NR 506NP Week 2: Organizational Change and Ethical-Legal Influences in Advanced Practice Nursing Case Study
NR 506NP Week 2: Organizational Change and Ethical-Legal Influences in Advanced Practice Nursing Case Study
Discussion
Purpose
The purpose of this discussion is to discuss organizational changes and ethical-legal influences in a clinical scenario at an out-patient family practice. Students will explore potential effects on patient outcomes and ethical and legal implications for members of the heath care team as a result of illegal behaviors. Students will develop strategies that result in prevention of untoward outcomes that result in a positive practice culture.
Activity Learning Outcomes
Through this discussion, the student will demonstrate the ability to:
- Demonstrate effective leadership styles in the management of organizational change (CO3)
- Interpret various forms of ethical theories and application into practice (CO4)
- Discuss practice guidelines and malpractice prevention (CO2)
Due Date: Wednesday by 11:59 pm MST of Week 2
Initial responses to the discussion topic must be posted by Wednesday 11:59 pm MT. Two additional posts to peers and/or faculty are due by Sunday at 11:59 pm MT. Students are expected to submit assignments by the time they are due.
A 10% late penalty will be imposed for discussions posted after the deadline on Wednesday of week 2, regardless of the number of days late. NOTHING will be accepted after 11:59 pm MT on Sunday (i.e. student will receive an automatic 0).
Total Points Possible: 100
Preparing the Discussion
You are a family nurse practitioner employed in a busy primary care office. The providers in the group include one physician and three nurse practitioners. The back office staff includes eight medical assistants who assist with patient care as well as filing, answering calls from patients, processing laboratory results and taking prescription renewal requests from patients and pharmacies. Stephanie, a medical assistant, has worked in the practice for 10 years and is very proficient at her job. She knows almost every patient in the practice, and has an excellent rapport with all of the providers.
Mrs. Smith was seen today in the office for an annual physical. Her last appointment was a year ago for the same reason. During this visit, Mrs. Smith brought an empty bottle of amoxicillin with her and asked if she could have a refill. You noted the patient’s name on the label, and the date on the bottle was 1 week ago. You also noted your name printed on the label as the prescriber. The patient admitted that she called last week concerned about her cough and spoke to Stephanie. You do not recall having discussed this patient with Stephanie nor do the other providers in the practice.
Case Study Questions:
- What are the potential ethical and legal implications for each of the following practice members?
- Medical assistant
- Nurse Practitioner
- Medical Director
- What strategies would you implement to prevent further episodes of potentially illegal behavior?
- What leadership qualities would you apply to effect a positive change in the practice? Be thinking about the culture of the practice.
- A scholarly resource must be used for EACH discussion question each week.
| Category | Points | % | Description | |
| DISCUSSION CONTENT | ||||
| Potential ethical & legal implications for healthcare team members | 30 | 30% | Provides relevant evidence of scholarly inquiry of the potential ethical and legal implications for each of the practice members. Uses valid, relevant, and reliable outside sources to contribute to the threaded discussion. | |
| Strategies to prevent further conflict | 30 | 30% | Provides relevant evidence of scholarly inquiry of strategies to implement to prevent further episodes of potentially illegal behavior. Uses valid, relevant, and reliable outside sources to contribute to the threaded discussion. | |
| Leadership qualities to effect positive change | 15 | 15% | Provides relevant evidence of scholarly inquiry of leadership qualities to apply to effect a positive change in the practice. Uses valid, relevant, and reliable outside sources to contribute to the threaded discussion. | |
| 75 | 75% | Total CONTENT Points= 75 pts | ||
| DISCUSSION FORMAT | ||||
| Interactive Dialogue | 20 | 20% | 4 Required Elements:
|
|
| Grammar, Syntax, Spelling, Punctuation | 5 | 5% | Grammar, syntax, spelling, and punctuation are accurate. | |
| 25 | 25% | Total FORMAT Points = 25 pts | ||
| 100 | 100% | DISCUSSION TOTAL = 100 pts |
What are the potential ethical and legal implications for each of the following practice members?
