health units in Region I of the Louisiana Office of Public Health. Basic demographic information was obtained along with information about the workers' previous instruction or training in ethics and the nature of ethical conflicts encountered in their public health practice. Only 38% (15 of 39) of the surveyed nurses had had formal instruction in ethics. Even fewer (7.3%) had received continuing education on ethics. Most of the nurses felt confident in their ability to recognize an ethical conflict or dilemma in the workplace; fewer felt confident in their ability to resolve an ethical conflict or dilemma. A high proportion of the nurses agreed that there is a need for continuing education courses on ethics for public health workers. Nurses who had received formal ethics instruction were more likely to feel confident in their ability to recognize an ethical conflict in their public health practice. Continuing education programs on ethics are needed that are designed to meet the specific needs of frontline public health workers.     

Ethics, Policy, and Educational Issues in Genetic Testing

PURPOSE: Analyze ethics, public policy, and education issues that arise in the United States (US) and the United Kingdom (UK) when genomic information acquired as a result of genetic testing is introduced into healthcare services. ORGANIZING CONSTRUCT: Priorities in the Ethical, Legal, and Social Issues Research Program include privacy, integration of genetic services into clinical health care, and educational preparation of the nursing workforce. These constructs are used to examine health policies in the US and UK, and professional interactions of individuals and families with healthcare providers. FINDINGS: Individual, family, and societal goals may conflict with current healthcare practices and policies when genetic testing is done. Current health policies do not fully address these concerns. Unresolved issues include protection of privacy of individuals while considering genetic information needs of family members, determination of appropriate monitoring of genetic tests, addressing genetic healthcare discrepancies, and assuring appropriate nursing workforce preparation. CONCLUSIONS: Introduction of genetic testing into health care requires that providers are knowledgeable regarding ethical, policy, and practice issues in order to minimize risk for harm, protect the rights of individuals and families, and consider societal context in the management of genetic test results. Understanding of these issues is a component of genetic nursing competency that must be addressed at all levels of nursing education.     

The ethics of non-intervention in a study of patients awaiting coronary artery bypass surgery

BACKGROUND: Nurses conducting clinical research frequently encounter ethically challenging situations that require careful analysis if the decisions taken are to be in the best interests of participants, researchers and society. There is a lack of literature which discusses the ethical aspects of the nurse's role in clinical research studies. AIM: The aim of this paper is to discuss the ethical conflicts and decisions taken during a combined qualitative and quantitative study of patients' experiences whilst awaiting coronary bypass surgery. DISCUSSION: Ethical conflict arose because, despite having gained ethics approval for a non-interventional study, the researcher became concerned for the health of some research participants, whose condition was observed to have deteriorated. During the course of the study four of the 70 participants died. As a result, changes to the original research protocol were negotiated and subsequently the researcher intervened in cases where participants' clinical condition had worsened. CONCLUSION: Nurses conducting clinical research studies can face serious ethical dilemmas, particularly if participants' health is at risk. This paper demonstrates the potential for both role conflict and role convergence in nursing research. We contend that since the roles of researcher and clinician are not mutually exclusive, the interface between the two requires further discussion. The paper may to help inform other researchers who struggle with the issue of non-intervention when presented with research participants in need of professional nursing care.