6 Accountability

• Ensuring/providing safe, quality care
• Delegation
• Following (and questioning) policy and procedures
• Practicing within the guidelines of the Nurse Practice Act
• Maintaining confidentiality
• Questioning standard of care, provider’s orders
• Alignment of care to organizational practices, philosophy
• Competence in clinical skills
• Lifelong learning
• Patient advocacy (Battié, & Steelman, 2014)

Accountability is a broad concept that is closely related to other concepts. It will be important to understand the differences between the following concepts as they are discussed throughout this chapter:

• Accountability:
  • Judgment and action on the part of the nurse
  • Answerable to self and others for judgments and actions (ANA, 2015a)
• Responsibility:
  • Accountability or liability associated with performance of a nursing task associated with one’s role
  • Portion of the responsibility can be shared with others involved in the situation (ANA, 2015a)
• Answerability:
  • The requirement to offer answers, rationale, and explanations (ANA, 2015a)
• Authority:
  • The position to make a decision and influence others to act
• Autonomy:
  • the authority to use professional knowledge and judgment to make decisions and take action (Skår, 2009)

Cox and Beeson (2018) describe accountability as a “… a willingness to answer for results and behavior” (p. 25). When nurses are accountable for their actions, they have made a promise to own that action, leading to learning lessons from making mistakes and successes. People don’t hold others accountable, it’s the individual’s job to be accountable.

In today’s healthcare settings, accountability in nursing practice revolves around activities associated with providing quality care, including:

• Assessments (patients or otherwise, depending on setting/role)
• Interventions (nursing care)
• Health outcomes (reduced infection rates, falls)
• Costs (containment)

Many organizations, both federal and private, have created programs to improve the quality of healthcare, including the U.S. Agency for Healthcare Research and Quality, The Joint Commission, National Patient Safety Goals, and the Institute for Healthcare Improvement. The Institute of Medicine (IOM) and Quality and Safety Education for Nurses Institute (QSEN) are two organizations focused on safety in nursing education. Scientific evidence reveals the gap in quality care and these organizations (and others) work from different vantage points inside and outside of the healthcare system to reduce the incidence of unsafe, poor quality care.

Transfer of accountability from one nurse to another is like a silent contract. For example, in an acute care setting, when a nurse receives report from the outgoing nurse, there is a transfer of accountability from one person to another. The oncoming nurse is responsible and answerable for the behaviors and outcomes of a group of patients for the duration of the shift. Thus, anytime a nurse establishes a professional relationship with a patient (depending on role/setting), there is a binding agreement where the nurse is legally bound (see Nurse Practice Act below) to implement care according to the patient’s needs and wishes.

State Boards of Nursing

As mentioned earlier, accountability within the nursing profession ensures safe, quality care. In order to protect the public and to ensure optimum care, nursing practice is regulated by state agencies. The U.S. Boards of Nursing (BON) are jurisdictional governmental agencies that have been established by each state government with the mission to protect the public’s health by overseeing nursing practice (National Council of State Boards of Nursing [NCSBN], 2020a).

The NCSBN (2020a) administers and coordinates services to all state BONs. The NCSBN works with each state BON to ensure nursing accountability through a number of organizational activities, including standards for safe nursing practice, issuing licenses to practice nursing, license verification, monitoring licensees’ compliance to state BON laws, and taking action against nurses who have exhibited unsafe nursing practice (NCSBN, 2020a).

Nurse Practice Act

Individual states, or jurisdictions, have a law called the nurse practice act (NPA), which is enforced by the BON in each state (NCSBN, 2020a). The NPA includes the following information:

• Qualifications for licensure
• Nursing titles that can be used
• Scope of practice (what the nurse is allowed to do)
• Actions that can or will occur if nurses do not follow the laws

The scope of practice is in place to safeguard patient care and maximize health outcomes. When nurses practice outside of their scope of practice, accountability to oneself, the patient/family, peers, the institution, and/or society are at risk. Familiarity with the NPA ensures accountability.

Access the NPA for New York at the Office of the Professions (OOP) website, located within the New York State Education Department. A number of articles and information about the nursing profession are available at the OOP, including laws about scope of practice, nursing education, education curricula/programs, disciplinary conduct, and more. Read Part 64 at the Office of the Professions (OOP) website to view the scope of practice for the registered nurse.

Nurses should review their NPA regularly to check for updates, and most importantly, when changing jobs or taking on a formal leadership role. Laws within the NPA pertain to certain settings and roles. For a full listing of all the NPAs in every state, visit the NCSBN website.

