PATIENT SAFETY FIRST

Accountability inNursing Practice: Why

It Is Important for PatientSafety

The AORN Journal

Sharon A. McNamar

http://dx.doi.org/10.1016/j.a

� AORN, Inc, 2014

RENAE BATTI�E, MN, RN, CNOR; VICTORIA M. STEELMAN, PhD, RN, CNOR, FAAN

Accountability is an essential component

of professional nursing practice; account-

ability also is an essential component of

patient safety. The American Nurses Association

Code of Ethics states that the definition of ac-

countability is “to be answerable to oneself and

others for one’s own actions.”1 As perioperative

nurses, we are accountable to our patients and their

family members, our colleagues, our workplace,

and our profession. Because of this, perioperative

nurses should hold themselves accountable for pa-

tient advocacy, continuity of care, lifelong learning,

to colleagues, the nursing profession, and their

organization.

PATIENT ADVOCATE

Perioperative nurses have a responsibility to act

on behalf of patients during times when patients

cannot advocate for themselves, particularly during

surgery or other invasive procedures when they

may be unable to communicate their needs or

wishes. This advocacy is based on the trust that the

perioperative nurse builds during the preoperative

assessment. It starts with understanding and com-

municating the patient’s cultural and treatment

preferences to other team members. For example,

is seeking contributors for the Patient S

a, column coordinator, by sending topi

orn.2014.08.008

a patient may have religious preferences that pre-

clude the administration of blood products or the

implantation of human allograft tissue. As the pa-

tient advocate, the nurse needs to help ensure that

the patient has the opportunity to discuss these

preferences with the surgeon and anesthesia pro-

fessional before the start of the procedure. The

nurse also needs to understand the patient’s pref-

erences for communication with his or her family

members during and after surgery. Understanding

and honoring these preferences protects the pa-

tient’s right to privacy. Advocacy also includes

verifying that the correct patient is present and

the correct procedure is performed and that it

occurs at the correct site.

Advocacy includes the nurse speaking up on

behalf of the patient in situations when safety issues

arise. Speaking up needs to be done in a respectful,

assertive manner that promotes high-quality care

from the entire team. For example, when the peri-

operative nurse is aware of a breach in sterile

technique, he or she is accountable to speak up

and bring it to the attention of the scrubbed team

members regardless of who is responsible for the

break in technique or what that person’s position or

seniority may be.

afety First column. Interested authors can contact

c ideas to journalcolumns@aorn.org.

November 2014 Vol 100 No 5 � AORN Journal j 537

November 2014 Vol 100 No 5 PATIENT SAFETY FIRST

Accountability relies on both clinical expertise

and effective communication skills. Excellent

clinical skills allow the nurse to identify gaps in

care that can negatively affect patient outcomes and

to effectively correct these gaps in a timely manner.

These skills help the entire team to provide the best

care possible. Accountability for high-quality care

depends as much on communication skills as it

does on clinical skills, especially in the complex

Accountability for high-quality care depends asmuch on communication skills as it does onclinical skills, especially in the complex teamenvironment of perioperative care.

team environment of

perioperative care.

Perioperative nurses

are accountable for

constantly developing

and improving their

skills in communica-

tion and team effec-

tiveness. It is important for every perioperative

nurse to ask if he or she knows the patient’s pref-

erences, has shared these preferences appropriately

with other perioperative team members, and prac-

tices effective communication.

ACCOUNTABILITY FOR CONTINUITY OFCARE

Perioperative nurses are accountable during the

time that they provide care for a patient but also for

ensuring continuity of patient care after surgery. As

part of this continuity of care, hand overs are an

essential component of patient safety that provide

caregivers the information necessary to ensure that

the patient receives safe, high-quality care after

surgery. During hand-over communication, the

nurse should report on the patient’s immediate

care needs, existing health issues, and risk of

complications.

Postoperative hand overs may be undervalued by

nursing personnel who are under time pressures,

particularly when the information is not directly

related to the surgical procedure. Reporting medi-

cation allergies and the surgical procedure performed

are examples of information that is obviously im-

portant during a hand over, but other details im-

portant to patient safety may be less obvious. For

538 j AORN Journal

example, information about surgical positioning

or the use of a pneumatic tourniquet may seem

unimportant to the person providing the report

during a hand over; however, these aspects of the

procedure might increase the risk of the patient

experiencing compartment syndrome. If post-

anesthesia nurses monitor for this potential compli-

cation and identify it early, then the patient can be

spared the loss of a limb. As another example, in-

formation about the

patient’s risk of sleep

apnea, although this

may not be directly

related to the surgical

procedure, is neces-

sary information to

pass along to prevent

hypoxia postoperatively. Information about a di-

fficult intubation may not seem important when the

patient has already been extubated. However, it is

vitally important if reintubation is necessary.

