Introduction: Nurses who work in an emergency department regularly care for acute patients in a fast-paced environment, being at risk of suffering high levels of burnout. This situation makes them especially vulnerable to be accountable for decisions they did not have time to consider or have been pressured into. Research objective: The objective of this study was to find which factors influence ethical, legal and professional accountability in nursing practice in an emergency department. Research design: Data were analysed, codified and (...) triangulated using qualitative ethnographic content analysis. Participants and research context: This research is set in a large emergency department in the Midlands area of England. Data were collected from 186 nurses using participant observation, 34 semi-structured interviews with nurses and ethical analysis of 54 applicable clinical policies. Ethical considerations: Ethical approval was granted by two research ethics committees and the National Health Service Health Research Authority. Results: The main result was the clinical nursing accountability cycle model, which showed accountability as a subjective concept that flows between the nurse and the healthcare institution. Moreover, the relations among the clinical nursing accountability factors are also analysed to understand which factors affect decision-making. Discussion: The retrospective understanding of the factors that regulate nursing accountability is essential to promote that both the nurse and the healthcare institution take responsibility not only for the direct consequences of their actions but also for the indirect consequences derived from previous decisions. Conclusion: The decision-making process and the accountability linked to it are affected by several factors that represent the holistic nature of both entities, which are organised and interconnected in a complex grid. This pragmatic interpretation of nursing accountability allows the nurse to comprehend how their decisions are affected, while the healthcare institution could act proactively to avoid any problems before they happen. (shrink)

A report suggests that United States’ army officers may engage in dishonest reporting regarding their compliance procedures. Similarly, nurses with espoused high ethical standards sometimes fail to live up to them and may do so while deceiving themselves about such practices. Reasons for lapses are complex. However, multitudinous managerial demands arising within ‘technical and instrumental rationality’ may impact on honest decision‐making. This paper suggests that compliance processes, which operates within the social structural context of the technical and instrumental rationality manifest (...) as ‘managerialism’, contributes to professional ‘dishonesty’ about lapses in care, sometimes through ‘thoughtlessness’. The need to manage risk, measure, account, and control in order to deliver efficiency, effectiveness, and economy (technical rationality) thus has both unintended and dysfunctional consequences. Meeting compliance requirements may be mediated by factors such as the ‘affect heuristic’ and ‘reflexive deliberations’ as part of the ‘structured agency’ of nurses. It is the complexity of ‘structured agency’ which may explain why some nurses fail to respond to such things as sentinel events, a failure to recognize ‘personal troubles’ as ‘public issues’, a failure which to outsiders who expect rational and professional responses may seem inconceivable. There is a need to understand these processes so that nurses can critique the context in which they work and to move beyond either/or explanations of structure or agency for care failures, and professional dishonesty. (shrink)