Nursing leaders set the tone for a culture of professional responsibility.
- Professional accountability is a commitment that you make to yourself and your career when you become a nurse to advance, grow, improve, and adapt to your work.
- Ownership comes from being fully engaged in your work and feeling a sense of pride in your profession.
Steve has been a nurse for 10 years, and she’s worked on her unit for 5 of them. She loves direct patient care and frequently receives positive feedback from patients, their families, and her manager. Recently, patients on Steve’s unit have been developing hospital-acquired pressure injuries. The unit-based practice council (UBPC) has been tasked to develop an evidence-based practice (EBP) project to reduce pressure injuries. Steve doesn’t believe this is an issue with her patients, and she doesn’t intend to change how she provides care.
Unfortunately, Steve’s reaction to this evidence-based project isn’t unusual. Getting professionals to change their practice or accept responsibility for their contributions to overall clinical outcomes can be challenging. This may result from the structure of nursing care delivery models and 12-hour shifts that don’t always promote care assignment continuity or feelings of ownership for patient outcomes. However, the current value-based healthcare reimbursement system requires professional accountability for quality outcomes, and nurses like Steve are expected to work as members of a team to achieve collective results (such as reducing hospital-acquired pressure injuries). Not surprisingly, the issue of professional accountability in nursing has become a concern in many healthcare environments.
We talk about nursing professional accountability as though all nurses share a common definition and understanding of what that means. For some nurses, accountability can provoke fear and mistrust because they think it will be used as a whipping stick to promote compliance. We also can’t assume that all professional nurses have a clear understanding of their role or what’s expected of them.
Steve might not realize that she’s not only accountable for the actions she’s currently taking in her practice but is also expected to use new evidence to guide her practice and comply with the policies and procedures implemented on her unit to improve care. To uphold her professional accountability commitment, she can’t opt out of implementing new guidelines for pressure injury care.
The professional accountability mindset
Professional accountability is an internally driven mindset. It’s a commitment that you make to yourself and your career when you become a nurse to advance, grow, improve, and adapt to your work. It’s also a pledge to apply your talents, energies, and gifts to improve patient outcomes. According to the American Nurses Association’s (ANA) Code of Ethics for Nurses with Interpretive Statements, nurses are both “accountable and responsible for the quality of their practice.” This means that nurses must take ownership of their actions and hold themselves accountable not only individually but also as members of a collective team. Variations in practice patterns of individual nurses who view professional accountability differently can result in patient safety issues and medical errors. (See Accountability at a glance.)
Steve may see no problem with her decision to deviate from new evidence-based practice recommendations, but her failure to follow them could have serious ramifications for patients. If she doesn’t make changes in her practice, she’s failing to uphold a professional accountability mindset.
Within their professional roles, nurses are expected to implement accountability safeguards. These include evaluating patient care through peer review, quality improvement, and research, which promotes the mindset that our actions have consequences that directly impact the patients we care for. Steve’s ethical responsibility is to reflect on the difference between not taking action because she believes hospital-acquired pressure injuries aren’t an issue with her patients and what it means to truly provide quality evidence-based care.
Checking in vs. checking out
Nursing is a specialized profession that requires rigorous education, licensure, and regulation. It also relies on scientific evidence and a commitment to lifelong learning. These defining characteristics demand that nurses stay checked into their profession through critical thinking and collaborative care with other nurses and healthcare providers. The other option is to check out professionally and view nursing as a 12-hour shift composed of tasks to be completed.
Steve should remember that she’s not working in a solo practice. She functions as part of a healthcare team. She can’t make individual clinical decisions that conflict with the care given by other team members even when it’s based on her clinical experience or expertise, although she should certainly speak up if she feels a decision will be detrimental to the patient. If Steve believes that “this is not my problem,” she’s both checking out on her profession and failing to demonstrate good teamwork. Checking out is detrimental to the safety and health of the patients we serve.
The Code of Ethics reminds us that nurses are required to contribute to professional advancement by respecting the contributions of individuals who promote quality patient outcomes and evidence application. That means nurses must stay checked in and be actively present during professional activities such as educational sessions, patient care, patient safety discussions, and nurse-to-nurse hand-offs. For Sally, this also means being committed to engaging in the EBP her unit is rolling out because it aligns with her obligated ethical responsibility to take part in quality patient care rooted in evidence.
Building a culture of professional ownership
If Steve refuses to change her practice, her nurse manager will need to address this as a performance issue. Failing to assume professional accountability frequently occurs when leaders don’t hold nurses accountable for their decisions and actions. Leaders must be vigilant about unprofessional behaviors and practices and take steps to stop them before they become normalized on a unit. Interestingly, deviation from expected practices occurs more frequently with experienced nurses like Steve who believe the rules don’t apply to them. If Steve is allowed to opt out of evidence-based practices implemented on the unit, these deviations may become part of the culture. Nursing staff knows when “good enough” is the culture of an organization.
Joe Tye and Bob Dent, in their book, Building a Culture of Ownership in Healthcare, suggest that accountability isn’t enough. Accountability using traditional definitions means that nurses do expected behaviors because others expect it of them. Maintaining a culture of accountability can be exhausting for leaders, and such a culture will never take an organization from good to great. Tye and Dent recommend that the goal should be a culture of ownership where nurses do the right thing because they expect it of themselves. Ownership comes from being fully engaged in one’s work and feeling a sense of pride in one’s profession. This can be achieved only by connecting the nurse’s core values to the organization’s values.
Set the expectations
Professional nursing accountability and ownership is a mindset. In an ideal world, all nurses would take ownership of their practice and understand that quickly adopting EBPs designed to improve care is part of their professional responsibility. Unfortunately, not all nurses have this mindset. Some nurses like Steve may still choose to check out professionally and will need to be held accountable for their decisions. Strong leadership expectations and ongoing coaching about what it means to be a professional are critical to building a culture of professional ownership.
Rose O. Sherman is a professor of nursing and director of the Nursing Leadership Institute at Florida Atlantic University and author of the book The Nurse Leader Coach: Become the Boss No One Wants to Leave. You can read her blog at emergingrnleader. com. Tanya M. Cohn is a nurse scientist in nursing and health sciences research at West Kendall Baptist Hospital in Miami, Florida.
American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. American Nurses Association: Silver Springs, MD; 2015.
Porter-O’Grady T, Malloch K. Quantum Leadership: Creating Sustainable Value in Healthcare. 5th ed. Burlington, MA: Jones & Bartlett Learning; 2018.
Rachel MM. Accountability: A concept worth revisiting. Am Nurse Today. 2012;7(3):36-40.
Tye J, Dent RL. Building a Culture of Ownership in Healthcare: The Invisible Architecture of Core Values, Attitude, and Self-Empowerment. Indianapolis, IN: Sigma Theta Tau; 2017.