Ethical and legal accountability in nursing clinical practiceanalysis of protocols and clinical activity in an english emergency department

Abstract

Introduction: In the case of England, emergency departments undergo a crowding stage that relaxes the limits of the accountability to which the nurse is subjected to, who must deal with the subjectivity of the presumption of emergency and the rigidity of the NMC Code. Due to this, factors affecting the decision-making process are decisive to improve the quality of care and to understand what influences nurses to work in one way or another. The analysis of ethical and legal problems has helped to improve nursing practice in different countries, so its application in such a delicate area as emergency nursing is necessary. In English nursing practice, this area suffers legal loopholes, such as emergency presumption subjectivity or deontological contradictions with the NMC Code. However, the study of this area of knowledge in England is very limited, which avoids that scientific evidence is used to find practical solutions. Objectives: The main objective of this thesis is to study ethical and legal factors influencing professional accountability in nursing practice at the Leicester Royal Infirmary Emergency Department. Methodology: A post-positivist paradigm was adopted in this thesis, in which a qualitative study using ethnographic content analysis was utilised, facilitating access to more diverse data and its verification by triangulation. The three techniques of data generation on which the study is divided are ethical analysis of clinical policies, reflections on practice and semi-structured interviews. Analysis of data from each technique was achieved parallel to its gathering through a unique code frame for each data gathering technique. When all data was codified, it was triangulated under a unified code frame. Results: The clinical nursing accountability cycle defines the interaction between the nurse and the healthcare institution both in decision-making and in the accountability management derived from the consequences of their decision. Due to its variability, nursing accountability needs to be analysed as a subjective concept, which depends on the nurse, the healthcare institution and the context in which the decision is made. Both entities involved in decision-making were deconstructed to explain in detail which factors influence nursing decision-making and the nursing accountability based on those decisions. The resulting model explains this web of relationships between the 32 nursing practice accountability factors, which are divided into ethical, legal, professional and personal. Through this theoretical model, subjectivity in nursing accountability, the symbiotic relationship between nurse and healthcare institution and how various relationships between factors can be limiting or create positive feedback loops are explained. Conclusions: Nursing accountability is a subjective concept which perception and application vary depending on the nurse, in which a continuous interaction with his healthcare institution is produced. This interaction manifests the symbiotic relationship between both entities, which participate in each nursing decision-making process how is described in the cycle of nursing clinical accountability. When delving into which factors affect subjective nursing accountability, it can be perceived that those factors are connected in a way that influences present and future decisions. Analysis of those connections between factors allows the identification of which one was decisive in each individual decision-making process, improving the comprehension of subjective nursing accountability through the nurse's reasoning.