Provision Four
Laurie A. Badzek JD, LLM, MS, RN, NAP
Laurie A. Badzek, JD, LLM, MS, RN, NAP, is currently Director of the American Nurses Association Center of Ethics and Human Rights, a role in which she previously served from 1998-99. During that time, Badzek was instrumental in developing a plan that ultimately resulted in the approval of a new Code of Ethics for Nurses by the 2001 House of Delegates. Currently a tenured, full professor at the West Virginia University School of Nursing, Badzek, a nurse attorney, teaches nursing, ethics, law, and health policy. Having practiced in a variety of nursing and law positions, she is an active researcher, investigating ethical and legal healthcare issues. Her current research interests include patient and family decision making, nutraceutical use, mature minors, genomics, and professional healthcare ethics. Her research has been published in nursing, medical, and communication studies journals, including Journal of’ Nursing Law, Nephrology Nursing Journal, Annals of Internal Medicine, Journal of Palliative Care, and Health Communication.
The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care.
Provision History
The framework for the inclusion of accountability and responsibility in the nursing ethical code is based upon many of the observations made by Florence Nightingale in the late 1800s. Nightingale dedicated her life to the advancement of the patient’s physical, emotional, and environmental well-being. Nightingale’s advances were the direct result of actions that improved quality care and the provision of education to those caring for persons of ill health. As detailed in Notes on Nursing, Nightingale recognized the importance of the choices made by a nurse in the daily care of patients and the accountability of the nurse for the outcomes of such care provided based on those choices.
The observations and documentations that Florence Nightingale made over a century ago recognized accountability as an essential characteristic of the nurse, and has enabled nursing to evolve into a strong, trusted profession, even in the face of current realities that complicate accountability and responsibility. Both the foresight and ingenuity Nightingale demonstrated resulted in an acknowledgement of the importance of accountability in providing high-quality care. The ethical accountability that nurses have today for the decisions and judgments they make can be directly traced to the writings of Nightingale.
In addition to a historical context dating back to Nightingale’s time, accountability and responsibility for nursing care have a more recent context in the current laws related to licensure, contracts, and malpractice. Increasingly frequent lawsuits against healthcare providers that result in high monetary awards to injured plaintiffs make the application of nursing skill and judgment, including delegation of tasks, even more challenging. Nurses who lack competency or who fail to provide appropriate professional nursing care may be subject to legal liability as determined by the courts as well as licensure actions determined by the State Board of Nursing, which may potentially impact the ability of the nurse to practice. Nursing practices that reflect incompetence or other such failures of care does not meet the moral standards of the profession as embodied, in part, by this Code of Ethics.
Content of Provision 4
Provision 4 of the Code of Ethics for Nurses addresses the individual responsibilities and obligations of the nurse. Although much of nursing is collective and involves relationships with others, the inclusion of responsibility and accountability in the Code of Ethics for Nurses informs the nurse that responsibility for the individual actions and judgments made minute by minute, hour by hour, and daily over a lifetime of practice belongs solely to the individual nurse making the decisions. The Code of Ethics for Nurses helps define the relevant ethical obligations and duties nurses have not only to the public, but to themselves as well. Expanded knowledge of responsibility and accountability in nursing helps not only the profession, but also the general public to better understand the level to which nurses as professionals hold themselves and one another accountable and responsible for nursing practice.
Accountability is often identified as an attribute of a profession. The acceptance of accountability by the members of the profession is an implied contract with the public (Burkhart and Nathaniel, 2002). The Code of Ethics for Nurses sets forth explicitly the values and obligations of the nurse. The Code of Ethics for Nurses also provides a clear statement of what the public can expect from the nurse and the nursing community in relation to their professional practice.
Public confidence is a necessity for any profession and is especially important in health care where the services provided are of a personal and sensitive nature. Accountability of nurses for patient care outcomes enables them to hold an autonomous position in the health care industry. Nursing has time and again been selected as the most trusted profession in several national polls, including the Gallup Poll (2006), thus demonstrating that nursing as a profession is held in extremely high confidence by the public at large.
An ethical dilemma occurs when two or more moral obligations or values conflict or compete and the appropriate choice in the situation is unclear. Exercising moral accountablity means the nurse will make a reasoned judgment about what is right and will act accordingly. An individual nurse’s determination of what is right may or may not be the same decision that others, including those to whom the nurse is accountable, believe is the right decision. Moral accountability does not mean congruence with others, but rather that nurses will be able adequately to defend and justify their decisions on moral grounds.
