With reference to the scope of Practise as outlined by An Bord Altranais and to your personal professional practise describe Your

role in accountability, autonomy and delegation

.Nurses are self- directed and, with proper leadership and motivation, can resolve most complex problems. Accountability, autonomy and delegation are considered as vital parts of professional nursing and midwifery practise. It is essential to have autonomy to achieve accountability.

Accountability: It refers to the ability to answer for ones own actions. The nurse is accountable for keeping current and competent in technical skills and informed of the knowledge needed to perform nursing care. The nurse balances accountability to the client, the profession, the employer and society. For example, a nurse may know that a client who will be discharged soon remains confused about how to administer insulin. The action that a nurse takes in response to this situation will be guided by the sense of accountability. The nurse may request more hospitalization or arrange home care to continue teaching at home. As outlined by An Bord Altranais ,Accountability refers to individuals being answerable not only for their actions but also their omissions. It involves follow-up and reflective analysis of ones decisions to evaluate their effectiveness.

A primary nurse is accountable for his clients outcomes. For example, a primary nurse managing a caseload of clients, may discover that members of the nursing team did not follow through on a discharge teaching plan for an assigned client. The primary nurse is accountable for ensuring that the client learns the information necessary to improve self-care. The nurse demonstrates accountability in checking on the client and family after discharge and in reviewing with the nursing team whether continuity in teaching occurred. Accountability is the fulfilment of a formal obligation to disclose to referent others the purposes, principles, procedures, relationships, results income and expenditures for which one

has authority.

When caring for clients , a nurse has a responsibility to correctly perform nursing care activities based upon standards of practice. Standards of practice are the minimum level of performance accepted to ensure high-quality care. For example, the nurse does not take shortcuts (example: failing to identify a patient) when administering medications. The nurse who intervenes for a client must be answerable or accountable for the outcomes of any nursing actions. An accountable nurse is reliable and willing to recognize when nursing care is ineffective. Ultimately , the nurse assumes accountability for whatever decisions and resultant actions are made on the clients behalf.

Autonomy: Autonomy is the freedom to decide and act. I t means that a person is reasonably independent and self-governing in decision making and practise. Autonomy consistent with the scope of professional nursing practise will maximise the effectiveness of the nurse.The nurse plans the care for the client within the scope of professional practice , and provides the client independent nursing interventions without physicians permission. Autonomy is not an absolute, but occurs in degrees. Higher levels of education can help nurses attain autonomy.

As a standard in ethics, autonomy represents an agreement to respect anothers right to determine a course of action. The agreement to respect autonomy involves the recognition that clients are in charge of their own destiny in matters of health and illness. For example, the purpose of the preoperative consent that clients must read and sign before surgery is the assurance in writing that the health care team respects the clients independence by obtaining permission to proceed.

In his essay Autonomy under Duress Leonard Harris (1992) challenges the notion that respect for autonomy guarantees respect for all persons. He recommends a thorough selfexamination to ensure that when the term autonomy is applied, it is applied with respect,

compassion, and value, as though no differences existed between classes or races of people. Most of the people who are doing research about autonomy focus on appreciating culture differences.

Innovation by nurses , increased productivity , higher nurse retention, and greater client satisfaction are results of autonomy in nursing practice .For example, a nurse has the autonomy to develop and implement a discharge teaching plan based on specific client needs for any client who has been hospitalized. The nurse is providing the nursing care that complements the prescribed medical therapy.

Delegation: The art of effective delegation is an essential skill for nurses. The American Nurses Association defines delegation as transferring responsibility for the performance of an activity or task while retaining accountability for the outcome. One of the purpose of delegation is to improve efficiency. Asking a staff member to obtain and ordered specimen while the nurse attends to a clients pain medication request effectively prevents a delay in the client gaining pain relief. It can also provide job enrichment.

A nurse never delegates a task that he or she dislikes doing or wouldnt do independently because this can create negative feelings and poor working relationships. For example if a nurse is in the room when a client asks to be placed on a bed pan the nurse should assist the client rather than leave the room to find the nurse assistant. It is important to know that even though the delegation of a task transfers the responsibility and authority to another person, the nurse who is delegating retains accountability for the delegated task. A nurse cannot simply assign assistive personal to tasks without considering the implications. The nurse asses a client and determines a plan of care before identifying which tasks someone else can perform. When directing assistive personnel, the Staff nurse must determine the degree of supervision that may be required. Is it the first time a staff member

performed the task? Does the client present a complicating factor whereby the Staff nurses assistance is necessary? Does the staff member have prior experience with a particular type of client in addition to having received training of skill performance? The Nurses final responsibility is to evaluate whether assistive personnel performed a task properly and whether desired outcomes were realized.

Appropriate delegation begins with knowing what skills can be delegated. An essential knowledge of the states nurse practise act, institutional policies and procedures , and the institutions job description for assistive personnel. These standards help to define the necessary level of competency of assistive personnel. An institutions policies and procedures and job description for assistive personnel provide specific guide lines in regard to what tasks or activities can be delegated. The job description should specify any required education and the type of tasks assistive personal can perform , either independently or with Nurses direct supervision.

Another important matter is that, Efficient delegation requires constant communication. That means sending clear messages and listening so that all participants understand expectations regarding client care. A nurse should provide clear instructions when delegating tasks.These instructions may initially focus on the procedure itself, as well as on the unique needs of a given client. As the nurse becomes more familiar with a staff members competency, trust builds and fewer instructions may be needed , but clarification of clients specific needs will always be necessary.

Appropriate delegation requires assessing the knowledge and skill s of the delegate. Choose some open-ended questions that will elicit conversations and details on what the person knows : for example, Tell me how you prepare the tubing before you give an enema.

Match tasks to the delegates skills: Know what skill s are included in the training program for assistive personnel at your facility. Determine if personnel have learned critical thinking skills, such as knowing when a client may be in harm or knowing the difference between normal clinical findings and changes to report. Communicate clearly: clearly mention the desired outcome, and the time frame within which the task should be completed. Never give direction through another staff member. Make them feel that they are also part of the team.

Listen attentively: Do the assistive people feel comfortable in asking questions or requesting clarifications after you give instructions. If you encourage a response, listen to what the person ahs to say. Be especially attentive if the staff member has been given a dead line to meet by another nurse. Provide feed back: Give feed back regarding performance, regardless of outcome. Let the assistants know of a job well done. If an outcome is undesirable, find a private place to discuss what occurred , any miscommunication, and how to achieve a better outcome in the future.

Conclusion:

The nursing profession itself regulates accountability through nursing audits and standards of practice. Staff members must feel comfortable in expressing differences of opinion and in challenging ways in which the team functions, while recognising their own accountability and autonomy.Five rights of Delegation outlined by National Council of State board of Nursing, Chicago, 1995 are Right Task, Right circumstances , Right person, Right direction/communication and Right Supervision.

REFERENCES: 1. Scope of Nursing and midwifery practice framework , April 2000. An Bord Altranais. Section 4

1. British journal of nursing ,Vol 5, Iss.16, 12sept 1996, pp 984-990 2. Journal oof Clinical Nursing , Volume 12 Issue 2 Page 158-167, March 2003 3. Harris L: Autonomy under duress.In Flack HE, Pellegrino ED, editors:African perspectives on biomedical ethics , Washington DC, 1992 4. American Nurses association : Position statement on registered nurse utilization of assistive personnel, Am Nurse 25(2):7, 1995. 5.Curtin L: The heart of patient care , Nurs Manage 25(5): 7, 1994. 6. Nursing and Midwifery in Ireland in the twentieth Century, Joseph Robins, Fifty years of An Bord Altranais 1950-200