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The realities of accountability

Cohen, Shelley MSN, RN, CEN

Nursing Management (Springhouse): September 2013 - Volume 44 - Issue 9 - p 26–28
doi: 10.1097/01.NUMA.0000433388.72637.08
Department: Manager Matters

Shelley Cohen is a founder and educator at Health Resources Unlimited, LLC, in Hohenwald, Tenn.

The author has disclosed that she has no financial relationships related to this article.

In the August issue, we introduced you to Hank, a new nurse manager who was trying to find his way through the maze of staff meeting effectiveness. Now he's faced with staff accountability issues.

Hank looks at the clock and is amazed that he has been in the department for less than 2 hours and already several staff accountability issues have come to his attention. He thinks back to how challenging it was for him as a direct care nurse to balance the multiple priorities of patient care. Yet, he can't recall a time when he didn't feel a sense of accountability or ownership for his actions or inactions. Hank doesn't want to believe that any of the staff members don't care about their roles, so he dismisses the morning issues hoping the frequency of events is simply unusual.



Before grabbing a quick lunch, Hank stops by to check in with the team leader, Sara Beth, to see how the day's progressing. He's thankful for the team leaders in the department and recognizes the vital role they play in maintaining safe and efficient patient practices. Hank stops when he overhears a conversation Sara Beth is having with another staff member.

Sara Beth: “Is there a reason you didn't check your room supplies at shift change this morning?” Janine: “Yes, it's ridiculous that a nurse should have to stock a patient room, that's what we have techs for—isn't it?”

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Trouble's brewing

After Janine leaves, Sara Beth says to Hank, “Staff members just don't want to be accountable for anything anymore.” Concerned, Hank asks for her perception of how pervasive this problem really is, and she shares multiple examples of several staff members, licensed and unlicensed, who don't seem to care about doing their jobs. She says, “It's not like this is a volunteer position—after all, they're being paid to do their jobs!” Hank decides to add this topic to the agenda for the next team leader meeting and thanks Sara Beth for her honesty.

Waiting for the elevator, Hank reflects on the very basics of what he expects from the staff members:

  • Follow organization policy and procedure.
  • Meet the requirements of the employee handbook.
  • Maintain the required competencies for their job descriptions.
  • Commit to the Code of Ethics from their nursing specialties.
  • Take accountability for problems/concerns and assist with the resolution process.

Stepping into the elevator engrossed in thought, Hank is greeted by his director, Stacy. He shares his encounter from this morning and Stacy tells Hank that he's the third manager this month who has expressed similar concerns for a lack of accountability among some of the staff. Stacy reminds Hank of the nurse manager meeting today at 4 p.m. and notes that she has placed this topic on the agenda.

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The ABCs of accountability

Stacy decides to focus on the following key elements related to accountability:

  • understanding accountability and its relationship to taking ownership
  • clarifying the expectations leaders have of staff members
  • defining and supporting consequences for lack of accountability
  • assessing the impact on patient care when staff members aren't held accountable
  • empowering team leaders to take timely action.

Her presentation outline provides the nurse managers with a clear understanding of each key element and, in addition, offers steps leaders can take to shift the accountability back to the staff members. During the meeting, Stacy asks the group: “What's the number one most neglected or avoided behavior among executives?”

Some guess delegating, whereas others think it's not seeing the “big picture.” Stacy shares survey results of over 5,000 managers revealing that they most often shirk the responsibility of holding people accountable.1 The group learns that as the nursing workforce continues to shift to one that's more diverse, this trend of “turning our backs” on accountability has intensified.1

As the meeting progresses, Hank realizes that it's easier for him to make excuses as to why he hasn't been paying closer attention to many accountability concerns in his department.

At the round table, each manager is asked to provide one example from his or her department that demonstrates staff members' lack of accountability. In addition, Stacy asks them to share with the group what they did to hold that staff member accountable for his or her action or inaction. Only two out of the 12 managers had held the staff member accountable.

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Key responsibilities

Stacy brought the group's attention back to the initial key accountability elements for further discussion and explanation. Within each point, she offered a leadership tip for the managers to consider so they could recognize the pivotal role they play in staff member accountability.

