In seeking to determine whether there were discernable causes for the trend of increasing incidence in APN claim data during the five-year period between 2004 and 2008, the
demographics, educational preparation, specialty areas and practice conditions of advanced practice nurses with and without claims were compared and contrasted. While this survey was dependent upon voluntary submission of information from claims respondents, the comparison to non-claim respondents facilitated in detecting lack of preparation in APN training programs, discovering patterns of hazardous practice conditions and recognizing some of the causes of malpractice allegations against APNs. These findings attempt to identify areas where risk management educational efforts may be most effectively directed in order to minimize risk exposures and improve patient quality of care in APN practice settings.
The APNs have predominately earned their APN designation through a university or college on-site program. Although distance learning and on-line programs are becoming more
widespread in recent years, there is no evidence that these newer educational programs have led to the increase in claims incidence or severity. Regardless of their claim status or the type of educational program they attended, the APNs recalled being required to spend an average of more than 600 clinical hours in their APN program. Because this is based solely on recall, the actual clinical hours required may have been considerably less.
Most APNs also spent a significant number of years and gained additional on-the-job clinical experience as an RN prior to becoming an APN. On average, the APNs spent 13 years practicing as a registered nurse before becoming certified to practice as an APN. As we might expect, this implies that nurses are typically age 30 to 35 before becoming an APN. There were no claim respondents under age 30; however, the 4% of APNs without claims in the age 18 to 29 category reported spending an average of more than 3 years working as an RN before becoming an APN.
Demographically, there are proportionately more APNs with claims who are over age 50, despite the fact that these APNs reported an average of nearly 15 years practicing as an RN prior to becoming an APN. These facts seem to suggest that additional years of experience as an RN does not provide better preparation for APN practice.
Some APNs prepare for the increased responsibilities of their new role with the help of a mentor. While mentorship presumably has a positive impact on the APNs confidence and competence in his or her role as an APN, it is paradoxical that mentorship is more commonly found among the APNs who were ultimately involved in a claim. Half of APNs with claims maintain that they had a mentor during their first two years of practice compared to only 37% of APNs without claims. An analysis of claim severity confirms that mentorship is truly ineffective in minimizing claim losses for APNs. The mentor was most often a physician (M.D.). APNs mentored by a physician were observed in our sample to have average claims paid/reserved that are 3.88 times higher than APNs with other mentors and 2.16 times higher than all other APNs, including those who had no mentor. Our model predicts claim severity to be 2.03 times greater for APNs with an MD mentor.
Although the majority of APNs consider themselves fully trained to provide the clinical services required for their position, APNs with claims are more likely to admit feeling
inadequately trained in the area where the incident occurred. Based upon incidence only, nursing home and prison settings have a higher risk of APN incidents, while convenient care clinics, school/college clinics and community clinics and health centers may offer less risk of exposure.
Our incidence model predicts that practicing in a physician‟s office, nursing home or prison increases the odds of having a claim by a factor of 4.142 times while practicing in a community clinic & health center or school/college clinic decreases the odds by a factor of 1.859 times compared to APNs in the remaining practicing settings.
In the vast majority of cases, APNs are certified to practice in the specialty area in which they work. APNs certified in Obstetrics/perinatal have average claim losses 3.49 times greater than APNs certified in other specialties. While about half of all APNs are certified in family practice, the risk of incidence was proportionately greater than other specialties and claim severity was observed to be 2.53 times greater for APNs practicing in a physician‟s office/clinic.
Family practice certified APNs are predicted to be 1.791 times more likely to have a claim.
Although 13% of the APNs with claims admitted to practicing in an area where they were not certified to work at the time of the incidence, there were no significant findings with respect to claims incidence or severity for these precarious situations.
Kretschman Research & Consulting At the time of the incident, more than half of the APNs with claims had been working in the particular position less than 4 years; nearly three-quarters had been working in the position less than 6 years. Lack of years in the same position has a small but significant association with claim incidence, as APNs with claims had on average eight months less experience in the position than APNs without claims. APNs who do not have claims reported working a similar number of years at their current position.
While the APNs‟ years in a particular position was not found to be a factor, their years of experience as an APN can minimize the risk of an incident. Years of APN experience has a negative correlation with likelihood to be involved in an incident. 9% of those with claims practiced less than 2 years and 44% practiced less than 6 years at the time of the incident. On average, the APNs with claims were found to have 2 years less experience as an APN than the group of APNs without claims.
The vast majority of APNs work for an employer. Very few APNs provide services for a staffing or placement service and there are no significant findings with regards to claims among these APNs. Among the self-employed, however, are a greater proportion of APNs who have reported professional liability incidents. Self-employed APNs account for roughly 14% of positions, 10% working full-time and another 4% working part-time. Along with the increased autonomy of independent practice comes greater responsibility and increased exposure to potential risk.
It seems at first to be incongruous that the APNs with claims reported having less prescriptive authority than APNs without claims. However, the APNs are not usually named alone; two-thirds of APNs with claims were named in the lawsuit along with their employer, facility and/or other healthcare professionals. Being named along with others was the most significant predictor of claim severity. Being named with others is expected to increase claims by 11.54 times. When named along with a physician, the average severity observed in our sample is 7.4 times higher than for APNs named alone. Because a physician is among those named in 92%
of cases, the average claims paid or reserved for APNs named with physicians are analogous to those for APNs named with others in general.