Foundational Documents

Standards of Professional Practice

Accountability is an essential element of nursing practice within the Scope and Standards of Practice. Below are a few examples where accountability and responsibility for nursing practice are illustrated throughout the Standards of Professional Performance.

• Standard 7: Ethics
  • “Safeguards sensitive information within ethical, legal, and regulatory parameters” (ANA, 2021, p. 89).
• Standard 10: Collaboration
  • “Clearly articulates the nurse’s role and responsibilities within the team” (ANA, 2021, p. 96).
• Standard 11: Leadership
  • “Demonstrates authority, ownership, accountability, and responsibility for appropriate delegation of nursing care” (ANA, 2021 p. 97).
• Standard 15: Professional Practice Evaluation
  • “Ensures that nursing practice is consistent with regulatory requirements pertaining to licensure, relevant statutes, rules, and regulations” (ANA, 2021, p. 104).

Nursing’s Social Policy Statement

Nursing’s social policy statement describes nursing’s social responsibility, accountability and contribution to healthcare (ANA, 2015b). The nursing profession is entrusted with providing quality, ethical care to society. The ANA is responsible for ensuring societies’ needs are met by articulating, maintaining, and strengthening the social contracts between the nursing profession and society.

Code of Ethics

The (ANA, 2015a) Code of Ethics sets forth the values and obligations of the nurse. Provision 4 has a core focus on accountability and responsibility, stating, “The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care” (ANA, 2015a, p. 59). The nurse’s ethical obligation is to protect and be accountable to oneself, and also to the general public.

The following four interpretive statements from Provision 4 further illustrate the depth of accountability and responsibility in nursing practice:

4.1 Authority, Accountability, and Responsibility

• Accountable for one’s own practice, care ordered by a provider, care coordination.

4.2 Accountability for Nursing Judgments, Decisions, and Actions

• Nurses must follow a code of ethical conduct.
• Follow the scope and standards of nursing practice.

4.3 Responsibility for Nursing Judgments, Decisions, and Action

• The nurse is always accountable for judgments, decisions, and actions, though the employer may be jointly responsible depending on the situation.
• Nurses accept or reject an assignment based on education, experience, competence, and risk for patient safety.

4.4 Assignment and Delegation of Nursing Activities or Tasks

• Assignments and delegation activities must be consistent with the Nurse Practice Act, organizational policy, and nursing standards of practice.
• Assess individual competence prior to assigning (ANA, 2015a, p. 59).

The Essentials

The following competencies can be found in The Essentials document (AACN, 2021):

• Domain 2: Demonstrate accountability for care delivery (p.32)
• Domain 3: Demonstrate effective collaboration and mutual accountability with relevant stakeholders (p.35)
• Domain 5: Assume accountability for reporting unsafe conditions, near misses, and errors to reduce harm (p. 43)
• Domain 9: Demonstrate accountability to the individual, society, and the profession (p. 53)
• Domain 9: Formation and cultivation of a sustainable professional nursing identity, accountability, perspective, collaborative disposition, and comportment that reflects nursings characteristics and values (p. 54)

More information can be found in The Essentials document.

Types of Accountability

Nurses are accountable for their actions to themselves, their peers, employer, healthcare consumers, society, and the nursing profession.

Accountability to Self

Nurses must be accountable to themselves, otherwise they risk accountability to their peers and their patients. Nurses work very long hours, often working well past a 12-hour shift to complete care, documentation, and report to the oncoming nurse. A nurse may resent having to work a 13- or 14-hour shift, especially when compensation may not cover the extra time on the unit. Miller (2012) explains the importance of strengthening personal accountability in situations where a nurse may begin complaining or blaming others about the long hours or other issues that are beyond the nurse’s control. Personal accountability begins with looking inward, rather than pointing fingers. Miller (2012) suggests asking oneself two important questions:

• What can I do?
• How can I help?

Instead of just complaining to the manager about the long shift or a different problem, nurses can offer assistance on how to find a resolution and offer their help with carrying out the solution. Part of resolving problems is being part of the solution. Nurses who refuse to complain, and instead choose to find solutions, become empowered. Choosing to be positive, and part of the solution, leads to improving one’s personal accountability.

As previously mentioned, working long hours in a stressful environment requires nurses to have adequate physical stamina and emotional stability. Fatigue, minor illnesses, and a stressful personal life can negatively impact professional practice. Working extra shifts in addition to a very busy life can also hamper practice. Maintaining a healthy lifestyle, including adequate sleep, diet, and exercise, and having a balanced work-personal life, is essential for one’s personal accountability.

