Sample Answer for NR 510 Week 4: Organizational Change and Ethical-Legal Influences in Advanced Practice Nursing Case Study Part Two Included After Question
NR 510 Week 4: Organizational Change and Ethical-Legal Influences in Advanced Practice Nursing Case Study Part Two
NR 510 Week 4: Organizational Change and Ethical-Legal Influences in Advanced Practice Nursing Case Study Part Two
Upon further investigation, you learn that Stephanie spoke with the patient and called the medication into the patient’s pharmacy without consulting with a provider. Stephanie claimed that the patient was insistent about needing a prescription. Because Mrs. Smith was coming into the office the following week for an appointment, she didn’t think you would mind if the patient received the prescription early.
Discussion Question:
What are the ethical-legal concerns associated with this situation? What is your liability in this situation, if any? What is the practice’s liability in this situation? What quality improvement strategies might you implement as an APN in this practice to safeguard your role and assure patient safety? Provide evidence to support your response.
Like I stated in Part 1, this can be a serious matter even if the patient is not physically harmed. Since Stephanie is the medical assistant, placing and verifying orders are not in her job description. Even as I am now as a bedside nurse, placing orders without proper verification from a MD/NP/DO would land me in some trouble if this happened.Only nursing orders, like IV pump, heating pad or basic equipment/care can be placed by the nurse at the hospital I work at.
A Sample Answer For the Assignment: NR 510 Week 4: Organizational Change and Ethical-Legal Influences in Advanced Practice Nursing Case Study Part Two
Title: NR 510 Week 4: Organizational Change and Ethical-Legal Influences in Advanced Practice Nursing Case Study Part Two
As an NP in this situation, I do not think that the NP is held liable. If a nurse places an order and document that it was verified by the MD, but thru investigation it was found that it was not, the MD is not held liable. The same should go for the NP. The nurse would be reprimanded for doing that and the MD will not held liable or be found at fault. In school for each profession, one is taught what they can and cannot do within legal limits. Stephanie got comfortable and thought it was go to go outside of her job description that I am sure she already knows. The practice as a whole may be liable, especially if harm was done to the patient. The principle of non-maleficence (to do no harm) states that a health care professional should act in such a way that he or she does no harm, even if her or his patient or client requests this. Stephanie may have not had bad intent and was thinking she was probably helping in this situation to alleviate some of the work for the providers and NPs. Also, she probably thought she was making it more simple for the patient. However, this could cause harm to the patient as a NP or MD must assess if and why a new antibiotic must be ordered in the first place.
Also, the practice is responsible and must be held liable of alerting Mrs. Smith of the situation so the he knows what he going on. This maybe the hardest part as Mrs. Smith might lose trust in the practice, place a bad review and can have the right to sue the facility even if no physical harm was done. Negligence can be seen as failure to take reasonable care or steps to prevent loss or injury to another person. Nursing negligence is when a nurse who is fully capable of caring does not care in the way a reasonably prudent nurse would, and as a result the patient suffers unnecessarily. Even though this was not directly a , she can still sue for negligence. Mrs. Smith may do nothing at all once told if she feels strongly tied to the practice. However, it is completely up to Mrs. Smith how she wants to go about the issue. If she decides to take it that far into suing the practice, Stephanie might be at risk to lose her job as she now becomes a liability to the practice. There is many ways this situation goes depending on the outcome. (Tinnon, 2017)
To prevent that issue, maybe the medical assistant can only have access to certain parts of the program. For example, maybe when it comes to prescriptions, the medical assistant can not print out or issue it out to the patient till the NP/MD signs off and verifies it. The program should stop her from issuing it to the patient without proper verification. For example, in the hospital setting, even if the program is the same name, each profession has their own set customized for their job description. A nurse’s screen will look different from a PCA, unit secretary or a respiratory therapist. With this setup, one can only access what is felt is allowed for the specific job description. (Schub & Kornusky, 2016)
Reference:
Schub, T. B., & Kornusky, J. M. (2016). Standing Orders, Order Sets, and Protocols: Government Regulations. CINAHL Nursing Guide,
Tinnon, E (2017). Situational awareness and Nursing Code of Ethics. Nurse Educator, 43(1), 32-36.
