title: Ethical conflict in nurse practitioners and physician assistants in managed care.
abstract: BACKGROUND
  More patients are receiving healthcare services from nurse practitioners (NPs) and physician assistants (PAs). These providers are likely to be confronted with a variety of ethical issues as they balance quality care with their patients' rising cost concerns. However, very little is known about the ethical conflicts and causes of these conflicts experienced by these clinicians in their daily practice.
  
  
  OBJECTIVE
  To identify ethical concerns and conflicts NPs and PAs encounter related to managed care in the delivery of primary care to patients and the factors that influence ethical conflict.
  
  
  METHODS
  A cross-sectional self-administered mailed questionnaire was sent to 3,900 NPs and PAs randomly selected from primary care and primary care subspecialties in the United States (adjusted response rate, 50.6%). Respondents were surveyed on ethical issues and concerns, ethics preparedness, and ethical conflict. Bivariate and multiple linear regression analyses were used to evaluate predictors of ethical conflict.
  
  
  RESULTS
  Insurance constraints were reported to have interfered with the ability to provide quality patient care by 72% of respondents, with 55.3% reporting daily to weekly interferences. Nearly half of respondents (47%) have been asked by a patient to mislead insurers to assist them in receiving care. A perceived obligation to advocate for patients, even if it means exaggerating the severity of a patient's condition, was the single most significant predictor of ethical conflict, explaining 25% of the variance.
  
  
  CONCLUSIONS
  NPs and PAs are experiencing ethical conflict often associated with their perceived professional obligations to advocate for patients. Being well-prepared in ethics and having sufficient professional independence help clinicians balance the ethical complexities and demands of meeting patients' needs within a constrained healthcare system.
authors.affiliation: School of Nursing, University of Pennsylvania, Philadelphia, PA 19104-4210, USA. culrich@nursing.upenn.edu
authors.forename: Connie M
authors.initials: CM
authors.lastname: Ulrich
authors.forename: Marion
authors.initials: M
authors.lastname: Danis
authors.forename: Sarah J
authors.initials: SJ
authors.lastname: Ratcliffe
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Garrett-Mayer
authors.forename: Deloris
authors.initials: D
authors.lastname: Koziol
authors.forename: Karen L
authors.initials: KL
authors.lastname: Soeken
authors.forename: Christine
authors.initials: C
authors.lastname: Grady
mesh_terms: D000328:Adult; D016265:Conflict of Interest; D003220:Conflict, Psychological; D003430:Cross-Sectional Studies; D005260:Female; D006297:Health Services Accessibility / Q000941:ethics; D006801:Humans; D016014:Linear Models; D008297:Male; D008329:Managed Care Programs; D008875:Middle Aged; D015999:Multivariate Analysis; D009722:Nurse Practitioners / Q000941:ethics*; D010344:Patient Advocacy / Q000941:ethics; D010823:Physician Assistants / Q000941:ethics*; D017009:Professional Autonomy; D011369:Professional-Patient Relations / Q000941:ethics*; D014481:United States