Working in an unsafe practice setting is another example where nurses need to be accountable to themselves. Some examples include working in an unfamiliar setting or having a high-acuity/high patient load assignment. Nurses need to view refusal to work in an unsafe setting as a way to protect the public, and to be personally accountable. Be sure to follow organizational policies on how to refuse and/or make a statement about working in an unsafe environment.

Accountability to Peers

Accountability to peers is also known as shared accountability. Shared accountability occurs when team members support each other, work together to ensure a safe working environment, and act as role models to demonstrate a culture of respect. If nurses need to speak up about a concern, they need to do so in a constructive, considerate way. Communication with team members should be provided consistently, in a way that does not cause embarrassment or anger. When team members consistently share feedback with each other it reinforces the desire for a supportive, cohesive team. The goal is to create an environment where suggestions for change are expected and become the norm. Establishing a culture of trust, respect, and support leads to a healthy work environment and quality safe patient care (Battié, & Steelman, 2014).

Accountability to the Employer

Nurses are accountable to their employers by following their rules and regulations and fulfilling their job duties. Since nurses must be accountable with the laws set forth in the NPA, they need to verify organization policies do not conflict with NPA regulations. Nurses risk violating regulations if they do not review the NPA regularly. Nurses are also responsible, and held accountable, for monitoring unlicensed personnel. Nurses can improve accountability to their employer by taking an active role in organization-wide committees focused on improving the delivery of care.

Accountability to the Patient

Patients have the right to safe, quality care. Nurses are held accountable to their patient by the fulfilling their obligations set for in the Scope and Standards of Practice and the Code of Ethics. As previously stated, these two foundational documents illustrate the requirement of all registered nurses to provide exemplary care to individuals in need of healthcare.

Nurses can also be accountable to their patients by educating them about the Hospital Compare website. All hospitals are now required to post health outcomes and other measures at the Hospital Compare website so patients can make choices about where to receive care. Visit the Hospital Compare website to view all of the outcomes. The following is a brief list of the outcomes found in the Hospital Compare website:

• Timely and effective care
• Healthcare associated infections (HAI)
• Adverse effects (i.e. mortality rates)
• Patient satisfaction/experiences

The quality measures available from the Hospital Compare website provides the healthcare system and nurses important data that helps them be more competitive with other healthcare systems, thus, further improving quality care. Nurses need to be aware their patients often enter the healthcare system with increased knowledge of healthcare in general and awareness of the organization’s level of quality care. Patients may have a sense of what to expect from nurses when they begin receiving care, and nurses must be prepared to work with patients in a collaborative way. Like any other business, healthcare organizations and their employees must be accountable to their patients and their needs.

Since the healthcare system has moved towards a proactive, preventive care approach, nurses need to provide patients with the education and tools to promote health and well-being in order to prevent illness and disease. As nurses develop relationships with their patients, it will be important to understand their distinct needs and how they relate to health promotion activities. For example, determining any barriers and motivating factors will be important for nurses to include in their collaborative efforts with patients. When nurses create a plan that is patient-centered, and focused on current evidence to offer safe, quality care, nurses are taking the right steps to being accountable to their patients.

Accountability to Society

One of the characteristics of a profession is service to society. Consumers have the right to receive safe, quality care, and nurses are held accountable to meet the healthcare needs of society. To meet these needs and requirements, nurses are obligated to stay abreast of current literature, attain continuing education, maintain skill competencies, and more. Through the NPA and the ANA’s Nursing’s Social Policy Statement, nurses are legally held accountable to provide professional nursing care that meets the required scopes and standards of practice.

Accountability to the Nursing Profession

Just as nurses are advocates for their patients, they must also be strong advocates for the nursing profession. Through participation in professional nursing organizations, nurses need to promote safe, quality nursing care, improved nursing autonomy, nurses’ rights, and more. Nurses need to support professional organizations as a way to be accountable to the nursing profession (Battié, & Steelman, 2014). Nurses can demonstrate their accountability by the following activities:

• Participate in organization-sponsored conferences and activities
• Stay current with recommended practices within one’s specialty
• Political advocacy
• Vote for candidates who support the profession’s mission (Battié, & Steelman, 2014)

Nurses play an important role in shaping the nursing profession through formulating its own policies and laws. Nurses work collaboratively to formulate the profession’s scope, standards of care, licensing, entry into practice, and more.

Provision 3 in the ANA (2015a) Code of Ethics states, “The nurse promotes, advocates for, and protects the rights, health, and safety of the patient” (p. 41). Interpretive statement 3.5 explains how nurses must act on questionable practice. Nurses must be alert to all instances of incompetent, unethical, illegal, or impaired practice by another member of the healthcare team, which includes issues that occur within the entire healthcare system. Nurses must take action to resolve such issues in order to protect the healthcare consumer from injustice or injury.

