Accountability of the Anp free essay sample

Over the last few years there has been a precipitous change in the delivery of healthcare within the National Health Service (NHS), which inevitably brought about modification of the nursing role and an adaptation in the professional nursing competencies. It was recognised that vital health improvements that the NHS required could not be made without the advancement of nursing skills and roles (Walsh amp; Crumbie 2003). In the early 1980s the nurse practitioner’s role was first introduced into general practice, the role has now further developed and changed. Advanced Nurse Practitioners (ANPs) are now working in diverse and varied roles within the National Health Service (Crumbie 2008). By accepting new areas of responsibility and accountability requires more from the advanced practitioner than simply a change of uniform and title. There is a need to safeguard the quality in the development and implementation of these roles and continuous evaluation of their success (Whiteing 2008). Since the 1980s there has been considerable amount written in nursing literature regarding the measurement and maintenance of quality nursing care and with the introduction of Clinical Governance (DOH 1998) and the NHS Plan (DOH 2000) the UK government has made it a quality high on the political agenda. The role of advanced nurse practitioner has developed over recent years to provide a high quality and cost effective care, but at times has caused confusion regarding title, professional boundaries and educational obligations which brings about the question of clinical accountability and the advanced nurse practitioner (Griffin amp; Mebly 2005). The Oxford Dictionary (1995) defines the term ‘accountable’ as being ‘responsible; required to account for one’s conduct, and is an integral part of professional practice (NMC 2006b). Accountability can be perceived as being an elevated activity to that of responsibility, as it requires not only designation of who is responsible of an action but also need for the individual who carries out the task is able to give an account, reason and or an explanation for their action. As the enhancement of advanced practice progresses, the ANPs could find themselves in a situation where they are solely responsible for a patient caseload without alternative medical input, although these situations are innovative and unusual Pennel 2008 stresses that these situations exemplifies the level of accountability that could be ut upon the ANP, by performing a role of a medical consultant by maintaining absolute accountability for the patient’s clinical care. Clinical governance requires the ANP to be comprehensible in their judgement and decision-making, yet in some situations this could prove to be complicated for the ANP, since they may be fearful of being held responsible for the outcome of their decision. Currie and Loftus-Hills 2002), however Caulfield (2005) views accountability with a more positive outlook and states: ‘A wider view of accountability is that it is an inherent confidence as a professional that allows a nurse to take pride in being transparent about the way he or she has carried out their practice. This definition reviews accountability as positive element in the development and validation of competent practice. Cornock (2011) also comments that accountability can be perceived as being essential for monitoring when things are going right and therefore necessary to distribute that information for the benefit and to enhance the knowledge of others. Nuttall (1993) verifies that there is a link with accountability and autonomy, and argues that without autonomy the practitioner is unable to be accountable if they are unable to make a decision about their choice of action freely. The Oxford Dictionary (1995) suggests that autonomy gives independence and freedom from control. In order for the ANP to be autonomous they need to have the ownership of all the details and information, though education and communication, and have the authority to act as they see fit with proper mechanisms for measuring the outcomes, by carrying out audits for example. In the framework of the professional role the ANP would seemingly have the authority and autonomy to act in the patient’s best interest, having the ability to explain and justify why, conversely Walsh (2003) maintains that no clinician can be fully completely independent as ANPs work within a team, and alongside the patient’s involvement in the decision-making regarding their care. Consequently the ANP should examine the situation and consider alternative options that may be available, validate their knowledge and understanding of the possible outcomes of these options and decide the best course of action, to which they can justify their actions from their knowledge base (Marks-Maran 1993). ANPs are required to be able to explain the rationale that prompts their actions and the consequences that follow. An accountable ANP should not agree to carry out a task simply because they have been ask by a senior colleague has told them to. Nurses have been encouraged to question and challenge clinical decisions and not just following what is ordered by the doctor (Fletcher amp; Holt 1995), thus guiding professional judgement towards accountability (Watson 1992). In the eyes of the law inexperience is not a defence. If the ANP believes that they are not proficient the skills or ability for a task, at the standard that is required, it is their responsibility to decline the action or to obtain supervision from a senior medical colleague or their mentor (RCN 2010). ANP are accountable to their employers as agreed in their job description/framework and contract (Cox 2010) and is specific to their level of practice to ensure that practitioners are working within boundaries approved by their employers (Walsh 2003). As the working confines between healthcare practitioners modify, with ANPs taking on board several of the tasks formerly assumed to be the work of the doctor, while Health Care Assistants (HCAs) and assistant practitioners perform roles that were customarily carried out by registered nurses, inevitably some confusion arises as staff continue to grasp the effects of these modifications in their role (Mulryan 2009). The established legal advice is that a practitioner would be judged by the standard that are required for the post, for instance if an ANP is carry out a role that would historically have been