ALL INDIA INSTITUTE OF MEDICAL SCIENCES, JODHPUR

COLLEGE OF NURSING

SEMINAR PRESENTATION
ON

Autonomy, Accountability and Assertiveness

Visibility of Nurses, Legal Considerations

SUBJECT- ADVANCE NURSING PRACTICE

SUBMITTED TO SUBMITTED BY
Mrs. Gomathi A Pooja
Associate Professor M.Sc. Nursing 1st year
College of Nursing College of Nursing
AIIMS, Jodhpur AIIMS, Jodhpur

Date of Submission:15-10-2022

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AUTONOMY
INTRODUCTION:
Autonomy is derived from a Greek word.
‘Autos’ means ‘self’
‘Nomo’s’ means ‘laws’
The ability to make your own decisions without being controlled by anyone else.
Nurses have ethical obligation to their clients & to the agency that employs them, thus
balancing the clients need for autonomy with family members responsibilities for the clients
well-being.
DEFINITION:
According to Lewis & Batey (1982):
It’s the freedom to make discretionary & binding decisions consistent with ones scope of
practice & freedom to act on those decisions.
According to Immanuel Kant:
It’s the moral right one possesses, or the capacity we have in order to think & make decisions
for oneself providing some degree of control over the events that unfolds within one’s everyday
life.
AUTONOMY IN NURSING PRACTICE:
• Nurses attain increased autonomy through higher levels of education.
• In changing health care system, advance practice, nurses are increasingly taking
independent roles in nurses run clinics, collaborative practice & advance nursing practice
settings.
• Innovation by nurses, increased productivity, higher retention & greater client satisfaction
are results of autonomy.
• With increased autonomy, comes greater responsibility & accountability.

BARRIERS OF NURSING AUTONOMY:

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

ENHANCING AUTONOMY IN NURSING:

• Organizing medical & teaching rounds.

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 • Developing protocol for administration of medications & decisions regarding particular
procedures.
• Clearing, addressing & identifying expectations practiced for verbal medication orders
& unique situations in the particular units, that evoke issues related to practice.
• Supporting continuing education & a climate of enquiry & learning in every day
practice.
• Autonomous nursing practice depends on mutually respectful relationships with
nursing colleagues & other healthcare personals.

ACCOUNTABILITY
INTRODUCTION:
• According to Webster, ‘Account’ means ‘subject to giving an account, answerable.’
• Manifesting accountability in nursing practice provides the opportunity to evaluate
nursing practice within healthcare & is a means of clarifying the significance of nursing
to society.
DEFINITION:
According to Sullivan & Deekan,
“Accountability is being responsible for one’s actions & accepting the consequences of one’s
behaviour. It is not a vague feeling or an obscure concept. It is a clear obligation which must
be manifested as a structured component of nursing practice, based on responsibility, authority
& autonomy”.

HIERARCHY OF ACCOUNTABILITY:
1. At Individual level: Accountability is reflected in nurse’s ethical integrity.
2. At the institutional level: It is reflected in the statement of philosophy & objectives of
nursing departments & nursing audits.
3. At the professional level: It is reflected in the standard of practice developed by
national or provincial nursing association.
4. At the societal level: It is reflected in legislated nurse practice acts.
LINES OF ACCOUNTABILTY:
• Upward: Looking up the line & doing what managers & administration require.
• Lateral: As a self-regulation, in which practitioners are accountable to & judged by the
criteria set by peers.
• Downward: Where staff are accountable for / to patients.
TYPES OF NURSING ACCOUNTABILITY:
1. Fiscal Accountability: It is concerned with financial probity & the ability to trace &
adequately explain expenditure.
2. Process Accountability: It is concerned with the use of proper procedures.
3. Program Accountability: It is concerned with the activities undertaken & their
quality.

