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We all know about the three Cs choice, continuity and
control, the central tenets of woman-centred care. However,
what we might be less familiar with is the concept of the three
As Autonomy, Assertiveness and Accountability. What does
this really have to do with everyday practice and the midwifery
A recent Healthcare Commission report highlighted several
issues, what part did a lack of assertiveness play? Are you
assertive? If you see a problem what is your response? Does
your accountability mean writing doctor informed? Midwives
need to question their own custom and practice, whether in
management, education or clinical practice. Do you have the
three As? If not, why not?
Accountability is a concept in ethics and governance with
several meanings. It is often used synonymously with such
concepts as responsibility, answerability,
blameworthiness, liability, and other terms associated with the
expectation of account-giving.
In leadership roles, accountability is the acknowledgment and
assumption of responsibility for actions, products, decisions, and
policies including the administration, governance, and
implementation within the scope of the role or employment
position and encompassing the obligation to report, be explain
and answerable for resulting consequences.

The ability and willingness to assume responsibility for
ones actions and accepting the consequences of one's
Accountability: being answerable to someone for something
-ANA, 2002
The state of being accountable; liability to be called on to
render an account; the obligation to bear the consequences
for failure to perform as expected; accountableness.
- R. Hall (The awful idea of accountability)


Bruce Stone, O.P. Dwivedi, and Joseph G. Jabbra listed 8 types
of accountability, namely:

Constituency relation

V. Dimensions of Accountability in Health care

Leat (1988) suggests that accountability has different
dimensions in the health care context. These include:
1. Fiscal accountability (concerning financial probity and the
ability to trace and adequately explain expenditure);
2. Process accountability (concerning the use of proper
procedures: for example, demonstrating that locally
derived standards and those set out by National Service
Frameworks are being adhered to);
3. Programme accountability (concerning the activities
undertaken and their quality); and
4. Priorities accountability (concerning the relevance or
appropriateness of chosen activities).
VI. Nurse and accountability (Accountability Checklists)
Nurse is accountable to
1. Her patients, through a duty of care, underpinned by a
common-law duty to promote safety and efficiency, and
legal responsibility through civil law;
2. Her employer, as defined by your contract of employment
and job description;
3. Her profession, as stated in the relevant codes of conduct;
4. The other members of health care team
5. The public

6. Self
1. Accountable to your Employer
All workers must be issued with a written contract of
employment within of starting a job. Your contract could
- What was agreed at your interview;
- Any document you have signed;
- Any implied terms of your employment.
2. Accountable to the profession
The position on your accountability forms the basis from which
to challenge unacceptable standards of care and makes it clear
that responsibility for your actions rests with you as an
individual nurse.
- Maintaining and improving professional knowledge and
- Acknowledging limitations in knowledge and competence;
- Declining any duty or responsibility unless you are able to
perform it in a safe and skilled manner.
3. Accountability to Clients
Clinical competence: knowing how & why things are done
Safe nursing care
Allow clients to participate in nursing care activities,
including planning
Respect individual client differences
Altruistic intentions
Serve as a client advocate when the need arises

4. Accountability to Health Care Team

Bring specialized nursing knowledge & skills to the health
care delivery situation
Share information with team members
Confront if potential errors may occur
Perform nursing tasks with competence
Treat members with dignity & respect
Accountability to Employing Agency
Quality of work
Protect against unsafe practice situations
Attitude conveyed about the agency
Use of outside agency personnel
5. Accountability to Self
Practice nursing to personal standards using professional
standards as a basis
Be true to oneself
Take care of personal, physical, mental, & spiritual health
Protect self from harm
The relationship between ability, responsibility and
accountability is illustrated in the diagram below:

VII. Accountability and standards

One aspect of exercising your professional accountability as a
nurse is the need to recognise and balance a range of
perspectives on what constitutes acceptable standards of care.
Patients have their own standards of personal health care that
will affect their view of the nursing care they receive. This
means that what is acceptable to a nurse may not be acceptable
to a patient, and vice versa.
Equally, although each qualified health care professional may be
an independent and accountable practitioner, he or she also
works as part of a team and teams often have members with
different standards. In addition, the team develops standards of
care that affect the patient. The team, as well as each individual
practitioner, is also affected by organisational and occupational

VIII. Accountability and Autonomy

Increasing clinical discretion and accept greater professional
responsibility by making their own decisions. They were also
required to carry out more direct care, research and
management, and were expected to contribute to policy-making
and strategy development.

