As registered nurses you are legally and professionally accountable for your actions, irrespective of whether you are following the instructions of another or using your own initiative (Griffith and Tengnah, 2010). The consideration of what accountability means in nursing practice is a key part in the foundation of nursing, some would say that being accountable means being responsible, and as a consequence taking the blame when something goes wrong.
To be accountable is to be answerable for your acts and omissions, this is the approach adopted by the Nursing and Midwifery Council (NMC) the nursing regulatory body.
It states within its code “You are personally accountable for your actions and omissions in your practice and must always be able to justify your decisions” (NMC, 2008). Therefore accountability is being answerable for your acts to a higher authority with whom you have a legal relationship. A wider view of accountability is defined as an inherent confidence as a professional that allows a nurse to take pride in being transparent about the way he or she has carried out their practice (Caulfield, 2005).
In order to provide maximum protection to the public and patients against misconduct of registered nurses, four areas of law are drawn together which individually hold you to account. These are society through public law, patient through tort law, employer through the contract of employment and profession through statute law, such as the NMC.
This assignment will reflect on the work and study carried out within the Accountable Practitioner module including lectures and facilitated group sessions in which reflective diaries were completed [see appendix I-IV].
By completing a Root Cause Analysis (RCA), a system used to find flaws and opportunities for improvement of health care, on the Pamela Scenario, it was highlighted that the theme ‘consent’ was an area of concern (Transition to Practice, 2012). I will therefore be looking into the three pillars of accountability which are professional, legal and ethical and relating each of these to my chosen theme and applying this to the Pamela Scenario.
Professional accountability consists of an ethos in nursing that is based on promoting the welfare and wellbeing of patients through nursing care. This all comes together within the heart of nursing. Within our group sessions we discussed who registered nurses are accountable to, these being through the provisions of the Nurses, Midwives and Health Visitors Act 1997 and the Nursing and Midwifery Order 2001.
The NMC was established under these provisions in 2002 to protect the public by establishing standards of education, training, conduct and performance for nurses to ensure these standards are maintained (Nursing and Midwifery Order, 2001). Professional accountability allows nurses to work within a framework of practice and follow principles of conduct set out by the NMC that maintain the patients trust in the individual nurse and nursing as a whole (Caulfield, 2005).
Obtaining consent affirms the patient’s right to self-discrimination and autonomy. The NMC code of professional conduct has a separate section on consent (NMC, 2002). Clause 3 requires that ‘as a registered nurse, midwife or health visitor you must obtain consent before you give any treatment or care’.
The professional duty recognises the value of autonomy in clause 3.2 and states that a refusal to receive treatment must be protected even where this may result in harm or death to the individual. The professional duty also requires that the nurse gives information that is accurate and truthful and this must be presented in a way that is easily understood (Bowman, 2012).
Within the Pamela scenario there is no suggestion as to whether consent was gained. At the beginning of her care, when she was admitted to an orthopaedic ward they suggested a skin traction should be applied to the affected limb, however no consent was gained and the staff on the ward took it upon themselves to determine whether this was the best action. Within our group we discussed that at this point Pamela was mentally capable of giving informed consent [see appendix II].
Pamela later became very agitated and confused and was eventually referred for a CT scan which showed findings of Alzheimer’s disease. From this point onwards there is no evidence to suggest that consent was gained from someone with capacity following the Mental Capacity Act (2005) where they state “a person is unable to make a decision for themselves if they are unable to: understand information given to them, retain that information, use or weigh that information as part of the process in making a decision and communicate that information”.
In this instance it is not possible to determine whether Pamela was able to give informed consent herself or whether any family members gave this for her. Professionally the staff within the ward that made this decision on her behalf would be held accountable.
The law is a major area of accountability for nursing practice. The law is a set of rules, regulations and cases that provide interpretation of the rules and regulations that apply to society. There are very clear penalties for anyone, including nurses, who fail to follow the rules set out by law. Within our group sessions we discussed the two systems of law within the UK [see appendix I]: civil law and criminal law, each one consists of its own structure and different rules apply for each system (Young, 2008). The types of civil law that affect accountability in nursing practice include disputes with employers, cases of patients suing due to allegations of negligence and cases where a nurse sues her employer due to injury at work.
All these cases are heard in civil courts and the judge can award compensation. Criminal law is the system designed to assess that rules set out by parliament are followed. The acts of parliament deal with issues such as medicines, suicide, organ and tissue donation, mental health and decisions about health care where a person does not have the capacity to make their views known.
Criminal penalties include fines or imprisonment (Caulfield, 2005).
