Nursing for Management and Supervision of Patient Care - Essay Example

Nurse Accountability in the Management and Supervision of Patient Care. In the last couple of decades, the nursing profession has experienced tremendous changes and transformation; the profession has evolved from the simple carrying out of tasks, which it was hitherto attributed with, to a process of decision-making premised on specialist knowledge and responsibility. According to Savage & Lucy (2004:9), the nursing process that was introduced late in the 1970s, is largely responsible for this transformation in the nursing profession, while at the same time creating the avenue for the evaluation of individual nurse practitioner. These changes coupled with the escalating complexities of the ever evolving healthcare delivery system and the changing socio-political market has further heightened the pressure on nurses to be more responsible and accountable for delivery of quality patient care (Lenburg, 1999; Savage & Lucy, 2004:9). As the healthcare environment becomes more demanding with the increasing complexity and changing patterns of healthcare delivery, and the development and evolution of the nursing practice in response to the increasing health needs of clients, nurses are faced with the increasing pressures of decision making (Accountability in Nursing and Midwifery, 1997). In all these changes, what stands the same is that the nurse must exercise discretion and judgment in the management and supervision of patient care, in accepting or rejecting responsibilities, seeking consultation and even in assigning responsibilities to others who may carry out nursing care. With this increasing level of responsibility in patient management and care, the demand for nurses to be accountable for their decisions, judgment of discretion becomes more crucial for evaluating and improving quality of care. The Nursing and Midwifery Council (NMC) A-Z Advise sheet on Accountability states that "registered nurses have a responsibility to deliver safe and effective care based on current evidence, best practice, and where applicable, validated research." (NMC, 2006:1). While the NMC code of ethics also states that as a registered nurse, "you are personally accountable for your practice. This means that you are answerable for your actions and omissions, regardless of advice or directions from another professional." (NMC 2002) These policies hold grave implication for the nursing management of patient care. This paper therefore aims to look at the subject of accountability, in the light of the related concepts such as responsibility, autonomy and authority and how it affects the nurse delivery, supervision and management of patient care in the adult branch of nursing. For a start, let us take a look at what the term 'accountability' entails. According to Savage & Lucy (2004), although accountability is not a recent concept, it has however evolved over the last couple of decades from "a matter of regular reporting to an explanation of actions and outcomes and, more recently, a justification of the values informing actions and outcomes"(pg13). They argue that despite the fact that the use of the term is increasing in frequency in management and policy making circles, the term is becoming more vague as it now appears to refer to an increasing number of phenomena. However, within the nursing context, accountability has been described in different lights, by different authors. For instance, while the American association of Nurses (ANA) described nurse accountability as being Answerable to someone for something one has done. It means providing an explanation or rationale to oneself, to clients, to peers, to the nursing profession, and to society. In order to be accountable, nurses act under a code of ethical conduct that is grounded in the moral principles of fidelity and respect for the dignity, worth and self-determination of clients (Accountability in Nursing and Midwifery, 1997). The NMC considers accountability as being "fundamentally concerned with weighing up the interests of patients and clients in complex situations, using professional knowledge, judgement and skills to make a decision and enabling you to account for the decision made." (NMC, 2002). What is evident from these definitions is that professional accountability means that individual nurse is held responsible for the rendering of safe, effective nursing care to clients and for judgments exercised and actions taken in the course of providing care (Accountability & Responsibility of Nurses, 2005), or as described by Savage & Lucy (2004:15), the requirement of each and every nurse to be able to give account of his or her decisions and actions throughout the management and care of a patient. From the foregoing, it is apparent that accountability in nursing care delivery is not an easy task; however, it is also obvious that for effective and quality nursing care, accountability becomes an integral part of the professional practice. During the course of patient/client management, the professional nurse has to make a variety of decisions and judgements in a wide array of conditions and circumstances, since this impact greatly on the quality of care, the nurse must be answerable and able to defend these judgements, in the interest of the patient (NMC, 2006:2). Scherb & Meridean (2004) believes that nurse accountability hold great implications for the quality of care delivered and patient outcomes. They argue that when patients are hospitalised, nurses are saddled with the responsibility of care-giving and assisting the patients in reaching the expected patient outcome, however, if nurses do not see their role in the management of patient as having professional accountability, the expected patient outcomes may not be achieved. This argument was conveyed in their statement that "a professional accountability framework is an important means of enhancing quality and cost outcomes of nursing care" (Scherb & Meridean, 2004:10). This was buttressed by Daniels (2005) who also argued that an evidence-based framework for professional accountability is not only essential for high standards of patient care and safety, but also for the advancement of the nursing profession. Considering the implication of nurse accountability for the quality of care delivered, Savage & Lucy opine that the concept of accountability, in this regard, can be seen to rest on two different but interrelated concepts; ability and competence. These two concepts, largely defines the impact of nurse