Ethical conflict of advanced practice providers related to drug testing and reporting for maternity patients with...

Advanced practice maternity providers (APPs; midwives, nurse practitioners, physician associates) have described decision-making about drug testing and child welfare system (CWS) reporting as a source of ethical conflict. Ethical conflict in clinical practice is linked to provider burnout and poor patient outcomes. However, ethical conflict related to drug testing and reporting across APPs caring for pregnant and postpartum patients with opioid use disorder (OUD) has not been quantitatively evaluated.

This study describes the amount and types of ethical conflict experienced by APPs over drug testing and CWS reporting decisions when caring for pregnant and postpartum women with OUD, considering variation across provider demographics.

APPs across the US (N = 171) completed an online cross-sectional survey adapted from Falcó-Pegueroles' Ethical Conflict in Nursing Questionnaire, measuring (1) exposure to and (2) type of ethical conflict experienced in various scenarios about drug testing and CWS reporting for pregnant and postpartum patients with OUD. Descriptive statistics and general linear regression modeling described demographic predictors of ethical conflict exposure. Moral types of ethical conflict (i.e., dilemma, distress, wellbeing) were characterized.

All participants were female, average age 43 years. Most were white (86%), had children (78.9%), and were well-represented across US regions. After controlling for demographics, practicing across both inpatient/outpatient settings predicted significantly higher overall ethical conflict exposure (p = .03), and having children predicted significantly less exposure (p = .01). Midwives and providers in the South (vs Northeast) reported higher exposure to ethical conflict in scenarios concerning patient autonomy and structural factors (e.g., lack of resources) impacting drug testing and reporting. Providers most frequently reported moral dilemmas in scenarios related to beliefs and judgements; moral distress in those related to patient rights/autonomy and structural factors; and moral wellbeing in those related to policies and laws.

Providers who practice as midwives, work across both outpatient/inpatient settings, practice in southern (vs northeastern) states, and do not have children are more vulnerable to ethical conflict in drug testing and CWS reporting decisions. Future research should contextualize these demographic predictors within broader provider- and policy-level factors.