AUTONOMY AND ACCOUNTABILITY

AUTONOMY

Introduction of autonomy:-

Autonomy is derived from a Greek word “Autos” means “Self” and “nomos” means ‘Laws”. The
right of self-Government acting independently or having the freedom to do so.

It`s the right of personal freedom of action, which is regarded as one of the hall marks of the
profession.

Definition of autonomy:-

Autonomy means that individuals are able to act for themselves to the level of their capacity. It is
the right of individuals, governing their actions according to their own purpose and reason.

Autonomy refers to the ability to act according to one`s knowledge and judgment, providing
nursing care within the full scope of practice as defined by existing professional, regulatory and
organizational rules.

Definition of Professional nurse autonomy:-

Professional nurse autonomy is defined as belief in centrality of the client when making responsible
discretionary decisions, both independently and interdependently that reflect advocacy for the
client.

Critical attributes including caring, afflictive relationships with clients, responsible discretionary
decision making, collegial interdependence, and proactive advocacy for clients. Antecedents
include educational and personal qualities that promote professional nurse autonomy.

Benefits of autonomy:-

 Professional autonomy leads to work autonomy and job satisfaction.

 Freedom to act on the binding decisions the nurse makes.
 For example, the nurse does not need to obtain permission from others to carry out actions she
has decided on. Instead, the nurse`s education has prepared her to enact the decisions. For
example, a nurse can decide to initiate an educational teaching plan with a new mother who is
trying to initiate breast feeding her newborn but is not being consistently successful. No one
needs to give the nurse permission to do this education with the mother.
 Autonomy in nurse`s practice contributes to the well-being of patients and add to the quality
of services and care that patients receive.

Strategies for enhancing autonomy in nursing

While a nurses scope of practice is legally defined based on educational qualifications and specific
experiences, professional and organizational expectations determined the degree to which
autonomous practice occurs.
 As described in the following section, strategies for enhancing autonomy are based on setting clear
expectations for autonomous decision making and providing support for increasing knowledge and
expertise of nurses.

a) Clarify expectations about clinical autonomy:-

Professionally and organizationally sanctioning and supporting the application of nursing

knowledge and expertise in the care of patients has been associated with enhancing autonomous
nursing practice.

Nurses can enhance autonomy by clearly communicating and organizing their work to ensure that
they have the freedom to act on nursing decisions using sound clinical judgment.

Describing expected behaviors involves communicating that nurses are expected and encouraged to
make decisions about clinical patient care, that are based on the science and art of nursing.

This involves setting an expectation of independent nursing action and supporting decisions making
within the scope of nursing practice.

In addition because nursing practice involves both independent and interdependent action, clearly
identifying acceptable responses to situations that are at the edge of nurses commonly accepted
scope of practice is helpful in this process.

Examples of such identifications including outlining expectations related to verbal physician orders
and establishing protocols for over the counter medications.

Behavioral expectations can be formally outlined in orientation programs, demonstrated by

preceptors and highlighted through ongoing discussions about clinical practice.

In addition to clearly defining expectations for autonomous clinical practice, incorporating nursing
knowledge and expertise into clinical practice embeds autonomous practice into patient care.

For example, patient care rounds can be organized in a way that ensures that nurses contribute to
decision making about the treatment plan of patients.

Recognizing autonomous practice can reinforce verbally communicated expectations. For example,
acknowledging exemplary performance by having nurses share clinical examples that highlight
autonomous practice.

This provides a venue for displaying sanctioned autonomous practice. Nursing grand rounds,
poster sessions on clinical case studies and situations shared during staff meetings can all be used to
illustrate examples of autonomous nursing practice.

In addition, emphasizing expected behaviors through recognitions and rewards outlines for nurses
the realm of autonomous actions. Clinical ladder programs formally reward and recognize clinical
practice, further delineating expected autonomous actions.

Role modeling, expected behaviors also reinforces autonomous clinical practice. Notice nurses
quickly observe the nature of clinical judgment and autonomous nurse actions, demonstrated by
more senior colleagues and use these observations to identify accepted levels of independent and
interdependent decision making.

Clinical nurse leaders and clinical nurse specialists in the practice setting can engage in behaviors
reflective of autonomy and serve as an ongoing resource for role modelling, coaching, mentoring
excellence in clinical practice.

b) Enhance competence in practice:-

The establishment of the sound clinical judgment needed for autonomous practice requires a
foundation of nursing expertise.

Although difficult to define, nursing expertise is a combination of knowledge and skill along with
extensive experience. Thus, implementing strategies to increase the competence of nurses by
creating a learning environment can foster autonomy.

Autonomy can be fostered by enhancing competence and confidence through strategies such as
teaching rounds, formal continuing education, and a climate of inquiry in everyday practice. Also
during staff meetings, clinicians can share complicated patient scenarios that have challenged their
autonomous decision making to both exemplify excellence in practice and receive feedback on how
to further enhance patient care.

Promoting evaluation of autonomous practice and encouraging the continuous examination of

practice allows nurses to reflect on the degree of autonomy present in their making.

In addition, establishing an evidence based practice approach may develop and enhance autonomy.
By identifying and evaluating relevant research, while simultaneously assessing and incorporating
information about patient preferences into their plans, nurses have the opportunity to make
autonomous patient care decisions.

Further, development of skills related to communication, interdisciplinary teamwork and

negotiation can assist nurses to master the skills necessary to advocate for their patients way allows
for unique variations in culture and norms between units.

In summary autonomy can be increased by strategies that incorporate the unique knowledge and
expertise of nurses into clinical patient care.

Clarifying the expectation that valuable nursing knowledge should be applied in the practice setting
provides the framework for enhancing clinical autonomy.