accountability on effective and qualitative management of patient care. While ability is better described as the relevant knowledge, skills and values that are vital to making sound decisions and acting upon these decisions, competence, on the other hand, is best seen as the ability to perform a responsibility with appropriate knowledge and skill and to perform the responsibility within the limits of appropriate scope and quality (2004:16). Essentially, accountability represents one of the foundations of adult nursing, in the sense that nurses play vital roles in effectively managing patient care, and thus patient outcomes (Berlandi, 2002), however, according to Savage & Lucy (2004:16), the term 'accountability' when related to nursing conveys little meaning in itself, the term is better understood when considered with respect to other similar concepts like 'responsibility, 'authority' etc than when considered in isolation. They argue that these similar concepts are relevant to the discharge of the 'charge' placed on the nurse. In the same light, Berlandi opine that it is important to differentiate 'responsibility' from accountability. He argue that while accountability refers to being "answerable and culpable for an outcome", responsibility involve "being able to answer for one's conduct and performance" (2002:5). He believes that responsibility lies in accepting and performing the duties associated with adult nursing. While accepting this line of thought, Savage & Lucy noted that much of the literature on nursing accountability indicates that responsibility is more of a prerequisite or the main component of accountability (2004:17). Quoting Eby, they assert that responsibility entails the "the acceptance of a course of action as well as the acceptance that an individual should be willing to give an account for the nature and conduct of that task" (2000:190). However, Savage & Lucy agreed that accountability, because it requires independent thought, could be said to be on a higher plane compared to responsibility. They explained that while accountability entails justifying and explaining nursing actions, omissions and decisions based on sound professional knowledge, logical and replicable decision making process, responsibility, in its traditional sense, entails performing tasks in an accurate and timely fashion (2004:17). While accountability involve the exercise of independent thought, accepting responsibility for care in adult nursing, largely has to do with the nurse's educational preparation, competence and work experience. Berlandi (2002) argues that as result of expanding clinical knowledge, modern technological equipments, higher patient acuity, nursing responsibilities in the adult branch of nursing has been on the increase and so the degree of accountability expected of the nurse. Essentially, it is the nurse's responsibility to: Provide competent nursing care to the patient. Safeguard patients and avoid actions that place the interests of the patient(s) in jeopardy. A refusal of an assignment may be justified when the risk of harm to the patient(s) is greater by accepting the assignment than by rejecting it. Exercise informed judgment and use individual competence and qualifications as criteria in giving, accepting or rejecting an assignment. Clarify assignments, assess personal capabilities and jointly identify options for patient care assignments when the nurse does not feel personally competent or adequately prepared to carry out a specific function. Determine what will put a patient in immediate, serious danger (Accountability in Nursing and Midwifery, 1997). The nurse accountability is obviously borne out of the necessity to discharge these responsibilities in the most efficient, safe and diligent manner, in the best interest of the patient. Autonomy is another concept that is closely related to accountability. Savage & Lucy succinctly described this relationship between nurse accountability and autonomy when they stated that "accountability is a consequence of autonomy" (2004:18). Autonomy is described, in nursing context as self determination, self direction and the freedom to interact on an independent level with other professionals. It is argued that this is crucial to nurse accountability as it accord the nurse the independence to act in a manner to achieve a desirable outcome. It is obvious from this argument that for the nurse to be accountable for her actions and decisions in patient care, he or she must be allowed the right to act independently. Another concept that closely defines accountability in adult nursing is 'authority'. Savage & Lucy defined authority as the "legitimate power to fulfil a charge or responsibility" (2004:18). They observe that authority and responsibility are prerequisite of accountability. In their view, a person who lacks authority to perform a charge cannot be held accountable. Quoting Dewar, they stated that "authority is an appropriate term for describing the power that underpins accountability" (1999:26). In the adult nursing, authority is derived from a number of sources, which includes authority of the situation, as in emergency situations; authority of expert knowledge, granted through professional registration; and authority of position. Emphasising the importance of authority to accountability, Savage & Lucy stated thus: Enabling the clinical nurse to be responsible relates very closely to the way in which we organise nursing care. If it is organised along the lines of task assignment and routines and procedures, the nurse cannot take responsibility for her [sic] charge, she has no professional authority, she cannot take discretionary decisions and act on them, she cannot be accountable. Only if the nurse is involved in informed decision-making about patient care, which is planned and implemented on an individualised basis, can she be held accountable (2004:21). These three concepts of responsibility, autonomy and authority are considered important, not only in the manner they relate to accountability in adult nursing, but also in the role they play as determinants of the quality of care delivered by nurses in charge of patient management (Savage & Lucy, 2004). Although, quality of patient care and safety is the bottom line of all nursing policies and thus the main thrust behind nurse accountability (Nicklin, 2003), the professional nurse is not only accountable to the clients. Nurse accountability involves providing explanation or rationale to oneself, to clients, to other members of the healthcare