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Newly qualified nurses may lack confidence when they transition from student to registered status. This article, part 1 in a three-part series on skills for newly qualified nurses explains accountability and how to manage it
Transitioning from student to newly qualified nurse is a difficult process. Along with the pressure of providing safe, high-quality care unsupervised, newly qualified nurses have to be comfortable and confident with those aspects of nursing that may have been more difficult to teach and learn – accountability is one such aspect. This article examines accountability, its translation into clinical practice, why newly qualified nurses may find it challenging, and how they can manage it.
Citation: Cathala X, Moorley C (2019) Skills for newly qualified nurses 1: understanding and managing accountability. Nursing Times [online]; 116: 15/10/2020.
Authors: Xabi Cathala is lecturer, School of Health and Social Care/Institute of Vocational Learning; Calvin Moorley is associate professor for nursing research and diversity in care, School of Health and Social Care/Adult Nursing & Midwifery Studies; both at London South Bank University.
The transition from pre-registered nursing student to qualified nurse can be stressful (Tracey and McGowan, 2015) and has even been described as a reality shock (Stacey and Hardy, 2011). During nursing education, students will work under the supervision of a registered nurse (RN), learning skills, knowledge, behaviour, critical thinking and becoming competent at delivering safe, high-quality patient care. However, despite the best efforts of mentors, clinical educators and universities, it can be difficult to fully prepare students for some aspects of the nursing role, such as accountability, and they go from being a supervised student to an RN who is in charge of patients – and therefore accountable for their own practice as soon as they gain registration.
Newly qualified nurses (NQNs) may experience a lack of confidence and feelings of isolation (Bjerknes and Bjork, 2012), along with the pressure that goes with being a decision maker and directly responsible for patients’ lives. This highlights one of the most challenging changes for NQNs: accountability. This article explores accountability, how it is translated into practice and how to manage it as an NQN.
“Sometimes, accountability means refusing to provide care that is not in the patient’s best interest”
What is accountability?
Accountability is a subject each nurse will hear about at some point in their education, and a constant presence in clinical nursing practice. Surprisingly, the Nursing and Midwifery Council’s (2018a) standards of proficiency for RNs does not clearly define it but the organisation’s Delegation and Accountability describes it as “the principle that individuals and organisations are responsible for their actions, and may be required to explain them to others” (NMC, 2018b).
The Royal College of Nursing defines accountability as: “taking responsibility for your actions, always ensuring you are competent to do the activity you’ve been asked to perform, and always putting patients’/clients’ interests first”. This definition was outlined in information for healthcare assistants (HCAs) but both definitions help practitioners to understand that accountability is about:
- Patients’ best interests;
- Being competent at providing care.
Having multiple definitions highlights the lack of consensus on what accountability actually is. This is not only an issue in the UK: Krautscheid (2014) also reported an inconsistency in the nursing accountability definition in the United States.
As well as taking responsibility for an individual’s care, accountability involves the ability to:
- Recognise your limits;
- Refrain from care that you are not competent or confident at delivering;
- Be able to report an error or raise a concern (Mullen, 2014).
On some occasions, accountability involve refusing to provide care that is not in the patient’s best interests. Box 1 lists some questions nurses should ask themselves before providing care.
Box 1. Being accountable
Why am I doing this?
- Is there a clinical need or indication?
- Will the patient benefit from this intervention?
- Do I have the required skills/competency?
How will I do it?
- Have I got the correct equipment?
- Have I got the resources, or do I know where to get them?
- Have I gained consent from the patient?
Is it in the best interests of my patient?
- What short- and long-term impact will this have on the patient?
Do I need to raise a concern?
- Does this situation or practice raise a safeguarding issue?
Accountability in practice
The first day as an RN could be one of the most stressful days in a nurse’s career. One of the reasons for this is that NQNs are now accountable for their practice. For the first time, they are independent decision makers, responsible for providing care – their decisions will have a direct impact on their patients. The difficulty of the transition period is well known, and research – such as that by Whitehead and Holmes (2011) – has been undertaken to understand, and reduce, the occurrence of mistakes. The areas in which NQNs identified difficulties can be divided into three categories:
- Clinical skills;
- Documentation and communication skills;
- Time management.
Regarding clinical performance, NQNs reported feeling stressed, unprepared for practice and lacking in competence and confidence (Monaghan, 2015; Health Education England, 2014).
In the UK, local variations exist and, while some students are allowed to perform a range of clinical skills involving patients (for example, intravenous medication administration, cannula insertion, nasogastric tube insertion, urinary catheterisation), others are not; their training is gained through simulation. No matter how close to reality the simulation is, however, it remains a simulation – it is not a live patient, you are not the nurse in charge of this patient, and there is no sense of accountability (particularly in low-fidelity simulations). This could partly explain why NQNs experience stress and difficulty with clinical skills. The fear of making a mistake, together with a lack of confidence and competence, can make being accountable daunting.
Documentation and communication skills
Students are exposed to effective communication and completing documentation (under supervision) during their nursing education. Documentation is an important component of nursing as it creates a trail of:
- The patient’s condition;
- Any issues identified;
- The care provided;
- How that care has been provided.
