Management Autonomy and Accountability.

MEANING

 Autonomy is derived from a Greek word ‘autos’ means ‘self’ and ‘Nomo’s means
‘Laws'.
 Autonomy means that one is reasonably independent and self-governing in decision
making and practice.
 The client’s rights to self determination
 In healthcare, autonomy means to self-directing freedom and moral independence in
which an individual is free to choose and implement own decisions.

DEFINITION

It’s the freedom to make discretionary and binding decisions consistent with one’s scope of
practice and freedom to act on those decisions.

[Lewis and Batey]

BENEFITS

1. Professional autonomy leads to job satisfactions

2. Freedom to act on the binding decisions the nurse makes.
3. Autonomy in nurses’ practice contributes to the well being of patients and add to the
quality of services and care that patients receive.

Autonomy in nursing practice

Principles

I. Paternalism: it is the deliberate restriction of people’s autonomy by health care

professionals based on the idea that, they know what is best for the clients. In some
instances, it is justifiable.
II. Informed consent: By contrast, marked by disclosure, understanding, voluntariness,
competence and permission giving in a clinical situation, this means that the nurse is
obligated to ensure that,
The client is given appropriate information
He or she is able to understand the information
The client agrees to a treatment voluntarily
Informed consent is closely associated with the notions of self-determination, and free choice.
It is the key element of autonomy.

III. Advanced Directive: nurse promote client autonomy by integrating clients wishes
into the treatment plan clients communicate their wishes to health care provider by
verbally participating in the health issue decision making and through written
documents called advanced directives.
a. Proxy Directive: is a type of advanced directive, which allows an individual to
designate another person to make decisions if the client becomes incapacitated and
unable to make decisions independently.
b. Living will: is a type of advanced directive that specifies the types of medical
treatment a client does or no doesn’t want to receive, should be unable to speak for
themselves and in a terminal condition.

Scope of autonomy in nursing

The most important to understand the scope of autonomy as it relates the facility functioning
in an academic setting. Autonomy involves the range of decisions and behaviors that can be
performed at the discretion of the group.

Professionals possess autonomy to the extent that are allowed to use their own judgement if
no independent judgements are required, then no autonomy exists and no progressions either.

Autonomy is in effect an ultimate value for self-identified members of an occupational

category, and they are extremely unlikely to achieve goal without prior qualifications.

Nurse physician relationship and autonomy

Ensure that the nurse physician relationship is one of the dominances of the doctor over the
nurse. The doctor assumes full responsibility for all decisions affecting patient care such an
outlook assumes that the body of all health care knowledge is sub screened under medical
knowledge and that all other health care workers are dependent on the decisions of doctors
relative to patient care. But in recent years, nursing is an autonomous, self-governing
profession when compared to the past, is a distinct scientific discipline with many
autonomous practice features.

Autonomy in regard to patient

In regard to patient respect for autonomy is the basics for the client’s right to self-
determination. Clients are to make decisions about what will happen to them and their bodies.
Adults with capacity (mental and physical ability) to make decisions have the right to consent
or to refuse the treatment. Even if the health care team do not agree with the client’s decision,
they respect the client’s decision and wishes. In case the client does not have the power to
take up the decision maker should be identified to act on the behalf of client. Thus, this
principle of autonomy supports the client’s right to know to be informed and to be able to act
on autonomous decisions. Health care providers are not entitled to force the clients to take up
a decision or action that do not reflect the client’s beliefs, values, choices and life spans.
Clients are given opportunities to make decisions and informed consent is designed to protect
autonomous choice in those health care decision.

Barriers of nursing autonomy

 Lack of recognition and valuing of nursing knowledge and contribution to patient care
goals by physician’s and other members of health care team
 Inability to raise and resolve concerns about treatment plan.
 Interruptions to the nurse’s ability to access, Coordinate resources for the patient care.
 Relationship with nursing colleagues, physicians and managers that undermine
collaboration, confidence and shared decision making.
 Organizing medical and teaching rounds

Strategies for enhancing autonomy in nursing

 Clearing, addressing and identifying expectations practiced for verbal medication

orders and cover order and unique situations in the particular units, that evoke issues
related to practice.
 Developing protocol for administration of the medications and decisions regarding
particular procedures.
 Supporting continuing education and a climate of enquiry and learning in everyday
practice.
 Enhancing clinical knowledge fosters competence and clinical expertise that
strengthen autonomous decision making.
 Autonomous nursing practice depends on mutually respectful relationships with
nursing colleagues and other healthcare personals.

ACCOUNTABILITY

Meaning

The fact of being responsible for what you do and able to give a satisfactory reason for it,
or the degree to which this happens.

Definition

According to ANA code of ethics:

Accountability is being responsible to someone for something, one has done. It means
providing an explanation to self, to the client, to the employees, agency and to the nursing
profession.

