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attitudes, ethics, managed care, nurse practitioners



  1. Ulrich, Connie M.
  2. Soeken, Karen L.
  3. Miller, Nancy


Background: Ethical conflict of nurse practitioners (NPs) practicing within a managed care environment has not been systematically examined, yet like physician practitioners, NPs are confronted with daily ethical conflicts.


Objective: To determine perceptions toward ethical conflict in practice espoused by NPs affiliated with managed care systems and to identify the relationship between selected individual, organizational, and societal/market contextual factors and ethical conflict in practice.


Method: Descriptive, cross-sectional, correlational survey of a stratified random sample of 700 NPs licensed and certified to practice in the state of Maryland, conducted from November 2000 to January 2001.


Results: A majority of respondents reported being moderately to extremely concerned with managed care. Eighty percent of the sample perceived that it was sometimes necessary to bend managed care guidelines with 61% agreeing that the practitioner must weigh the patient's interest against managed care organizations' interests. The NPs in a staff/group model health maintenance organization (a) were less ethically concerned (p < .001); (b) perceived the ethical environment more positively (p <.001); and (c) had lower ethical conflict scores (p < .001) than NPs in other types of practice settings.


Discussion: Results from this study indicate that NPs are experiencing ethical conflict associated with practicing within a managed care environment; however, NPs in a staff/group model health maintenance organization report these concerns less. Ethical support through intervening strategies (i.e., ethics education and interdisciplinary ethics support systems) may help mitigate the conflict associated with this system of care.


Healthcare in the United States has been drastically altered in the past several years. With the shift from traditional indemnity fee-for-service provision of healthcare to integrated managed care networks, many questions are surfacing regarding the advantages and disadvantages of the managed care model. The environment of managed care has created new ethical concerns for practitioners with respect to professional autonomy and ethical practice associated with clinical decision-making. In a recent study by the Kaiser Family Foundation (1999), physicians (26%) and nurses (30%) reported exaggerating a patient's condition in order to obtain coverage that they perceived as being medically necessary. Wynia and associates (2000) reported physicians (28.5%) surveyed agreed that "gaming" the system was necessary. Ethical behavior associated with lying and "ratcheting up" an illness or diagnosis is a tempting practice to gain insurance coverage on behalf of the patient. However, this practice violates fundamental moral values of veracity (Pellegrino, 1997). Both autonomy and professional integrity are threatened if practitioners treat with duplicity a system that owns the resources essential to their patients' care (Morreim, 1995). The American Nurses Association Revised Code for Nurses (2001) asserts "the nurse owes the same duties to self as to others, including the responsibility to preserve integrity" (


As public servants, both medical and nursing communities are responsible and accountable for their judgments and actions in delivering health services. Yet, providing care at the clinical level continues to be juxtaposed with what one should or should not do for the greater good (Perkel, 1996). Thus, ethics and economics are in conflict, and this conflict may place providers in perilous situations of divided loyalties. With the greatest projected growth among nonphysician clinicians (Cooper, Laud, & Dietrich, 1998), knowledge of factors that influence ethical practice will be relevant in shaping the future role of the NP for the provision of quality, cost-effective healthcare. This information is critical if healthcare providers are to practice with moral integrity within a changing delivery system.