Part 5.

1: Accountability, autonomy and standards

3 May, 2001 VOL: 97, ISSUE: 18, PAGE NO: 47 Petra Kopp Nurses' demands for increased professional recognition bring with them increased responsibilities. While it is doctors who have 24-hour legal responsibility for the treatment of patients, nurses are making more independent nursing decisions for which they are legally accountable in a court of law, over and above their professional accountability for all their actions. Nurses' demands for increased professional recognition bring with them increased responsibilities. While it is doctors who have 24-hour legal responsibility for the treatment of patients, nurses are making more independent nursing decisions for which they are legally accountable in a court of law, over and above their professional accountability for all their actions. In addition, patients are becoming more aware of their options to litigate if things go wrong and know that they can sue individual professionals as well as trusts or other authorities. What is accountability? The principle of accountability, as stated in the UKCC code of conduct (UKCC, 1992), is enshrined in various laws, particularly the common law of negligence. If you are a professional in charge of a task you can be called to account for what happens, especially if something goes wrong. If you perform a task, such as admitting a patient, you take responsibility for that task and its outcomes. Similarly, if you are supervising a student or team member, you take some responsibility for his or her performance of the task. Delegating tasks to others As a nurse, you need to know how you are accountable when you delegate tasks to others, such as nursing auxiliaries or care assistants. When delegating, you should take on board the mix of skills in your team. 'Make sure that the person who does the work is able to do it and that appropriate levels of supervision or support are in place' (UKCC, 1996). Accountable to whom? You are accountable to: - Your patients, through a duty of care, underpinned by a common-law duty to promote safety and efficiency, and legal responsibility through civil law;

- Your employer, as defined by your contract of employment and job description; - Your profession, as stated in the relevant codes of conduct; - The public (UKCC, 1992; Dimond, 1995). Accountable to your employer UK law stipulates that all workers must be issued with a written contract of employment within 13 weeks of starting a job. Your contract could include: - What was agreed at your interview; - Any document you have signed; - Any implied terms of your employment. Implied terms are those that may not have been discussed but which the court could assume to exist unless there is evidence to the contrary. For example, it is an implied term of a contract of employment that an employee will obey the reasonable instructions of the employer and will use all care and skill. If you do something that contravenes the terms of your contract, for example by being grossly negligent, your employer can take disciplinary action against you for breach of contract. Accountable to the profession The UKCC code of conduct (UKCC, 1992) sets out the position on your accountability to the profession. It forms the basis from which to challenge unacceptable standards of care and makes it clear that responsibility for your actions rests with you as an individual nurse. No one person, rule, code of practice or guideline can tell you what to do in every situation. But the UKCC code of conduct's clauses 4 and 5 (UKCC, 1992) do help by setting out important principles such as: - Maintaining and improving professional knowledge and competence; - Acknowledging limitations in knowledge and competence; - Declining any duty or responsibility unless you are able to perform it in a safe and skilled manner. To be accountable to the nursing profession, you need to be accountable to yourself too. Keeping a reflective diary is one way of accounting to yourself for your thoughts and actions and questioning and improving the quality of the care you provide, perhaps through discussion with colleagues or with your manager or clinical supervisor. Reflective practice was considered in part 2 of this series (Nursing Times, March 1, p45-48).

Accountability and autonomy The UKCC report Project 2000: A new preparation for practice (UKCC, 1986) explained that autonomous practitioners were to exercise increasing clinical discretion and accept greater professional responsibility by making their own decisions. They were also required to carry out more direct care, research and management, and were expected to contribute to policy-making and strategy development. Many nurses cite autonomous practice as a professional aspiration. That is, you and your professional colleagues, not just your employer, make the decisions about your practice. You have your own caseload, perhaps working in a nurse-led unit. You and your unit admit and assess patients, perform all the care during their treatment and take responsibility for discharging them. There is a clear link between accountability and autonomy: if you want to be autonomous, you need to take responsibility for your decisions and the results of your actions. Accountability and standards One aspect of exercising your professional accountability as a nurse is the need to recognise and balance a range of perspectives on what constitutes acceptable standards of care. Patients have their own standards of personal health care that will affect their view of the nursing care they receive. This means that what is acceptable to a nurse may not be acceptable to a patient, and vice versa. Equally, although each qualified health care professional may be an independent and accountable practitioner, he or she also works as part of a team and teams often have members with different standards. In addition, the team develops standards of care that affect the patient. The team, as well as each individual practitioner, is also affected by organisational and occupational standards. Standards - the wider picture Applying individual standards to health care can be problematic because one person's standards may not be acceptable to others. One way of addressing this potential discrepancy is by establishing a framework within which care should be delivered. This framework can range from high-level statements, such as a vision and mission statement, to detailed guidelines, procedures and protocols for delivering specific services (to be discussed in Part 6: Delivering quality care). Government policy (Department of Health, 1997; 1998), as described in Part 4 of this series (Nursing Times, April 12, p47-50), emphasises the need to provide a framework of standards within which health care is delivered. Through the National Institute of Clinical Excellence, the Commission for Health Improvement and national service frameworks for different areas of care, variations in health care are to be reduced. In doing so patients and individual practitioners should get a clear idea of what to expect and what is expected of them. Competencies and standards Professional competencies and occupational standards in the health care environment are another

way to clarify expectations and support practitioners in meeting the demands of their professional codes. - Fit for Practice is compiled by Petra Kopp For full details of programmes run by Emap Healthcare Open Learning, or for advice on programmes or support materials, call the Open Learning helpline on 020 7874 0600 or write to Emap Healthcare Open Learning, Greater London House, Hampstead Road, London NW1 7EJ. Additional activities are available weekly on the Nursing Times website at: www.nursingtimes.net Useful websites Website addresses were correct at the time of publishing but, like many addresses, they do change. Use key words and web browsers to search the internet if the address listed is no longer available. Department of Health: www.doh.gov.uk English National Board (ENB): www.enb.org.uk Healthwork UK (the health care national training organisation): www.healthwork.co.uk National Board for Nursing, Midwifery and Health Visiting for Northern Ireland: www.ni.nhs.uk/NBNI/index.htm National Board for Scotland: www.nbs.org.uk Northern Ireland Department of Health and Social Services: www.dhssni.gov.uk Royal College of Nursing: www.rcn.org.uk Welsh National Board: www.wnb.org.uk FURTHER READING Duggan, M. (1997)Pulling Together: The Future Roles and Training of Mental Health Staff. London: Sainsbury Centre for Mental Health. UKCC (1995)Standards for Post-registration Education and Practice. London: UKCC. UKCC (1999)Fitness for Practice. London: UKCC. UKCC (2000)Requirements for Pre-registration Nursing Programmes. London: UKCC.

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