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 4. Priorities Accountability: This deals with the relevance / appropriateness of chosen
activities.
ELEMENTS OF ACCOUNTABILITY:
• Clarity: Expectations & goals are clear & specific. If staff members are aware about
reason behind the expectations, they are more likely to commit themselves to meeting
it.
• Commitment: The accountable person must listen, understand, agree & commit to
achieving the objectives.
• Consequence: Consequence are the after of the negligence to commitment. A person
should bear the consequences of being accountable.
PRINCIPALS AGAINST WHICH TO EXERCISE ACCOUNTABILITY (UKCC,
1989):
• The interest of the patient or client is paramount.
• Professional accountability must be exercised in such a manner as to ensure that the
primacy of interest of patients is respected & must not be over ridden by those of the
professions or their practitioners.
• The practitioner must seek to achieve & maintain high standard.
• Advocacy on behalf of patients or clients is an essential feature of the exercise of
accountability by a professional practitioner.
• The role of the other persons in the delivery of health care to patients or clients must be
recognized & respected, provided that the first principle above is honoured.
• Public trust & confidence in the profession is dependent on its practitioners being seen
to exercise their accountability responsibility.
• Each registered nurse, midwife or health visitor must be able to justify any action or
decision not to act taken in the course of her professional practice.
ACCOUNTABLE FOR WHAT?
According to Lewis & Vailey; You can only be accountable for which you are responsible,
& you can only be responsible for those things which are clearly designated as accepted as your
responsibility. In addition, one must have authority to act & be expected to use judgement
based on knowledge in order to fulfil one’s responsibility as a professional.
For Example;
• For providing safe & therapeutic environment.
• Maintaining adequate supplies, material, equipment for smooth functioning of working
unit.
• Protecting client’s legal rights & privacy.
• Maintaining accurate records & reports.
• Working within ethical boundaries.
• Maintaining good interpersonal relationship.
• Delivering the care as per standards lay down by profession, statutory body &
institution.
• Delegating responsibility appropriately.

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 • Contributing to development of the profession.
ACCOUNTABLE TO WHOM?
• Nurses are accountable to nursing council.
• This relates to practicing within scope of practice, according to roll or register in
which your name is entered, & being accountable for your professional conduct.
• The nursing council’s code of conduct for nurses & midwives further outlines
professional accountability in terms of ethics, rights of patients/clients & justifying
public trust & confidence.
• Professional actions are explainable to your clients & your employer. Health care
institutions also play a role in accountability by monitoring individual & institutional
compliance with national standards established by the joint commission & the ANA.
• Ultimate accountability for nursing practice & its outcomes must be provided its
recipients within society. All nurses are accountable for the proper use of their
knowledge & skills in provision of care.
• Nurse, physicians & institutions are equally accountable for their specific functions,
within healthcare delivery & there is now a sharing accountability to society & the
recipients of care.
ROLE OF ACCOUNTABILITY IN NURSING:
1. Each registered nurse; Practices in accordance with:
• The registered nurses act, regulation & by-laws
• The CRNNS standards for nursing practice
• The CNA code of ethics for registered nurses
• Other relevant acts & legislation
2. Make nurses responsible for own actions & decisions at all the times.
3. Recognizes & report errors and take necessary actions to prevent & minimize harm
arising from an adverse event.
4. Take actions in situations where client safety & well-being is potentially or actually
compromised.
5. Exercise reasonable judgement in practice.
6. Seek assistance appropriately & in a timely manner.
7. Support policies & practices consistent with the college standards for nursing practice
& questions those in conflict with the standards.
8. Understands, promotes & complies with the values & beliefs in the code of ethics for
registered nurses.
9. Contributes to a safe, supportive & professional practice environment.
WAYS FOR ENHANCING ACCOUNTABILITY IN NURSING:
• Well defined duties & job description.
• Written policies, protocols & procedures.
• Nursing audit & standard of practice. Proper delegation of responsibilities.
• Proper training & education of self.
• Periodical evaluation of each individual’s nursing practice.
• Refine & modify outdate policies & procedures.