In this weeks reading, we learned about the legal scope of nursing practice and how to solve ethical dilemmas. Thankfully Stephanie was honest and admitted what she did. In a healthcare dilemma that is probably seen far too often, Stephanie was in the wrong for assuming the prescription was ok without consulting me. Patients can be pushy, but Stephanie could have either set Mrs. Smith up with a same-day appointment, have her come in a day or two to be seen early, or at least checked with the on-call physician or Nurse Practitioner in the practice to see if the prescription was ok. The first legal concern is a medical assistant prescribing. The role of a Medical Assistant is to escort patient, take vital signs, and write down the chief complaint in the medical record (Chapman & Blash, 2017). Prescribing is outside of her scope of practice. The ethical dilemma is reporting a hard-worker or not for trying to help you out. This may be her first offense, but she should know better, especially with ten years experience, that she was acting outside her job description.
Telephone prescribing is risky due to lack of physical assessment, testing for infections, and the possibility of over-prescribing antibiotics (Ewen, Willey, Kolm, McGhan, & Drees, 2015). An antibiotic for a cough is probably useless and could potentially lead to yeast infections or lead to antibiotic-resistant infections, doing Mrs. Smith more harm than good. I am liable for this situation because my name is on the prescription, and any harm to the patient could be a negligence or malpractice suit. I should also follow up with all of my patients and their symptoms. I also need the correct coding and documentation for billing purposes. Things need to be appropriately documented. Depending on the state of practice and the ability of the physician to delegate NPs to prescribe, the practice could also be seen liable. The practice should also oversee the hiring and firing of employees as well as making sure people are in their scopes of practice. A good way to safeguard my role would be to not prescribe via telephone. Although more time consuming, physically assessing my patients and testing for illness before I prescribe medications is safer for my license and my patients.
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Chapman, S. A., & Blash, L. K. (2017). New roles for medical assistants in innovative primary care practices. Health Services Research, 5(2), 383-406. doi:10.1111/1475-6773.12602
Ewen, E., Willey, V. J., Kolm, P., McGhan, W. F., & Drees, M. (2015). Antibiotic prescribing by telephone in primary care. Pharmacoepidemiology And Drug Safety, 24(2), 113-120. doi:10.1002/pds.3686
Do you feel the consequences for calling in an antibiotic should vary from consequences for calling in a controlled substance?
Although writing an unauthorized prescription is illegal, regardless of the type, I do believe she should be punished more for writing a prescription for a controlled substance. Controlled substances usually have harsher side effects and a higher potential for abuse, meaning the patient should be monitored closely. Antibiotic resistance and yeast infection are far better than overdose and addiction. She knows nothing about the patient or drug. If every person that walked in the door got what they asked for, the world would be filled with addicted people. Assessing for the true need of medications is crucial- the opioid epidemic is already so high. Patients need to know the medication, how to properly take, the side effects, and come back to be checked. I would be cautious in prescribing refills too. Nurse Practitioners can only prescribe so much depending on state laws and drug class. A medical assistant with no pharmacology and assessment training has no business doing either, and I would not want her to ruin me practicing as an NP under my educational scope.
When you said you will make it a practice not to prescribe over the phone it made me think. I have not thought of that and I feel that it may be a good idea. I haven’t worked in an office setting but I can imagine that they receive a lot of requests for prescriptions and refills every day. Of course I want to see and assess any patient that I am writing a prescription for but when I think about that a little more I think there might be times when I am comfortable calling in certain scripts depending on the patient. There will be some patients that I get to know very well and they may have a chronic or recurrent condition that I have treated or am aware of enough to trust the patients report of their symptoms. I think it would be difficult to never call in a script. Charting policies are important. The hospital system I work in documents every phone conversation and recommendation with a patient. I love that we have the capability to look at conversations between the offices and patients. In the ER we frequently have patients check in and say “my doctor sent me” and they don’t completely know why. Reading about their conversation and the Dr.’s recommendation helps us to address the true issues at hand.
On a basic/standard level of ethical legal concerns, no medical professional should be doing anything in representation of another provider;this should be well known to all medical professionals. It’s as basic as not giving someone your badge to take a blood sugar, common practice learned day 1. As a medical assistant Stephanie should have known this was wrong, she knows she shouldn’t document under another provider and is fully aware she can not decide which medication a patient needs, only a refill of a prescription which is authorized by the provider whose name will be on the prescription. 
