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Bioethical Dilemma - Prescriptive Authority of APNs
- 1. Advanced Practice Nurses: A Prescription for Autonomy NSG 602: Diversity, Ethics, and Professional Practice in Nursing The University of Southern Mississippi Desiree Peterson Jessica Simpson
- 4. The Ethical Question Does limited prescriptive authority of nurse practitioners pose an ethical dilemma in the treatment of patients?
Notes de l'éditeur
- A study conducted by Kaplan and Brown (2004) found that many nurse practitioners have the preconceived notion that increased prescriptive authority would not be helpful to their practice. Additionally, there was a concern among nurse practitioners that liability increases as prescriptive authority increases, but there is no increase in pay. In other words, what is in in for them? Most states require that a physician is at least minimally involved in the prescribing of schedule II – IV medications. It was found that only 51% of nurse practitioners in Washington admitted to always involving a physician when prescribing schedule II-IV medications (Kaplan & Brown, 2004). The same study found that 27% did not consult with a physician prior to signing prescriptions, 25% used pre-signed prescription pads, 10% prescribed schedule II-IV drugs without physician involvement, and 46% would prescribe a non-schedule medication rather than the preferred medication for treatment. State laws vary greatly from state to state. Please refer to handout (http://www.medscape.com/viewarticle/440315). This website allows you to choose any state and view the prescribing regulations for that state. Quickly compare Massachusetts, Michigan, Minnesota, Mississippi, and Missouri by clicking on the state of Massachusetts. This will give the reader a good idea of the variance of laws governing the prescription of medications by the nurse practitioners. There are several concerns voiced by physicians regarding the increased autonomy in the prescribing of medications. According to Pennington (2007), physicians verbalize a concern of the quality of care as a reason for limiting the autonomy in practice of a nurse practitioner.
- Kaplan and Brown (2004) found that 46% of nurse practitioners would prescribe a non-schedule medication rather than the recommended schedule medication for treatment related to barriers in prescriptive authority. Additionally, relying on physicians to prescribe medications writing who have not assessed the patient could have the potential to cause more harm than good.
- Ethics is the study of ideal human behavior and ideal ways of being. Eighteenth century philosopher, Immanuel Kant, believed that ideal behavior is acting in accordance with one's duty. Human well being is having the freedom to exercise autonomy and the capability to think rationally (Butts & Rich, p. 4, 2008). Kant's ethical theory reasons that actions are ethical or right with practical reasoning would put these actions into universal law. “If the course of action someone plans to take can be willed upon everyone then it is an ethical choice” (Davison, 2006, para. 2).
- NPs are bound to the duty of promoting and protecting the wellbeing of their patients. NPs also have an ethical duty to their profession to commit to continuous professional development. One must also advocate for one’s profession by supporting the growth of the occupation. The bioethics principles were derived by deontology theories. The principles of respect for autonomy, beneficence, and nonmaleficence are in dissonance when limiting the prescriptive authority of NPs. (To be discussed later).
- The variation in laws from state to state has the potential to be unethical according to Kant’s Deontology. This theory states that if it is okay for one individual to perform a certain behavior, in order for the behavior to be ethical, it should be acceptable for anyone in the profession to perform the same behavior under similar circumstances.
- Respect for autonomy: According to Butts and Rich (2008), rational patients should have the right to make choices in their healthcare. One of the choices a patient will make is that of which healthcare provider to use. If a patient should choose a nurse practitioner as a primary care provider, this choice should be respected by allowing the patient to be assessed and treated within the scope of the nurse practitioner’s practice. If a nurse practitioner can diagnose a disorder requiring particular medications, he/she should be allowed to treat such disorders accordingly. Beneficence: Butts and Rich (2008) describe beneficence as actions taken to benefit and promote the welfare of people. It is becoming an increasing reality that nurse practitioners are necessary to meet the primary care needs of our society. Healthcare reform nearly mandates the increase of nurse practitioners. In light of this, more autonomy in practice is a must! Nonmaleficence: Butts and Rich (2008) states that nonmaleficence includes the need to avoid negligent care and to avoid withholding treatment. When NPs are unable to prescribe medications for client needs, there can be a delay in treatment.
- As nurse practitioner’s increase the scope of their practice, they also increase their liability. Pennington (2007) reported that when comparing the prescriptive practices of NPs with that of physicians, the prescriptions were comparable, except nurse practitioners prescribed fewer medications that their counterparts. In addition to nurse practitioner liability issues, the collaborating physicians have an increase in liability. As discussed previously in this presentation, the varying state laws and regulations are an additional concern regarding the practice of NP.
