Unit 1 - Foundations of Prescribing Practice

Professional Accountability


Accountability

Accountability means being responsible to someone for some action, and to be able to justify one's actions and decisions.

The NMC code of professional conduct: standards for conduct, performance and ethics (2004) clearly states that all registered nurses, midwives and health visitors are personally accountable for the care they provide to patients/clients. This means you are responsible for your actions and omissions, regardless of any advice or directions you may be given by another professional.

To whom are you accountable?

  • To the public, via criminal law
    Criminal law: criminal prosecution may ensue if a criminal act is thought to have occurred. Criminal law seeks to establish guilt and determine punishment.

  • To the patient, via civil law
    Patients or their relatives may sue for damages if negligence is implicated in the injury or death of a patient. Civil action will seek to establish accountability: the process may result in the award of damages.

  • To the employer, via a contract of employment
    Failure to comply with an employer's contract and the terms set out within it can result in disciplinary action against the employee.
    However, a contract of employment is reciprocal, and an employee may take out a grievance against an employer.

  • To the profession, via the NMC
    Following a civil or criminal law suit, the NMC will review possible misconduct charges and any action that should be taken.

Groups to whom nurses are accountable:

Groups to whom nurses are accountable

Accountability underpins all aspects of nursing practice because, as nurses, you will have to make judgements in a variety of circumstances. Professional accountability is fundamentally concerned with weighing up the interests of patients and clients in complex situations, using professional knowledge, judgement and skills to make a decision. It provides the framework within which you can account for the decision you made.

Because nurses are accountable, whether or not they prescribe, prescribing merely presents a new challenge (Skinner and Savage, 2001a; 2001b).

Further Reading

Further reading

Luker, K.A. et al (1998) Decision making: the context of nurse prescribing. Journal of Advanced Nursing 27: 3, 657-665.

Legal issues in accountability

There is very little legislation in the UK relating to the performance of specific tasks by different types of healthcare professional. In other countries 'who can do what' is prescribed in some detail. In the UK, however, the allocation of many individual tasks relating to professional practice has evolved as a result of custom and practice rather than legal directives. This has resulted in the boundaries of professional practice becoming open to negotiation.

'Reasonable' and 'reasonable care'

If you were called to account for an action you had taken, the courts or professional conduct mechanisms would have to decide whether the action you had taken was 'reasonable'. The test of what is reasonable is often referred to as the Bolam test and is based on the case of Bolam versus Friern Barnet Hospital Management Committee (1957). In simple terms, the principle suggests that you are not expected to be an expert, unless you profess to be one, but you are expected to be a reasonably competent practitioner. You would be expected to know, and be able to articulate, the basis on which you had made any decision regarding care (for example, evidence, research, experience). You would need to be able to demonstrate that most reasonable practitioners would have acted in the same way.

If you do profess to have knowledge and skills above that of the ordinary competent practitioner, you would have to be able to justify that claim if you were called to account for actions taken as an expert or specialist.

Duty of care

In law, a duty of care exists between nurses and their patients/clients. In simple terms, a duty of care exists if the actions of one person can be seen as being reasonably foreseeable to affect or harm another person. The NMC Code of Professional Conduct (2002) underlines this duty of care. It states:

  1. Always act in such a manner as to promote and safeguard the interests and well-being of patients
  2. Ensure that no act or omission on your part, or within your sphere of responsibility, is detrimental to the interests, condition or safety of patients.

Negligence

In law, negligence is judged to have occurred if it can be established that:

  1. A duty of care existed
  2. There was a breach of that duty
  3. The breach of the duty of care resulted in physical, psychological or financial damage to the patient.
Reflection

Identify a recent case of negligence in patient prescribing (this may be local or national). Try to find some information about the case and consider how negligence could be established in relation to the three factors identified above.

Could the Bolam test be applied to this case?

Further Reading

Further reading

McHale, J. (2003) A review of the legal framework for accountable nurse prescribing. Nurse Prescribing. 1 (3) 107-112.

Make Notes

Write down your definitions of the following words:

  • Actions
  • Omissions
  • Spheres of influence
  • Delegation
  • Acquiescence.

Once you have done this, try to apply their meaning, in the context of accountability, to the situations listed below:

Situations you may come across:

  • To prescribe or not to prescribe?
  • Instruction to a carer or relative on the administration of medication/eye drops/topical applications
  • Free samples from drug representatives - for example, the rep may give you a box of a particular dressing to 'try' for a particular patient
  • Patient compliance or non-compliance - how would you ensure that a patient is making an informed choice and is not merely assenting to the prescriber's wishes without protest?

Is acquiescence to do with the patient/client assenting to the prescriber's wishes when the patient may not have had the opportunity to object, or is this to do with assent by the prescriber to the patient's/client's wishes?

Reading

Reading

Griffith, R. (2003) Tablet crushing and the law. Pharmaceutical Journal 271: 90-91.
www.pjonline.com/pdf/articles/pj_20030719_harkness_tablet.pdf
(The Griffith article begins on page 2 of this document)

UKCC/NMC (2001) UKCC Position Statement on the Covert Administration of Medicines — disguising medicines in food and drink. UKCC: London.
http://www.nmc-uk.org/(t3zlok554be34u55bqad2d55)/
aFrameDisplay.aspx?DocumentID=69

Further Reading

Further reading

Dimond, B. (2004) Accountability and medicinal products 1: criminal law. British Journal of Nursing 13: 3, 161-164.

Dimond, B. (2004) Accountability and medicinal products 2: civil law. British Journal of Nursing 13: 4, 217-219.

Dimond, B. (2004) Accountability and medicinal products 3: employment. British Journal of Nursing 13: 5, 276-279.


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