considered a medical role; taking the patient’s history, carrying out the physical examination of the patient in order to obtain an interim diagnosis of the patient’s condition, and would be critiqued at a standard of a reasonably proficient doctor (RCN 2010). Therefore as the ANP develop the advanced practice of their role it may be prudent to focus on corresponding standards that is required of their medical counterparts. All these modifications continue against the setting of the general public beliefs of health care services and consequently the questions of risk management and legal accountability unavoidably come to pass (Cox 2010). It is reasonable therefore, to conclude that ANPs are personally and professionally accountable for their practice and as per se are obliged to make sure that they have the capability to take on and perform advanced practice actions to the similar paradigm as the person that would usually have been delegated with those actions, such as a doctor (Whiteing 2008), which bring to light the need of the ANPs to practise both within the law and to the same standards as doctors (DH 2002). As the ANP’s role develops into a more complex and demanding expectation, an increase in the amount of activities that were previously performed by the ANP have to be delegated to other members of the health care team. Delegation of such activities may have a legal implication upon the ANP if they inappropriately delegate a task or fail to supervise the delegated task (Whiteing 2008). The ANP should make sure that they are confident in the competencies of the individual who is delegated the task, and also ensure that sufficient supervision is offered to maintain the safety of the patient (Dimond 2003). With these advances the ANPs should reflect upon the professional, ethical and legal implication of their practice (Humphries amp; Masterson 1998). Poyser (1996) noted that with the expansion of advanced practice a greater legal and professional accountability has been distinguished, and therefore a higher level of responsibility is required in conjunction to the mounting complexities of the patient’s healthcare needs (Jones amp; Davies 1999). The Scope of Professional Practice present clear guidelines to those nurses who aspired to develop their role, and made certain that they accepted accountability for their own actions (NMC 2008). The recommendation for the professional and ethical practice of advanced nurse practitioners is the Code of professional conduct (NMC 2008). The essential principles in determining the susceptibility of advanced nurse practitioners are the degree of their self-governance (autonomy), their ability to take responsibility for their own actions (accountability), and their knowledge of the boundaries of their own practice (RCN 2010). For any advanced practice role to be effectively incorporated into a multidisciplinary team, clear and concise boundaries must be approved by the team, particularly by the medical colleagues, who must accept and support the role. By accepting and agreeing of advanced practice roles, members of the multidisciplinary team can understand when the ANP reaches a point that is beyond their area of expertise these colleagues then can understand that it would be professionally appropriate for the ANP to refer onwards to other colleagues, if the ANP believes it necessary (Pennel 2008). The ownership by ANP of credentials, recording their capability to carry out extended nursing duties does not automatically suggest that they are competent in these skills (Crinson 1995); Fletcher and Holt (1995) state, such certificates have ‘never provided blanket immunity from legal liability’. The NMC are also clear on the matter that nurses are personally accountable for their professional conduct (NMC 2002a). Complications may occur if ANPs are unprepared for their scope of practice, with inadequate knowledge and skills to accomplish their role (Whiteing 2008). As a result it is vital for the ANP to have a clear definition of the scope of their working practice. Identification of possibilities and limitations of their practice should also be defined and documented clearly (Furlong amp; Smith 2005) along with advice and from the ANPs designated mentor during clinical supervision sessions. Chalmers and Bond (1997), and Doyal (1998) argue that extended roles that involve high levels of autonomy are deficient in the educational preparation for their practice, Walsh and Crumbie (2003), maintain that there are inconsistencies in the training of practitioners, with some courses involving only a few days of study and others being undertaking their education at a masters level to fulfil their competencies to practice as an ANP. Considerable amount of the uncertainty and ambiguity has resulted from the modernization of delivery of healthcare, and developments of ‘new nursing roles’, Cox 2010 believes that these issues would be reduced or disregarded if the employing organisations and the educational bodies reduced the gap with appropriate standardisation training of ANP. Inappropriate educational preparation, of the ANPs and their employers could be vulnerable to accusations if the educational framework of advanced practice is lacking (Tye 1997). By developing a framework for ANPs, such as, Framework for Advanced Nursing, Midwifery and Allied Health Professional Practice in Wales (NLIAH 2008), gives clarity to what is expected of an advanced practitioner in the terms of defining the role, education, workforce planning, regulation and governance requirements of the ANP in Wales. Nurse educators should be obliged to comprehend the future role of the ANPs in the administration of healthcare, by delivering the correct training to accomplish appropriate preparation, education and demonstrated competence to be practice as a proficient and skilled clinical practitioner (Furlong and Smith 2005). NMC (2007) recommended that educational programmes addressing advanced practice should make precise core and specific competencies for the role of the ANP. Hamric et al. 2000) additional states that master’s degree program for the ANP should include: advanced nursing practice, pharmacology, pathology, physiology, advanced physical assessment skills, research, leadership, quality improvement and case management. The Department of Health (2010) envisage that nurses who are working in an advanced role should complete their education at a Masters level or its equivalent, and the development