Ethical accountability requires decision making on the part of the nurse. Application of an ethical framework or decision-making process to issues of moral concern
is helpful to the analysis of an ethical question. Application of a reflective ethical framework to questions about what the nurse should do results not only in decisions that the nurse feels are right or good, but also in actions that can be justified by the nurse. Preferably, ethical analysis by the nurse should not require an emergency situation, but rather thoughtful applications of an ethical framework or decision making process with reflection on values and principles as a means to resolving conflict should be part of a nurse’s daily routine. Obviously, in the clinical setting, time is often a luxury; therefore, prior familiarity with ethical theory and a framework for ethical decision makingis essential. For example, making ethical determinations at the time a when treatment is ordered “stat” or staffing decisions must be made are examples of decisions that do not afford the luxury of lengthy deliberation.
is helpful to the analysis of an ethical question. Application of a reflective ethical framework to questions about what the nurse should do results not only in decisions that the nurse feels are right or good, but also in actions that can be justified by the nurse. Preferably, ethical analysis by the nurse should not require an emergency situation, but rather thoughtful applications of an ethical framework or decision making process with reflection on values and principles as a means to resolving conflict should be part of a nurse’s daily routine. Obviously, in the clinical setting, time is often a luxury; therefore, prior familiarity with ethical theory and a framework for ethical decision makingis essential. For example, making ethical determinations at the time a when treatment is ordered “stat” or staffing decisions must be made are examples of decisions that do not afford the luxury of lengthy deliberation.
Interpretive Statements
The purpose of the interpretive statements related to Provision 4 of the Code of Ethics for Nurses is to develop more fully the meaning of accountability and responsibility in nursing practice in order to provide consistent, universal application of the provision’s intent. The interpretive statements provide nurses with a social context for application of the provisions in practice and help to define them within the expanded roles of the nursing profession.
Practical Application of Interpretive Statements
Acceptance of Accountability and Responsibility
Accountability is both related to answerability and responsibility. Accountability is judgment and action on the part of the nurse for which the nurse is answerable to self and others for those judgments and actions. Responsibility refers to the specific accountability or liability associated with the performance of duties of a particular nursing role and may, at times be shared in the sense that a portion of responsibility may be seen as belonging to another who was involved in the situation. Nursing practice is individualized and the responsibilities of the nurse are role dependent. The individual role of the nurse carries with it specific duties and obligations. To meet the role obligations of the nursing profession, the nurse must be familiar with the scope and standards of the profession as well as those of the specific role carried out by the nurse. Regardless of nursing role, the nurse must adhere to the scope and standards of practice when performing or assigning the duties within that role in order to ensure safe, high-quality patient care. Depending on the role
of the nurse, the standards are layered and become more complicated as the expertise, complexity, and expectations of that role increases.
of the nurse, the standards are layered and become more complicated as the expertise, complexity, and expectations of that role increases.
Nurses are expected to be able to justify actions based upon nursing skill and knowledge and the application of the nursing process, critical thinking, and nursing knowledge to the care they provide. For example, at a novice or entry level, a professional nurse would have: an understanding of the current scope and standards of practice, the Code of Ethics, and Nursing’s Social Policy Statement; the basic knowledge and skills needed to demonstrate competency in the practice of nursing and a working knowledge of the laws and policies that govern nursing practice. Thus, a newly licensed nurse would not be expected to be able to make a decision about whether the healthcare organization in which they worked had acted appropriately or had instead put nurses and patients at risk when a management decision was made to pull a nurse from direct care for other nonpatient care-related duties. Conversely, nurses who choose to develop expertise or to specialize would add to the basic level of their understanding advanced knowledge and skill defined by the nursing literature and specific specialty standards and guidelines that extend beyond the level defined for generic entry into the nursing profession. Thus, a nurse manager or senior level nursing administrator would be expected to be able to evaluate whether the removal of a nurse from staffing was a right or wrong decision.
Instilling professional nursing accountability into direct or indirect patient care helps to ensure accurate, safe, high quality service. The nurse is held accountable for making adjustments to practice based upon changing systems of care. Technology, medicine, and health care are constantly changing, and so must the nurse’s knowledge and practice change with the environment. When practice changes occur the nurse may need to seek education and consultation prior to accepting responsibilities. Ultimately, nurses carry out their duties or assign activities to others using nursing knowledge and judgment to assess, evaluate, and determine the appropriate course of action. Even where tasks are assigned to others, the nurse who delegates or assigns these retains accountability and responsibility for those them; this is to say, that tasks and activities can be delegated or assigned, but duties cannot.
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