In this weeks reading, we learned about the legal scope of nursing practice and how to solve ethical dilemmas. Thankfully Stephanie was honest and admitted what she did. In a healthcare dilemma that is probably seen far too often, Stephanie was in the wrong for assuming the prescription was ok without consulting me. Patients can be pushy, but Stephanie could have either set Mrs. Smith up with a same-day appointment, have her come in a day or two to be seen early, or at least checked with the on-call physician or Nurse Practitioner in the practice to see if the prescription was ok. The first legal concern is a medical assistant prescribing. The role of a Medical Assistant is to escort patient, take vital signs, and write down the chief complaint in the medical record (Chapman & Blash, 2017). Prescribing is outside of her scope of practice. The ethical dilemma is reporting a hard-worker or not for trying to help you out. This may be her first offense, but she should know better, especially with ten years experience, that she was acting outside her job description. Telephone prescribing is risky due to lack of physical assessment, testing for infections, and the possibility of over-prescribing antibiotics (Ewen, Willey, Kolm, McGhan, & Drees, 2015).
An antibiotic for a cough is probably useless and could potentially lead to yeast infections or lead to antibiotic-resistant infections, doing Mrs. Smith more harm than good. I am liable for this situation because my name is on the prescription, and any harm to the patient could be a negligence or malpractice suit. I should also follow up with all of my patients and their symptoms. I also need the correct coding and documentation for billing purposes. Things need to be appropriately documented. Depending on the state of practice and the ability of the physician to delegate NPs to prescribe, the practice could also be seen liable. The practice should also oversee the hiring and firing of employees as well as making sure people are in their scopes of practice. A good way to safeguard my role would be to not prescribe via telephone. Although more time consuming, physically assessing my patients and testing for illness before I prescribe medications is safer for my license and my patients.
Chapman, S. A., & Blash, L. K. (2017). New roles for medical assistants in innovative primary care practices. Health Services Research, 5(2), 383-406. doi:10.1111/1475-6773.12602
Ewen, E., Willey, V. J., Kolm, P., McGhan, W. F., & Drees, M. (2015). Antibiotic prescribing by telephone in primary care. Pharmacoepidemiology And Drug Safety, 24(2), 113-120. doi:10.1002/pds.3686
Do you feel the consequences for calling in an antibiotic should vary from consequences for calling in a controlled substance?
Although writing an unauthorized prescription is illegal, regardless of the type, I do believe she should be punished more for writing a prescription for a controlled substance. Controlled substances usually have harsher side effects and a higher potential for abuse, meaning the patient should be monitored closely. Antibiotic resistance and yeast infection are far better than overdose and addiction. She knows nothing about the patient or drug. If every person that walked in the door got what they asked for, the world would be filled with addicted people. Assessing for the true need of medications is crucial- the opioid epidemic is already so high. Patients need to know the medication, how to properly take, the side effects, and come back to be checked. I would be cautious in prescribing refills too. Nurse Practitioners can only prescribe so much depending on state laws and drug class. A medical assistant with no pharmacology and assessment training has no business doing either, and I would not want her to ruin me practicing as an NP under my educational scope.
When you said you will make it a practice not to prescribe over the phone it made me think. I have not thought of that and I feel that it may be a good idea. I haven’t worked in an office setting but I can imagine that they receive a lot of requests for prescriptions and refills every day. Of course I want to see and assess any patient that I am writing a prescription for but when I think about that a little more I think there might be times when I am comfortable calling in certain scripts depending on the patient. There will be some patients that I get to know very well and they may have a chronic or recurrent condition that I have treated or am aware of enough to trust the patients report of their symptoms. I think it would be difficult to never call in a script. Charting policies are important. The hospital system I work in documents every phone conversation and recommendation with a patient. I love that we have the capability to look at conversations between the offices and patients. In the ER we frequently have patients check in and say “my doctor sent me” and they don’t completely know why. Reading about their conversation and the Dr.’s recommendation helps us to address the true issues at hand.
On a basic/standard level of ethical legal concerns, no medical professional should be doing anything in representation of another provider;this should be well known to all medical professionals. It’s as basic as not giving someone your badge to take a blood sugar, common practice learned day 1. As a medical assistant Stephanie should have known this was wrong, she knows she shouldn’t document under another provider and is fully aware she can not decide which medication a patient needs, only a refill of a prescription which is authorized by the provider whose name will be on the prescription.
