Ethical conflict in nurse practitioners and physician assistants in managed care

BACKGROUND: More patients are receiving healthcare services from nurse practitioners (NPs) and physician assistants (PAs). These providers are likely to be confronted with a variety of ethical issues as they balance quality care with their patients' rising cost concerns. However, very little is known about the ethical conflicts and causes of these conflicts experienced by these clinicians in their daily practice. OBJECTIVE: To identify ethical concerns and conflicts NPs and PAs encounter related to managed care in the delivery of primary care to patients and the factors that influence ethical conflict. METHODS: A cross-sectional self-administered mailed questionnaire was sent to 3,900 NPs and PAs randomly selected from primary care and primary care subspecialties in the United States (adjusted response rate, 50.6%). Respondents were surveyed on ethical issues and concerns, ethics preparedness, and ethical conflict. Bivariate and multiple linear regression analyses were used to evaluate predictors of ethical conflict. RESULTS: Insurance constraints were reported to have interfered with the ability to provide quality patient care by 72% of respondents, with 55.3% reporting daily to weekly interferences. Nearly half of respondents (47%) have been asked by a patient to mislead insurers to assist them in receiving care. A perceived obligation to advocate for patients, even if it means exaggerating the severity of a patient's condition, was the single most significant predictor of ethical conflict, explaining 25% of the variance. DISCUSSION: NPs and PAs are experiencing ethical conflict often associated with their perceived professional obligations to advocate for patients. Being well-prepared in ethics and having sufficient professional independence help clinicians balance the ethical complexities and demands of meeting patients' needs within a constrained healthcare system.     

Are nurse practitioners prepared for the AIDS epidemic?

Treatment of HIV-infected individuals will become a regular part of mainstream medical practice because of the increasing numbers of infected persons, the geographical dispersion of the disease, and the routine nature of much of the care required by seropositive patients. Nurse practitioners, like other health care professionals, need to be willing and able to provide such primary care. One hundred sixty-five NPs constituted an opportunity sample that was surveyed using an instrument that had been adapted from one used successfully in studies of other health professionals. The instrument consisted of 80 forced-answer and six open-ended questions. The response rate was 63 percent. It was found that nurse practitioners believed there was moderate risk of occupational contraction of HIV. NPs were more likely to agree on activities they believed to be of low risk than about the danger of perceived higher-risk activities. The respondents judged themselves as fairly competent in their ability to provide counseling and information to patients about HIV and risk-reduction. Half believed that their lack of knowledge was the biggest barrier to providing care to HIV-infected persons. Eighty-five percent thought courses on the medical aspects of AIDS were necessary, and 78 percent wanted courses in the social, ethical and legal implications of the disease. This study shows that there is a widely perceived need for continuing education on both medical and social aspects of AIDS in order to enable nurse practitioners to play a greater role in primary care provision for persons with AIDS.     

Florida nurse practitioners' attitudes and practices regarding oral cancer prevention and early detection

PURPOSE: To examine Florida nurse practitioners' (NPs') attitudes and practices regarding oral cancer prevention and early detection. DATA SOURCE: A statewide mail survey was conducted among Florida NPs who provided primary care. The questionnaire was adapted from an existing survey instrument used to measure NPs' knowledge, attitudes, and practices about oral cancer prevention and early detection. A total of 448 Florida NPs (33% response rate) completed the survey. CONCLUSIONS: Florida NPs reportedly were not well prepared for oral cancer prevention and early detection. Although most NPs realized the importance of annual oral cancer screening for high-risk populations and held positive attitudes toward the benefit of early detection, only 39.3% of respondents thought his or her knowledge about oral cancer was current and more than half had never provided oral cancer examinations. IMPLICATIONS FOR PRACTICE: Florida has among the nation's highest oral cancer rates, but persons at highest risk are among those least likely to see a dentist. Therefore, a multidisciplinary approach involving all relevant healthcare providers, including NPs, may be more effective than relying only on dentists' efforts in improving survival rates for oral cancer. Strategies are needed to increase the involvement of Florida's NPs in oral cancer detection.     

Treatment and career attitudes of prehospital care providers associated with potential exposure to HIV/AIDS

Career and treatment attitudes related to potential human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) exposure are reported based on a survey of 1,228 Maryland career and volunteer prehospital care providers trained to provide basic (BLS) and advanced (ALS) life support. Sixty-five percent stated potential exposure to HIV/AIDS was a major occupational stressor. Ninety-two percent stated they would treat HIV/AIDS patients if protected. Given a choice, 38% would avoid providing treatment to HIV/AIDS patients. Eighteen percent considered resigning from emergency medical services (EMS) work. An attitudinal scale (AIDSTRESS) was developed to evaluate overall treatment and career reactions. Respondents with significantly higher (more negative reactions) AIDSTRESS scores were: BLS providers, men, paid providers, personnel with more than 3 years of field experience, those working in urban areas, personnel with no formal education beyond high school, and those who stated that their HIV/AIDS training was inadequate. Implications of the findings for quality of care, career decision making, and inservice education are discussed.     

