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The aim of this assignment is to discuss accountability and autonomy as being a fundamental aspect of nursing practice in Ireland. The author will define autonomy and accountability, the role of management, primary nursing, barriers to autonomy and accountability, nurse education and whether autonomy is something nurses really want.
An Bord Altranais (2000 p.7) citing Lewis and Batey (1982) define accountability as “the fulfilment of a formal obligation to disclose to referent others the purposes, principles, procedures, relationships, results, income and expenditures for which one has authority”, and autonomy as having the “freedom to make discretionary and binding decisions in accordance with their scope of practice and act on those decisions”.
The numerous changes to the operations of health care organisations and the striving for professionalism of nurses requires the enhancement of nurses autonomy to adjust and cope with these continuous practice changes. The attainment of nursing autonomy is encompassed in the context of accountability, authority and responsibility (Mrayyan 2006).
The involvement of nurses in their patients’ care and the daily functioning of the healthcare setting is an aspect of their autonomy…this attainment of “autonomy will influence nurses’ job satisfaction and retention, patients’ satisfaction and the quality of nursing care” (Mrayyan 2006, p.391). Nursing professionals know all to well that professional status cannot be attained without autonomy. Therefore, for example, nurse managers play important roles in promoting autonomous decision making of their nurses (Mrayyan 2006).
Autonomy in general and autonomous decision making in particular can be influenced by managerial interventions. Nurse managers can initiate interventions at ward level that promote nurses’ autonomy, which will influence job satisfaction and retention as well as patients’ satisfaction and the quality of nursing care (Mrayyan 2006). Autonomy requires delegation; delegation by nurse managers to their nursing staff can provide nurses with more opportunity for professional nursing roles, offering the scope to have autonomy (Parsons 1998).
Managerial interventions, whether director, assistant director or nurse manager instigated, are actions initiated at the ward or departmental levels to promote autonomy and accountability. In nursing, these interventions aim to enhance nursing performance, patients, outcomes and the quality of nursing care (Goode & Blegen 1993). Nurse managers’ can support and promote nurses at the ward level, thus enhancing their autonomy. Autonomous decision making reflects positively on the quality of nursing care and nurses’ job satisfaction and desire to stay in the post.
Nurses’ participation in decision making is a part of their autonomy and enhances their power (Krairiksh & Anthony 2001). Ward-based managerial actions initiated to promote nurse autonomy become more crucial because of the frequent changes in health care systems. The freedom and confidence attained with autonomy in turn leads the nurse to be able to be accountable for their decision making, answering such questions as how decision will affect patient care, how the decision will affect nurses, how decision will affect unit operations, and how decision will affect organizational outcomes (Mrayyan 2006).
As above autonomy is often addressed in the context of accountability, authority and responsibility (Specht 1996). The freedom to make independent decisions about one’s practice is an essential aspect of autonomy. In order to attain autonomy, and thus accountability the role of the nurse must be clearly defined. Clear role definition is a basic component of nurse autonomy, and clear roles are essentials for determining one’s rights and duties (Mrayyan 2006), and a clear role definition can be achieved through primary nursing care.
Primary nursing is a style of care that promotes nurses autonomy and accountability while providing continuity of patient care. Primary nursing will encourage nurses to participate in patient care and ward functioning decisions. Primary nursing appears to be the standard type of nursing in Irelands psychiatric wards. As stated previously, autonomous decision making encourages nurses to retain their jobs for an average of 4-5 years. Nurses’ turnover contributes to a decline in the quality of nursing care or the closure of some hospital beds (Mrayyan 2006).
“The antecedents related to education include: (i) competence based on a strong knowledge base; (ii) a clear understanding of the scope of nursing practice; and (iii) a baccalaureate or higher degree in nursing. Personal attributes that precede professional nurse autonomy include: (i) self-respect or caring for oneself; (ii) personal autonomy; and (iii) androgyny” (Wade 1999, p.314).
To develop autonomy related attitudes in students, a curriculum based on a nursing theoretical framework with a learner-centred design is needed. The theoretical framework provides structure for organising the course content and the way nursing is taught. The application of a nursing theory to the curriculum helps students understand the relationship of nursing knowledge to practice, define the domain of nursing, and gain control over nursing practice (Moloney 1992). Furthermore, a more theoretically focused curriculum is related to higher levels of student autonomy than modules that focus primarily on practice skills (Hallsworth 1993).
