Accountability is a key concern for nurses and midwives in the National Health Service (NHS) today. Accountability means assuming responsibility for ones actions (Daniels 2004). The modern concept of professional accountability, applied to nursing, assumes that the nurse is a member of a profession. It depends on individual nurses being aware of their membership of a profession and accepting that status, with the rights and responsibilities that go with it. With the passing of the Nurses Registration Act, in 1919, nurses in Britain achieved the status of an accountable profession, which meant that registered nurses were legally accountable for their work and can be struck off the register for unprofessional behaviour (Tilley and Watson 2004). The drive to demonstrate professional accountability led to the creation of a body that was responsible for setting standards of conduct and practice for nurses. This is the regulatory body for nurses and midwives and is currently the Nursing and midwifery Council (NMC). One of the functions of the NMC is to create the limits on professional accountability in nursing and midwifery practice (Caulfield 2005).
Accountability is integral to professional practice. Nurses make judgements in a wide variety of circumstances. Nurses use their professional knowledge, judgement and skills to make decision based on evidence for best practice and the person’s best interests and they must be able to justify the decisions they make (NMC 2008a).
Accountability cannot be considered in isolation. Other terms such as ‘autonomy’, ‘responsibility’ and ‘authority’ need to be considered too (Dewar 1999). Walsh (1997) implies there should be a clear distinction between accountability and responsibility in nursing practice. He goes on to say that accountability involves explaining and justifying actions based on sound professional knowledge and transparent, logical and replicable decision-making. Equally he believes that responsibility, in the traditional sense, means performing tasks in an accurate and timely way through delegation. Registered Nurses are responsible for all the actions they perform, whether they are dependent, interdependent or independent (Rosdahl and Kowalski 2008).
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Keenan (1999 p.561) suggests that accountability is a consequence of autonomy. He defines autonomy as ‘the exercise of considered, independent judgement to affect a desirable outcome’. Structural autonomy exists when professional people are expected to use their judgement to determine the provision of patient services in the context of their work. Attitudinal autonomy exists for people who believe themselves to be free to exercise judgement in decision-making (Savage and Moore 2004)). Batey and Lewis (1982 p.15) suggests there is a close relationship between autonomy and certain forms of authority, particularly positional authority and the authority associated with expert knowledge. They go on to say authority in nursing originates from a number of sources including authority of the situation (as in emergency situations), of position (where authority is invested in a formal position rather than an individual) and of expert knowledge (as granted through professional registration).
‘Responsibility’, ‘autonomy’ and ‘authority’ are important terms, not only in the way they overlap with the concept of or exist as preconditions for accountability. They are also relevant for understanding lines of accountability (Savage and Moore 2004).
There are four ‘pillars’ that make up a framework of professional accountability deriving from different types of authority in nursing practice these are professional, ethical, lawful and employment/contractual (Caulfield 2005).
Professional accountability and being responsible for your actions and for the outcomes of these actions is part of the framework for clinical governance (Tilley and Watson 2004). ‘Clinical governance is a system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish’ (Scally and Donaldson 1998, p. 61).
Ethical values come from the individual practitioner, and result from aspects such as religion, education and the values we grow up within our families and local communities. Being able to stand up for high standards of care, or challenging others who may not have the same value base, such as those who discriminate against other people or who are negligent in their practice, or even do harm to others deliberately. This may involve the nurse needing to draw attention to poor practice or standards or even lead to the need for ‘whistle-blowing’ (Jasper 2006).
There are two systems of law in the United Kingdom these are civil and criminal law, which provide a framework of rules, regulations, and cases that determine how we live in society. Civil law would apply, in nursing in areas of negligence or lack of consent. Legal accountability for nurses has implications for the standards of record keeping, as these will provide evidence of the actions and decisions made by them if needed (Jasper 2006).
A contract of employment sets out the relationship between the nurse and the employer in terms of the responsibilities and rights of each party. The contract is a legal contract, and therefore can be enforced in law, on both sides (Jasper 2006).
