Nursing Research  November/December 2006  Vol 55, No 6, 391–401 Ethical Conflict in Nurse Practitioners and Physician Assistants in Managed Care Connie M. Ulrich 4 Marion Danis 4 Sarah J. Ratcliffe 4 Elizabeth Garrett-Mayer Deloris Koziol 4 Karen L. Soeken 4 Christine Grady b Background: More patients are receiving healthcare ser- vices from nurse practitioners (NPs) and physician assis- tants (PAs). These providers are likely to be confronted with a variety of ethical issues as they balance quality care with their patients’ rising cost concerns. However, very little is known about the ethical conflicts and causes of these conflicts experienced by these clinicians in their daily practice. b Objective: To identify ethical concerns and conflicts NPs and PAs encounter related to managed care in the delivery of primary care to patients and the factors that influence ethi- cal conflict. b Methods: A cross-sectional self-administered mailed ques- tionnaire was sent to 3,900 NPs and PAs randomly selected from primary care and primary care subspecialties in the United States (adjusted response rate, 50.6%). Re- spondents were surveyed on ethical issues and concerns, ethics preparedness, and ethical conflict. Bivariate and multiple linear regression analyses were used to evaluate predictors of ethical conflict. b Results: Insurance constraints were reported to have interfered with the ability to provide quality patient care by 72% of respondents, with 55.3% reporting daily to weekly interferences. Nearly half of respondents (47%) have been asked by a patient to mislead insurers to assist them in receiving care. A perceived obligation to advocate for patients, even if it means exaggerating the severity of a patient’s condition, was the single most significant predictor of ethical conflict, explaining 25% of the variance. b Discussion: NPs and PAs are experiencing ethical conflict often associated with their perceived professional obliga- tions to advocate for patients. Being well-prepared in ethics and having sufficient professional independence help clinicians balance the ethical complexities and demands of meeting patients’ needs within a constrained healthcare system. b Key Words: conflict & ethics & practitioners & professionalism A provider’s professional obligations to patient care are a cornerstone of professional ethics and should outweigh obligations to third-party payers (Brennan et al., 2002; Emanuel & Goldman, 1998; Pearson, Sabin, & Emanuel, 2003; Sulmasy, Bloche, Mitchell, & Hadley, 2000). However, obligations to patient care and cost control can be seen as competing moral claims. Sometimes controlling costs does or appears to jeopardize obligations to patients, creating tension, stress, and ethical conflict for providers in prioritizing these claims. With financial pressures creating incentives to reduce services, providers are experiencing greater limitations on providing qual- ity care for their patients. Previous studies have described the ethical tensions physicians and nurse practitioners (NPs) experience while balancing rising costs and insur- ance constraints with their fiduciary responsibilities to patients. Bending the rules, exaggerating the severity of a patient’s illness, and not offering useful services have been reported as mechanisms used to address coverage restrictions (Freeman, Rathore, Weinfurt, Schulman, & Nursing Research November/December 2006 Vol 55, No 6 391 Connie M. Ulrich, PhD, RN, is Assistant Professor, School of Nursing, Senior Fellow, Center for Bioethics, Department of Medical Ethics; Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia. Marion Danis, MD, is Chief of Bioethics Consultations and Head Section on Ethics and Health Policy, Department of Clinical Bio- ethics, Clinical Center, National Institutes of Health, Bethesda, Maryland. Sarah J. Ratcliffe, PhD, is Assistant Professor of Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia. Elizabeth Garrett-Mayer, PhD, is Assistant Professor, Depart- ment of Biostatistics and Oncology, Johns Hopkins Kimmel Cancer Center, Johns Hopkins University, Baltimore, Maryland. Deloris Koziol, PhD, is a Clinical Epidemiologist, Clinical Epidemiology Service, Clinical Center, National Institutes of Health, Bethesda, Maryland. Karen L. Soeken, PhD, is Professor, School of Nursing, University of Maryland, Baltimore. Christine Grady, PhD, RN, is Head, Section on Human Subjects Research, Department of Clinical Bioethics, Clinical Center, National Institutes of Health, Bethesda, Maryland. Copyr ight © Lippincott Williams & Wilkins. Unauthor iz ed reproduction of this article is prohibited.