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 • Conducive working environment.
• Availability of adequate personnel & resources for patient care.
ACCOUNTABILITY & RESPONSIBILITY;
Are they synonyms?
• Although the terms are often used interchangeably, they are not the same.
• According to Lewis” defined responsibility as a “change for which one is answerable
whereas accountability consist of answering in relation to fulfilment of defined
responsibility,”
• In other means, accountability means that someone must be able to explain action &
results. Legally the registered nurse is accountable for nursing care. Responsibility
refers to reliability, dependability & obligation to accomplish work. It also refers to
each person’s obligation to perform at least an acceptable level.

ASSERTIVENESS:
It is a tool for expressing ourselves confidentially and a way of saying yes or no in an
appropriate way.
It is considered as healthy behaviour for all people against personal powerlessness and results
in personal empowerment.
Ex. Say ‘I won’t be able to’ instead of ‘I am not sure if I can’
BENEFITS-
• Creating health, meaningful relationship
• Less friction and conflicts
• Increase self-respect as well as respect from other
• Our self-esteem is enhanced and always feel in control
• Less stress at work and overall sense of wellbeing
• Emotional and physical health improves.
AIMS-
• To find the best possible solution for all the people
• It sees everyone as equal with equal right and responsibility
• It increases the change our needs being met
• It allows as to remain in control
• It brings greater self confidence
• Assertive people have more friend
• Reduce stress
ASSERTIVENESS MODEL:
A- Ask for god’s help
S- state the problem

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 E- express yourself
R- request change and feedback
T- talk it out
TECHNIQUE FOR BEING ASSERTIVE:
• Identify your personal rights, wants and needs
• Identify how you feel about a particular situation
• Be direct
• Own your message
• Avoid assumptions
• Ask for feedback
• Stop apologising all the time
• Act confident even you don’t feel confident
• Get your emotions under control
• Choose ideal time and place to communicate
• Feel free to say ‘NO’ ‘I DON’T KNOW’ ‘I DON’T UNDERSTAND’ etc
ASSERTIVENESS AND NURSING:
• It is an important issue in nursing practice
• Education programme in assertiveness knowledge and skills have been vague for some
time in nursing because nurses have recognized need for assertiveness in quality
nursing care
• Nurses have more on their minds than just helping patients, everyday they are
confronted with challenges such as communication issues and high stress level
• Nursing student will need assertiveness to adjust their behaviour in order to obtain a
job or promotion, to develop a career and to increase confidence
• To make exercise effectively nurses should choose a situation which they may have to
deal with in future
• As nurse work in different situations, they have to be assertive in order to meet the
challenges and to win the cooperation from others.

VISIBILITY OF NURSING
VISIBILITY: the way a person appears to others or in the case of a profession, the way that
profession appears to other discipline and to the general public- the consumer of the health
care.
CURRENT VISIBILITY OF NURSING:
• PUBLIC VIEW OF NURSING
Based on personal experiences
Consumer not recognise the nurses

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Public values nurses
Not know about the education needed
• NURSE’S VIEW OF THEMSELVES
Response of nursing towards the changes
Not taken the leading role
What is wrong with taking credit
FACTORS AFFECTING VISIBILITY:
• EXTERNAL FACTOR-
➢ Hand maiden role
➢ Hierarchial structure
➢ Perceived authority and directiveness
➢ Hospital policy
➢ Threat of disciplinary actions
• INTERNAL FACTOR-
➢ Role confusion
➢ Lack of personal confidence
➢ Timidity
➢ Fear
➢ Insecurity
➢ Inferiority
IMPORTANCE OF VISIBILITY:
• Recruitment of students
• Enhance public view
• Funding for nursing
• Relationship with administrators
• Relationship with government agencies
• Profession self-identity
HOW TO INCREASE VISIBILITY:
• Advertising nursing
• Role of media
• Nurses for healthier tomorrow
• Raise the voice campaign
• Institute of medicine quality reports
• Power and empowerment
• Assertiveness
• advocacy

