Review the scenario and address the questions below.
You are a nurse practitioner employed in a busy primary care office with responsibilities for managing the office staff, including the medical assistants who aid in client care as well as filing, answering calls from clients, processing laboratory results, and taking prescription renewal requests from clients and pharmacies. The office is part of a larger hospital system. One of the medical assistants has worked in the practice for 10 years and is very proficient at her job. She knows almost every client in the practice and has an excellent rapport with all the providers.
During an office visit, a client requested a refill for an amoxicillin prescription. When examining the empty bottle, you noted that the date on the bottle was 1 week ago. You also noted your name printed on the label as the prescriber though you did not see the client last week. The client explained that she called last week concerned about her cough and spoke to the medical assistant, who assured her that a prescription would be sent to the pharmacy for the concern. You do not recall having discussed this client with the medical assistant; the other providers in the practice deny speaking to or consulting about the client.
Include the following sections:
Application of Course Knowledge: Answer all questions/criteria with explanations and detail.
Based on the situation above, what are the ethical and legal implications for the practice at the micro-, meso-, and macro-level of the system?
What changes do you recommend to prevent further episodes of the problem behavior? What coaching and feedback skills can be used to discuss the event with the medical assistant?
Which change model would you use to implement the identified change and why: Lewin’s Theory of Planned Change, Plan-Do-Study-Act (PDSA), or Kotter’s 8-Step Process for Leading Change?
Identify and discuss one barrier to implementing the change process. Identify and discuss one factor that facilitated the change process.
2. Recommendations and Coaching/Feedback
Recommended Changes to Prevent Recurrence
The underlying problem is a failure in process control and a misunderstanding of professional scope of practice.
Immediate Policy Change (Micro-Level): Implement a "Zero Tolerance" policy stating that only licensed providers (NP, MD, PA) can communicate prescription decisions or delegate clinical tasks. MA access to e-prescribing software and prescription pads must be immediately revoked or strictly monitored.
Standardized Clinical Communication (Meso-Level): Institute a mandatory "Call Back/Triage" protocol where all client calls related to symptoms or medication requests are documented in a standardized electronic form before being reviewed by a licensed provider within a defined timeframe (e.g., 4 hours).
Cross-Training and Role Clarity: Conduct mandatory, system-wide training on the legal scope of practice for all non-licensed clinical staff (MAs). This reinforces that answering calls is administrative, but advising on treatment (like dispensing Amoxicillin) is clinical and illegal for MAs.
Coaching and Feedback Skills for the Medical Assistant
Given the MA's tenure and good rapport, the conversation must balance firm accountability with preserving professional dignity. The NP should use the "Feedback Sandwich" approach modified by the Pendleton Model (or similar structured feedback models).
Positive Start (Ego Shield): Acknowledge her value and expertise.
Example: "Monica, I value your 10 years of service and the excellent rapport you've built with our clients. You are a key part of our team."
The Event/Impact (Specific & Factual): State the unauthorized prescription event clearly, focusing on the behavior, not the person.
Example: "Last week, you sent an Amoxicillin prescription under my name for Mrs. Smith after she called about a cough. Because I did not authorize that, it represents unauthorized practice and a serious safety risk."
Ask for Perspective (Self-Correction/Reflection): Encourage the MA to analyze the behavior against professional standards.
Example: "Can you explain what your thought process was at that moment, and how your actions could legally impact the patient and my license?"
Action Plan/Expectation (Firm Direction): Clearly communicate the future expectation and consequences.
Example: "Moving forward, you must adhere strictly to your MA scope. All clinical decisions, including any medication renewals, must be routed through a licensed provider. This is non-negotiable."