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How can I clearly express my expectations of responsibility and accountability with my staff?


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Nurse managers can engage nurses in at least three different accountability conversations, each intended to generate commitments on performance. To demonstrate this, let’s examine the example of hourly rounding.

A unit has adopted the process of hourly rounding as a method to improve patient satisfaction. Nurses are expected to round each hour on their patients, and to use a script that involves checking on the three Ps: pain, position, and potty.

Three levels of conversation occur:

Level 1: Nurses are asked to be professionally responsible for the care they deliver. In this example, it is rounding with their patients every hour. The concept of accountability here is soft, since it becomes “be accountable for doing what you are responsible for doing.” There is no outcome beyond the activity.

Level 2: Nurses are asked to be accountable for the outcome of their care, such as patient satisfaction. Nurses are accountable and responsible. Nurses have control over their own practice and they can adjust that practice to achieve the outcome for which they are accountable.

Level 3: Nurses are asked to be accountable for the unit’s outcomes—in this case, patient satisfaction scores for the care given. This involves unit activities beyond individual nurses’ responsibilities. Nurses are accountable but not responsible. To be effective, they will have to collaborate with fellow nurses who collectively have the responsibility to deliver the outcome. It’s the nursing team that is accountable and responsible for unit performance. The individual nurses share the accountability.

Each of these conversations addresses responsibility and accountability. When a staff nurse is doing his or her job, the staff nurse is responsible for doing what his or her job description defines. This is the case in Level 1. As you move into the scenarios described in Levels 2 and 3, the nurse must influence other nurses’ practices. As the nurse talks to a coworker about a conversation she observed between a staff nurse and a patient and suggests how the observed nurse might respond differently to achieve higher patient satisfaction, the nurse is trying to influence the behavior of another nurse, yet she is not the nurse’s supervisor.

You may begin to see why conversations about accountability can be confusing and can fail to pin down the desired commitments. As managers move from Level 1 to 2 to 3, they need a framework to make distinctions so that they are clear about their expectations. Nurse managers need a game plan where they translate their intentions (expectations) into these three conversations.

- Eileen Lavin Dohmann, RN, MBA, NEA-BC

(March 2012)