The Code of Ethics directs nurses not only to recognize questionable practice due to impairment, such as substance abuse, but nurses are also obligated with assisting each other with obtaining treatment. Weber (2017) states substance and alcohol abuse is a significant issue for the nursing profession. Chemically addicted nurses and other healthcare workers pose a danger to themselves, patients, team members, and the organization.

Manthey (2018) discusses how nurses are at an increased risk for addiction due to working in highly stressful environments, easy access to highly addictive substances, and a “conspiracy of silence” that prevents treatment. Thomas and Siela (2011) states at least 1 in 10 nurses will develop a substance abuse disorder, similar to the general public. Resources and more information about substance abuse disorders in nurses can be found at the NCSBN website.

Nurses must be acutely aware of the high risk of addiction to alcohol and illegal substances for oneself. When nurses observe impaired practice or unsafe patient care from a coworker and believe wrongdoing has occurred (such as drug-diverting), nurses must be prepared to report this unethical behavior. Reporting such behaviors to authorities is known as whistleblowing. Whistleblowing is defined as “the disclosure by organisation members (former or current) of illegal, immoral or illegitimate practices under the control of their employers, to persons or organizations that may be able to effect action” (Near & Miceli, 1985, p. 4). Protecting patients from harm is one of the guiding principles of the nursing profession. Nurses owe it to themselves, and their patients to ensure be alert to impaired practice and reporting such behaviors. Additional information about whistleblowing can be found at the ANA website.

Nurses can advocate for their profession by supporting their peers who struggle with alcohol or substance abuse. Nurses can recommend their peers seek assistance from a program run by the New York State Nurses Association called the Statewide Peer Assistance for Nurses (SPAN, 2018) program. SPAN services are available to all nurses working in New York State. SPAN offers nurses assistance with substance abuse including other confidential services, such as education, support, and advocacy. Additional information on helping nurses with addiction can be found at the SPAN website.

In order to ensure the nursing profession continues to be known as an honorable and noble profession, nurses need to support and mentor their peers throughout one’s career.

Nursing Judgment and Action

Nurses practice and act within a learned code of ethics they implicitly follow when making judgments about care. Nurses practice by the principle of fidelity (being faithful, honest), respect for dignity, work, and patient autonomy when taking action. Nurses are accountable for judgments made about care. When nurses assume accountability and responsibility for their patients, they fulfill their commitment to practice with compassion and respect for patients. The ANA (2010a) states, “The moral standard of the profession is one to which nurses must hold themselves and their peers in order to be held accountable in for their practice” (p. 46).

Nurses must either reject or accept role demands based on one’s level of education, knowledge, competence, and experience. Nurses must assess their own competencies and seek out necessary education, consultation, and collaboration. Tasks should be performed only when nurses have demonstrated sufficient competence and confidence with the skill.

When nurses are answerable for their knowledge, skills, and actions, their level of respect and nursing autonomy grows. The general public needs nurses to be competent; therefore, when nurses demonstrate their strengths by providing competent care, they maintain the trust and respect of their patients including the healthcare system as a whole.

As described earlier, autonomy is centered around nurses making independent decisions about care based on their knowledge, judgment, and experience. Autonomy is related to accountability because nurses who make independent decisions, or any decision for that matter, are accountable for their actions. Autonomous decisions are made to ensure appropriate care, maintain high quality care, and satisfy the patient or healthcare consumer.

Shared Governance

Shared governance is an organizational model defined as “… a structure within the process of practicing professional nursing that results in favorable nurse, patient, and organizational outcomes” (Church, Baker, & Berry, 2008, p. 36). The two main assumptions of shared governance models are: 1) redistribute decision-making power from managers to staff [nurses], and 2) nurses have the interest in being part of the decision-making process (Anthony, 2004).

Golanowski, Beaudry, Kurz, Laffey, and Hook (2007) explains shared governance as a decision-making model containing four major concepts:

• Accountability: the foundational concept, includes authority (power to make decisions), autonomy (right to make independent decisions), and control (ability to act)
• Equity: measure of all team members contributions to the outcome
• Partnership: relationships among the team members with a focus on the outcome
• Ownership: invested in the organization, able to articulate personal contribution to the outcome

Shared governance can transform nurses’ personal practice and benefit healthcare organizations in many ways, including:

• Empowerment of practice (Hess, 2004)
• Improved nurse satisfaction (Church et al., 2008; Golanowski et al., 2007)
• Improved patient satisfaction scores (Church et al., 2008)
• Reduced mortality and healthcare-acquired infection rates (Church et al., 2008)
• Reduced nurse turnover and vacancy rates (Church et al., 2008)
• Improved staff morale (Golanowski et al., 2007)
• Improved staff member participation (Golanowski et al., 2007)
• Personal and professional development (Golanowski et al., 2007)

Improved levels of morale, job satisfaction, and empowerment leads nurses to being happier, and more fulfilled in their daily work. Patients can sense when their caregivers (nurses and staff members) exhibit more cheerful and contented behaviors, which may translate to feelings of being cared for, and having a satisfied patient experience.