Purposes of accountability

 It includes providing an explanation to self direct and the profession for what one
has done as a nurse consultant.
 It is basis for developing a contractual agreement between the nurse and the client.
 The nurse is responsible for delivering the competency in care.
 It helps to modify and suggests alternatives.
 It helps to monitor the effectiveness of plan of care.
 It improves the quality of care.

Lines of accountability

1) Upward: looking up the line and doing what managers and administers require.
2) Lateral: accountability as a self-regulation, in which practitioners are accountable to
and judged by criteria set by their peers.
3) Downward or public accountability: where staff are accountable for or to patients.

Types of nursing accountability

1. Fiscal accountability: this accountability is concerned with financial probity and

the ability to trace and adequately explain expenditure.
 2. Process accountability: this is concerned with the use of proper procedures
3. Programme accountability: this is concerned with the activities undertaken and
their quality.
4. Priorities accountability: this deals with the relevance of appropriateness of
chosen activities

Elements of accountability

1. Clarity: expectations and goals are clear and specific. If staff members know
about reason behind the expectations, they are more likely to commit
themselves to meeting it.
2. Commitment: the accountable person must listen, understand, agree, and
commit to achieving the objectives.
3. Consequence: consequences are the after of the negligence to commitments a
person should bear the consequences of being accountable.

Accountability for standards

The standards of nursing practice are:

Standard 1 – Assessment: A registered Nurse collects comprehensive data pertinent to the

patient’s health or the situation.

Standard 2- Diagnosis: the registered nurse analyzes the assessment data to determine the
diagnosis and issues.

Standard 3-Outcome identification: the registered nurse identifies expected outcomes for a
plan of individualized to the patient or the situation.

Standard 4-planning: the nurse develops a plan that prescribes strategies and alternatives to
attain expected outcomes.

Standard 5-Implementation: the registered nurse implements the identified plan

Standard 5A: Co -ordination of care: the registered nurse coordinates the delivery

Standard 5B: Health teaching and health promotion: the registered nurse employs
strategies to promote health and safe environment.
Standard 5 C: Consultation: the advanced nursing practice and the nursing specialist
provide consultation to influence the identified plan, enhance the ability to others and effect
change.

Standard 5D: Prescriptive authority and treatment: the advanced practice registered
nurse uses prescriptive authority, procedures referrals, treatments and therapies in accordance
with safe and federal laws and regulations.

Standard 6: Evaluation: The RN evaluates progress towards the attainment of outcomes

The standards of professional performance are

Standard 7: Outskirts of practice

Standard 8: Education

Standard 9: Professional practice evaluation

Standard 10: Collegiality

Standard 11: Collaboration

Standard 12: Ethics

Standard 14: Resources utilisation

Standard 15: Leadership

[ANA and Specialty nursing organizations developed in 2004]

Accountability in nursing profession

To be accountable in nursing practice the nurse must know for which she is accountable by
using the standards of nursing practice (ANA), the individual nurse can see, clearly layout the
scope and limit of practice.

Accountability to the client

As a knowledgeable professional the nurse should ultimately be accountable for health care
delivery nationally by accepting an appropriate degree of responsibility for the correct
situation and actively pursuing methods of improving it, the nurse acts on a more professional
level.

Accountability to self
The profession of nursing is exercising it’s accountability toward itself in the performance of
its duty to formulate its own policy and control its activities

Accountability to the public

A profession exists to provide service to the public. The consumer has the right to receive the
best possible quality of care and so accountable to public. As the consumers are becoming
more knowledgeable, nurses must be able to respond it in an equally knowledgeable manner.

Accountability to the employing agency

The nurse should be accountable to the agencies in which the nurse is employed. The agency
is accountable to the public, for the care provided under its auspices. Therefore, it has the
right to expect the nurse to be accountable to that agency.

Accountability in the future

Primary nursing with its increased accountability from its practitioners. Professional nurses
are and will be ultimately acceptable for the care rendered by the service. Advanced
technology has provided the means of nursing to become more accountable. Nursing must
clearly show what does the nursing deliver, cost and outcomes.

Reasons For Lack of accountability

1. Job description not available

2. Lack of guidelines, standards, and control
3. Authority not specified
4. Overburdened staff due to shortage of staff
5. Lack of adequate training and efficient experience
6. Lack of up-to-date knowledge, skill and competence
7. Inadequate supervision by ward managers
8. Outdated policies protocols and procedures
9. Lack of decision making

Ways for enhancing accountability in nursing

1. Well defined duties and job description

2. Written policies, protocols and procedures
3. Nursing audit and standards of practice
4. Proper delegation of responsibilities
5. Proper training and education of the self
6. Periodical evaluation of each individuals nursing practice
7. Refine and modify outdated policies and procedures
8. Conducive working environment
9. Availability of adequate number of personnel and resources for patient care