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MNA Position Statement
Ethical Guidelines
for Decision-Making Related to Patient Advocacy and Linkage of Nursing Care
to Compensation Methods in Managed Care
I. Preamble
The nursing profession
has long subscribed to a body of ethical provisions contained within the American
Nurses Association (ANA) Code of Ethics. Ethical principles guide the
nurse in her or his relationship with patients, colleagues and other entities
in the health care arena. Several relevant principles adopted by the ANA and
unequivocally supported by the Massachusetts Nurses Association (MNA) remain
constant.
- The nursing
profession has a long-standing primary commitment to the health and welfare
of patients.
- Nurses act
under a code of ethical conduct that is grounded in the ethical principles
of non-maleficence, beneficence, autonomy, fidelity, veracity and justice.
- Nurses are
dedicated to providing competent nursing services with compassion and respect
for human dignity.
- Nurses deal
honestly with patients and colleagues. The nurse participates in the profession's
efforts to protect the public from misinformation and misrepresentation and
to maintain the integrity of nursing.
- Nurses recognize
a responsibility to seek changes in health policies that prove contrary to
the best interests of the patient.
Changes in the practice
environment now require nurses to examine their professional relationships even
more closely. This position statement is offered to reaffirm the primacy of the
nurse-patient relationship and relationships among professionals. It also seeks
to clarify appropriate conduct between nurses and health care organizations concerning
compensation in the evolving care delivery system.
II. Nurse to
Patient Relationship
The MNA recognizes
that patient advocacy is a fundamental responsibility of registered professional
nurses. This role cannot be abdicated.
"Nursing provides
services with respect for human dignity and the uniqueness of each patient unrestricted
by considerations of social or economic status, personal attributes or the nature
of health problems" (ANA, 1985, p. 1).
"The nurse assumes
responsibility and accountability for individual nursing judgments and actions"
(ANA, 1985, p. 1).
MNA supports full
disclosure of benefits to patients enrolled in managed care plans. The MNA opposes
any activities or business agreements by health care plans that directly or
indirectly require a health care practitioner to withhold information from patients
about treatment care options whether they are reimbursable or not. Regardless
of any allocation guidelines or gatekeeper directives, nurses must advocate
for care they believe will materially benefit the patient.
Providers must
be able to clearly and adequately respond to inquiries by patients regarding
any financial incentives. Under no circumstances may a nurse's financial interests
be placed above the welfare of a patient.
"The nurse acts
to safeguard the client and the public when health care and safety are affected
by incompetent, unethical or illegal practice guidelines. . ." (ANA, 1985, p.
1). The MNA opposes any employment language in the health care industry that
prohibits whistleblowing.
The MNA believes
that all plans should have an appeals process for claims that are denied in
any managed care system. The nursing profession's duty as patient advocate requires
that nurses challenge any denials of nursing care deemed necessary and seek
a modification or an elimination of that health care guideline at the health
plan's policy-making level.
III. Nurse
to Health Care Organizations
NONPARTICIPATION
IN UNPROFESSIONAL CARE
Nurses must advocate
for patients and seek modification or elimination of any allocation guidelines
that are generally unfair to patients. Nurses must strive to achieve delivery
of patient care in accord with professional standards.
INCENTIVES TO
LIMIT SERVICES
Financial incentives
should not affect the provision of appropriate nursing care or support resources.
MNA opposes nurses' participation in organizations that establish financial
incentives or quotas that interfere with clinical management by limiting access
to care, diagnostic testing, or full care options.
Efforts to limit
health care costs or cost to employers should not negatively impact patient
welfare or affect the provision of necessary nursing services.
Nurses employed
in managed care plans that offer financial incentives to limit care may be in
conflict with the nurse's moral obligation to act in the patient's best interests.
An inevitable dilemma exists when nurses choose between their own economic security
and quality patient care. A registered nurse who puts his or her financial interests
ahead of the patient's well being also risks the undermining of the profession's
moral center and essential patient confidence. Diminution of the nurse's advocacy
role will negatively effect nursing's ability to link its legitimate economic
interest to quality care and circumscribe the MNA's influence in shaping public
discussion of health care issues.
INFORMED CONSENT
AND PLAN DISCLOSURE
Under the requirement
of informed consent, managed care organizations are obliged to fully disclose
information to patients appropriate to their needs. Full disclosure also involves
informing potential subscribers of benefit limitation or restrictions under
the managed care agreement both when initial enrollment is considered and during
the annual re-enrollment process.
NURSES' DISCLOSURE
TO PATIENTS
Nurses have an
obligation to promote full disclosure to managed care patients. The obligation
to disclose information within the scope of nursing practice should not be restricted
by the patient's managed care plan. For advanced practice primary care nurse
providers, full disclosure includes the provision of information concerning
all treatment options, even those that may not be covered under the specific
managed care plan. Patients should be able to appeal the decision to deny uncovered
treatment options or to seek treatment options outside the plan.
DISCLOSURE OF
INCENTIVES TO PATIENTS BY PLAN AND NURSE
Managed care plans
are obligated to disclose any financial incentives or contractual agreements
that limit the diagnostic and therapeutic choices offered to patients or restrict
referral or treatment options. Nurses must respond clearly and fully to patient
inquiries regarding any known financial incentives to limit or withhold care.
NURSING JUDGMENTS
AND PLAN ADNIMSTRATION
Nurses may be employed
by the managed care organization, be a member of a practice group or be employed
by a hospital that contracts with the managed care organization to provide services.
Within these organizations, nurses should not be subjected to lay interference
in professional decision-making as they strive to meet their primary responsibility
to patients.
NURSING CONTRACTUAL
ARRANGEMENTS
Nurses have the
right to enter into whatever contractual arrangements with health care systems
they deem desirable and necessary but should be aware of the potential conflict
of interest that may arise due to financial incentives to withhold needed health
care services.
American
Nurses Association. (1985). "Code for Nurses with Interpretive Statements"
The Massachusetts
Nurses Association gratefully acknowledges that the Massachusetts Medical Society's
Policy "Ethical Standards in Managed Care (1996)" served as the model for this
MNA position statement.
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