Ethics in Funding NP Clinical Education (Week #3)

An ounce of prevention is worth a pound of cure; our healthcare system is showing a shift that recognizes the wisdom of this old adage as we move from an acute care or cure focus to a focus on health prevention. Prevention is being proactive; avoiding or limiting negative effects of disease on a population or an individual. However, there is one area where the future harms and risks are acknowledged, but little work on prevention is being accomplished – the predicted severe shortage of healthcare providers. Within the next eight years, primary care is estimated to have a 14,900 to 35,600 shortfall; add in specialty providers and it predicted the U.S. will be short nearly 100,000 providers (Association of American Medical Colleges, 2016; Clabo et al., 2012; Levin & Bateman, 2012; U.S. Department of Health & Human Services, 2013). Further complicating this issue is the distribution pattern of providers, with approximately 44% of rural areas already experiencing shortages that are negatively impacting the population’s health (Association of American Medical Colleges, 2012; Levin & Bateman, 2012). Patients without providers, or severely overworked providers will certainly place our patients in harm’s way. This is a violation of one of the core ethical principles of healthcare – non-maleficence – to do no harm. What are we doing to prevent this harm or at the very least minimize the looming deficit? Click here to see a 2 minute video on the shortage and primary care.

Medical schools have great difficulty increasing their enrollments due to caps placed on the number of sponsored residencies allotted through the Centers for Medicare & Medicaid (CMS). Nursing schools dramatically increased their nurse practitioner (NP) programs, but were also limited by available faculty and clinical preceptors (Clabo et al., 2012; Levin & Bateman, 2012). While physicians and healthcare organizations are offered direct pay and tax benefits for training future physicians, NPs have mainly relied on exchange of benefits and professional duties/passion to secure preceptorships. The value of precepting NP students must be acknowledged and rewarded if we are to have enough quality preceptors to meet the needs of increased enrollments; which are absolutely necessary to prevent catastrophic provider shortages. To expect NPs to be trained on almost only altruistic means, while paying for physician training, but then demanding the same quality of outcomes for either healthcare provider violates the ethical principles of justness and fairness. NPs are cost-efficient providers, so the fact that CMS reimburses them 85% of what physicians can bill may be equitable; but there is nothing equitable about paying for one provider’s training but not another’s.

Beneficence is another core principle of ethical patient care. It states that plans, actions, and treatments should be driven by what is in the best interest of the patient (Bickley, 2012). It is definitely in the patients’ best interest to have an adequate supply of accessible healthcare providers. It is also in the patients’ best interest that these providers be both competent and confident. High-caliber preceptors are needed to ensure that NP students preparing to practice independently have the knowledge, skills, and self-assurance necessary to provide quality healthcare. Failing to properly train our future providers not only violates the principles of non-maleficence, justness and fairness, and beneficence; but also, a utilitarian principle that if healthcare students are not trained, there will be no future healthcare providers (Bickley, 2012). Solutions to address the healthcare provider shortage are available, we need to make sure these solutions are equitable as well to keep the teachers, students, providers, and patients healthy.

 

 

Association of American Medical Colleges, Center for Workforce Studies. (2012). Recent studies and reports on physician shortages in the US. Retrieved from https://www.aamc.org/download/100598/data/

Association of American Medical Colleges. (2016, April 5). New research confirms looming physician shortage. (News Releases). Retrieved from https://www.aamc.org/newsroom/newsreleases/458074/2016_workforce_projections_04052016.html

Bickley. L.  (2012). Bates’ guide to physical examination and history taking (11th ed.). [VitalSource Bookshelf version].  Retrieved from https://bookshelf.vitalsource.com/books/9781469825106

Clabo, L.L., Giddens, J., Jeffries, P., McQuade-Jones, B., Morton, P., & Ryan, S. (2012). A perfect storm: A window of opportunity for revolution in nurse practitioner education. Journal of Nursing Education, 51, 539-541. doi:10-3928/01484834-20120920-01

Levin, P.J., & Bateman, R. (2012). Organizing and investing to expand primary care availability with nurse practitioners. Journal of Community Health, 37. 265-269. doi:10.1007/s10900-011-9537-5

U.S. Department of Health & Human Services, Health Resources & Services Administration, National Center for Health Workforce Analysis. (2013). Projecting the supply and demand for primary care practitioners through 2020. Retrieved from https://bhw.hrsa.gov/health-workforce-analysis/primary-care-2020

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2 Comments Add yours

  1. bindumari says:

    Thank you for bringing up this topic. It is so unfair to the NP’s that they are not getting financial benefits for guiding and precepting students. It is my personal and professional experience that Universities even when they receive some funds for nurse education randomly picking providers keeping nurse practitioners out of equation depends on private or public practice or having no clear criteria. During my second and third year I had a wonderful preceptor who is an NP for more than 20 years and who is willing to teach students even during breaks. The consideration, knowledge, experience and the willingness to share the good and bad patient outcomes made me stronger in every aspect of our practice. She precepted for more than 15 years for our university and received a small incentive one semester and then received a notice she is no more in the list. Further enquiry revealed there is no criteria set who should receive these small incentives when they are available. She is under the impression that our university is probably considering doctors to reimburse vs NPs. I told her may be it is because she is in a private sector vs community public sector. She felt hurt and decided to stop precepting. And I learned indirectly, running a private clinic by an NP is a difficult task with millions of hurdles with no support and financial loss.
    She is one of the best teachers I’ve came across my professional studies and realizing how great a loss to the nurse practitioner students. Considering the salary differences of doctors and NPs who are fulfilling the same job requirements, now they have to face inequalities in teaching, precepting & so on. Nursing and Nurses historically well known for sacrificing and this is another area we need to stop sacrificing and stand up to say “This is our right”. The IOM report (2010), recommended nurses should be full partners with physicians and other healthcare professionals in redesigning healthcare in the United States. Yes Deb, I fully support your view and wish to add to IOM report that we are fully entitled for compensation of additional services for the growth of our profession and that will help with the shortage of nurses & nursing faculty (Johnson et al, 2012).
    Reference
    Institute of Medicine, (2010). The future of nursing: Leading change, advancing health. Retrieved from http://www.iom.edu/Reports/2010
    Johnson, J. E., Malast, T., Mulligan, L., Veneziano, T., Smith, A. L., Moran, A., & Mastro, K. (2012). Nursing’s future: What’s the message? follow one facility’s response to the 2010 IOM report.(robert wood johnson university hospital). Nursing Management, 43(7), 36.

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    1. Deb says:

      Thank you for sharing your experience. It is so disheartening to hear of good preceptors leaving in the face of struggles, and little support (esp. in light of the innovative approach our school touts proudly). The IOM has recognized the shortcomings with our current healthcare system’s professional relationships and expectations, as well as the educational and practice limitations. “Key Message #2: Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression (IOM, 2011, p. 163). In the details of this aspect of the report the IOM mentions lifelong learning and intraprofessional education at ALL LEVELS (emphasis mine) of nursing education. In my Linked-in conversation on preceptor searching one male NP student stated ” I find it repugnant that BSN, PA, and MD programs all provide clinical placements, but APN students are left to their own devices.” Our education would be much smoother with well-organized preceptors, and our lifelong learning would be greatly enhanced if we were valued as preceptors.

      IOM (Institute of Medicine). 2011. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press. Retrieved from: https://www.nap.edu/read/12956/chapter/9

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