When the flu strikes somewhere in the little country somewhere in the Middle America, residents can either drive for about an hour to see the nearest physician or instead they can address the local registered nurse with the correspondent training who runs an independent clinic. A well-qualified nurse is able to diagnose and treat most common diseases and health problems. In the last years, the number of nurse practitioners that run their private health establishments have been increasing. The popularity of the last group is caused by the fact that they are available to provide health care in areas where doctors are unavailable. They also are taking less serious cases where physicians’ interference is not necessary.
For the general consultation and prescriptions of a long term course of treatment it makes sense to see a licensed doctor, however the in-between visits can be done to nurse practitioners with the same results. Most of physicians, in their turn, backup themselves with the presence of nurse practitioners who do things that are too time-consuming to be done by the physician. Doctors are trained to focus on a specific disease or health problem, whereas nurses are trained to be more holistic, focusing on prevention, management of chronic diseases and the impact of health problems on the patient and the family. Nurse practitioners have time to talk to patients, to evaluate their life style and observe the harmful habits that can affect health. Therefore, in many instances nurse practitioners not only prescribe the needed medicine but also provide counseling and useful advices as to the patient’s life style, diet and so on.
History of Nurse Practitioners
Nurse practitioners got their start about 30 years ago as a way to extend the reach of doctors. They are entitled to six-year course and two years of postgraduate training to receive a master’s degree in advanced practice nursing. After some additional training, it is also possible to specialize in areas like pediatrics and gynecology. Unlike nurses without the additional training, nurse practitioners are licensed to diagnose and treat common illnesses and injuries, order and interpret medical tests, prescribe medications, and advise patients on prevention. They also can take a responsibility of referring to a physician when patient needs additional consultation. Nurse practitioners are limited from dealing with more serious and complicated cases by the state laws. For example, they cannot take patients in intensive care or make surgeries.
Lately nurse practitioners have been trying to get more autonomy and responsibility in their practice. In some states now, their activity has been expended to the point where they can prescribe any medication, including narcotics and other controlled substances. After struggling for more authority, nurse practitioners are now allowed to run independent clinics without supervision but only in some states, though.
The main opponents of Nurse Practitioners
Doctors are the main opponents of nurse practitioners in their struggle for more independence. Doctors are often battling the laws allowing more freedom for nurse practitioners. They are enthusiastic about nurse practitioners working in the team with them but consistently oppose any independent moves from the latter.
Doctors question whether nurses have enough training to recognize more serious health problems that need to be referred to a physician. Nurse practitioners say that they are the ones to be in the front line evaluating patients from the start since this was always the primary role for nurses. In hospitals, they say, nurses are expected to recognize when a doctor is needed because a patient’s condition is worsening. The point of existing of nurse practitioners is to improve health care in the conditions when the financial pressure is present, to provide care to the poor and other groups that are usually neglected.
Recently, both nurse practitioners and doctors have been having problems with legal responsibilities, caused by patients’ complaints. However, medical errors are much harder on the first groups. According to JCAHO (2000) up to 7,000 deaths are caused by mistakes made in prescribing or dispensing medications. These medical errors are quite costly and loses are estimated to be between $17 and $29 billion nationally in lost income, disability and health care expenses. The research had shown that errors are partly caused by cutbacks in nursing staff, replacing experienced nurses with less experienced nurses and an excessive use of overtime when personal loose concentration and effectiveness.
Responsibilities of Nurse Practitioners
Expanded responsibilities of nurses are naturally followed by the increased accountabilities. Financial risk is shared by nurses as well as other health care providers. In addition, new areas of risk are appearing. For instance, triage and utilization- management nurses now have obligations to ensure that the appropriate care is given. For the most part nursing activity is evaluated on the basis of traditional standards however there are some deviations which have not been yet well-established. The three main areas of practice remained to be the most important in evaluation process: competence with accordance to nursing standards, ethical practice and legal practice, measured by the departures from the law. Nurses must be vigilant about staying up to date on the Nurse Practice Act in their state, nursing standards specific for their area of expertise, and current state and federal health laws.
The risk management guidelines have been in the process of constant development and change, it is even more difficult to come to the one standard because of several factors. These are the “newness” of the field, the limited volume of litigation leading to a foundation of legal precedence, and the complex contractual agreements among the parties involved.
Liability issues, such as failure to process claims according to established procedure, their denial and delay in treatment are becoming clearer to deal with; all those cases can lead to liability. They all have common question to answer: Who should be liable when things like that happen?
The courts have managed few cases related to poor patient care outcomes received from care organizations. These case are usually referred as malpractice claims. However, the unclearness to contractual agreements makes it quite hard to delineate the legal responsibilities. During the legal process as suit is attached to the legal precedent and is lengthy and complicated. Legal precedent is considered with a major time delay and before the actual lawsuit is filed, all counter-claims filed, cross-claims, preliminary motions, and the appeals process have to be examined. Only after a trial verdict is appealed on legal grounds to a higher court and the court formulates an opinion can a precedent be established.