A key element of an effective hand over is the

willingness of the receiving nurse to clarify infor-

mation and ask questions. The OR nurse needs to

be aware of the priorities of the receiving nurse and

provide an opportunity for questions to be asked

and answered before completing the hand over.

This may seem obvious, but with pressure to min-

imize turnover times, this vital part of effective

communication may sometimes be overlooked. For

this reason, it is important for nurses to evaluate

whether their hand overs are as thorough as they

should be and whether their hand overs help the

receiving caregivers provide high-quality post-

operative patient care. The expectation to ask ques-

tions or clarify the hand over is an essential part of

effective hand overs and should be structured into the

process. Staying until the questions have been asked

and answered is a key element of a hand over.

ACCOUNTABILITY FOR LIFELONGLEARNING

As professionals, perioperative nurses are account-

able for continually learning about how to use the

PATIENT SAFETY FIRST www.aornjournal.org

best evidence available for patient care. Lifelong

learning is a key recommendation of the Institute of

Medicine report, The Future of Nursing: Leading

Change, Advancing Health.2 Examples of the im-

portance of lifelong learning can be seen in im-

provements in health care and, subsequently, patient

outcomes during the past decade. Catheter-associated

urinary tract infections were once seen as being un-

avoidable. Now, through the use of newer evidence-

Accountability is the key to increasing trust,reducing fear, and improving morale andperformance, and should be the basis forestablishing a culture of trust, support, anddedication to excellence.

based practices, nurses

know that these com-

plications are prevent-

able.3 Perioperative

hypothermia also was

once considered to be

unavoidable. Today,

nurses know that,

through active preop-

erative and intraoperative warming, they can prevent

perioperative hypothermia.4 A recent meta-analysis

shows that the use of a surgical safety checklist

improves teamwork and communication, reduces

morbidity and mortality, and improves compliance

with safety measures.5 Without lifelong learning,

these improvements in patient safety would not have

been made.

Perioperative nurses are accountable for basing

their practices on the best evidence available and

current national practice standards. It is challenging

to stay current with rapidly growing evidence-

based practices, increasing knowledge, and evolving

technology. To ensure that the care they provide is

based on the best evidence available, nurses should

know what AORN’s recommended practices say

about current practice issues, read peer-reviewed

journals, and become part of their facility’s process

for reviewing and updating policies and procedures

related to work and standards for education and

training.

SHARED ACCOUNTABILITY

Accountability should not be viewed as a way to

blame someone for making a mistake, and it should

not result in fear. Accountability is the key to in-

creasing trust, reducing fear, and improving morale

and performance, and should be the basis for es-

tablishing a culture of trust, support, and dedication

to excellence.6 Establishing this culture is every-

one’s responsibility.

Shared accountability means, for example, that

each perioperative nurse is accountable to make

the work environment safe for others to speak up

by providing support

and by acting as role

models by demon-

strating appropriate

behaviors. To do this,

nurses should ensure

that, when they speak

up about a concern,

they do so in a re-

spectful, constructive manner. When a person

communicates effectively, he or she helps others

learn how to communicate effectively themselves.

Nurses should do their best to receive and provide

constructive feedback in a way that reinforces the

desire to hear more and improve practice or be-

havior. It is not helpful to the nurse or others if

feedback is provided in a way that results in em-

barrassment or anger. Nurses should ask them-

selves whether feedback is provided consistently in

their practice environment, and, if not, how they

can help make delivering respectful, constructive

feedback an expected norm.

Providing education about participating in

“crucial conversations”7 and reviewing just culture

principles could improve a team’s ability to speak

up and be accountable. Just culture principles pro-

vide a framework for balancing accountability

among individuals and organizations in a way that

improves the workplace.8 In the book, Creating the

Accountable Organization,6 Samuels stresses how

accountability that is consistent and clear makes

it safe for personnel to address issues and conflicts

in a way that allows conflicts to surface and be

resolved, rather than forcing them underground.

AORN Journal j 539

November 2014 Vol 100 No 5 PATIENT SAFETY FIRST

ACCOUNTABILITY TO THE NURSINGPROFESSION

Perioperative nurses are accountable for sharing

and supporting their profession and professional

organization. Just as a nurse is an advocate for a

patient, nursing organizations are advocates for

nursing issues on a larger scale. Supporting the

organizations that represent the broader voice for

safety and quality helps ensure the effectiveness of

the message and the increased leverage of a larger

number of representation. To support nurses in this

effort, AORN regularly updates its position state-

ments and recommended practices, which are

intended to guide perioperative nurses’ practice in

the many settings where surgery or other invasive

procedures may occur. To demonstrate professional

accountability and ensure that their voices are

heard, nurses should regularly review the recom-

mended practices drafts when AORN posts them

online (http://www.aorn.org) for public comment.

