Advanced Profession Practice
This essay will address the issue of becoming an accountable professional practitioner. I will discuss the issues around accountable professional practice as I see them and explore what these mean for my nursing practice, I will then conclude with the main points I have raised and implications for my future practice.
Just what is an Accountable Professional Practitioner? Perhaps it would be best to examine what accountability means within the healthcare setting. The NMC Code (2008) states that “you are personally accountable for actions and omissions in your practice and must always be able to justify your decisions.” Although this definition is useful it lacks a certain clarity of by what is meant by the term accountability as it gives a general overview without being specific, Savage and Moore (2004) go on to argue this that lack of clarity can lead to indistinctive views that confuse those working in the health care field and it is this lack of precision that can lead to nurses professional conduct being called into question (NMC 2002).
Perhaps for the professional practitioner what is useful is to examine what makes you accountable rather than what is accountable, by this I mean how you become an accountable professional practioner, what are the prerequisites required for this. One could argue that perhaps this all begins with critical thinking and reflection, Brittner and Gravlin (2009) argue that critical thinking is essential in today’s nursing practice and can assist in making essential choices about patient care and clinical emergencies (St.Cyr & All 2009, Toofany 2008, Cirocco 2007). Being a recently qualified nurse this isn’t always an easy task to do, because I often lack the skills and knowledge that would allow me to make complex decisions, this is not unusual though as St.Cyr & All (2009) highlighted that newly qualified nurses can lack some critical thinking skills for patient care, a useful tool that I have discovered that can enable me to develop my critical thinking abilities are mind maps, as these can increase my knowledge and understanding of a situation by linking concepts, themes and ideas (Toofany 2008) and can assist me in discovering a deeper understanding of the issues and indentify learning needs and positive behaviours to aid my development (St.Cyr and All 2009). To this end I do use mind maps as a way of linking theory and knowledge to gain a better overview of the patient or the clinical situation, it highlights my gaps in knowledge or indeed raises my awareness of what I already know.
To move this a stage further by then applying these critical thinking skills to reflection I can begin to critically reflect on my practice. By becoming a critical reflector I am aiding my self-awareness (Horton-Deutsch & Sherwood 2008) and developing a deeper understanding of the issues relating to patient care, my own actions and the reasons I choose them (Cirocco 2007, Redmond 2004) challenging my own actions (Forneris & Peden-McAlpine 2009) and highlighting any learning needs I may wish to follow up on to aid my development as an accountable practioner by linking theory into practice (Rolfe & Gardner 2006, Rolfe et al 2001).
The best example of this I can give to date was when I was involved in a clinical emergency with a patient just after a couple of months of qualification, who despite every attempt made died very suddenly, I was left with lots of confusion, anger and upset over the incident and more importantly with the question of could I have done more? Through a process of critical reflection both written then verbally with my mentor I realised that we could have done nothing more, that I acted in a very professional manner throughout the incident and afterwards with the support I offered the family and colleagues, but I needed to go through that process in order to make sense of the situation and highlight possible learning objectives for me including developing coping strategies that would enable me to cope with a sudden death. When a situation very similar occurred again a few months ago I was able to take a more active role and recover from it much quicker knowing I did all that I could to help the patient and supporting the family and some colleagues after the incident. Benner (1984) states that this type of actions are that of an advanced beginner working towards becoming a competent nurse whereby by being involved in similar experiences I was able to make sense of a meaningful situation. By beginning to recognise patterns of behaviours and events I am beginning to develop my expertise through increasing my experiential learning knowledge (Benner 1984, Rolfe et al 2001). It is by making meaningful sense of these experiences though a process of critical reflection that have aided and will continue to improve my decision-making skills and self-awareness (Horton-Deutsch & Sherwood 2008, Avis & Freshwater 2006). It also empowers me to continue to participate in continuing education maintaining and developing professional competences (Griffitts 2002) by identifying learning needs through gaps in my knowledge.
In becoming an accountable professional practioner this process of reflection can be a quality standard whereby I take responsibility for my own performance and deliver best quality care (Johns 2004). This links into clinical governance whereby I have to ensure I am prepared to accept accountability and consequences for any decision-making judgements that comes with any new role development (Cronin & Rawlings-Anderson 2004). Through the system of clinical governance I can monitor through self-evaluation and feedback the quality of care and service I offer to my patients, families and colleagues ensuring that it is both effective and safe (NHS QIS 2005, Pickering & Thompson 2004).