The law recognises that adults have a right to determine what will be done to their bodies. Touching a person without consent is generally unlawful and will amount to infringe to the person or, more rarely, a criminal assault. Unlike other civil wrong doings such as negligence which requires harm, any unlawful touching is actionable despite whether being done with the best of motives (Tingle and Cribb, 2007). When obtaining consent, you must ensure that the patient agrees with all the treatment intended to be carried out. Proceeding with treatment that the patient is unaware of, or has refused to agree to will be a trespass to the person and actionable to law.
Nurses must therefore take care to explain all the treatment or touching that will occur when obtaining consent from a patient and ensure that any additional treatment is subject to further consent (Savage and Moore, 2004). “Consent is an expression of autonomy and must be free choice of the individual. It cannot be obtained by undue influence” (Griffith and Tengnah, 2010, p.82). In law, undue means that the influence must remove the patient’s free will and be so forceful that the patient excludes all other considerations when making their choice.
It is an established part of law that no treatment may be given to an individual, whether it be clinical or nursing unless the patient has consented (Johnstone, 2009). Therefore as consent was not gained within the Pamela scenario when deciding whether to apply traction to her leg the doctors and nurses involved in making the decision on her behalf would be held legally accountable and could face criminal prosecution.
Within our facilitated group sessions we discussed the following established principles which must all be satisfied before consent is sufficient [see appendix III]: ‘consent should be given by someone with capacity’. Within the scenario it is stated that Pamela was diagnosed with Alzheimer’s disease, however the family were not asked to consent on her behalf following the Mental Capacity Act (2005).
‘Sufficient information should be given to the patient’ is the second principle. Pamela’s family state they were unaware of what was happening with her care and within the complaints letter, Pamela’s daughter states staff did not give her relevant information even when Pamela was diagnosed with Alzheimer’s. The third principle ‘the consent must be freely given’, due to the staff not gaining any consent and taking the decision into their own hands this principle like the previous two was also not followed. The negligence and consent alone within this scenario would place the staff involved directly into legal accountability.
Accountability is an important ethical concept because nursing practice involves a relationship between the nurse and the patient (Fry, 2004). Within our group sessions we discussed Beauchamp and Childress (2001) who developed a framework which offers a broad consideration of ethical issues. This consists of four principles: respect for autonomy which means respecting the decision-making capacities of autonomous persons; enabling individuals to make reasoned informed choices. Beneficence, this considers the balancing of benefits of treatment against the risks and costs; the healthcare professional should act in a way that benefits the patient.
Non maleficence, this means avoiding the causation of harm, the healthcare professional should not harm the patient. All treatment involves some harm, even if minimal, but the harm should not be disproportionate to the benefits of treatment. And finally, justice, this includes distributing benefits, risks and costs fairly, the notion that patients in similar positions should be treated in a similar manner.
Consent is a moral and legal foundation of modern health care. Treatment that proceeds without consent of the patient immediately requires a thorough moral investigation. Despite the fact that consent may have been given it is important to ensure this means more than the mere fact a form has been signed. The main role of consent is to protect patients and in particular to protect their status of autonomy and enable them to remain in control of their own lives (Fry and Johnstone, 2008).
In ethical terms, consent is important because it demonstrates respect for autonomy, therefore through participating in a consent process the person’s autonomy may be further enhanced by having the choice to accept or decline care. For some individuals their ability to consent may be compromised by their position within their cultural group. For example, women within certain cultures might have the capacity to consent but would not expect to have the right to determine what happens to them (Chadwick and Tadd, 2003). If consent was not gained and treatment was carried out on a person within an ethical group who did not agree to the treatment, then that person would be held ethically accountable.
In the scenario, nurses did not apply skin traction to Pamela’s leg despite the admitting doctor suggesting that it be applied. Ethically, this related to non-maleficence as it can be assumed the traction was not applied due to the treatment having a conservative nature and the nurses believing it would be of no benefit to Pamela in regards to pain relief. Also a large majority of care was carried out after Pamela was diagnosed with Alzheimer’s which leaves her vulnerable to treatment being carried out without consent from her or her family.
Throughout the module I have developed my awareness of the professional, ethical and legal issues that are associated with providing accountable health and social care. I was able to reflect on my own learning and development as an accountable practitioner and participate in the facilitated group sessions. I have increased in confidence and developed communication skills by having the opportunity to speak and voice my opinion in front of other colleagues; this will enable me to participate in handover and various team meetings whilst out in practice.
Analysing the scenario in groups enabled me to gain a clearer understanding into the issues raised and this allowed the assignment to be completed with confidence. I was able to strengthen my ability to appraise and use related evidence based literature to back up my statements which were from a variety of sources. Finally, being able to choose our own theme from the scenario enabled me to have a greater awareness of consent which will benefit me when out in practice.
