NR 510 Week 4 Discussion Part One: Organizational Change and Ethical-Legal Influences in Advanced Practice Nursing Case Study

NR 510 Week 4 Discussion Part One: Organizational Change and Ethical-Legal Influences in Advanced Practice Nursing Case Study

NR 510 Week 4 Discussion Part One: Organizational Change and Ethical-Legal Influences in Advanced Practice Nursing Case Study

The case study has potential and legal implications for the medical assistant, nurse practitioner, medical director, and the practice. First, medical assistants do not have the legal mandate to engage in activities such as prescribing and refilling prescriptions. Stephanie should understand the consequences of her actions such as her license for practice being revoked because of the safety issues associated with her actions. The nurse practitioner, medical director, and practice administrator have the responsibility of ensuring that each of the personnel in the institution perform as per their scope of practice (Griffith & Tengnah, 2020). They must assess the skill levels and competencies of the medical assistants and other providers to provide the required care and communicate their limitations to them.

I will embrace some strategies to prevent potentially illegal behaviors in the future in the practice site. One of them is clarifying the roles and responsibilities of the different members involved in the patient care in the setting. The roles and responsibilities should be communicated to ensure accountability, transparency and responsibility. I will also administer staff assessment tests to determine their understanding of their expected responsibilities and consider strategies such as training them to prevent similar occurrences in the future (Varkey, 2021). Lastly, I will display the policies, standards, and regulations that guide employee behaviors in the organization to eliminate potential issues in the future.

One of the leadership qualities that I would apply to effect a positive change in the practice is leading as an example. Nurse practitioners should demonstrate best practices that others can emulate for safety, quality, and efficiency. The other leadership quality I would apply is strengthening open communication, seeking and providing feedback to the other members of the team to ensure continuous quality improvement (Heinen et al., 2019). Lastly, I will advocate the adoption of effective leadership styles such as transformational leadership to encourage the development of the desired competencies among the care team.

NR 510 Week 4 Discussion Part One: Organizational Change and Ethical-Legal Influences in Advanced Practice Nursing Case Study References

Griffith, R., & Tengnah, C. (2020). Law and Professional Issues in Nursing. SAGE.

Heinen, M., van Oostveen, C., Peters, J., Vermeulen, H., & Huis, A. (2019). An integrative review of leadership competencies and attributes in advanced nursing practice. Journal of Advanced Nursing, 75(11), 2378–2392. https://doi.org/10.1111/jan.14092

Varkey, B. (2021). Principles of Clinical Ethics and Their Application to Practice. Medical Principles and Practice, 30(1), 17–28. https://doi.org/10.1159/000509119

NR 510 Week 4 Discussion Part One – 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.

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NR 510 Week 4 Discussion Part One – Discussion Question:

What is your next logically sound course of action? Provide evidence to support your response.

My immediate action is to address the patient’s reason for the visit. According to Mitchell and Oliphant (2016), I have a responsibility to conduct a comprehensive patient interview or consultation before prescribing any medications. While there are ethical issues with what Stephanie did, even though her intentions were good, this must be addressed in private later. Mrs. Smith has already taken a prescribed dose of amoxicillin for her cough. If the amoxicillin has not cleared up the cough, I should not provide her with a refill order just yet. This may have been the wrong medicine to prescribe for a cough in the first place. For one, if Mrs. Smith felt comfortable with Stephanie calling in a prescription order without the doctor’s consent, this may not be the first time she has been prescribed an antibiotic without being checked-out first. Mrs. Smith may have developed a resistance to the antibiotic.  Norris et al. (2013) state antibiotic resistance is a serious, growing threat that causes the bacteria in patients’ bodies to become immune to the antibiotics medicinal properties. Many respiratory conditions are viral infections not bacteria-based illnesses, and Mrs. Smith may not have known that antibiotics only work against bacteria. There are many possible factors as to why Mrs. Smith has developed a chronic cough. I should conduct her physical exam and ask her questions about her cough (when it developed, the type of cough like wet or dry, does the patient smoke, any shortness of breath, has she taken any medication other than amoxicillin to treat the cough). I should then draw Mrs. Smith’s blood to send to lab for testing to determine if she has become resistant to amoxicillin. Also, during her physical, I can see if movement or exertion prompt her to cough. Once the physical has been performed and cough symptoms evaluated, I will take medications, past health history, and any present conditions I have recognized during the physical into consideration then decide on the best cough treatment plan. Once the patient has been taken care of, I will create thorough notes to document the visit, my findings and actions, and Stephanie’s actions then report what has occurred to the primary physician and office manager.