Many nurses cite autonomous practice as a professional

aspiration. That is, you and your professional colleagues, not
just your employer, make the decisions about your practice. You
have your own caseload, perhaps working in a nurse-led unit.
You and your unit admit and assess patients, perform all the care
during their treatment and take responsibility for discharging
There is a clear link between accountability and autonomy: if
you want to be autonomous, you need to take responsibility for
your decisions and the results of your actions.
IX. The Groundwork for Accountability
Nurse or any health care professional should have some
qualities and give emphasis the groundwork to practice for
Growth & development of theoretical base for
professional practice
Clinical & professional competence
Leadership skills
Ethical framework
Baccalaureate nursing education & beyond
X. Accountability in the Era of Cost Containment

Unlicensed Health Care Worker

Managed Care & Third Party
Conflicts between Professional Values & Cost

XI. Accountability in the Future

Primary nursing
Team nursing
Shared governance
Advanced technology
Increasing ambiguity as part of an interdisciplinary
health care team member

XII. Positive Aspects of Accountability

Increased respect
Responsible & commended for maintaining safe
standards for client care


Professional accountability applies to everyone involved in
health care.
Accountability is a legal obligation; in health care it is also an
ethical and moral responsibility. Within the realm of
professional accountability, there are many factors.
Assuming responsibility for ones own nursing practice is the
most important. The American Nursing Association (ANA)
states in its code that the nurse will assume accountability for
nursing judgment and actions.
A professional nurse has the responsibility to practice within

his/her scope of care, calling upon his/her knowledge and skills

to make decisions in the best interest of the patient.
The level of responsibility and accountability depends on
professional levels. The Charge Nurse has more responsibility
then the staff nurse, the RN has more responsibility then the
LPN, and therefore their levels of professional judgment and
practice are different. Their levels of professional accountability
are not different.
Accountability has become central to the modernisation of the
NHS yet there has been little research since the introduction of
clinical governance on understandings or implications of
practitioners accountability. Historically, the literature suggests
that accountability has been attributed with multiple meanings
and that there have been multiple attempts to impose order on
these to map out types and lines of accountability, for example
but that accountability remains resistant to such efforts.
Arguably, nurses have wrestled with accountability more than
any other health care group once nursing seized accountability
as an emblem of its professional status. At the same time, the
meaning of accountability has changed. It has become
increasingly associated with audit and the technicalisation of
care, rather than, say, moral responsibility.

Each nurse is accountable to the public and responsible for
ensuring that her/his practice and conduct meets legislative
requirements and the standards of the profession. Nurses are
responsible for their actions and the consequences of those
actions. Theyre also accountable for conducting themselves in
ways that promote respect for the profession. Nurses are not
accountable for the decisions or actions of other care providers
when there was no way of knowing about those actions
Accountability is the right, power, and competence to act.
Accountability includes the autonomy, authority and control of
ones actions and decisions. Sample professional behaviours
evaluates client care and implements changes in care
practices to improve outcomes of care;
serves as a responsible steward of the environment, and
human and material resources while coordinating care;
uses an evidence-based approach to meet specific needs of
individuals, clinical populations or communities;
manages, monitors and manipulates the environment to
foster health and health care quality; and
prevents or limits unsafe or unethical care practices.

i) Book References:
1. Glover, D. (1999a) To do or not to do. The UKCC Code of
Conduct: A Critical Guide (ed. I Heywood-Jones),
London: Nursing Times Books: 2738.
2. Gold, R. (1958) Roles in sociological field observations.
Social Forces 36 (3): 217223.
3. Wiener, C. and Kayser-Jones, J. (1989) Defensive work in
nursing homes: accountability gone amok. Social Science
and Medicine 28 (1): 3744.
4. Watson, R. (1995b) Introduction: accountability in
nursing. Accountability in Nursing Practice (ed.
R.Watson), London: Chapman and Hall: 117.
5. Walsh, M. (1997) Accountability and intuition: justifying
nursing practice. Nursing Standard 11 (23):3941.
6. Tingle, J. (1997) Expanded role of the nurse:
accountability confusion. British Journal of Nursing 6
(17): 10111013.

ii) Journal References:

1. Ferguson-Pare, M. (1998). Nursing leadership and
autonomous professional practice of registered nurses.
Canadian Journal of Nursing Administration, 11(2), pp. 7
2. Lamond, D. & Thompson, C. (2000). Intuition and
analysis in decision making and choice. Journal of Nursing
Scholarship, 33(2), pp. 411414.
3. Murdoch-Perra, B. (2001). Leadership: The key to quality
outcomes. Journal of Nursing Care Quality, 15(2), pp. 68
4. Royle, J., Dicenso, A., Boblin-Cummings, B., Blythe, J. &
Mallette, C. (2000). RN and RPN decision making across
settings. Canadian Journal of Nursing Leadership, 13(4),
pp. 11-18.
5. Allen, P. (2000) Accountability for clinical governance:
developing collective responsibility for quality in primary
care. British Medical Journal 321: 608611.


Submitted to
M.Sc (N)
Associate Professor
Mamata College of

Submitted by
Mrs. Udaya Sree.G
M.Sc Nursing Ist Year
Mamata College of Nursing