I shall be using the Gibbs Reflective Cycle (1988) to reflect upon a critical incident that I have witnessed out during a ward based placement. The Gibbs reflective cycle suggests that theory and practice supplement each other in a never-ending circle which was coined from Kolb’s experiential learning cycle. By using the Gibbs reflective cycle I shall be looking into how I felt during the time, what I felt and thought after the incident and most importantly what I would do differently next time. Event
The incident I will be looking back on occurred whilst on placement within an orthopaedic ward when I was given the opportunity to assist a registered nurse on her drug round. I had previously assisted her on drugs rounds she was happy for me to administer the medication which was Enoxaparin on this particular patient. As I joined her with the drug round part way through, due to helping another patient she had already confirmed the patients name and date of birth and the patient had verbally consented to the administration and therefore I was told me to just administer it.
I followed all the relevant policies and procedures whilst administering the medication however I did not understand why the registered nurse would allow me to administer the drug without myself gaining consent from the patient to ensure he was happy for a student nurse to carry out the administration. I therefore explained to the patient that I was a student nurse and I had previously carried out an administration of enoxaparin but explained to him that I would not be offended if he was not happy for me to administer the drug myself. I had been looking after this patient over a number of days and had therefore gained his trust so he verbally consented to me administering the drug and allowed me to continue.
Whilst I was administering the medication I felt very confident as I had administered a number of these previously and also having a patient who was happy for me to carry this out enabled me to complete this competently. The patient also spoke to me throughout about his personal life so I was reassured that he was not feeling worried or anxious and therefore placed me in a confident frame of mind. The registered nurse was also shadowing me whilst I administered the drug so I was happy I was not going to make a mistake.
There was nothing bad about this experience apart from the confusion of the registered nurse telling me not to follow protocol and double check his date of birth and consent, however I felt I did the correct thing. I enjoyed administering the Enoxaparin as I felt it would enhance my experience and it was good practice for me, especially as this drug was a very common drug used within most hospital wards.
Although I felt confident administering the Enoxaparin, I did not feel all that confident when asked to administer the medication without checking the patient’s name and date of birth and gaining consent which is a vital protocol of administration of medicines set out by the NMC (2010). Looking back I should have voiced my concerns and asked why she did not want me to confirm these; however I did not want to question my mentors’ experience or authority.
A number of accountability issues were raised within this practice in which I later discussed with my mentor so I could confirm I did the correct thing. The Nursing and Midwifery Council (NMC) states that the administration of medicines is a vital aspect of professional practice for registered nurses which are to be performed in strict compliance with the written prescription of a medical practitioner requiring exercise of professional judgement (NMC, 2010).
The NMC (2010) also state within their consent code “To make the care of people their first concern and ensure they gain consent before they begin any treatment or care” I did carry out this principle although asked not to by the nurse I was working with. If I did not carry out these checks although only a student nurse I would still be held accountable for my actions when I knew this was against protocol.
As a student nurse it is acceptable to assist with drug ward rounds and administering medications, however when I was asked to administer the medication without the patients identity confirmed and consent gained I should have said I did not feel comfortable with the task as it was not working in conjunction with the NMC’s standards of medicines administrations but I would observe. When teaching a student and to improve general practice overall the nurse in question should have asked me to confirm the patients name and date of birth and gained consent before administering the medicine.
Although there was no issue with administering medicine to the wrong patient or any ethical issues due to not gaining consent on this day, this could have been a very big nursing error causing a potentially big problem with accountability on my behalf.
As a student nurse it is important to take opportunities to learn new skills when following a mentor that you might not necessarily feel entirely confident with however ultimate responsibility remains with me if I do not feel confident in the situation that I have been assigned. Although I was confident with the task in hand I was not happy with the way I was asked to carry out this procedure by missing out vital NMC code protocols. The only thing I would have done different in this situation would be to say I did not feel comfortable with administering medication to a patient without carrying out the relevant checks and I should have confronted the nurse in question and asked why she did not tell me to ask for these details.
Although she had carried these out previously she did not explain to the patient that I was a student nurse and this could have gone very wrong. If placed in this situation again I would not change anything which I personally did myself, I would still follow the NMC guidance on medicines administration (NMC, 2010) which therefore takes me out of the accountability question if anything was to go wrong, however I would confront the nurse and ask why these checks were asked to be skipped.
Personal Diary Sheet 1 (25/06/12)
Personal Diary Sheet 2 (09/07/12)
Personal Diary Sheet 3 (16/07/12)
Personal Diary Sheet 4 (23/07/12)
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