requirements be identified and supported through ongoing appraisals, performance review in conjunction with a robust clinical supervision framework. A key feature in any education program for advanced nursing practice is that of suitably supervision Dunn (1998) although it is recognized that it is often carried out through personally directed refection it of consequence that the ANP shows that reflective practice has been carried out. Pennel (2008) suggests that it would be responsible practice to seek clinical supervision by the most appropriate senior colleague, for the appropriate situation, so as to maintain safe practice. As well as developing a program that recognizes advanced practice knowledge and skills that are common practice to all ANPs, Furlong and Smith (2005) note that distinguishing the specialist component is essential to provide the clinical expertise for the ANP in their specialty as they are required to implement an advanced level of judgment and decision-making in their clinical environment. Consequently, advanced nursing practice requires a distinctive kind of advanced knowledge, one that is identified as knowing in practice that allows modifications and transformations in order to tackle significant matters that are viewed to be valuable and worthwhile (Callahan 2007). The NHS has historically been regarded as a place of care and security for patients, but in recent years this institution has been stunned by the national and local enquiries of the nursing profession in the clinical environment somewhat lacking with regards patient care (Allan amp; Dennis 2010). Increasing complaints about poor attitudes and the unavailability of nurses to provide essential care of patients may be due to the lack of leadership at the ward level and above (Healthcare Commission 2009, CQC 2010, Cox 2010). According to David Nicholson NHS Chief Executive (2009) leadership is essential in the provision of high quality care and clinical leaders should be supported to drive this transformation both locally and across the NHS organizational boundaries. Dr Peter Carter, RCN General Secretary also noted that senior nurses have a responsibility to oversee patient care on a ward. The author believes that this is also true for the ANP as they need to implement their accountability and to act as role models in terms of the values, attitudes and behavior that are vital to nurses. Local evaluations have highlighted the importance of the ANP in augmenting the responsiveness and the efficiency in the stipulation of healthcare and the overall quality of patient care (RCN 2010). The future delivery of health care is a national in challenge for healthcare leaders, and the role of the ANP as a key player is recognized in the drive for a more effective healthcare through their ability to negotiate matters of health and social wellbeing in a diversity of clinical settings, that offers an opportunity to inaugurate nursing roles that are proficient in delivering, as Lowe et al (2010) explains, â€Å"the most appropriate care, in the most efficient manner and in the most suitable setting. As nursing practice has and continues to change from being task orientated to a team nursing approach that incorporate a holistic framework with the ANP accepting the role as a clinical leader by the very nature of the role. However the role of the ANP in the eyes of some critics is that it has arisen from the reduction in the working hours of junior doctors (Carroll 2002, Smith 2003), and could be argued that the role has been developed out of obligation and not from the necessity of professional autonomy in nursing. Barton (2011) concurs that the reality of reduction of working hours and problems in recruitment and retention of junior doctors, together with the deficiency of continuity due to doctor’s clinical rotation, are well understood and the development of advanced nursing practice has, to some extent, been goaded by these issues, though the nursing profession maintain that the development of advanced practice is of a nursing uniqueness (Hodges 2009, O’Brien et al. 009). Callaghan (2007) argues that ANPs inspire and encourage their team to become proficient and competent in the development of their practice, by sharing their knowledge and expertise rather than allowing habitual nursing practice, by personal, professional leadership in individual decision-making or by involving management teams. The encouragement of innovation and change in practice are fundamental qualities of the ANPs in being efficient and effective clinical leaders (Sofarelli amp; Brown 1998) and is commonly seen in provisions of leading a team or being one of the senior members of the team. This is displayed in decisions related to the priority of care, entrusting responsibilities to team members and the supervision of team members and therefore appropriate delegation of their team. Advanced Nurse Practitioners should able to identify their own and others’ clinical progress needs and take efficient measures to address them. ANPs are expected to have implemented a wide range of educational and developmental opportunities that are presented to achieve their advancement in the role, the Department of Health’s Advanced Level Nursing; A Position Statement (2010) suggests that this is not only carried out through formal education but also from the ANP’s own individual practice and the entities they work with. While is it vital to protect patients and public interest, it is essential to have statutory rights prepared to protect the professional interests of the ANP, and by doing so strengthening the role ANP as an effective clinical leader with self-assurance, mettle and belief in developing their nursing teams (DOH 2010). There is ample literature reviews presented with the confusion surrounding the role of the ANP, Mantzoukas and Watkinson (2006) propose that much of this confusion has been substantiated by the interchange-ability of nursing roles, even when the identical titles are used it does not automatically mean that the comprehension that the preparation and practice performance of the ANP are the same. As a result ANPs need to require their attainment of practice autonomy by having a clear understanding of their professional integrity and professional boundaries, within the multidisciplinary team, and give careful consideration to what applies in their particular role, so attaining their accountability to practice as an advanced nurse practitioner.