- Ensure continuity of care;
- Enhance patient safety;
- Stand as evidence of nursing care.
Communication forms part of nursing practice at all times, and NQNs should know how to communicate with colleagues and other healthcare staff, as well as patients, their carers and relatives. It is the nurse’s responsibility to collect adequate and pertinent information, and escalate it as appropriate.
Documentation and communication are features of nurses’ daily practice and directly linked to nurse accountability. However, being able to document accurately a 12-hour shift in one or two pages of notes per patient and communicate efficiently and accurately at all times are skills that need to be developed.
During education and training, student nurses work under supervision alongside an RN – that means there are, effectively, two nurses providing care. NQNs, however, must be able to work independently and manage all the required care. A typical nursing shift involves:
- Drugs administration;
- Personal hygiene care;
- Clinical and non-clinical assessments;
- Comforting patients;
- Updating care records and plans;
- Working with multidisciplinary teams (including, for example, physiotherapists, occupational therapists);
- Wound management;
- Discharge planning (Ausserhofer et al, 2014).
This care is for each patient and, usually, a nurse on a hospital ward could be caring for 6-8 patients at any one time. It is the nurse’s responsibility to ensure all care is provided.
Effective nursing care and documentation takes time; the multi- and interdisciplinary working required demonstrates the complexity involved in planning and organising a day; this can cause NQNs to feel even more pressure.
“Accountability cannot be separated from practice, nurses have to manage it”
Regulation and challenges
Recently, in England, new healthcare roles have been created – namely, those of assistant practitioner (AP) and nursing associate (NA). The implementation of these new roles involves regulation and structural reorganisation, so the NMC set a new standard of practice for RNs and NAs. APs are not registered with the NMC; their role is delegated and falls under the supervision of an RN. This raises further questions about accountability, for example, when tasks are delegated to an AP by an RN.
Task delegation can also occur between an RN and NA. To guide and help set up policies, in the NMC (2018b) published Delegation and Accountability. Although the regulator did not define accountability in its standards of practice for RNs, it did so in this document and added a section about the possible need for nurses to explain their actions to others. If a cause for concern is reported to the NMC an investigation can take place to determine whether it was the delegation or the acceptance of the task that was inappropriate. This may raise some concerns and fear among the nursing workforce about task delegation.
With all these examples, it is easy to see why accountability can appear as something of a synonym for stress, anxiety and obligation. Accountability can be much more than this, however – taking accountability can also be rewarding. Being responsible for your patient and the care you are providing makes you directly involved in their recovery; most nurses consider this a satisfying feeling.
Much of the time, accountability is linked with patients’ recognition of the hard work and support that has been provided. What can be more rewarding than a patient going home or returning to your ward in a healthy state to say thank you? This is the result of nurses’ hard work and commitment. This is the result of your accountability.
We have clearly identified that accountability is part of everyday nursing practice. Accountability cannot be separated from practice so nurses have to manage it – and every department or ward is different in terms of how it does this. Some may offer more support than others, but the crux of the matter is always with the nurse looking after the patient. All nurses, including NQNs, need to provide care in line with the NMC Code and local policies. To ensure accountable practice, NQNs can seek help and support from, for example, senior nurses, nurses in charge or specialist healthcare workers. Asking for help when unsure about an element of care is an important part of feeling confident in the care provided – as such, it can play an important role in accountability.
Most clinical areas provide advanced support programmes to NQNs, known as preceptorship. These programmes allocate preceptors (experienced nurses) to NQNs for 4-6 months to support them, and help them to develop and transition. Preceptorship has been proven effective at supporting NQNs (Marks-Maran et al, 2013) but may be difficult to put in place in every area due to staffing levels and the organisation’s values or ethos. Preceptorship is mandated by the NMC and the Department of Health and Social Care, and the onus is on the employer to ensure it is in place. All NQNs should seek this support.
Regardless of the support or the situation, any nurse who does not know, has a doubt, or is not competent or confident about a care situation, must seek help. This is a universal rule ensuring the provision of safe, high-quality care. Three simple rules may help nurses remember what to consider to be accountable with confidence:
- Always think before acting;
- Don’t act without knowing what you are doing and why;
- In difficulty, seek help (Box 2).
Box 2. Three rules of accountability
- Always think before acting
- Don’t act without knowing what you are doing and why
- If you are unsure what to do, seek help
Accountability has an important place in nursing but, even with preparation at University, being accountable for a patient’s care can be difficult. More than being accountable for the care provided, nurses are required to act in the best interest of the patient. Recognition of their own limits and delegation is part of accountability. Seeking support and help from the team is a sign of professionalism and accountability to provide the best and safest care possible for our patients.
- Transitioning from being a student nurse working under supervision to a registered nurse working autonomously is challenging
- Clinical skills education and training may differ across the country
- Performing procedures on real patients can feel very different to performing the same procedure in a simulation exercise
- Newly qualified nurses are responsible for the care they provide to their patients but may lack confidence in their abilities and experience feelings of isolation
Also in this series
- Skills for newly qualified nurses 2: identifying and managing stress
- Skills for newly qualified nurses 3: managing errors and mistakes
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