APNs with claims reported having less prescriptive authority than those without claims;
however, if physician supervision is required, the physician oversight is often specifically
required for prescriptive authority. The APN‟s scope of practice requirements vary by state, with some states requiring APNs to operate under a formal agreement with a supervising physician.
The majority of APNs, though, maintain that regulations in their state allow APNs to practice under a collaborative practice agreement. Collaboration implies that APNs work together with physicians and other healthcare professionals rather than under the direct supervision of a physician.
Although most states within the country are equally proportioned between APNs with claims and those without, Missouri has a greater proportion of APNs with claims, while Maryland has a lower proportion of APNs with claims. Pennsylvania, Alabama and New York had extreme claims far exceeding maximums paid or reserved in other states and are among the states with the highest average claims. APNs primarily certified in Pennsylvania and New York are predicted to have claim losses 4.29 times greater on average compared to APNs in other states.
Geographically, practicing in a rural location may add to the risk of exposure as a greater proportion of APNs with claims were found to work in rural settings. A Pennsylvania rural setting was responsible for one $1,035,548 claim settlement; however, rural settings were found to have lower average severity. As a somewhat weak predictor in our model, claim severity in rural settings is expected to be 50% lower than average.
While 11% of APNs with claims were required by their facility to work overtime at the time of the incident, this does not appear to be a contributing factor to the incidence or severity of malpractice suits against APNs. Lack of sufficient personnel assistance, however, may contribute to an incident. APNs with claims report having less personnel assistance than other APNs – specifically, fewer had clerical support and other NP assistance at their practice. Practices with clerical support, NP assistance and/or “other” assistance are significantly associated with higher severity. Still, only 12% of APNs with claims believe that inadequate staffing levels at their facility may have contributed to the cause of the incident. According to the severity model, APN practices with CNS assistance are expected to have 94% lower average severity.
Kretschman Research & Consulting The risk of exposure to incidents obviously increases with the number of patients seen.
APNs typically see an average of 16 patients per day, while APNs who have had claims report seeing more than 19 patients per day at the time of the incident. While each additional patient seen clearly represents added exposure, the institution of daily patient quotas within a practice was not applicable to most APNs and has no proven association with an increase in the incidence or severity of claims. With the autonomy of independent APN practice, it seems more likely that the increased patient loads were not “required” or mandated, but rather a self-inflicted
responsibility of the APN‟s position.
In contrast to current APN practices, few APNs with claims in this study reported using electronic medical records at their facility when the incident occurred. Nearly three-quarters of APNs with claims utilized handwritten medical records only at the time of the incident. Because our sample included APNs with incidents as far back as 5 years ago, when electronic medical records were not common, the difference seen between the use of electronic medical records by APNs with claims and those without may be a factor of the timeframe rather than a cause of the incident itself. According to our predictive models, the odds of having a claim paid or reserved is 5.4 times greater in practices that do not use electronic medical records and the use of electronic medical records is expected to decrease claim severity by 74%. The increased use of electronic medical records should help APN practices of the future to document, search, review, and update patient charts with greater speed and efficiency and should help to reduce, if not eliminate, the incidence and severity of suits due to errors in interpreting “poorly handwritten notes” in charts.
For APNs in practice, each and every incident can be a threat to the quality of patient care delivered, whether it has the potential to become a lawsuit or merely an inquiry that causes a distraction. The likelihood for increased exposure to APN liability claims was found to be associated with APNs who have family practice certifications or work in a physician‟s
office/clinic, nursing home or prison practice setting. As half of all APNs are certified in family practice and one-third of all APNs practice in a physician‟s office, it is troubling that these same areas present a greater threat for a lawsuit. The odds of being involved in an APN liability lawsuit decrease for APNs who work in community clinic/health center or school/college clinic practice settings.
Using electronic medical records or using a combination of electronic medical records with handwritten notes is also associated with a decrease in the odds of having a claim. Surprisingly, the odds of an incident decrease also for APNs being asked to increase or maintain the number of patients seen daily.
While keeping the APN safe and avoiding lawsuits of any size are the ultimate goals, it is important to understand the dynamics that occur in events that pay out the highest indemnities or incur the largest reserves. APN liability claim payout and reserves are predicted to be higher for APNs who are named in a lawsuit along with others, certified primarily in Pennsylvania or New York, age 50 or over, or who had an MD mentor during the first two years of APN practice. The odds of having severe claim losses is expected to decrease for APNs who have CNS assistance, use electronic medical records or work in rural practice settings.
The utilization of electronic medical records is one predictor that has an inverse association with both incidence and severity of APN claims. While there is still lack of standardization that make it difficult for systems at different facilities to talk to each other, EMR systems are increasingly being installed to replace the handwritten notes by healthcare professionals. With continued improvements in the efficiencies of EMR systems, an anticipated decline in medical errors due to misinterpretation of illegible handwritten notes seems inevitable.
The freedom and choice to practice in a variety of settings for which the APN is certified or licensed come with varied risk of incidence and exposure. The stakes are high as lawsuits threaten the APN‟s reputation and ability to continue to practice. Risk management educational efforts should be directed toward improving awareness of the reality of the dangers that come with an APN‟s work environment and daily responsibilities. Helping APNs reduce the unnecessary hazardous conditions and circumvent the perilous situations linked with increased exposure will minimize the incidence of claims reported and the severity of losses connected with them.
Minimizing real losses helps to keep professional liability insurance affordable for all APNs.