Little is known about the influence of practice site resource scarcities on the clinical decision making of nurse practitioners. This descriptive study explored nurse practitioners' perceptions of practice site scarcities, the strategies used to allocate scarce resources, and the ethical difficulties experienced in doing so. The survey instrument was developed by Hurst et al. (2006). The theory of naturalistic decision making (Klein, 1989, 1993) and the Recognition Primed Decision model (2008) provided the conceptual framework.
Nurse practitioners and nurse practitioner students practicing in community clinics in 22 Ohio counties completed the electronic survey (N=68, response rate 27.9%, mean age 44.9 years, mean number of years in NP practice 10.7 years, 90% of NP's held prescriptive privileges, 72% were clinic employees, 69% provided adult primary care services, 30% provided pediatric services, and 95% of the clinics provided indigent care).
Practice site resource scarcities were reported by 41%. “Compromised decision making” and “care impacted by the inability to pay for services” were themes emerging from the examples of the ethical issues described by nurse practitioners in narratives. Pharmaceuticals (31%), mental health services (31%) and referrals to specialists (27%), were the services most frequently unavailable, most difficult to obtain, and most often not provided for patients. The most frequently used strategies to manage resource scarcities were substitution of another option (34%) and explanation of why the service could not be provided (44%). Poor efficacy of a therapy (85%), small marginal benefit (78%), short life expectancy (49%), and age > 85 years (47%) were the most frequently identified criteria for not providing services. This study found evidence of practice site resource scarcities resulting in ethical dilemmas for nurse practitioners providing primary care services in community clinics.