Research Objectives: The environment of managed care has created ethical concerns for practitioners with respect to professional autonomy and ethical conflict in practice associated with clinical decision-making. Yet, knowledge and research in this area is limited. The primary purpose of this research was to investigate the influence of individual, organizational, and societal/market contextual factors on practitioners' perceptions of ethical aspects of the managed care environment.
Study Design: This study was a cross-sectional, descriptive survey design using a mailed self-administered questionnaire. Data were obtained from a random sample of 700 nurse practitioners (NPs) in the state of Maryland with a response rate of 42.4%.
Principal Findings: Nearly two-thirds (63%) of NPs indicated that their ethical concerns were not addressed in the managed care environment, and 67% agreed to some extent that their personal values and ethics were being compromised by managed care practices. Eighty percent of the sample perceived to some degree that it was necessary to bend managed care guidelines to do what is necessary for the patient with 60.6% indicating that the practitioner must sometimes weigh the patients' interests against managed care organization's interests. Analysis of Variance (ANOVA) indicated significant mean differences for ethical concern (p < .001), ethical environment (p < .001), ethical conflict inpractice (p < .001), and autonomy (p < .05) in relationship to practice setting. NPs in a staff/group model HMO were less ethically concerned, perceived the ethical environment more positively, and had lower ethical conflict scores than NPs in other types of practice settings. Based on the multiple regression results, the perception of the ethical environment, ethical concerns, and the importance of governmental regulation explained 47.8% of the variance in ethical conflict in practice scores. Market penetration, an idealistic moral philosophy, ethical concerns, ethics content in a continuing education program, and the percentage of the client population enrolled in managed care explained 18.2% of the variance in autonomy scores.
Conclusions: Results from this study indicate that the conflict between commitment to the patient good and commitment to managed care goals has intensified for the practitioner. NPs are experiencing ethical conflict associated with practicing within a managed care environment. However, NPs in a staff/group model HMO report these concerns less.
Implications for Policy, Practice, and Education: Providing practitioners with ethical skills and ethical support through education may mitigate ethical conflict in practice. Political and professional activism to address ethical issues for NPs associated with managed care is supported.
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