The Legal Responsibility of Nurse Practitioners
The variety in views as to who the legal responsibility goes to, have challenged the legal system. Traditionally, law relies on precedent when faced with new forms of behavior. When the precedent is not there, the laws have to address different sources. This situation has caused very interesting trend in development of managed care laws. Here are some examples taken out of the medical law statements as of 1996 – 1997:
- MCOs often adopt clinical practice guidelines to manage particular problems and improve care outcomes. In a relatively new phenomenon, guidelines may be admitted as inculpatory or exculpatory evidence by judges in malpractice claims (Brennan, 1997).
- Credentialing refers to the process of including the appropriate delineation of clinical privileges. In addition to physicians, MCOs may decide to credential “limited-license practitioners” (nurse practitioners, nurse midwives, physician assistants, physical therapists, etc.). MCOs may prefer to credential limited license practitioners because of their cost-saving potential and consumer demand, but physicians may protest because of the way the supervision of limited license providers impacts physician liability. Conversely, antitrust actions have been filed against MCOs by limited-liability providers who were excluded from credentialing (Mattioli, 1997).
- Any willing provider laws. These proposed laws were set up to require MCOs to pay any provider who agreed to meet the MCO’s terms and conditions of participation for services provided to the enrollees, whether or not the provider is part of the MCO’s network. They were launched by the concern that MCOs were restricting enrollee choice of provider. In 1996, 69 AWP proposals were introduced in 24 states but none passed. AWP proposals have now given way to new initiatives by MCOs to increase choice of providers including point of service (POS) options and self-referral systems (Roth, 1997).
- Disclosure of physician incentives. This is a provision of a proposal by the American Medical Association (AMA) that would require MCOs to disclose all “financial arrangements, incentives, or contractual provisions with hospitals, review companies, physicians, or any other provider of health services that could limit or induce the limitation of the offered services (Roth, 1997)
Past experience show that Physicians always pass the professional courtesy issues to their colleagues. The physician and his/her patient used to determine the level of professional courtesy themselves. Today the situation has considerably changed basing on the legal system this day. For instance, physician used to determine professional courtesy as accepting whatever insurance plan allows paying. What if the patient is from the category of Medicare beneficiary? This type of issue gets confusing.
Medics should be very cautious in extending the limits of professional courtesy where patient can make referrals. In this situation, the court will be in the situation to prosecute fraud or abuse care for a violation of the anti-kickback law.
However, there have not been any instances of prosecution for fraud or abuse based on professional courtesy. There is very little chance of a fraud or abuse case being initiated on the basis of professional courtesy aspect. On the other side, there are some schemes allowing the prosecution of providing medically unnecessary services, but they were not related to professional courtesy.
Medical errors of Nurse Practitioners
Medical errors remain the main source of recognized risks. Almost 95 percent of errors stay unreported. The reasons of this are obvious: fear of punishment, loss of job, legal responsibility and jeopardizing reputation. These errors are even worsen because of the constant pressure of the fear being punished if something under the specific medic supervision area goes wrong. In addition, as the result of not reporting errors, the analyzing institutions have no reliable source of knowledge about the true error presence situation.
The disclosure of errors has many questions that have to be answered. Should the patient and his/her family be informed about the error? Who should inform them? Should they be given the full information? It is generally accepted principle to inform the patient, if the errors require change or modification of treatment. In cases like that, patients should know that they will not incur and additional charges because of the change and why the modification took place.
What if the error caused no harm? The decision has to be made, whether it is worth needlessly worry the patient and his/her family or is it better to keep the uniformed and jeopardize the medic and patient trust relationship. Therefore, when making the decision like that, one should consider the amount of benefit or harm to the patient and maintaining social trust.
Obviously the issue is not settled. The only way to ensure accurate reporting of errors is to relieve caretakers from the punishment, but this still raises the question of full disclosure. However, the ultimate goal is to improve the integrity and patient care, thus risk management should take the error as the whole system failure, establish trends and reduce the error.
When a patient-caretaker relationship begins, the caretaker has to provide services as long as the patient is in need of them; this has to be done according to ethical and legal laws. There are numerous examples when a caretaker is not able to continue giving treatment as the patient is noncompliant, too demanding or even threatening a caretaker. Sometimes it is simply necessary to end the established relationship because of simple relocation, retirement, changing job or anything else of that type. To avoid the so-called “patient abandonment” and properly end the relationship, a caretaker has to follow the set of established rules. Abandonment is defined as the termination of a professional relationship between physician and patient at an unreasonable time and without giving the patient the chance to find an equally qualified replacement.
Conclusion on Nurse Practitioners
As you see, the necessity of nurse practitioners activity is obvious. Access to care is a significant and growing issue in this country. Almost forty one million people are uninsured and many more underinsured. People require cheap and quality medical treatment, which cannot often be provided by doctors, and their only choice are nurse practitioners. Dealing with the poorly conceived regulations in health care is a major headache for nurse practitioner, often limited and pressured by the legal considerations; they are not able to give the quality treatment to the full extent of their capabilities.
It is up to legal system to make it possible to have the affordable line of quality medical services and give them to all those in need. In addition, the nurse practitioner should always be in tune with all the legal regulations and be able to provide the services like that.