In order for a shared governance model to bring about positive outcomes, both nurses and managers need to buy into the idea that nurses need to have a voice in decisions that impact their practice, and the delivery of healthcare.

Delegation

Delegation is defined as, “The transfer of responsibility for the performance of a task from one individual to another while retaining accountability for the outcome” (ANA, 2015c, p. 86). The ANA and NCSBN (2019) created the Joint Statement on Delegation in order to support and guide nurses on how to use delegation safely and effectively. These organizations share the following definition and meanings about delegation:

• The process for a nurse to direct another person to perform nursing tasks and activities. The nurse retains the accountability for the delegated task (ANA & NCSBN, 2019, para 3). The two organizations further delineate:
  • NCSBN: nurse transfers authority
  • ANA: nurse transfer of responsibility

Nurses often work in chaotic healthcare environments, have a large patient load, a high acuity assignment with complex patient needs, with an added emphasis on patient satisfaction. These are just a few factors that leave nurses no choice but to delegate tasks to other members of the healthcare team. Delegation frees up nurses’ valuable time so nurses can attend to more complex patient care tasks. Delegation is an essential skill of professional nursing practice, and when done correctly, can result in safe and effective nursing care (ANA, 2019).

In order to delegate, nurses must consider the following:

• Nurses’ legal authority to practice
• Context of their practice
• Nurse Practice Act regulations
• Professional standards
• Employer’s policies and procedures on delegation (ANA, 2019)

More information about the ANA’s Principles for Delegation and NCSBN’s Decision Tree for Delegation to Nursing Assistive Personnel can be found in their the Joint Statement on Delegation document.

Creating a Culture of Accountability

It is essential to view accountability as a process of supporting others who want to be accountable for the work they accomplish. Nurses in leadership positions, whether formal (i.e. nurse manager) or informal (i.e. charge or staff nurse), should reflect on their thoughts about accountability in order to get a full understanding of one’s thoughts on the topic. Reflection is an important first step because leaders set the tone for the work setting and understanding oneself better can impact thinking and actions for the future (Cox & Beeson, 2018). Some questions to consider include:

• Do you set a tone of learning from mistakes or do you focus on punishing?
• Do you focus on blaming others or fix the system?
• Are you the first or last to admit your own mistakes? (Cox & Beeson, 2018)

Providing support to individuals who make mistakes, rather than finding faults, will create an environment where accountability can grow. Enforcing a punitive consequence destroys the possibility of creating trust and a sense of partnership with a peer or follower. Accountability should be associated with support, encouragement, trust, and unquestionably, not punishment (Cox & Beeson, 2018).

Cox and Beeson (2018) explains the three major components of accountability:

• Clear expectations: clearly explain the expectations by answering the 4-Ws and the 1-H, such as:
  • What needs to be done?
  • Why is this important?
  • When does it need to be completed?
  • Who else will I be working with on the project?
  • How do I begin?
• Follow-through: connect with staff to offer motivation or inspiration to carry out the task or project:
  • Mentoring
  • Coaching
  • Guiding
  • Feedback
  • Encouragement
  • Support
• Rewards or consequences
  • Reward: A pat on the back when the task is complete. Be sincere and timely
  • Consequence: be firm and compassionate

Summary of How to Enhance Accountability

• Clear and open communication
• Skill competency
• Advanced education
• Collaboration with peers, managers
• Clear expectations
• Participate in professional organization opportunities
• Support peers, mentor new nurses, offer guidance
• Read the NPA regularly, especially when changing roles/settings
• Delegate
• Ask yourself, “What can I do? and “How can I help?”
• Maintain a healthy lifestyle; physically, emotionally, spiritually
• Choose to be positive, find a solution
• Participate in organization-wide committees
• Be compassionate, listen
• Organize a shared governance model for your unit/organization
• Compare employer’s policies/processes to NPA

Attribution

Transitions to Professional Nursing Practice. Authored by: Jamie Murphy. Provided by: SUNY Delhi. Located at: https://courses.lumenlearning.com/suny-delhi-professionalnursing. License: CC BY: Attribution