Examining nursing accountability in the context of record keeping
Examining nursing accountability in the context of record keeping
The aim of this essay is to improve nurse awareness of the issues related to accountability in health and social care settings. Accountability refers to the legal, professional and ethical guidelines that underpin the responsibility of nursing professionals working in health and social care environments (Caulfield 2005; Carvalho et al 2011). Specifically, the essay will examine these accountability factors as they relate to recordkeeping by nurses within the healthcare sector.
Defining record keeping accountability in the context of health and social care
Recordkeeping in the context of health and social care is a process through which the actions taken by nursing professionals in their role to cater for the health and medical needs of the individual patients are documented (Jones 1996). This written documentation is therefore accessible to any other stakeholder involved in or affected by the healthcare service provided, which includes the patient and more important, senior managers and regulators (Tilley and Watson 2004). Taking into account these objectives, it is apparent that the healthcare professional responsible for creating these records is accountable for ensuring that accuracy of the data and information they contain (Caulfield 2005).
Accountability is generally considered to provide a justification of the professional’s activities and action in terms of the care provided to patients, and a means by which the individual nursing professional can be held responsible for the outcome of those actions (Schwartz et al 2002; Hope et al 2008). In other words, it provides others with written evidence as to why certain events or steps have been taken by the nurse creating the written record, whether these prove to be right or wrong. Nevertheless, one definition that includes a more positive view on accountability is that “it is an innate certainty as an expert that permits a medical attendant to take pride in being straightforward about the way he or she has completed their practice" (Caulfield, 2005: 3).
Legislation and professional guidelines
From a legislative aspect, following a number of high profile healthcare failures, accountability has been embedded in the Health and Social Care Act 2012. Central to this legislation is the need for maintaining accurate recordkeeping by all healthcare professionals (HM Gov 2012). This is important because, as indicated in the Act [Section 104:3c], it is stated that the regulator has the power to demand documents “from any person who has provided, or is providing, a health care service”.
This is a preview of the whole essay
Consequently, it is apparent that if those records are found to be not complete or inaccurate, this will have serious consequences for the professional. Equally, as indicated in the NHS (2012: 1) advice on recordkeeping, the approach adopted by the courts is that “if it is not recorded, it has not been done”, which means that the healthcare professional may be held liable for any perceived failure. Equally, as noted within this guideline, the clarity and accuracy of the records will have a similar effect on professional accountability.
The importance of recordkeeping in relation to nurses also forms an integral part of the professional code of conduct guideline requirements of the NMC (2015). For example, section 7 of this code clearly infers that nursing professionals are accountable for providing written records that enables other team members involved with the patient’s care to understand the patient’s need and demands (NMC 2015). Indeed, as confirmed by the NHS (2012: 2), “health care professionals have a duty to keep up to date with, and adhere to, relevant legislation, case law and national and local policies relating to information and record keeping”. Additionally, the NMC (2015) code of professional conduct also requires the nursing professional to comply with the requirements of the law, which further confirms that they will be accountable for every aspect of their personal involvement with the delivery of a healthcare service to the patient.
Ethical performance and record keeping
From an ethical viewpoint, one of the main benefits of recordkeeping is that it enables the healthcare professional to identify and confine his/her intervention in patient healthcare within the limits of their own expertise. Ethical behaviour is based on a personal moral judgement through which the individual decides between right or wrong (Hendricks 2004). In terms of nursing, this means that not only should the nurse perform his/her duties within the context of what they personally consider to be ethically correct, but are also ethically bound to provide healthcare services only within the limits of their own expertise and competences (De Cruz 2005). This is supported in the research conducted by Griffith and Tengnah (2010) which recognised that a nursing professional is legally and professionally liable for his/her own personal conduct irrespective of the actions of others. This includes working as part of a multidisciplinary team and being focused on improving the health and wellbeing of the patients relying on their care (Rumbold 1999; Swartz et al 2002).
Beauchamp and Childress (2008) offer four rules that they consider important for the foundation for moral leadership in nursing, which consist of Autonomy, Non-wrathfulness, Beneficence and Justice. They consider these four standards to lie at the centre of nursing performance. Essentially, this means that the nurse should be guided by his/her own moral judgement and not only ensure that no harm should be caused to a patient either purposefully or intentionally, but also that the patient receives the quality of care that he/she justly deserves. In this respect, justice is about treating people decently and similarly and obliges the nursing professional to be non-judgemental. Additionally, as suggested by the NHS (2010), this ethical approach should be focused on providing the patient with the opportunity of involvement with the decision-making and choices related to their own care, Recordkeeping is important in this respect, in that it allows the patient access to an understanding of the care being provided. Furthermore, through the recording of their own needs and demands, it provides other healthcare professionals with detail information regarding the patient’s preferences and choices. The NHS (2010) guidelines on equality and excellence confirm that engaging and empowering patients to talk about their considerations with nursing professionals and noting these on record is an inherent part of their moral duty, and one for which they will be held accountable.