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LEGAL ASPECTS IN NURSING
INTRODUCTION: in the beginning what is wrong and right behaviour from our parents,
teachers and authority figures. Most of that was shaped by religious beliefs and philosophies,
but with time we learnt a personal set of ethics to guide our behaviour in our daily life. Every
profession including nursing has a set of ethics usually call a code. It will state responsibilities
towards their profession and society as a whole.
TERMINOLOGY:
ETHICS: the principles of conduct governing one’s relationship with others, basic beliefs about
right and wrong.
LAW: the body of rules that guides human action.
LEGAL RESPONSIBILITIS: the way in which one is obliged to obey the laws in the
professional activities.
ACT: it is a written law. When the law is passed in assembly and is approved by government.
LEGISLATION: it is the process of making laws. Legislation is a method of improving public
services.
IMPORTANCE OF LAW IN NURSING:
• It differentiate nursing practice from other health care profession
• Protects rights of patients
• Protects patient against deliberate to inadvertent injury
• Prohibits unlicensed individual to work under name of license nurse
• Updates the knowledge of individual about legal controls affecting nursing
• Use to prevent a nurse who is below the standards set by the code
• Protects the nurse who is falsly accused of wrong doing
• Used as a guide when legal action has to be taken in lawsuit
LAWS APPLICABLE TO NURSING PRACTICE:
• Right to sue for fees
• Right to refuse to treat a patient accept in a emergency situation
• Right to add tittle and description to the name
• To exercise the reasonable skill and knowledge in treating patient
• There is an obligation to attend the patient once relationship is established unless
patient request withdrawal
• A practitioner must give personal attention to the cases
• Children must be protected from harming themselves
• Special precautions must be taken in patients, who are incapable of taking care of
themselves
• The Indian panel code demands that poisonous drugs be kept in separate
container, properly labelled and marked
• The patient record must be treated as confidential unless the practitioner is called
upon to give evident in the court

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 • Dangerous cases must be recorded
• Nurses are responsible for their own professional acts irrespective of the
employment authority
TORT:
It is a civil wrong committed against a person or persons property. It derived from the French,
are acts which unlawfully violate a persons right by law and for which the appropriate
remedy is a common law action for damages by injured party.
TYPES OF TORT:
1. NONINTENTIONAL
• NEGLIGENCE VERSUS MALPRACTICE:
Negligence denotes conduct lacking in due care. Thus, it equates with carelessness, a
deviation from the standard of care that a normal person would use in a practical set of
circumstances.
Malpractice is a more specific term and looks at professional standards of care as well as the
professional status of care giver.
ELEMENTS OF MALPRACTICE AND NEGLIGENCE:
•
Duty owed the patient- falling to monitor the patient
•
Breach of the duty owed the patient- falling to report a change in patient
situation
• Foreseeability- falling to report another health care providers in competence
• Causation- falling to provide for the patient’s safety
• Injury- allowing a patient to burn
• Damage- using equipments incorrectly
2. INTENTIONAL
• ASSAULT- action that places another person in apprehension for being
touched in a manner that is offensive, insulting or physical injury without
consent.
• BATTERY- intentional touching of another’s body without consent, injuries
not required.
• FALSE IMPRISONMENT- the unjustifiable detention of a person without
legal warrant to confine any person.
• CONVERSION OF PROPERTY- when practitioner interferes with the right
of possession of patient’s property either by intermeddling or by disposing the
property of person.
• TRACEPASS TO LAND- unlawful interference with another’s possession of
land, either intentionally or as the result of negligency
• INVASION OF PRIVACY- when confidentiality of the client is not
maintained.
• DEFAMATION OF CHARACTER- act of holding a person to ridicule,
scorner, contempt with in the community. There are two types;
slander(spoken), libel(written).