-Medical assistant
The medical assistant works in outpatient, ambulatory care facilities, and medical offices, working with physicians to perform administrative and clinical duties. They are responsible for obtaining medical histories, explaining treatments or procedures to patients, assisting during patient examinations, collecting lab specimens, EKGs, phlebotomy, preparing and administering medications. Administrative duties include computer use, filing, coding, scheduling appointments, and insurance authorizations (AMA, 2023). On a national level they can perform these duties but cannot write prescriptions, treat patients, diagnose, or use other providers’ information to prescribe. This is considered illegal activity and what Stephanie did was unacceptable. As a medical assistant Stephanie is supposed to keep patients safe and she acted outside of her scope of practice.
She treated a patient with a medication- Amoxicillin, that she could have mistakenly worsened the patient condition, caused an allergic reaction, inappropriately dosed the patient, and caused irreparable harm to the patient, all while using the NPs information to illegally prescribe that medication. Stephanie could be terminated from her position, lose her medical assistant license, monetary penalties, or face jail time for impersonation of a nurse practitioner. An advanced practice nurse is a person who holds certification in accordance with section 8 or 9 of P.L.1991, c.377 (NJ Division of Consumer Affairs, 2020). Not to mention that if the patient were harmed the medical assistant could face a lawsuit for impersonation of a provider and unintentional harm to a patient. This is unethical as the medical assistant is practicing medicine illegally.
-Nurse Practitioner
The nurse practitioner in this scenario is at risk of losing her license, being involved in a lawsuit, and facing other damages. A national provider identifier (NPI) acts like a social security number, allowing the provider to prescribe medications and place orders. It is dangerous to prescribe medications without seeing your patient and assessing them. In this case study the NP had no idea that the medication was being prescribed to Mrs. Smith without her authority. Although this was fraud, it could become difficult to prove that the prescription was given by Stephanie and not the nurse practitioner.
Stephanie committed fraud and theft by using the NPI number of the nurse practitioner and acting outside of her scope of practice. According to Capozzola et.al., 2018) there was a similar situation where a physician prescribed a narcotic and muscle relaxant to a patient without seeing the patient prior to prescribing. The patient had a heart condition and ended up drinking before taking both the medications. The provider who did not see the patient never had a chance to do a workup or assess the patient. The patient involved expired with an autopsy performed, which indicated the cause of death was due to cardiac reasons, drug, and alcohol toxicity. The patient’s daughter sued the physician for negligence and medical malpractice resulting in wrongful death (Capozzola et.al., 2018). This is just an example of what can happen when medications are prescribed unsafely.
-Medical Director
The medical director can face a lawsuit due to patient harm, fraud, and theft. This is the first time that someone caught Stephanie using an NPI number to prescribe medication, act out of her scope of practice, impersonate a provider, and practice medicine illegally. The case study doesn’t reference whether she has done this before or if the patient experienced any harm. The issue is Stephanie is aware of her role, ethics, and her scope of practice, yet she still acted unethically. The medical director will have to decide to protect the practice and its employees. There will need to be a decision about pressing charges for violating the law, impersonation, and fraud. Stephanie will most likely be terminated and could face legal charges.
-Practice
The practice is at risk of malpractice, especially if this patient was harmed or if Stephanie has done this before. This is a serious situation. Prescribing the wrong medication is considered negligence and there is a reason why an individual needs extensive education and to pass the boards prior to being able to prescribe medications. In the case study introduced by Capozzola et. al. (2018) the patient’s daughter sued the physician and the practice for patient harm, negligence, and malpractice.
In that situation she didn’t win the lawsuit because the patient was educated on the medication and side effects. In these situations, a practice can face harsh monetary penalties, settlements in favor of the patient, and possible close down. The practice will have to take extreme measures to prevent this situation from occurring. Although Stephanie is knowledgeable and was considered an asset, she has become a liability risk for the practice. She will most likely face termination for what she did. To prevent these issues from happening again, the practice will need to enforce new policies restricting employees.
What strategies would you implement to prevent further episodes of potentially illegal behavior?