The NMC (2015) code, while not specifically mentioning ethics, equally infers that it is a central part of a nurse’s professional conduct to prioritise and protect the needs and demands of the patient, which means the nurse has a moral duty to ensure that these needs are accurately recorded.
Recordkeeping challenges and good practice
Notwithstanding the previous discussion however, as indicated in the literature there are challenges faced by nursing professionals, which can have an adverse effect on their recordkeeping performance. In the modern healthcare environment, these challenges can occur as a result of work overload, time constraints other external influences (Kushmer and Thomasma 2001). The effect of these challenges can result in accurate and appropriate recordkeeping being compromised. This is particularly likely is the case of time and work constraints, where the nurse may consider that other areas of his/her role is of more importance than spending time updating records (Carvalho et al 2011). Equally, as has been previously noted, the quality of the recordkeeping is another issue that can adversely affect the level of accountability that can be applied to the written documentation. Equally, as a result of external influences, such as pressure that may be exerted on the nursing professional by their peers and other stakeholders in the patient care, there may arise situations where there is a temptation to present inaccurate or false information in documented data recorded (NHS 2012). Additionally, there may also arise occasions where the nursing professional may be tempted to record inaccurate data where he/she considers that they personally may be criticised for either making a mistake or have not responded to a patient’s needs with the appropriate intervention.
To combat and avoid all of these challenges, and to ensure good practice in terms of accountability, the NHS (2012), introduced a set of guidelines that nursing professionals should follow in recordkeeping. There are several important elements within these guidelines that nursing professions need to consider in ensuring the robustness of their recordkeeping practice. In addition to providing accurate and honest information, the clarity of the record in terms of legibility and the content of the wording is an important consideration. Furthermore, the dating of the record is considered equally essential as it provides accurate evidence of when the event being recorded took place. In this respect, the NHS (2012: 2) further recommends that “all entries in a record must be recorded as soon as possible after an event has occurred, providing current information on the care and condition of the patient/ client”, as this practice will further improve accuracy of the record. Accuracy of the recorded evidence is particularly important in healthcare situations, as it will enhance the quality and appropriateness of the healthcare intervention being provided for the patient. Moreover, good practice in recordkeeping and compliance with the guidelines provided will have a positive impact on the issue of accurate and meaningful accountability (Caulfield 2005).
The discussion presented in this essay confirms that recordkeeping is a process in healthcare that is used not only for the purpose of effectively sharing information, but also as a process that ensures the nursing professional can be held accountable for his/her actions. However, providing the actions are recorded clearly and correctly, and is supported by the evidence, it is a process that also clearly defines where the boundaries of the professional’s accountability exist. More importantly, recordkeeping accountability is the process through which managers and other healthcare team members can be assured that the patient has received the quality of care to which they are entitled, and in this respect, it also serves to reduce the risk of medical and clinical failures. Consequently, despite the practical challenges that may affect the recordkeeping process, it is important for the nursing professional to ensuring that they maintain an accurate and transparent approach to recordkeeping, which must be based on the facts and not their individual personal interpretation of the events that have occurred. Good practice in recordkeeping enhances accountability and it should therefore should guide nursing conduct in the healthcare environment.
Beauchamp, T. L. and Childress, J. F (2012), Principles of Biomedical Ethics, Oxford: Oxford University Press
Carvalho, S., Orford, J. and Reeves, M (2011), Fundamental aspects of legal, ethical and professional issues in nursing, London: Quay
Caulfield, H (2005), Accountability, Oxford: Blackwell Publishing
De Cruz, P (2005), Medical Law in a Nutshell, London: Sweet and Maxwell
Dimond, B (2015), Legal Aspects of Nursing, Harlow: Pearson Education
Griffith, R. and Tengnah, C (2008), Law and professional issues in nursing, Exeter: Learning Matters
Hendrick, J (2004), Law and Ethics: Foundations in Nursing and Health Care, Cheltenham: Nelson Thornes
HM Gov (2012), Health and Social Care Act 2012, Available from: [Accessed 25 April 2016]
Hope, R. A., Savulescu, J. and Hendrick, J (2008), Medical Ethics & Law: The Core Curriculum, Edinburgh: Churchill Livingstone
Jones, M (1996), Accountability in practice: a guide to professional responsibility for nurses in general practice, Dinton: Quay Publishing
Kushner, T. and Thomasma, D. C (2001), Ward Ethics: dilemmas for medical students and doctors in training, Cambridge: Cambridge University Press
NHS (2010), Equality and Excellence, Available from: [Accessed 25 April 2016]
NHS (2012), Recordkeeping guidelines, Available from: [Accessed 25 April 2016]
Rumbold, G, (1999), Ethics in Nursing Practice, Edinburgh: Baillière Tindall in association with the RCN
Schwartz, L., Preece, P. E. and Hendry, R. A (2002), Medical Ethics: A Case Based Approach, Edinburgh: Saunders
Tilley, S. and Watson, R (2004), Accountability in Nursing and Midwifery, Oxford: Blackwell Science