- In order to make the best ethical decision, nurses should know themselves and understand their beliefs. The practice of ethics requires reflection of one's actions. Gibb's Reflective Cycle (Butts & Rich, 2008) could be used by NPs to examine their actions and to ensure themselves, the nursing board, and others that their standard of care improves to protect patients served. Additionally, the use of an ethical decision making model can offer assistance in the formulation of potential solutions. The EAF is the preferred ethical decision-making model for the New York State Nurses’ Association. The process consists of (as related on the NYNA website): Assessment: Identify the problem Issues, conflicts and/or uncertainties Gather relevant facts Medical (objective data); contextual (subjective data); policies, state and federal laws etc. Identify methods of ethical justification to help resolve the dilemma [Consequentialism (consequences); deontology (duty); principalism (principles); care (relationships); casuistry (cases); virtue (character)] Consciously clarify relevant values, rights, and duties of patient, self and significant persons associated with the issue(s). Identify if there is an ethical dilemma(s) present. Identify guidelines from nursing and professional codes of ethics. Identify and use relevant interdisciplinary resources. Ethics committee, ethics consultants, clergy, literature, administrators, lawyers, colleagues, etc. Identify and prioritize alternative actions/options. Plan of Action Select a morally justified action/option from alternatives identified Implementation Act upon/support the action/option selected Evaluation Evaluate action/option(s) taken; short and long term (http://www.nysna.org/practice/positions/position6.htm) This framework appears to be a hybrid of various models to meet the needs of nursing. It also includes concepts that are common to most decision-making models, but also includes the component of evaluation which many of the other models are lacking.
- Our first solution is collaboration between the physician and the nurse practitioner as currently exists in Mississippi and 27 other states to write prescriptions of controlled substances (Lebo, 2007). Of course, both the doctor and NP retain their own liabilities and ethical dilemmas to the patient, but does this really solve anything with regards to providing the best possible care to the patient? “ Physician collaboration” is a term used by many nursing boards to mandate prescribing controlled substances, and others use the terms supervise or on-site supervision for collaboration. See handout (http://www.rmf.harvard.edu/files/documents/Forum_V18N5_a4.pdf). Read the “The Consultative Process in Practice.” For collaboration to occur, the physician and NP must see the same type of patient population. They must work at the same site, use the same references, including the same pharmacologic guidelines. If the NP wants to use a different medication, she must consult with the collaborating physician. This situation could possibly worsen as schedules must be predetermined to have proper coverage. Prescription consultation can occur over the telephone or in person (see handout). According to the Mississippi State Board of Nursing (2010), when a NP changes jobs or if there is a change in her work environment or with her collaborating physician, the board must be notified immediately and determines if the NP may practice there (www.msbn.state.ms.us). Is this autonomy, beneficence, or nonmaleficence for the anyone involved, be it the patient, NP, or physician? Cons, of course, is that the Controlled Substance prescriptive abilities are limited and remain confusing. Nurse Practitioners are forced to prescribe within their current realm of available medications, and limit medication options for the patient. For example, restrictions may mean that a patient who had chosen a NP as a provider would have to see different providers and require multiple visits to have his/her medications ordered. If a patient needed Coumadin, a physician would have to do it, or if he/she needed a benzodiazepine, well NPs can only order a three day supply depending on which state he/she is located (Lebo, 2007). Scudder (2006) reports that the majority of drug management by nurse practitioners can be accomplished with little or no physician consultation. When as far back as 2002, a study found that NPs write 11-15 prescriptions per day. A poll by the American Academy of Nurse Practitioners also found that 37% of NP respondents write 1-50 scripts per week, and 32% write between 51-100 per week, yet nurse practitioners are still limited to what they can prescribe for various types of patients or patient conditions (Lebo, 2007). It is confusing for nurses, physicians, and pharmacists to remember prescription authorities, much less, expect the general public too.
- An article expressing the desire of NPs to obtain increased prescribing authority discussed the potential of reduced healthcare savings. Hoholik (2010) reports that if a physician is unavailable to collaborate with or prescribe pain medication for a patient experiencing a kidney stone, the patient must be sent to an emergency room thus increasing the costs of healthcare. If the NP could be empowered to treat the patient which he/she diagnosed, the trip to an over-crowded emergency room where the patient could potentially have to wait for hours for treatment could be avoided. Increased authority with prescribing controlled substances, would also mean that a patient would not have to wait to see a physician to have various medications ordered, such as anticoagulants, anti-anxiety, pain medications, anti-neoplastics, stronger cough or anti-diarrheal medications, which NPs cannot prescribe alone in most states (Tumolo, 2009). The evolution of NP autonomy and continuous failure of physicians to meet patient expectations, could open the health care arena for quality patient providers that are flexible, less expensive, and available in all areas. Pennington (2007) reported an increase in patient satisfaction with their care and patient education in patients that utilized nurse practitioners as compared to patients of physicians. Cons: Debates continue over how much prescriptive authority is needed when our prescriptive and non-prescriptive drug use is on the rise. Many group physical dependence, tolerance, and addiction to the use of pain medications. Physicians and the American Medical Association dislike it, because they believe NPs are invading the medical field. We are now viewed as competitors instead of collaborators. Many doctors also believe that increased authority with prescribing controlled substances will remove regulation which has the potential to decrease quality and accountability (Slupphaug, 2010).
