An exploration of accountability in nursing and its impact on professional practice - a multiple case study

Abstract

Background: Accountability is of critical importance to the nursing profession. It is assumed that greater accountability can safeguard patient outcomes, quality of care and standards of the profession. However, there is no empirical data of how accountability is enacted and very limited data on its impact on professional practice. Aims: To explore how accountability is understood and enacted across the nursing hierarchy and to identify how it could be enhanced to safeguard patient outcomes, quality of care and standards of the nursing profession. Design and methods: Multiple case study design. Semi structured interviews and focus groups were conducted with 49 Registered Nurses (RN) in three NHS Scotland Health Boards (HB). Each HB represented a case and each case had RN participants from point of care to Health Board. Framework analysis was used to analyse the data. Findings: RNs had appropriate knowledge and understanding of accountability as it related to their individual role, level in the hierarchy and experience. There were similarities and differences of RNs perceptions of accountability which related to their position in the hierarchy. Overall, accountability across the nursing hierarchy was focussed on retrospective assurance and answerability, mainly through audit and ‘tick box’ documentation. RNs reported being disproportionately burdened with accountability for care, which was associated with a lack of collective accountability and fear of anticipated consequences and blame. Accountability to safeguard patient outcomes was linked to decision making, ability to challenge and effective record keeping. RNs ability to accept accountability was dependent on self–confidence, resilience and autonomy which were influenced by - identity and feeling valued, level of knowledge and skills, trust and support, and control of responsibilities and fairness. Conclusion: In conclusion, this study identified that RNs had appropriate knowledge and understanding of accountability. They articulated two discourses of accountability task- responsibility and answerability. This study provides valuable insights into the factors that facilitate or hinder RNs accepting accountability. The findings also support the notion that it cannot be assumed that the purpose and influence of accountability as perceived and experienced by RNs is as the profession intends. Calls for greater accountability need to be cognisant of the complexity of the concept and the perceptions of the nursing workforce. Based on the study findings, a model for practice is proposed to enhance accountability to safeguard patient outcomes, quality of care and standards of the profession (Appendix 4). Such a targeted approach needs to be formally evaluated in future research and practice.