NR 510 Week 4 Discussion Part One: Organizational Change and Ethical-Legal Influences in Advanced Practice Nursing Case Study References

Mitchell, A., & Oliphant, C. M. (2016). Responsibility for ethical prescribing. The Journal for Nurse Practitioners, 12(3), A20. Retrieved from DOI: https://doi.org/10.1016/j.nurpra.2016.01.008Links to an external site.

Norris, P., Chamberlain, K., Dew, K., Gabe, J., Hodgetts, D., & Madden, H. (2013). Public beliefs about antibiotics, infection and resistance: A qualitative study. Antibiotics, 2(4), 465-476. doi:10.3390/antibiotics2040465

In the above scenario, there is potentially an unethical action with legal implications.  As medical assistants can call in prescribed medications, it is defined within state laws that it must be under the delegation of the physician or nurse practitioner with prescriptive authority.  It is important for clinicians and staff to understand delegation and defined responsibilities as it varies state to state.  These responsibilities are defined in statutory language and important when there are ethical and legal implications.  Delegation is the ability to assign to another to complete a task that is within one’s scope of practice (Miller, 2018).  When delegation and/or actions are taken that are in question to standards of care, there is risk to each participant and a potential unhealthy outcome. In this case, there was lack of delegation putting the practice, APN, medical director, and the medical assistant at risk for medical malpractice.  In the state of Oklahoma, an APN must have a collaborating physician to prescribe medications.  Because this was a medication error, it put not only the APN at risk, but also the collaborating physician.  According to Aburumman and Sadig (2020), the delegating physician remains responsible for all acts of the person performing delegated task and is ultimately responsible to make sure clinicians are properly trained with competency. The medical assistant is at risk for falsifying medical prescription with lack of supportive delegation putting herself and the practice at risk for legal action.

Understanding state laws as well as national guidelines should be the starting point for understanding delegation and legal standards of care. When there are doubts about delegation, the National Council of State Boards of Nursing’s Clinical Judgment Measurement Model (NCSBN) or the NCBN 5 “rights” should be considered.  With the Task Model, steps can be taught in clinical practice to guide expected actions and behaviors (Miller, 2018).  Strategies to improve potential illegal behavior would be to educate all staff and clinicians on state/national policies and law.  As patient safety concerns arise from lack of appropriate clinical judgment, a concrete structure and understanding could help develop safe clinical practice improving quality of care (Hensel and Billings, 2020).  In this scenario, understanding the background of the situation and where the breakdown of clinical policy and standards of care should be addressed.  Educating would be an effective way to develop clinical judgement skills with framework and guided discussion strategies.

Studies have shown that with a positive transformational leadership style, there are fewer occurrences of adverse events.  Transformational leadership promotes trust and respect of leadership promoting motivation towards organizational goals. Through a staff culture of supportive practice environment, collaborative practice, and creative ways to resolve problems can help influence positive change (Boamah, 2018).  In this scenario, addressing the MA privately in a nonthreatening manner first to discuss while understanding the background would be important.  Was the patient demanding, was there too many tasks to complete, was there lack of time to see patient, has this happened before, etc.  Taking time to understand the situation while reinforcement of proper policy can become a teachable moment for the staff member.  Assisting on how to address whichever background influenced the action, may help guide future ethical and legal decisions.  Lastly a review of policy with entire staff would help set the goal for best practices. Nurse leaders must be diligent about multidisciplinary understanding, discussion of delegation, and education especially with unlicensed personnel (Miller, 2018).

Aburumman, N. & Sadig, M. (2020). The legal delegation of medical responsibility: A comparative framework.  Journal of Legal, Ethical and Regulatory Issues, 23(4), 1–9.

Boamah, S. (2018). Linking Nurses’ Clinical Leadership to Patient Care Quality: The Role of Transformational Leadership and Workplace Empowerment. Canadian Journal of Nursing Research, 50(1), 9–19. https://doi.org/10.1177/0844562117732490

Hensel, D. & Billings, D. (2020). Strategies to teach the National Council of State Boards of Nursing Clinical Judgment Model. Nurse Educator, 45(3), 128–132. https://doi.org/10.1097/NNE.0000000000000773Links to an external site.

Miller, L. (2018). Delegation. The Journal of Perinatal & Neonatal Nursing, 32 (2), 104-106. doi: 10.1097/JPN.0000000000000327