In order to prevent potentially illegal behavior, it is important to understand each individual’s scope of practice and have an appreciation for the code of ethics; doing no patient harm. The practice should hire people with a clear understanding of their role and a commitment to core values evolved from the code of ethics. Recommendations include recruitment of staff that embrace core values of medicine, practicing compassion, re4specft for patient autonomy, competence, and caring for all patients. Educate leaders to create a professional integrity culture within the practice (DuBois et. al., 2018).
Through establishing a practice culture, everyone has a clear understanding of professional standards and expectations. Increase oversight from providers on colleagues to prevent mistakes. It is important for staff to work independently but they should be supervised by higher ups to ensure patient safety, adherence to practice policies, and ethics. Tracking serious errors and placing consequences is important to avoid situations where staff work outside of their defined scope of practice. Tracking consequences enables evaluation by state boards and other disciplines (DeBois et.al., 2018).
What leadership qualities would you apply to effect a positive change in the practice? Be thinking about the culture of the practice.
Leadership is one of the most important qualities in a medical practice because it defines a standard and helps in the development of a culture. Leading through example can show other staff members the way they should act, interact with patients, handle patient concerns, and follow policy. Center for Creative Leadership (2023) explains that there are 3 Cs of change- Communication, Collaboration, and Commitment. Communication through successful leadership is about understanding organizational values, urgency for change, and the explanation of benefits directing people to embrace a positive change. Collaboration unites people in working toward change. Leaders work with employees to cross boundaries and remove unhealthy competition.
Employees should be included in decision making processes early on and commit to the change process. Commitment made through successful leadership is conveyed through support in the change, stepping outside of comfort zones, and embracing common values shared within the facility (Center for Creative Leadership, 2023). It isn’t easy to enact change, especially when a practice has been doing things the same way for a very long time. Having a strong leader capable of listening, understanding, and presenting the way is important to creating change. People are scared of changes and may remain reserved, but a successful leader will guide them and find ways for them to be involved in decision making.
Reference:
AMA. (n.d). What is a Medical Assistant. Retrieved 2023
Capozzola, Jamie Terrence, & Lynch, M. (2018). Physician Defeats Liability for Prescribing Without In-person Consultation. Healthcare Risk Management, 40(8).
Center for Creative Leadership (2023) How to Be a Successful Change Leader. Retrieved https://www.ccl.org/articles/leading-effectively-articles/successful-change-leader/
DuBois, Anderson, E. A., Chibnall, J. T., Diakov, L., Doukas, D. J., Holmboe, E. S., Koenig, H. M., Krause, J. H., McMillan, G., Mendelsohn, M., Mozersky, J., Norcross, W. A., & Whelan, A. J. (2018). Preventing Egregious Ethical Violations in Medical Practice: Evidence-Informed Recommendations from a Multidisciplinary Working Group. Journal of Medical Regulation, 104(4), 23–31. https://doi.org/10.30770/2572-1852-104.4.23
NJ Division of Consumer Affairs. (2020). NJ Board of Nursing Statutes. Retrieved https://www.njconsumeraffairs.gov/Statutes/nursing-law.pdfLinks to an external site. Thank you for your post and for addressing the importance of being a transparent leader, communicating expectations with your team and the importance of involving your team in decision makeing. . Please take a look at this clip and share your thoughts. Great Work! 
I found the video very helpful and informative. I didn’t know about the different types of malpractice insurance offered to nurse practitioners and going into the field, it may have been something most people would overlook. If employers offer claims made insurance instead of the occurrence insurance, if you don’t know better, you might just accept what they are offering without any negotiation for a tail or extended coverage. I decided to research further and found a retrospective cohort study involving medical malpractice claims taken from the Comparative Benchmarking Database.