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CONTRACTS FOR NURSING SERVICES:
It is a set of promises, for breach of which the law gives a remedy or in some way recognises
the fulfilment as a duty.
TYPES: FORMAL- required to be in writing
INFORMAL- as the result of spoken discussions
EXPRESS- combination of both written and spoken
IMPLIED- as a result of conduct on the part of the parties to which the law subscribe an
objective intention on entering into contract
LEGAL RESPONSIBILITIES OF NURSES:
• Responsibility of appointing and assigning
• Quality control
• Equipment
• Observation and reporting
• To protect public
• Record keeping and reporting
• For the death and dying
• Knowledge regarding institutional rules and policies
LEGAL SAFEGUARD IN NURSING PRACTICE:
• LICENSURE- nurses have to possess a valid licensure issued by the respective state
nursing council or INC.
• GOOD SAMARITAN LAW- exempt doctors and nurses from liability when they are
rendered first aid during emergency.
• GOOD RAPPORT- a lawsuit is often circumvented when the nursing staff threats the
client with warrants and caring.
• STANDING ORDER- nurse may apply standing order treatment guidelines that may
have been established by the doctors as appropriate for certain problems.
• CONTRACT- written or oral agreement between two people in which services are
exchange. Any treatment of serious nature which include anaesthetics, requires the
written consent of the patient.
• CORRECT IDENTITY- making sure all the babies born in the hospital are correctly
labelled at birth with time and place.
• COUNTING OF SPONGES, INSTRUMENT AND NEEDLES- in order to make sure
that it may not left in the patient’s body during surgery.
• DRUG MAINTENANCE- it includes two laws regarding storage of poisonous drug
and misuse of drugs.
• SELF DISCHARGE OF THE PATIENT- when the patient wants to discharge
himself, then the nurse of duty should try to dissuade him and inform medical officer
concerned with the case.
• PROFESSIONAL CONFIDENCE- health care professionals should never discuss
personal information received by nature of their position except with the senior
member of the staff.
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 • DOCUMENTATION- the nursing record is a legal document and admissible in court
as evidence.
• PATIENT’S PROPERTY- hospital should inform all patient’s under it’s care that the
hospital can not accept the responsibility for any valuables unless they have been
handed over for safekeeping.
• REPORTING- nurse’s have obligation to report certain communicable diseases or
criminal activities to appropriate authority.

RESEARCH:
Awareness of Nurses on Legal and Ethical Aspects of Nursing in Selected Hospitals of
Lalitpur
Sarju Maharjan, Mamta Thapa, Bijay Maharjan
A descriptive cross-sectional study was conducted in Sumeru, Sumeru City & Ganeshman
Singh Memorial Hospital of Lalitpur district on 168 nurses.The semi-structured questionnaire
was self-administered to collect the data.Around 40% of the respondents had inadequate
knowledge of ethical and legal aspects of nursing. The present knowledge level of nurses
emphasizes the need for making aware of these topics.

CONCLUSION:
As we have discussed, that autonomy, accountability & assertiveness are the essential
characteristics that a nurse should have in herself/himself. As assertiveness is simply saying
yes or no to anything & autonomy is so relative that itself means taking your own decisions
are equally important so that we can take responsibility for our actions as it comes under
accountability. If we compare the historical perspective with the present image of nursing, it
is quite impressionable that this profession has Changed its image towards self & others. If
we view ourselves as an important part of the health care delivery system then nobody else
can make us feel less important. The legal rights of the patients & the health care
professionals are equally important to study & be knowledgeable about. If we know our
rights & responsibilities well then we can make the future visibility of nursing even better
than today.

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REFERENCE:
• Navdeep Kaur Brar, HC Rawat, Textbook of Advance Nursing Practice 1st edition,
Jaypee Bros, The Health Sciences Publisher, page no.28-58.

• Dubnick, Melvin (1998). "Clarifying Accountability: An Ethical Theory Framework".

In Charles Sampford; Noel Preston; C. A. Bois (eds.). Public Sector Ethics: Finding
And Implementing Values. Leichhardt, NSW, Australia: The Federation
Press/Routledge. pp. 68–81.

• Moreno, Ivan; Jauregui-Sánchez, Y.; Avendaño-Alejo, Maximino (2014). "Invisibility

assessment: a visual perception approach" . Journal of the Optical Society of America
A. 31 (10): 2244 2248.

• Bibcode:2014JOSAA..31.2244M. doi:10.1364/josaa.31.002244. PMID 25401251.

• https://www.researchgate.net/publication/350598394_Awareness_of_Nurses_on_Leg
al_and_Ethical_Aspects_of_Nursing_in_Selected_Hospitals_of_Lalitpur

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