Becoming partners: the meaning of caring for patients with HIV and AIDS

The purpose of this study was to understand and describe what constitutes caring as experienced by persons living with HIV and AIDS (PLWAs) along their illness trajectory. Interpretative phenomenology was employed. Six men and one woman living with HIV or AIDS participated in open-ended interviews. Interviews were analyzed according to Benner (1994) through paradigm cases, thematic analyses, and analyses of examples. Convenience sampling was used to select participants. Two distinct categories were interpreted: Letting go step by step and becoming partners. Letting go step by step encompasses the entire time people are living with HIV/AIDS illness trajectory. Becoming partners describes the relationship and commitments between PLWAs and families, friends, and health care providers. These findings reinforce the need for families, friends, and health care providers to become partners with PLWASs and to work on this partnership along the entire illness trajectory.     

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.     

Primary care intervention and management for adults with early HIV infection.

Recent clinical drug trials have demonstrated that early intervention with zidovudine will delay disease progression in asymptomatic or minimally symptomatic HIV-infected individuals. These trials will encourage larger numbers of seropositive persons to seek access to primary care, overloading specialized clinics for AIDS and HIV care. The care of early HIV-infected individuals will need to be delivered by mainstream primary care providers. This article discusses the initiation and management of zidovudine, and chemoprophylaxis against Pneumocystis carinii pneumonia in early HIV infection.     

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.     

Hard-to-reach providers: targeted HIV education by the national AIDS education and training centers.

A national system of AIDS Education and Training Centers (AETCs) has received federal funding since 1987 to provide education to health care personnel (HCP) about HIV infection. The purpose of this study is to describe how AETC program personnel define and recognize HCP who are hard to reach and educate about HIV and to clarify the issues that make providers hard to reach. Twenty-three semistructured telephone interviews were used to collect data from AETC faculty and staff. Respondents were asked to identify the types of HCP who are hard to reach and to discuss why they are hard to reach. Themes identified to establish which HCP are hard to reach include specific professional groups (especially physicians and dentists) as well as providers who treated less than 10 HIV-infected clients and some HIV-expert clinicians. Themes identified to establish why they are hard to reach include convenience, isolation, and attitudes. Analysis posits that hard-to-reach HCP fall into identifiable categories: "already know the information," "don't know they don't know the information," "don't think they need to know the information," or "don't want to know the information." Respondents also identified innovative ways to approach hard-to-reach providers.     

Effectiveness of an HIV/AIDS educational programme for Chinese nurses

AIM: This paper reports a study examining the effect of a multifaceted HIV/AIDS educational intervention on the knowledge, attitudes and willingness of Chinese nurses in caring for patients with human immunodeficiency virus. BACKGROUND: The expanding HIV/AIDS epidemic challenges nurses to increase their knowledge about this devastating illness to provide effective HIV/AIDS prevention and care to their patients. HIV/AIDS educational interventions, which were developed for North American and European nurses, have not been studied among nurses in other societies. METHODS: The study employed a pretest, post-test experimental design with 208 nurses from seven Chinese provinces. The intervention consisted of a 5-day workshop comprising didactic lectures interspersed with activities designed to elicit discussion of participants' values and personal feelings about HIV/AIDS. Bloom's Taxonomy and principles of good HIV/AIDS educational practice guided the educational intervention. Outcome variables were HIV/AIDS knowledge, attitude toward patients with HIV/AIDS (including empathy for and desire to avoid these patients) and willingness to provide nursing care to these patients. The data were collected in 2003. FINDINGS: At baseline, HIV/AIDS knowledge was not high and attitudes and willingness to care were neutral. Knowledge, attitudes toward patients with HIV/AIDS and willingness to provide nursing care to these patients were each improved at the conclusion of the workshop (P<0.001). CONCLUSIONS: As the HIV/AIDS epidemic expands, nurses will be called upon to deliver competent, compassionate and comprehensive care to patients and their significant others. Intensive, interactive HIV/AIDS professional workshops can contribute to the national effort by increasing knowledge and improving attitudes towards and willingness to provide nursing care for patients with HIV/AIDS.     

Rural nursing students' knowledge, attitudes, and beliefs about HIV/AIDS: a research brief.

The purpose of this study was to explore rural student nurses' knowledge, attitudes, and beliefs about caring for people with HIV/AIDS. The results from this study were consistent with other past studies where judgmental attitudes toward patients with HIV/AIDS were demonstrated. Data indicate that nursing students' attitudes, beliefs, and knowledge about HIV/AIDS have not changed over the past decade. Based on these findings, many implications for nurse educators exist. Nurse educators need to examine approaches to teaching about HIV/AIDS that can increase knowledge and influence the actual treatment of individuals who have this disease. In addition, the focus for rural nursing programs should be on increasing the understanding of the impact of HIV/AIDS on rural communities and to help project future needs for HIV/AIDS-related services.     

