Nurse Leaders and Accountability in Nursing

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Accountability in nursing affects patient health outcomes and quality improvements at the institutional level.

Since 1999, nursing has outpaced 21 leading professions to be voted the most honest and ethical occupation in the United States. More than eight in 10 people surveyed in an annual Gallup poll described nurses’ ethics as high or very high, surpassing medical doctors, grade school teachers, and firefighters. The level of trust underscores the importance of peer accountability in nursing practice.

Accountability — or a willingness to accept responsibility for one’s actions — is a cornerstone of nursing. One of the keys to being an effective nurse manager is promoting peer accountability. In many medical facilities, registered nurses (RNs) who have earned a Doctor of Nursing Practice (DNP) degrees are the impetus behind peer accountability because they are skilled and respected practitioners.

Accountability in nursing practice has been linked to better patient health outcomes and quality improvements at the institutional level. Accountability is vital to the future of healthcare, experts say.

“Nursing leaders are successful in meeting quality and financial goals of their departments when they hire motivated nurses who understand how they affect those goals and are empowered through shared decision-making,” said Cherry Shogren, director of professional development at UnityPoint Health in Des Moines, IA.

“Peer review promotes that understanding and empowerment by linking practice standards, outcomes and constructive peer feedback to enhance quality.”

As nurse leaders, RNs with DNPs are responsible for creating and maintaining a culture of accountability. Learning how to initiate such a culture is an essential element of being an effective nurse manager.

Accountability in Nursing in Action

In the 1980s, the ANA published its peer-review guidelines. Since then, the guidelines have been used across the United States to create a culture of accountability in healthcare. Hospitals hoping to attain and maintain the American Nurses Credentialing Center (ANCC) Magnet status must establish and continue a formal peer-review system. The Magnet distinction signifies the healthcare organization meets excellence standards for nursing and patient outcomes.

The ANA uses these six basic principles to ensure consistent application of the peer-review process:

  1. A peer is a nurse colleague of the same rank: Only nursing peer groups should provide feedback and constructive criticism to each other. The ANA describes peer groups as those of the same employment level such as direct-care nurse to a direct-care nurse or advanced practice registered nurse (APRN) to APRN.
  1. Peer review is focused on practice alone: The process is solely focused on patient outcomes and ensures nursing standards of care are being met. Effective peer review utilizes evidence-based practices and incorporates professional standards.
  1. Feedback is timely, routine, and continually expected: Peer reviews should happen in real-time, rather than during yearly evaluations. This process allows nurses to understand and correct policy failures immediately.
  1. Peer reviews foster the continuous learning of patient safety and best practices: Peer reviews are completed under the framework of learning and education and should never include blaming or shaming. The purpose is to gather information to determine how effective changes can be implemented
  2.  Feedback is never anonymous: Open collaboration fosters positive relationships between peers and prevents the appearance of backstabbing or tattling. Respectful, open communication fosters integrity, and safety.
  1. Feedback takes into consideration the developmental stage of the nurse: When experienced nurses act as mentors to new nurses, they can provide supportive insights and constructive criticism that is not presented in a bullying manner.

Creating a Culture of Accountability in Nursing

Peer accountability enables nurses to speak out when a coworker is observed not meeting practice standards. The initial steps to creating peer accountability include developing a culture of accountability.

Workforce bullying expert Renee Thompson said to make accountability in nursing work, employees must be able to identify and address problems as they happen, thus creating a culture of accountability. Employees must understand the benefits of direct communication and have the skills to speak out in a professional manner.

“The good news is that establishing a culture where employees are willing to hold each other accountable instead of tattling to the boss is a skill that can be developed,” she said.

Indeed, Thompson and other workplace communications experts say building a culture of accountability depends on strong leadership and an overall willingness to change. Some of the steps to creating a culture of accountability include:

  • Building trust: The foundation for successful workplace accountability is trust. Employees who trust each other are more willing to accept and act on constructive criticism rather than assuming it is ill-willed.
  • Developing strong communication skills: Individuals who use an assertive communication style can express information in an honest, open, and direct manner. The assertive communication style is not aggressive in tone, but instead is respectful and avoids blame and criticism.
  • Developing clear expectations: The American Nurses Association (ANA) outlines the expectations and responsibilities for all nurses including the overall responsibility for their patients and practice. Nurse leaders should continually remind nurses of the expectations of practice.
  • Modeling accountability: A workplace that has leaders who accept responsibility and hold themselves and others accountable creates a culture of accountability. DNP-educated RNs who are leading teams of nurses must be open to feedback and criticism. Being an effective nurse manager begins with learning DNP leadership skills.

Many nurses use online DNP programs to put learned leadership skills into immediate clinical practice. Nurse leaders who have earned DNPs are positioned to assist with peer accountability to uphold the behaviors and values of an organization.

Accountability in Nursing Practice

Part of being an effective nurse manager is to celebrate successes but also be forthcoming and honest regarding errors or near misses, RN Charlotte Davis said in “The importance of professional accountability.” When missteps do happen, nurses should embrace professional accountability rather than avoiding it, she said.

“Each year, we lose more of our experienced baby boomer nurses to retirement,” she said. “As new graduate nurses enter our clinical areas, we have the responsibility to model professional behaviors, with patient-centered care as our focus rather than a task-based environment.”

When DNP-educated nurses model professional accountability and engage in peer accountability, they are creating the new standard for success for the future of the nursing practice. Earning a DNP education, either in the classroom or through an online DNP program, allows RNs to develop successful peer accountability programs. Nurses who earn a DNP through an online DNP program can put their knowledge into practice immediately because they can continue their careers while learning advanced DNP skills.

About Duquesne University’s Online DNP Program

Duquesne University, a leader in nursing education, offers three DNP tracks:

  • Clinical Leadership DNP
  • Post-Bachelor’s Executive Nurse Leadership DNP
  • Post-Master’s Executive Nurse Leadership DNP

Duquesne University’s online DNP program prepares RNs for clinical leadership positions to encourage positive changes and professional accountability in healthcare. The university’s curriculum builds on existing experiences and knowledge, allowing graduates to implement evidence-based practice in clinical settings.

Duquesne University’s online DNP program allows students to continue working and maintain family responsibilities while earning an advanced degree. Apply today!


Gallup, Nurses Keep Healthy Lead as Most Honest, Ethical Profession
Part 1: OR Manager, Professional peer review compels staff to improve performance and quality
Principles and practice, Nursing peer review
Renee Thompson, How to Establish Peer-to-Peer Accountability
Evidence-Based Care, Accountability in Nursing Practice
Nursing Made Incredibly Easy, The importance of professional accountability