There is also the issue of autonomy and accountability. This for me has been to date the biggest struggle in becoming an accountable professional, autonomy can be demonstrated through patient care by using the processes of critical thinking, reflection and your existing knowledge base (Keys 2009) however this can become frustrating when you take on autonomous responsibility but are limited by circumstances and sometimes colleagues to utilise your training and experience (Laperriere 2008). As a mature student who came into nursing as a second career I find myself often perturbed by colleagues who often quote that I am a newly qualified member of staff and it will take time to develop skills especially around issues of patient and family communication without knowing my background. It has be shown that newly qualified mature nurses can use previous life experiences to aid in a problem solving approach (Stuttard 2008) and as many of the skills I have developed over the years are transferrable, I would argue that by having these transferrable skills I can offer a wider range of skills and flexibility to my nursing experiences (Shirey 2009) that can aid my self-awareness and autonomy (Postler-Slattery & Foley 2003). One of my ways of coping with these frustrations is to develop resilience.
By becoming resilient to the negativity or challenges I receive I am able to motivate myself, Roth et al (2007) show that motivation within an autonomous concept and the actual experience of autonomy are essential for self-development and well-being, by using this autonomous motivation I can use it to aid my self-awareness of critical thinking and reflection (Leipold & Greve 2009). This is a view supported by Darbyshire & Fleming (2007) who state that those who practise autonomy are encouraged to be critical thinkers and self-directed in their learning. Of course within the concept of autonomy comes the acceptance of being responsible and being aware of your own limitations, at all times autonomous practice must be practiced safely with the care of the patients at the forefront it is not a weakness to say I cannot do this or participate in a skill that I know very little about (Richards & Edwards 2003) it instead highlights how much I value patient care and respect for those I work with.
Autonomy means ownership (Lyon 1990) and by claiming ownership of my practice it could be argued I increase patient safety and increase the quality of care I give my patients (Weston 2008) as well as developing my critical thinking, knowledge and accountability (Atkins 2006).
With the above in mind I find myself asking the question of what else can support me in developing into an accountable professional practitioner? Certainly the processes of reflection and critical thinking can help but what I personally find of great use is to utilise the support systems I have around me, I certainly acknowledge how fortunate I am with having the amount of support systems in place to support me compared with some of my fellow colleagues as a result of the Early Clinical Career Fellowship. Currently I have three main formal systems in place a mentor, clinical coach and participation in action learning sets, these systems although very different from each other all have one thing in common and that is to aid my development, in addition to these systems I also have the informal support of my peers and management.
My mentor can assist me in adapting to my new environment and offer the support from their own experiences to enable my learning, they are motivated to support and encourage me (Wagner & Seymour 2007) to develop and try out new skills with support until I am confident enough to undertake these on my own, in addition to this they provide me with feedback on my progress and can suggest alternatives ways of working, they act as my role model and teacher (Morton-Cooper & Palmer 2000). They can also provide me with a safe place to take sensitive issues and challenge my views (May 2003)
Participation in action learning sets allows me to be supported and challenged by a group of my peers, it allows me to critically reflect and explore issues to a deeper level to aid my understanding and development and apply any new knowledge I have learned to practice, it can increase my motivation to learn and encourage my critical thinking into linking theory into practice. (Haan & Ridder 2006, Rayner et al 2002)
In addition to the above I also have my clinical coach. This is a very experienced nurse who can support, mentor, guide and coach me. She provides a higher degree of challenging to my practice encouraging my critical thinking and reflective skills and as she is detached from my clinical area is able to offer observations and questioning of my actions from a neutral perspective (Titchen 2003, Wright & Titchen 2003). This all encourages and challenges me into becoming an accountable professional practitioner.
In conclusion this essay has raised several points about leads you to become accountable rather than what is accountable. It is a complex dynamic composing of not one element but several that all interconnect almost as if it were a jigsaw puzzle. No one element is more important that the other as they are all necessary to help me in my development as an accountable professional practitioner. As my knowledge, understanding and experiences as a nurse increases so too will my accountability, this in itself will provide new challenges as I prepare myself for these new responsibilities and self-development What is clear for me and has been highlighted as a result of undertaking the essay is how my practice of an accountable professional practitioner can be used as a quality standard of care and measuring tool to ensure that my practice is safe and effective for all of those I work with and as O’Rourke (2006) states that this standard of care can only be improved on based on my understanding of roles, autonomy and accountability and that can only be understood once I develop my critical thinking, reflective skills and using my support systems that have been put in place for me.
I believe that throughout my career as a nurse even as I work towards becoming an expert nurse (Benner 1984), I will always be working towards becoming an Accountable Professional Practitioner as I will always be critically reflective, learning new skills, developing my autonomous practice and requiring support so to that end I don’t think I will ever be a fully accountable professional practitioner but I am accountable for the skills, knowledge and responsibility and level I am at. This brings a strange feeling of comfort rather than fear as I believe this will ensure nursing continues to evolve and develop and I will be there in the midst of it all.