As the provider who “prescribed” the medication it is my responsibility and liability if this was the wrong medication, the patient has an allergic or any adverse reaction because Stephanie was unaware of the patients allergies or other condition/medication that may interfere with the new medication. Talking more severely, had this been the wrong medication and adverse/serious reactions had resulted for the patient there may not have been a way to determine who had called in the prescription, leaving the NP open for a legal repercussions or medical malpractice(Buppert, 2015). This is one of many reasons functioning within ones scope of practice is pertinent daily life as an NP. Liability for the practice is high because if something had happened it would not only come back to the NP but the practice as you are a practice employee.
As far as quality improvement for now you could call in your own prescriptions and refills but long term this is not time efficient. The practice should hold a class or informational session required for anyone ordering prescriptions as well as a policy put into place for medical assistants to follow strictly in this role if they are going to have the responsibility of sending in medication refills. Another solution is that they could enter it but it has to be signed off by the NP, which is also time consuming for an NP daily schedule. In conclusion there are many alternatives other that what Stephanie chose and there needs to be serious education put into place.
Buppert, C. (2015). Nurse practitioner’s business practice & legal guide (5th ed.). Retrieved from https://bookshelf.vitalsource.com If you started to talk to Stephanie about the situation and she “shut down” and was not being open with communication, how could you redirect the conversation to help open her up?
It is important for Stephanie to not feel attacked, she is probably a long standing employee who is well respected and you don’t want to be the bad guy causing a problem but it is essential the problem is addressed. Hopefully if she did begin to shut down you could explain to her what a great job she does with everything she is responsible for, as long as that was actually the case. One could also share a time with her that you yourself made a mistake, and how it was corrected. We are all human and make mistakes unfortunately as a medical professional there is a lot of responsibility that comes along with those mistakes, involving lives of others.
If she had the opposite reaction, and began to yell defending herself it would be important to be prepared for this situation as well. Many institutions are implementing conflict resolution programs for their employees as this issue begins to grow. Particularly in the medical setting there are many people who can become uncooperative and sometimes even combative including patients, family members, or staff. A prime example, in the fall the hospital I work at implemented a mandatory training class for conflict resolution.
Brubaker, D., Noble, C., Fincher, R., Park, S. K., & Press, S. (2014). Conflict resolution in the workplace: What will the future bring? Conflict Resolution Quarterly, 31(4), 357-386. doi:http://dx.doi.org.chamberlainuniversity.idm.oclc.org/10.1002/crq.21104Links to an external site.
You make a great point that sharing an experience where you made a mistake could help ease the situation. Everyone makes mistakes, and fortunately, nobody was harmed during this. The potential for Mrs. Smith to be harmed was there, though.
We have also implemented a course that everyone takes that provides you with some sort of education for deescalation to be prepared for conflicts such as this one. This could, unfortunately, be the result of discussing with Stephanie what has happened. She may become very defensive. I could definitely see this happening, as she has been with the practice for 10 years and knows everyone so well. I would imagine she would use this as a comeback during this discussion. I might also be sure the supervising physician is aware of the situation as well. This can possibly help deescalate Stephanie, as there is a mediator during the discussion.
I agree with you. Everyone makes mistakes one way or another. Unfortunately, in our field it involves people’s lives. That’s what makes it so hard to just ignore. Stephanie has been there for 10 years and will most likely use that to save herself from this situation. Regardless of what happened it is important to consider how long she has been working there and the efforts she has contributed in making it a successful practice. Sitting down with your boss or bosses can be very intimidating. I think as long as you don’t make it into a big confrontation and like you mentioned, share a personal experience about mistakes that you have made yourself, it can ease the situation a bit and lighten up the mood.
Sorry, it seems I had begun answering this in my other post of part 1 of this question!
There are ethical-legal considerations in this situation, as Stephanie’s actions were outside her scope of practice. Additionally, if any harm came to the patient in any way, any blame and legal actions would be placed against the licensed prescriber (in this case the liability would lie in myself as the NP). I would have to speak with Stephanie about her actions. I would tell her I understand that patient’s can be persistent at times, however she should have taken a message with the patient and told her she would call her back, and then discuss the situation with me first. I may have still allowed for a prescription to be phoned in, but it would be up to my digression to do so, and would not only at least be aware of the situation, but be able to treat it accordingly.