Professional enrichment and education build the clinical knowledge and competence that is
necessary foundation for nurse autonomy.

c) Collaboration with physicians works very well with autonomy in nursing

Challenges to Autonomy in India:-

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

ACCOUNTABILITY

Accountability is the process that mandates that individuals are answerable for their actions and
have obligation to act.

 Accountability involves assuming only the responsibility that are within one`s scope of
practice and not assuming responsibility for activities in which competences has not been
achieved.
 Accountability is being responsible for one`s actions and accepting the consequences of
one`s behavior. Accountability is not a vague feelings or an obscure concept. It is clear
obligation which must be manifested as a structured component of nursing practice, based
on responsibility, authority and autonomy.
 “Accountability is a sense of overriding concern for nursing care, while responsibility is the
sense of duty in performing special tasks”.
 Accountability involves admitting mistakes rather than blaming others and evaluating the
outcomes of one`s own actions.
 Accountability includes a responsibility to the client to be competent to render nursing
services in accordance with standards of nursing practice and to adhere to the professional
ethics code.

The concepts of accountability have 2 major attributes:- answerability and responsibility

 Accountability can be defined in terms of either of these attributes but answerability for
how one has promoted, protected and met the health needs of the clients.

 It means to justify or to give an account according to accepted moral standards or norms for
choices and actions that the nurse has made and carried out.

 It involves a relationship between the nurse and other parties and its contractual. The terms
of legal account ability are contained in the ANA code for nurse and other standards of
nursing practice in the form of norms set by members of the profession.

It is noted that accountability means providing an explanation or rationale for what has
been done in nursing role.

Lines of Accountability:-

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

Types of nursing Accountability:-

 Fiscal accountability:- this accountability is concerned with financial probity and the
ability to trace and adequately explain expenditure.
 Process accountability:- this accountability is concerned with the use of proper
procedures.
 Programme accountability;- it is concerned with the activities undertaken and their
quality.
 Priorities accountability:- this deals with the relevance or appropriateness of chosen
activities.

Elements of accountability:-
Where an expectation of accountability exists-three elements- clarity, commitment, and
consequences must be present.

a. Clarity: clarity means expectations and goals are clear and specific.
Clarity also means explaining why. If staff members know the reasons behind the
expectation, they`re more likely to commit themselves to meeting it.

b. Commitment: you have to ask for a commitment to get it. Simply giving an order isn`t
enough. The accountable employee must listen, understand, agree and commit to
achieving the objectives.

c. Consequences: consequences are after effects of the negligence to commitments. A

person should bear the consequences of being unaccountable.

Accountability of nursing personnel

Accountability is at the heart of nursing, weaving its way through nursing practice in all settings
and at all levels. It`s an energizing force throughout an organization.

Nursing personnel are accountable for:-

1. Providing safe and therapeutic environment for the patients.

2. Delivering component and personalized care.

3. Maintaining adequate supplies for material and equipment for smooth functioning of
the unit.

4. Maintaining accurate and up to date records and reports.

5. Maintain good IPR.

 6. Protecting client`s legal rights and privacy.

7. Working within ethical and legal boundaries.

8. Keeping pace with changing health needs and developing technology.

9. Delivering care as per standards lay down by profession, statutory body and institution.

10. Delegating responsibility appropriately.

11. Contributing to development of the profession.

Reasons for lack of Accountability:-

o Job description not available.
o Lack of guidelines, standards and control.
o Authority not specified.
o Overburdened staff due to shortage of staff.
o Lack of adequate training and efficient experience.
o Lack of up to date knowledge, skill and competence.
o Unwilling.
o Inadequate supervision by ward managers.
o Out-dated policies, protocols & procedures.
o Lack of decision making.

Ways for enhancing accountability in Nursing:-

 Well defined duties and job description.

 Written policies, protocols and procedures.
 Nursing audit and standards of practice.
 Proper delegation of responsibilities.
 Proper training and education of the self.
 Periodical evaluation of each individual`s nursing practice.
 Refine and modify outdate policies and procedures.
 Conducive working environment.
 Availability of adequate number of personnel and resources for patient care.
Summary:-

Autonomy is the freedom to make discretionary and binding decisions consistent with ones scope
of practice and freedom to act on those decisions. Innovations by nurses, increased productivity,
higher retention and greater client satisfaction are results of autonomy. Accountability is a sense of
overriding concern for nursing care, while responsibility is the sense of duty in performing special
tasks.

Conclusion:-

Accountability cannot be achieved unless the nurse has autonomy to practice. It is necessary to
strike a proper balance between autonomy and accountability.
 GOVT. COLLEGE OF NURSING, JAGDALPUR

SUBJECT:

ADVANCE NURSING PRACTICE

SEMINAR ON:

“ AUTONOMY AND ACCOUNTABILITY”

SUBMITTED TO, SUBMITTED BY,

MS. POOJA NETAM AANCHAL BARIK
DEMONSTRATOR M.SC[N]PREVIOUS YR.
GOVT. COLLEGE OF NURSING, GOVT. COLLEGE OF JAGDALPUR
NURSING, JAGDALPUR

Bibliography

1. Navdeep Kaur Brar, HC Rawat, Textbook of Advance Nursing Practice, 1 st edition,

Jaypee Health science publisher.

2. Shabeer P Basheer, S Yaseen Khan, Textbook of Advance nursing practice, 2 nd edition,

Emmess medical publication.

3. Samta Soni, VJ Priti Nair, Textbook of Advance nursing practice, 1st edition.

4. I Clement, Textbook of Community Health Nursing, 1st edition

5. R. Sudha, Nursing Education principle concepts, Jaypee the health science publisher.
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