This database contains approximately 30% of United States claims (Myers et.al., 2021). When reviewing the claims in the study, claims involving APRNs were more likely to be paid on behalf of the defendant when compared with physicians, but they were usually paid out by the hospital or practice. APRNs usually work alongside physicians and the study indicates that APRNs are not usually named in claims due to allegations of surgical harm. Laceration was one of the largest malpractice claims filed accounting for 2,910 claims (Myers et.al., 2021).NR 506NP Week 2: Organizational Change and Ethical-Legal Influences in Advanced Practice Nursing Case Study
APRNs are also less likely to be named in claims involving diagnosis-related allegations, and the authors of the study feel this may be attributed to the fact that APRNs see less complex, lower risk patients when working without physician supervision (Myers et.al., 2021). Many APRNs work for hospitals, facilities, and private practices, so when malpractice claims are filed the employer usually pays the defendant (Myers et.al., 2021). This makes the video clip you provided even more valuable because it is important to know ahead of time what type of malpractice insurance your employer will be carrying.
Reference:
Myers, Sawicki, D., Heard, L., Camargo, C. A., & Mort, E. (2021). A description of medical malpractice claims involving advanced practice providers. Journal of Healthcare Risk Management, 40(3), 8–16. https://doi.org/10.1002/jhrm.21412
Thank you for sharing this video. I found it to be beneficial and Carolyn Buppert to be very knowledgeable. That way she explained what how one malpractice insurance policy was better than another was straightforward and easy to understand. Occurrence malpractice insurance is a much better option because once the payment is made for the year, you are covered anytime a lawsuit is filed. Even if the claim is made years later and you no longer work at that practice or have that insurance. In comparison, “claims made” require payment every year to be covered. There is an option to buy coverage Buppert mentioned called tail coverage. She recommended negotiating this aspect of our employment. If the employer has claims made insurance, then we should ask about tail coverage and get it in writing. It is always better to get an occurrence malpractice policy and make all premium payments (Buppert, 2017).
This video was extremely helpful. Thank you for sharing it with us and I started to follow her on YouTube.
Carolyn Buppert. (2017). Malpractice insurance for nurse practitioners: Claims made or occurrence? [Video]. YouTube. https://www.youtube.com/watch?v=jL1FLrq2SGY
Thank you so much for watching the clip, there was lots of great information. Excellent work!
I currently work for a health system in the Chicagoland area where I travel to different ERs based on their needs. I have observed many leadership issues when other nurses discuss problems with the ER and administration. Having good leadership is so important, like you explained. It is a foundation for the rest of the team and can even help build morale when times are tough. For instance, one of the hospitals that I am currently rotating to is seeing a mass exit of their ER nurses. There are about 10 nurses leaving between agency, staff, and internal floating pool. You can’t help but wonder why?
When you take a step back and look at the bigger picture you see how overworked and burnt out these nurses are. Leadership has failed them. When staffing is tight on the units, they are able to cap off and say no more patients to the ER. However, the ER has no “cap”. The ER doors are always open! These nurses never get a break, and are often handling 6-7 patients including psych, acute ER, and inpatient holds. In cases like this is where leadership should step in, and provide change but they have not. Like you mentioned, having a leader that can take feedback, listen, bring about change is crucial in healthcare. Unfortunately, the leadership at this hospital is not able to do any of that for its staff and thus are seeing a mass exit. NR 506NP Week 2: Organizational Change and Ethical-Legal Influences in Advanced Practice Nursing Case Study
Thanks for your post. Your description of the ED in Chicagoland sounds every familiar because I have lived it. I was an ED nurse for 4 years and it was something that I loved doing. I loved caring for patients in a fast-paced environment. It was my goal to be an ED nurse and I did that. I cared for patients before I cared for myself however it cost the ED a very experienced and passionate ED nurse. We did not get proper lunch breaks by proper I mean another floater nurse covering me.
Eventually all my hard work paid off and I was trained to be a charge nurse. I thought I could make a difference and not overload the nurses with patients, but I was wrong. Management who was not on floor started to move patients to treatment areas with my consent. There would be a night supervisor who would basically tell me to move over, and she would take over my station and become the “charge nurse” although I was still working. She would give multiple patients to nurses who were getting ready to leave for evening after working 12 hours. I left.
I was there for my nurses and patients. The management was more concerned with patient wait times. They literally pushed me aside to take move patients to