Understand accountability and its relationship to taking ownership. A manager can't make anyone do anything. It's up to individual employees as to whether they'll perform to expectation. However, when a culture of ownership is fostered by the leader through processes such as nurse councils and staff engagement, staff members feel like they're truly a part of something, which, in turn, makes them want to become accountable.

Leadership tips: Offer overt praise and support to those who take accountability to heart rather than focusing the majority of your efforts on those who seek to sabotage the culture shift you seek. Review your current leadership style to ensure it encourages staff engagement and involvement at the highest level.

Clarify the expectations of staff. On an ongoing basis, managers should review the job expectations of each job description. When staff members elect not to meet these expectations, use the power of the written job description when confronting the staff member. For items not delineated in that format, refer to the organizational vision or mission statement.

Leadership tips: Develop your “elevator speech” to use when confronting staff with accountability issues. Keep it short and to the point. For example:

  • “Your job description requires you to stock your assigned rooms each shift, what seems to be getting in the way of doing this?”
  • “I thought I saw you on the schedule yesterday and noted room 17 was part of your assignment. How did you manage to regulate the I.V. levofloxacin on that patient with a broken I.V. pump? What happened when you completed the repair tag for the pump, did the manufacturer refuse to fix it?”

Define and support consequences for lack of accountability. Don't wait for accountability issues to arise to review organizational consequences for unacceptable behaviors or practices. Identify those staff members who fail to comply and review the handbook or other policy references that relate to their lack of accountability history. Remember that it's a disservice to adherent, supportive staff members to make them sit through these types of communication—save it for staff members with accountability issues.

Leadership tips: Keep a readily available copy of each job description, the employee handbook, and other resources to refer to when holding accountability discussions with staff members.

For example:

  • “Kevin, here's a copy of page three from your job description, which outlines routine tasks you're responsible for, one of which is room stock. Are you telling me you can't meet the requirements of your job description? My expectations are that you'll comply with each requirement of your job, and if another lack of accountability event occurs, you'll find yourself with a written level one notice in your file. Do you have any questions about what I expect?”
  • “When I hired you, Cynthia, I made it clear that all staff members are responsible to assist in orientating any new hires. This is also part of your written job description. Your unwillingness to work with new hires is unacceptable. This type of behavior impacts retention, the respect of our profession, and the reputation of this organization. My expectations are that you'll immediately cease this unacceptable behavior and embrace all new hires. This conversation is a level one written action for you, the next step is termination. Do you have any questions?”

Assess the impact on patient care when staff members aren't held accountable. Other staff members take notice very quickly when peers “get away with” not being accountable for an action or inaction. The impact on department morale can't be overstated when the leader elects not to rein in noncompliant staff. When morale is diminished, it impacts overall trust and, like a runaway steamroller, patient care safety and efficiencies get flattened. Although leaders can expect some staff members to display a lack of accountability, it doesn't mean the leader has to tolerate it.

Leadership tips: Before confronting the staff member, consider the effects his or her action/inaction had on patient care and include it in your discussion if appropriate. Be patient, make no assumptions about employee performance, and be willing to truly hear what staff members have to say. There's always the possibility that there was a miscommunication or lack of awareness that led to what was perceived as irresponsibility.

Empower team leaders to take timely action. The team leader job description grants the authority to hold staff members accountable in the absence of the manager; however, team leaders are often concerned they won't be supported in their decisions. Managers need to reconnect with their team leaders to discuss true empowerment at their level and develop a platform for trust in their decisions.

Leadership tips: True empowerment can't occur without authority and the willingness to trust all decisions, even those in error. Be proactive—connect with team leaders about staff members who have accountability issues and commit your support for team leader decisions.

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It starts with managers

As Hank heads back to his department, he thinks about the events from this morning. He recognizes that he didn't hold staff members accountable, so he's going to stop by the Human Resources department to make sure he has the latest copy of the employee handbook. With the information and tools from the meeting with Stacy, Hank feels much more prepared to hold himself accountable in addressing staff nonadherence concerns.

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1. Overfield D, Kaiser R. One out of every two managers is terrible at accountability.
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