“To promote professional nurse autonomy, the curriculum should have a strong liberal education foundation. The aim of a liberal education is to prepare a graduate who `will exhibit qualities of mind and character that are necessary to live a free and fulfilling life, act in the public interest locally and globally, and contribute to health care improvements and the nursing profession” (Wade 1999 p.315). Professional nurse autonomy is a complex, multidimensional concept that may be a result of one’s beliefs, life experiences and socialisation; however it can be informed or guided by a solid nurse education (Wade 1999), as is been taught in Irelands third level institutions.
Bixler & Bixler (1945) noted that obstacles to overcome in achieving professional nurse autonomy are grounded in traditional conceptions of the term. Traditional views, based on a male model of autonomy that emphasizes control and separation, devalue the professional nurse’s relationship with the client and the attitudes and behaviours of a primarily female profession (Boughn 1995). Lach (1992) acknowledged that decisions may involve interdependence with other members of the health care team, such as Ireland’s multidisciplinary teams. Autonomous decision making does not involve the exercise of routine tasks or the unquestioning enactment of physician orders (Kramer & Schmalenberg 1993). Instead, self-direction and a strong knowledge base are required to negotiate and compromise within multidisciplinary teams. Discretionary decision making is crucial to autonomous practice (Holden 1991). Competent nurses; exercise discretionary decision making by using the critical thinking to select a course of action consistent with the client’s needs (Wade 1999).
Discretionary decision making, a key component of professional nurse autonomy, is based on nursing knowledge, and not emotions or the exercise of routine tasks. Autonomous nurses are accountable for their decisions, feel empowered, and may influence the professionalisation of nursing (Wade 1999). The author alleges that nurses’ in Ireland will question physicians.
Research in recent years has shown that nurses are making morally sound and ethically acceptable choices based on their own decision-making abilities, whilst having little or no active knowledge of the existing professional codes, according to Esterhuizen (2006), this may suggest that the ‘profession’ of nursing is one that can certainly be autonomous and accountable, but on the other hand also reject the accountable attained from autonomy. Norberg, Hirschfield, Davidson, Davis, Lauri and Lin (1994) report that registered nurses are able to make morally responsible decisions based on autonomy and beneficence, but are willing, however, to alter their decision on receiving a medical order to the contrary or a request from the family. Although the original decisions made by the nurses are in accordance with the nursing codes, they seem unwilling or unable to stand by their choice. The role of nursing code and its affects on nursing autonomy can therefore be scrutinised concerning its value to the physician, family or nursing staff, if nurses are unable to use it in substantiating their decisions (Esterhuizen 2006), which also may happen in Irish settings.
In the American literature pertaining to autonomy, it points to accountability as the principal outcome of professional autonomy. U.S. courts, including the Supreme
Court, for example, recognise that people in prison are dependent on specialist ‘correctional’ nurses for services; therefore, these correctional nurses and the institutions that employ them have a duty to provide health care services that reach at least minimally acceptable standards (Smith 2005).
Autonomous nurses must be able to carry out their duties independently, and have a role that is firmly based in nursing theory and that is independent of outside influence (Smith 2005). Nurses, like other groups throughout history, have been described as an oppressed group and traditionally the cultural narration of nurses is to be subordinate (Roberts 1983). This view is supported by a wealth of literature, “which advocates that nurses lack autonomy and control, have a lack of self-esteem, have a fear of success and subscribe to the submissive-aggressive syndrome” (Freshwater 2000 p. 481-2).
Ki-Kyong, Sook-Kim, Hee-Lee (2007) carried out a study in which a result being nurses identifying themselves as independent and autonomous practitioners involved in clinical decision-making, however there study suggested evidence of a reluctance to practice autonomously and to therefore be held fully responsible for nursing actions.
Nursing autonomy and accountability in Irish nursing is attained through good management, primary nursing and a strong founding education. Management need to delegate more to nursing staff offering more scope for autonomy, primary nursing gives nurses’ responsibility for a group of patients or clients, and a strong founding education can instil a basic desire and belief of autonomy in newly registered nurses’. There are many barriers to autonomy and accountability, ranging from nurses’ being lower on the medical hierarchy to denying autonomy and accountability in an attempt to protect themselves. However in Irish nursing there is great scope for the nurse to be autonomous and accountable, it really is just a case of ‘if they want it’.
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