The psychiatric nurse--accountable? to whom? for what?

Abstract

Accountability is a weighty subject. One that couldn't possibly be covered in a comprehensive way in a short speech. What I intend to do is to suggest the context in which the word accountability has emerged, to present a definition of the term, and then to highlight some applications in psychiatric care. Mostly, however, what I am likely to do is to raise questions which, I hope, you will mull over and resolve in good time. The term accountability started appearing in health care literature, with greater frequency, in the 1970s, although accountability is not a new concept. Nor is it the first term to be applied to prod the consciences of health professionals. In a much earlier time "dedication to duty" was used. That meant professionals were to perform their very best, almost as a sacred rite. Total devotion to duty, almost as a consecration of self, was expected. As the word "duty" became outmoded and "dedication" began to be seen as restrictive compelling devotion to duty as only one facet of a person's total life--responsibility became the watchword and along with its use long lists of functions of nurses were developed--a list for each nurse position--for which responsibility was expected. Responsibility meant being reliable, trustworthy, doing what was expected; a kind of moral and personal liability was implied. No doubt a case could be made that "dedication to duty" was used when fees and salaries were pitifully low, and knowledge and resources for health services were limited. As professional salaries escalate, as more professionals go on payrolls than are collecting private fees, and as management of larger resources becomes important, the term accountability enters the scene. "Dedication" has a religious tone; "responsibility" suggests a wider social conscience; whereas "accountability" is a term long associated with finances, administration, business, and management. In his definitive monograph on this subject, Matek(1977) traces the term to 400 B.C. Its basic meaning is "to count." For centuries it has been a central feature of performances for such occupations as accounting and auditing in which "balanced financial records" of public transactions were checked. All three terms have the same aim--dedication, responsibility, and accountability--to prod the professional toward proper behavior in health care work. The current use of the term "accountability" is in relation to management of health care systems. Where earlier there were primarily physicians and nurses, there are now many more kinds of health care professionals. There is an ever enlarging number of non-professional health care workers (and over 200 different kinds), where earlier there were primarily maids and orderlies. There is now extensive specialization and subspecialization, signifying an ever-broader array of new and advanced scientific knowledge, where earlier theories explanatory of health problems were of limited scope. Today, particularly in general health service systems, there are extensive technologies and many instruments to measure precisely those phenomena to be diagnosed and treated by health professionals, where earlier the major tools were a limited array of measuring devices and inexact human observation. Thousands of pharmaceuticals are available today for treatment as compared to the mere handful a half century ago. And, in part, as a direct consequence of these changes, the costs of present-day health care are high and escalating. Clearly, the health care systems of today are quite different from health services of a half century ago. However, the mission is unchanged: to provide health services which the public needs. The introduction of accountability as a prod, as a process, as a management effort, must be seen in this everchanging, increasingly complex context of present-day health-care systems. Two other significant changes have occurred which have a bearing on accountability. First, over the past half century there has been a shift from personal, private payment for health care and philanthropically financed "charity care" for the indigent, to third-party reimbursement by health insurance or by purchase of health services by governments. …