AANA journal course: update for nurse anesthetists--managing human immunodeficiency virus and acquired immune deficiency syndrome during anesthesia care.

The human immunodeficiency virus (HIV) and its advanced progression to acquired immune deficiency syndrome (AIDS) has had a greater impact on our society than any other disease entity during this century. Throughout the past decade the prevalence of HIV disease has grown to pandemic proportions throughout many regions of the world. The infectious and often fatal nature of HIV has made AIDS the most threatening epidemic currently facing modern medicine. A myriad of fears concerns, challenges, and frustration face all healthcare providers whose awareness and impact on practice is continuously challenged. Every nurse anesthetist is responsible for maintaining the ability to both prevent HIV disease transmission and appropriately care for HIV-infected patients during anesthesia care. Experience throughout the past decade of a continuously increasing prevalence of both HIV and AIDS has provided a wealth of information and knowledge that continues to enhance patient care. The following AANA Journal Course will present a current overview of HIV disease and considerations for providing quality anesthesia care while preventing disease transmission.     

Mid‐level providers and emergency care: Let's not lose the force

The progressive rise of ED visits globally, and insufficient numbers of emergency physicians, has resulted in the use of mid‐level providers as adjuncts for the provision of emergency care, especially in the US and Canada. Military medics, midwives, aeromedical paramedics, EMT‐Ps, flight nurses, forensic nurses, sexual assault nurse examiner nurses ‐ are some examples of well‐established mid‐level provider professionals who achieve their clinical credentials through accredited training programmes and formal certification. In emergency medicine, however, mid‐level providers are trained for general care, and typically acquire emergency medicine skills through on‐the‐job experience. There are very few training programmes for NPs and PAs in emergency care. The manpower gap for physicians in general, and emergency physicians specifically, will not be eliminated in the reasonable future. Mid‐level providers – ENTs, paramedics, NPs, PAs – are an excellent addition to the emergency medicine workforce. However, the specialty of emergency medicine developed because specific and focused training was needed for physicians to practice safe and qualify emergency care. This same principle applies to mid‐level providers. Emergency Medicine needs to develop a vision and a plan to train emergency medicine specialist NPs and PAs, and explore other innovations to expand our emergency care workforce.     

The Jamaican adolescent: an assessment of knowledge and attitudes regarding HIV/AIDS

PURPOSE: The purpose of this study was to assess the knowledge and attitudes of adolescent Jamaicans in a church youth group, regarding HIV/AIDS. METHODS: A convenience sample of 45 adolescents from a Jamaican youth group completed a modified version of the AIDS Attitude Scale (AAS). The subjects were assessed for having empathy or avoidance towards people with HIV/AIDS. A focus group discussion after completion of the AAS provided information about the participants' knowledge regarding HIV transmission and self-protection. FINDINGS: The adolescents' responses on the AAS indicated strong empathy (4.66) and an overall supportive attitude (+1.77) for people with HIV/AIDS. While the adolescents incorrectly felt that HIV/AIDS was being spread mainly by homosexual encounters in their country, other responses regarding mode of transmission were quite accurate. Since these adolescents were practicing abstinence and the avoidance of drugs and alcohol, they weren't worried about protecting themselves from the transmission of HIV; however, when asked what they would tell their friends outside of the church about HIV protection, most subjects were able to provide accurate information. CONCLUSIONS: These findings indicate that Jamaican adolescents actively committed to the teachings of the church are generally knowledgeable about HIV/AIDS and supportive of people with HIV/AIDS. Nurses and other health care professionals working with members of the church youth groups to develop peer educator programs, would have effective role models to help influence the sexual behaviors of their adolescents.     

Attitudes toward health care providers and appointment attendance in HIV/AIDS patients.

Patients with HIV/AIDS are likely to have numerous interactions with health care providers (HCPs) during the course of their disease. Research has shown that satisfaction with one's HCP is related to better medication adherence in patients with HIV/AIDS. Although a patient's attitude toward his or her HCP is important, little has been done to assess how it relates to appointment attendance. The current study assessed how attitudes toward HCPs as well as social support and depression relate to outpatient appointment attendance. Further, this study used a newly developed, psychometrically valid scale to assess specific patient attitudes toward HCPs including those related to disease stigma. Participants were predominantly low-income African American men (N = 109) recruited from a public southern HIV clinic. Analyses indicated that attitudes toward HIV HCPs, social support, and medication status but not depression or satisfaction with social support were associated with appointment attendance.