Each nurse has unique perspectives and experi-

ences, and adding his or her voice and clinical

experience to the AORN recommended practices

documents makes the documents stronger, better

validated, and more relevant.

AORN is only as strong as its members. To be

professionally accountable, nurses should keep

up with the political advocacy or governance is-

sues on which the association is working. Addi-

tionally, nurses should be accountable for voting

to support candidates who best support the as-

sociation’s mission.

The AORN Foundation supports many causes

and educational initiatives that also support peri-

operative nursing. By furthering their education,

perioperative nurses can provide better and safer

care to their patients, and there are many scholar-

ships that support perioperative nurses’ academic

preparation. When nurses contribute to the AORN

Foundation, they help further other nurses’ pro-

fessional growth and patient safety. This helps us

all support future perioperative nurses and improve

perioperative patient care.

540 j AORN Journal

ACCOUNTABLE CARE ORGANIZATIONS

Accountable care organization is the name for the

high-quality, coordinated care of patients from

groups of physicians, organizations, and other

providers. An accountable care organization’s goals

are to ensure that patients get the right care at the

right time, while avoiding duplication and errors.9

An accountable care organization has an under-

stood accountability or responsibility to ensure

higher quality and more effective use of health care

resources as a group rather than as individuals, in

an attempt to improve the consumers’ experience,

which too often has been inefficient and provided

by individual providers practicing in silos. This is

in alignment with the professional responsibility

and accountability to make a profession more than

just a job, and for professionals to work as a team to

improve care delivery and patient safety every day.

Nurses should ask themselves what they can do

today to build accountability in their organization

(eg, consider culture of safety principles, hand

overs, effective communication, and evidence-

based practice).

CONCLUSION

Accountability is more than a philosophical ideal

that nurses learn in school. Patients have identified

nurses as the most-trusted profession.10 They count

on nurses and hold them to a very high standard,

and so it is appropriate for nurses to hold them-

selves to this standard and level of accountability.

After all, surgical patients want nothing more for

themselves and their loved ones during a periop-

erative experience than to be cared for by highly

accountable perioperative nurses.

References1. Code of Ethics for Nurses with Interpretive Statements,

4.2. The American Nurses Association. http://www.nursing

world.org/mainmenucategories/ethicsstandards/codeof

ethicsfornurses/code-of-ethics.pdf. Accessed July 9, 2014.

2. Institute of Medicine. The Future of Nursing: Leading

Change, Advancing Health. Washington, DC: National

Academies Press; 2010.

3. Gould CV, Umscheid CA, Agarwal RK, Kuntz G,

Pegues DA. Guideline for prevention of catheter-associated

PATIENT SAFETY FIRST www.aornjournal.org

urinary tract infections. Infect Control Hosp Epidemiol.

2010;31(4):319-326.

4. Andrzejowski JC, Turnbull D, Nandakumar A,

Gowthaman S, Eapen G. A randomised single blinded

study of the administration of pre-warmed fluid vs active

fluid warming on the incidence of peri-operative hypo-

thermia in short surgical procedures. Anaesthesia. 2010;

65(9):942-945.

5. Lyons VE, Popejoy LL. Meta-analysis of surgical safety

checklist on teamwork, communication, morbidity, mor-

tality, and safety. Western J Nurs Res. 2014;36(2):

245-261.

6. Samuel M. Creating the Accountable Organization: A

Practical Guide to Improve Performance Execution.

Euless, TX: Xephor Press, LLC; 2006.

7. Patterson K, Grenny J, McMillan R, Switzler A. Crucial

Conversations. McGraw-Hill; 2011

8. Boysen PG. Just culture: a foundation for balanced

accountability and patient safety. Ochsner J. 2013;13(3):

400-406.

9. Accountable care organizations. Centers for Medicare &

Medicaid Services. http://www.cms.gov/Medicare/

Medicare-Fee-for-Service-Payment/ACO/. Accessed

July 9, 2014.

10. Nurses retain top spot as most ethical profession [news

release]. Silver Spring, MD: American Nurses Associa-

tion; December 26, 2013.

Renae Batti�e, MN, RN, CNOR, is the President-

elect of AORN and the associate vice president of

perioperative services, Franciscan Health System,

Tacoma, WA. Ms Batti�e has no declared affili-

ation that could be perceived as posing a potential

conflict of interest in the publication of this article.

Victoria M. Steelman, PhD, RN, CNOR, FAAN,

is the AORNPresident and an assistant professor at

The University of Iowa College of Nursing, Iowa

City. Dr Steelman has no declared affiliation that

could be perceived as posing a potential conflict of

interest in the publication of this article.

AORN Journal j 541