Accountability in primary health care nursing: primary health care nurses need to be fully aware of all legislation, regulations and policies that govern their practice.

ACCOUNTABILITY IS about being concerned for the moral and legal requirements of patient care. (1)

Nurses are always accountable for their practice. The introduction of the Health Practitioners Competency Assurance Act (2) has highlighted to nurses that they are accountable to the public, whether to an individual or to the wider community. The public has a right to expect a demonstration of that accountability. Nurses are also accountable to their regulatory body, the Nursing Council, and to employers. Direction and guiding principles for each nurse can be viewed as either a vertical or lateral line of accountability. This has been described in terms of:

* upward accountability (looking up the line and doing what managers and administrators require);

* lateral accountability (accountability as self-regulation, in which practitioners are accountable to, and judged by, criteria set by their peers); and

* downward, or public accountability (where staff are accountable to patients). (3)

Nursing is governed by legislation as statutes. Statutes can be further defined as rules and regulations, and are made by a designated person or body. Both statutes and rules/regulations can be equally binding and it is essential nurses have a working knowledge of the legal requirements on their practice.

Recent phone calls I have received, asking about the administration and dispensing of medications from blister packs, demonstrate where the legislation the Medicines Act 1981 (4), and the Regulations under this Act, are the same for all nurses. Accountability does not differ between the practice of the nurse who administers medications directly from the blister pack, and the practice of the nurse who dispenses the medication by transferring that medicine to another container, labels it as per the blister pack and hands it to a family member to administer. However, by breaking down the individual steps of care and comparing each step with legislative requirements, the nurse in each situation--ie administering and dispensing--will find the potential liability associated with accountable practice.

Secondly, nurses are accountable to Nursing Council. This relates to practising within your scope of practice, according to the register or roll in which your name is entered, and being accountable for your professional conduct. The Nursing Council's Code of Conduct for Nurses and Midwives further outlines professional accountability in terms of ethics, standards of practice, rights of patients/clients and justifying public trust and confidence. (5) Criteria for ensuring that the principles of the Code are met are listed.

Primary health care (PHC) nurses have privileged access to information about patients'/clients' lifestyle, relationships and home environment. Use of that information is guided firstly by legislation, ie the Health Information and Privacy Code, (6) and secondly by the Council's Code of Conduct.

Accountability to your employer is directed through operational procedures and policies. These may be specific for a practice setting, or within the wider organisation. Nurses face challenges with clinical governance in which decision making is still largely made by employing individuals and organisations. This is despite a report from the Expert Advisory Group on Primary Health Care Nursing to the Ministry of Health. This report states the vision for PHC nursing in New Zealand should include an environment where "nurses will be included in governance arrangements and influence all decisions regarding their practice". (7)

Organisational policies

A situation may exist where organisational policies or accepted procedures do not fit well with legislation or with professional conduct. An example is a standing order in which your name appears, without you having been consulted or signed as a party to it. In this situation the duty of care, public interest and public safety need to be carefully considered. Seeking support from colleagues throughout the decision to advocate for your patient and ensuring that their rights are being met, with a safe and appropriate service, will assist you to implement quality practice and organisational change.

Furthermore, many clinical decisionsand new roles for PHC nurses, are not covered within published documentation abut still provide opportunities for discussion and practice development.

One research study found that nursing and midwifery were marked by an increased risk because of the impact of consumerism and individual accountability placed on them by employing organisations. Nurses and midwives were pressured into taking on new tasks and roles, without the necessary competence. (8) This led to nurses and midwives feeling they had to be constantly vigilant about their practice and documentation. The situation was compounded by general line management, who were not familiar with clinical concerns, and without additional nursing line management. This study highlights potential accountability and safety issues for PHC nurses working in a changing environment.

Primary health care nurses today are developing an understanding of their legal and professional boundaries. They are developing this understanding within the context of high consumer demands and little or no inter-professional understanding of their expanding roles, knowledge and skill. These challenges will continue as PHC nurses' understanding of their professional and legal responsibilities evolve.

REFERENCES

(1) Mosby's Dictionary (1990) Medical, nursing and allied health. (3rd ed). Missouri: C.V Mosby Company.

(2) Health Practitioners Competency Assurance Act (2003) New Zealand Government: Wellington.

(3) Hunt, G. (1994) Nursing accountability: Ethical Issues in Nursing (ed.G.Hunt), London, Routledge, 129-147 in Savage, J & Moore, L (2004) Interpreting Accountability: An ethnographic study of practice nurses accountability, multidisciplinary team decision-making in the context of clinical governance. Royal College of Nursing: London.

(4) Medicines Act (1981) and Regulations, NZ Government: Wellington.

(5) Nursing Council of New Zealand (2001) Code of Conduct for Nurses and Midwives. Nursing Council of New Zealand: Wellington.

(6) Health Information Privacy Code (1994) The Health and Disability Commissioner, NZ Government: Wellington.

(7) Ministry of Health (2003) Investing in health: Whakatohutia te Oranga Tangata, A framework for activiating primary health care nursing in New Zealand. Report to the Ministry of Health from the Expert Nursing Advisory Group on Primary Health Care Nursing. Ministry, of Health: Wellington.

(8) Annandale, E .(1996) Working on the front-line: risk culture and nursing in the new NHS. The Sociological Review; 94: 3, 416-451.