Ethical issues experienced by primary care nurse practitioners caring for vulnerable patients in nursing centers

Primary care nurse practitioners (NPs), working in nursing centers, frequently care for vulnerable patients who are at increased risk for poor health outcomes and diminished quality of life. Risk and marginalization compound vulnerability and create the context for a variety of ethical issues. Daily exposure to ethical issues leads NPs to become frustrated and stressed. This study explored the ethical issues experienced by primary care NPs caring for vulnerable patients in nursing centers and how they handled these issues. A naturalistic inquiry using a multiple, embedded case study design with cross-case analysis was used. Participants were primary care NPs selected from community-based nursing centers in the Mid-Atlantic States. In-depth interviews, non-participant observation, and document analysis were the methods of data collection. A preliminary typology of ethical issues experienced by primary care NPs caring for vulnerable patients in nursing centers was also induced. Ethical issues were found to occur at different levels within the sociopolitical context of health care delivery. The ability for the NP to change the circumstances resulting in these issues depended upon the level at which they occurred. The Beidler Level of Ethical Issues Framework was inductively derived. Nurse Practitioners handled ethical issues with a stance akin to various ethical principles and theories, however, none of the NPs identified a method of ethical decision making or theoretical framework for their decisions. The possibility that this is related to nurses' ethical knowledge transitioning from a universalistic principle-based ethic to a postmodern relational narrative ethic, consistent with the way in which NPs emphasized the patient-nurse relationship as the foundation of their ethical knowing, needs to be further explored.