Registered Nurses can no longer expect to perform all patient care activities in this age of decentralisation, shared governance, and redefining of work duties to include nurse extenders such as health care assistants. Delegation is a much needed skill for hospital nurses, because it can free them to deal with professional activities of care (Adams 1995). The nature of the NHS and the various activities undertaken within it dictate that the workload is distributed among various members of the workforce (Wheeler 2001).
As a Registered Nurse, I am expected to delegate aspects of care such as asking a health care assistant to take a patients temperature every hour. Before delegating the task to the health care assistant I must be sure that he/she has the skills, competence, attitudes and experience to carry out the task involved and that it meets the requirements of the patient involved. Using Caulfield’s (2005) four ‘pillars’ as a framework I am accountable:
Professionally
Whilst delegating I will be accountable to the NMC in terms of standards of practice and patient care. The NMC Code (2008b) states that as a professional, I am personally accountable for actions and omissions in practice and I must always be able to justify my decisions and I must always act lawfully, whether those laws relate to my professional practice or personal life. Advice by the NMC (2008c) on delegation states that I must establish that anyone I delegate to is able to carry out my instructions, and I must confirm that the outcome of the delegated task meets the required standards and I must make sure that everyone I am responsible for is supervised and supported.
Ethically
I must be aware of my own values. I am accountable if I do not stand up for high standards of care in relation to religion, education and peoples values (Jasper 2006). Lawfully
I have a legal responsibility to have determined the knowledge and skill level required to perform the delegated task such as taking a patients temperature. I am accountable to both the criminal and civil courts to ensure my activities conform to the legal requirements.
Employment/Contractual
In the NHS, the Knowledge and Skills Framework (KSF) represents the staff development element of Agenda for Change (AFC) (Department of Health 2004). It is concerned with identifying the relevant competency levels required for job roles with the NHS. This can provide me with evidence about the skills and knowledge of the health care assistant role. I must ensure the decision made to delegate was appropriate following guidelines and protocols of the workplace. I will be accountable for the decision to delegate and for its implementation on an organisational and professional level. I have the authority to delegate this task to distribute workload to achieve organisational effectiveness. It is the employer’s responsibility to ensure that the health care assistant has sufficient education and training to competently undertake aspects of care which I am expected to delegate to them (NMC 2008c).
Where a Registered Nurse has the authority to delegate tasks to another, they will retain responsibility and accountability for that delegation (NMC 2008c). As the Registered Nurse I will remain accountable for the appropriateness of that delegation and for providing the appropriate level of supervision in order to ensure competence.
Another example of my accountability as a Registered Nurse can be related to carrying out doctors’ orders that are wrong. For example, I may give an incorrectly prescribed drug. Although the doctor is accountable for prescribing it wrongly, I will also be held accountable for administering it, as I must be sure of all drugs, dosages, actions, contra-indications and side effects of the drugs that I give to patients. In the same way if I perform incorrectly a procedure that a doctor has asked me to do, I will be accountable. This is because I must be aware of my limitations and not carry out any procedure unless I am appropriately trained to do so. Even if I have received the recommended training, I may not have performed the skill for a period and will not have practiced the task; therefore, I will not be competent in that task and will be held accountable if I perform the task incorrectly (Hole 2009).
Conclusion
This essay has discussed what ‘accountability’ means and the problem that the term ‘accountability’ conveys little meaning in itself. The essay considers terms, such as ‘autonomy’, ‘responsibility’ and ‘authority’ and how they are relevant for understanding the lines of accountability.
Registered Nurses are accountable for everything that they do within their role as they are members of a profession. The NMC code (2008b) states ‘that as a professional you are accountable for your actions and omissions in practice and you must always be able to justify your actions’.
This essay goes on to explain the different forms of accountability i.e. professionally, ethically, lawfully and contractually and has related these to practice using delegation as an example. Registered Nurses must be sure that they can justify their actions at all times and that they are accountable for the actions of others to whom they delegate.
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