team, to the nursing profession, the employing agency and to society. To be accountable to the patient/client, the nurse must: know how and why things are done employ safe nursing care allow clients to participate in nursing care activities, including planning respect individual client differences altruistic intentions serve as a client advocate when the need arises To other member of the healthcare team: bring specialized nursing knowledge and skills to the health care delivery situation Share information with team members Confront if potential errors may occur Perform nursing tasks with competence Treat members with dignity and respect To the employer Quality of work Unsafe practice situations Attitude conveyed about the agency Use of outside agency personnel To 'self' Practice nursing to personal standards using professional standards as a basis Be true to oneself Take care of personal, physical, mental, and spiritual health Protect self from harm (Hood, 2005) Professional nurse accountability has been linked to the quality of care delivered by nurses and by extension, patient outcomes. Researches carried out on the relationship between nurse accountability and patient outcomes has been very useful in assessing how nursing care impacts patients outcomes, on a general note, and also serve as a requirement for the nursing profession's mandate to influence health policy. Understanding the effect of nurse accountability has been said to challenge the adult nurse to measure or quantify its positive impact on quality of care (Scherb & Meridean, 2004) Scherb & Meridean (2004) further asserted that so far, only a few studies have been directed at researching the relationship between nurse accountability and the quality of care patient receive or patient outcomes. They argue that during hospitalisation, nurses play the primary roles of care givers, whose nursing care is crucial in assisting the patient achieve the desired outcome. Thus, if nurses do not see their roles in the management of patient care to achieved the desired outcomes as having professional accountability, these desired patient outcomes may not be realised. Based on this argument, they opined that nurse accountability have a very unique contribution to the delivery of healthcare and thus patient outcomes. From the foregoing, it is apparent that accountability, together with responsibility and authority can be regarded as the foundation on which safe and effective adult nursing lies. The NMC codes provide the basis on which adult nurse accountability is premised, however, the core activities for adult nursing care include assessment, diagnosis, outcome identification, planning, implementation, and evaluation. Accordingly, when these activities are incorporated into daily practice, the adult care nurse is empowered to provide safe and competent care and to stand accountable for it. However, the adult nurse has to demonstrate a sense of accountability to the public and the profession, by continually upgrading their knowledge about new treatments, procedures and technology. Though, the NMC strives to ensure this is the case by making sure that license renewal of registered nurses is based on the verification of continuing education (Berlandi, 2002) The core of the adult nurse accountability lies in the power to evaluate patients and form judgements about the most effective care plan. The ability to make clinical judgements is learned through formal education and also from experiential knowledge. Nonetheless, it requires critical thinking or reasoning and the ability to take responsibility. In forming decisions about patients' care nurses take accountability for the outcomes of their actions (Berlandi, 2002). The NMC code specifically states that neither the healthcare organisation's policies nor a physician's order is enough excuse to relief a nurse of accountability for her decisions (NMC, 2002). This knowledge holds serious implication for patient care, as noted by Scherb & Meridean earlier on; the nurse's awareness that he/she is completely accountability for every judgement and decision made is capable of reinforcing a higher degree of discretion, critical thinking and caution on the part of the adult nurse. This ensures that nurses follow evidence-based practice and the most recent in health technological breakthrough. Furthermore, nurse accountability has been a major milestone in the effort towards transforming the nursing profession from mere task taking, into a more technical-rationale healthcare provision system, characterised by the use of techniques and instruments and sound logical thinking. In other words, accountability is a step towards increased technicalisation and professionalisation of the nursing profession (Savage & Lucy, 2004). This has further promoted the skills, motivation and organisation of nursing in the provision and management of patient care. Also, with the knowledge to act independently and the authority to accept accountability of every action, omission or decision, adult nurses are no longer afraid to challenge other healthcare team members if they believe that a patient's safety is at danger; afterall, they shall bear responsibility for every action or omission (Berlandi, 2002). For instance, if an adult nurse is required to provide care that is not inline with codes of ethics, or a physician's order is not in order, the knowledge that such physician's order is not enough excuse to relief the nurse of accountability for her action empowers the adult nurse to act appropriately. Besides achieving the desired patient outcome and delivery of safe, effective and quality care for patients; which is the main thrust of nursing care, nurse accountability has several other positive implications. It brings increased respect to the nurse and the profession, increasing the esteem of the profession in the minds of the public. Accountability improves nurse effectiveness, enhances action and control and in the end brings reward to the effective nurse, when he/she is commended for maintaining safe and standard nursing care for the patient/client. In conclusion, accountability in adult nursing improves the quality and effectiveness of the nursing profession and the standards of care provided for patients/clients. It also empowers the nursing profession to improve on her skills, education and technicality, creating a more responsible, effective and standardised nursing profession. References Accountability in Nursing and Midwifery (1997). 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