Accountability may be one of the most frequently used words in our profession. The Nursing and Midwifery Council (NMC)(2018)Code recognises that:
‘The professions we regulate have different knowledge and skills … They can work in diverse contexts and have different levels of autonomy and responsibility. However, all of the professions we regulate exercise professional judgement and are accountable for their work.’
The Code also says that we must:
‘Be accountable for your decisions to delegate tasks and duties to other people.’
Cornock (2014) explored the legal principles of responsibility and accountability in professional health care, reflecting that there is a trident of responsibility, accountability, and liability – the three terms may be seen to form a hierarchy with responsibility being the least onerous, moving through accountability, to liability having the most potential impact.
Cornock (2014) helpfully suggested that ‘professional accountability’ therefore refers to the autonomous health professional who has the knowledge, competence and authority to practice in the way that they see fit, according to their professional training; to act or not to act, using their own judgment to decide what treatment is necessary; the freedom to decide how best to deliver that treatment; and the ability to justify their action or inaction based on their knowledge and expertise.
The NMC is currently planning a refresh of The Code, considering where the current and future context and environment need to be reflected. This year, the NMC will publish the learning from several commissioned reviews following criticisms regarding the handling of several fitness to practise cases. One of the areas that I am looking to strengthen is working with employers.
The NMC (2021) fitness to practise principles outline the role of the employer in relation to fitness to practise concerns. Principle four states:
‘Employers should act first to deal with concerns about a nurse, midwife or nursing associate's practice, unless the risk to patients or the public is so serious that we need to take immediate action.’
This recognises that employers are closest to the source of the risk to patients or members of the public, and so can intervene more directly and quickly to deal with the risk. The NMC says that it only needs to become involved early on if the person poses a risk that the employer cannot manage effectively, and which means that their right to practise needs to be withdrawn or restricted immediately.
I have been reflecting on tools that professionally guide employers. The Just Culture Guide and current NHS patient safety strategy (NHS England/Improvement, 2018; 2019) provide frameworks to enable a systematic approach to ensure that we are proportionate in our considerations.
I have also been looking for tools to consider professional accountability. A colleague shared the Accountability Ladder with me, which I feel would add value for nurses. Duncan (2018) reflected on the importance of defining what accountability really means in the workplace and engaging people in ways that win their hearts and minds and commitment. It is well worth looking into the ladder of accountability in more depth with local teams to spark conversations. The ladder considers accountability in the sense of owning or taking responsibility for yourself, your actions and your impact. It acknowledges that accountability is a complex thing, made up of a number of behaviours and attitudes that allow us to either take ownership or adopt the role of a victim. Briefly, it is laid out as follows.
- Make it happen – this requires relentless commitment
- Finding solutions and just below this, those people who ‘embrace it’ or take ownership
- Acknowledge reality – accepting that something needs to be changed
- Wait and hope – a mindset that places the obligation to act on others
- ‘I can't’/personal excuses – a belief that they are controlled by circumstances
- Blaming others when things have gone wrong
- Unaware/unconscious – no awareness that a situation even needs attention.
To act or not to act is a key consideration of professional accountability – in understanding why the right actions regarding patient safety or professional issues are delayed, we should consider a range of concepts including the accountability ladder.