- Pros: Standardized controlled substance prescriptive authority across state lines would enable NPs to move freely from state to state, without concerns of whether or not they will be limiting their current prescriptive authority. As happens, when a NP moves from a state with controlled substance authority to one with a collaborative physician relationship. This would also enable NPs to treat the estimated 32 more million Americans with access to health care, and fill the shortage of primary care providers. According to a recent survey, only 7% of fourth year medical students are planning on practicing primary care due to the higher workloads and lower incomes (Phillips, Harper, Wakefield, Green, & Fryer, 2010). Cons: Discrepancies in reimbursement for equivalent services. NP midwives will receive equal to physician reimbursement, but all NPs will not. Inconsistent scopes of practice and varying payer laws make it difficult for primary providers to function effectively. The Balanced Budget Act of 1997 provided Medicare eligibility so that NPs in all settings are eligible for direct Medicare reimbursement at 85% of the physician rate when they collaborate with physicians. When care is billed as “incident to” a physician, it is billed in the doctor’s name and reimbursed at a physician’s rate. A survey of NPs found that only 4.4% bill directly, 71% bill “incident to”, and 8% have other arrangements (Phillips, Harper, Wakefield, Green, & Fryer, 2010). If NPs examine, evaluate, and prescribe all medications for patients, at which rate will they get reimbursed? Liability also increases. According to a lawsuit in Nursing 2005, a California family sued his physician, nurse, and hospital for poor pain management prior to his death, and was awarded $1.5 million. The nurse documented that the patient’s pain was a 7 out of 10 with 10 being worst, and that the pain medication failed to reduce his pain level. As advocates for patients, if something deviates from the standards of care, document specific reasons why . Remember, we are all liable. The autonomous nature of NPs requires accountability, certification, periodic peer review, clinical outcome evaluations, continuing education, development of clinical skills, and a code of ethics (Sherwood, Brown, Fay, & Wardell, 1997).
- Based on the evidence reviewed and the shortage of primary care physicians to treat over 32 million Americans, we believe that nurse practitioners should have standardized laws and regulations across all states. As it is now, only twelve states and the District of Columbia have independent prescriptive authority for controlled substances schedules II – V (Lebo, 2007). Although, these states have large rural areas, the DOC, our nation’s capitol, does not. Those states that do allow prescriptive authority for controlled substances require physician collaboration, and Georgia is the only state that does not allow NPs any prescriptive authority. As discussed earlier in our first solution, many patients with physician collaborative states must wait to seek physician approval for a scheduled medication. And as also mentioned, 46% of nurse practitioners delivered less than adequate care due to limited prescriptive authority. Should patients suffer from mismanaged guidelines and lack of primary care physicians? Should nurses have to make poor decisions and knowingly face that some may receive the medications they need and others may not, or have to wait for approval?
- According to Immanuel Kant, everyone is autonomous, has dignity, and is due respect (Butts & Rich, 2008). With this in mind, NPs would be allowed to practice as they have been trained, as leaders. NPs clarify their leadership role in primary heath care with the combination of provider, educator, researcher, mentor, and administrator. If as nurses, we do nothing about the confusing NP guidelines, everyone suffers. No one achieves autonomy, nonmaleficence, or beneficence. Everyone intends on promoting the welfare of others nor causing any harm, but when patient care is compromised due to lack of authority or inability to reach a physician, the standards of care are breached. No one wants patients to suffer, but time is limited. As with our second solution, with increased authority, health care costs should decrease, patient care should improve, and NPs could bridge the gap in underserved areas. With this in mind, our society should experience greater respect and autonomy. Truly, the principles of nonmaleficence and beneficence would coexist. With our third solution of standardized regulations and guidelines, all of our NPs could assist in our shortage of primary care providers and treat the more than estimated 32 million Americans with access to health care. Remember, nurses want justified pay for services, but we are willing and capable to work flexible hours in underserved areas. Standardized laws and regulations for NPs prescriptive authority, would enable everyone to have full access to medical care. Nurses would be united as a profession, and our society would not be confused about our capabilities.
- NPs conduct comprehensive health assessments, educate, promote health and disease prevention. We, as health care providers, are obligated to standards of care and a code of ethics. Limited prescriptive authority hinders our ethics, and places undue stress on our society as a whole. Although, the practice of NPs has truly evolved over the last 40 years and will continue to progress, the best solution for our society would allow primary care NPs to have DEA prescriptive numbers, in order to properly prescribe. As it is today, pharmacists place the DEA prescriptive number of the collaborating physician, which further confuses the patient if he/she has a question about their medication. Many times, the patient does not recognize the physician’s name on the prescription, because they may not have met. Insurance companies track the DEA numbers to identify providers for reimbursement. If pharmacies used the NPs DEA numbers, their prescriptions could be closely monitored and NPs would receive reimbursement. Primary care physicians are still needed and would exist in a collaborating role. Primary care physicians should be consulted for any issue that NPs feel is outside their scope of practice. Will physicians and NPs embrace improved patient care as a shared priority? We deserve no less.