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JONA
Volume 34, Number 3, pp 114-116
©2004, Lippincott Williams & Wilkins, Inc.
IN MY OPINION
Making a Case for Shared Accountability
Betty R. Kupperschmidt, EdD, RN
Nurse managers are expected to be
accountable for staff nurse job satisfaction, including providing cohesive
work groups1,2 and explaining nurses’
organizational roles and helping
them to find purpose and meaning in
their work.3 If staff nurses fail to
achieve these satisfiers, have nurse
managers failed to do their jobs? Is it
more appropriate for staff nurses and
managers to share the accountability
for job satisfaction? The purpose of
this article is to present the case for
shared accountability. The contrasting (and prevailing) view is the continued burden of staff nurse satisfaction being on managers, with an
attendant misguided entitlement of
staff nurses.
MISGUIDED ENTITLEMENT
Misguided entitlement is an exaggerated sense of self-importance, value,
and specialness.4 For example, during a previous nursing shortage, economic incentives and recruitment
strategies and nurses’ ensuing expectation of job security despite lack of
accountability for patient outcomes
and professional behaviors could be
considered misguided entitlement.5
Misguided entitlement is a change-resistant, interrelated pattern of behaviors and the belief that one must and
will be treated in a special way. It is a
mismatch between wants and expec-
Author affiliation: Assistant Professor,
College of Nursing, University of Oklahoma, Tulsa.
Correspondence: Dr Kupperschmidt, University of Oklahoma College of Nursing-Tulsa,
Tulsa, OK (betty-kupperschmidt@ouhsc.edu).
114
tations and what is reasonable under
prevailing circumstances. Consequences include diminished initiative
and failure to develop coping strategies and requisite skills to develop
positive interpersonal relationships.4
Staff nurse job satisfaction should
be achieved through shared accountability.6 Accountability means being responsible and accountable to self and
others for behaviors and outcomes included in one’s professional role: A
professional nurse is accountable for
embracing professional values, maintaining competence, and maintenance and improvement of professional practice environments.6
Professional nurses are ethically
responsible for respectful interactions and professional work environments, factors that should result in
cohesive work groups and enhanced
job satisfaction.1,2 Nurse administrators are advised to address individual
staff nurses’ personal esteem and
professional worth, find ways to reward and recognize individual staff
contributions, and develop multi-option retention strategies that encompass expectations of nurses of all
ages.1,2 Although these are worthwhile goals, there must also be strategies that address nurses’ accountability for cohesive work groups. For
example, staff nurses often value
coworker recognition more highly
than manager recognition; thus, professional staff nurses should be accountable for using a variety of
strategies to recognize coworker contributions, thus facilitating job satisfaction for themselves and coworkers.7 Until achieving cohesive work
groups becomes a shared accountability, with staff as active partici-
pants, staff have permission to ignore
this ethical accountability.
Nurses report higher levels of
personal empowerment if managers
foster their perceptions of autonomy,
confidence, and the meaningfulness
of their work.3 According to the ANA
Code of Ethics, competence and continued personal and professional
growth affect self-respect, self-esteem, professional status, and meaningfulness of work.6 Is professional
nurses’ lack of accountability for
competence, without managerial intervention, another example of misguided entitlement and a causative
factor in nurses’ inability to find
meaning and purpose in the work of
nursing?
Managed care and staff nurses’
inability to understand managed care
is cited as the cause of nurses’ inability
to cope with uncertain work environments and provide high-quality nursing care.7,8 Professional behaviors are
not promoted when nurses are continually defined in terms of their least resourceful conditions, such as inability
or unwillingness to trust administration and provide professional care in
uncertain environments or understand
managed care without managerial interventions.9 Rather, misguided entitlement is fostered.
Brandon9 asserts it is past time
to challenge the underlying principle
of entitlement, the doctrine that
some people have an unearned claim
on the mind, energy, and effort of
others. Entitlement treats people as
means to the ends of others and asserts the moral right to do so. True
community and collegial relationships suffer when professionals abdicate their responsibilities to some-
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one and that someone accepts
them.9 When nurse managers justify
their jobs by assuming staff nurses’
responsibilities, it is usually because
both parties perceive permission
from some authority to do so. Is this
permission the prevailing rhetoric of
nurse managers’ accountability for
staff nurse outcomes, rather than
shared accountability?
When responsible adults refuse to
share accountability, it poisons human
relationships, corrupts professions,
and makes self-esteem impossible.
Refusal to share accountability with
responsible adults is morally corrupting, psychologically disempowering,
and spiritually devaluing and dehumanizing. Brandon argues that moral
responsibility and accountability are
integral to human dignity, and shared
accountability moves employees
from being victims to being personally empowered.9 Outcomes in today’s complex organizations can not
be obtained and sustained through
the efforts of one individual; they
must be obtained through the interface and responsible participation of
all on whom the outcomes depend.
Excessive focus on managers’ accountability for staff nurses’ job
satisfaction promotes misguided entitlement rather than professional accountability. It is time to champion
shared accountability, the ethical imperative of professional staff nurses
and managers.
FOSTERING SHARED
ACCOUNTABILITY
DePree10 conceptualizes shared accountability as the marvelous gift leaders and employees must share. He contends that sharing this gift frees the
spirit because adults naturally understand, want, and expect to be held accountable for their choices and actions.
How can staff nurses and nurse managers begin to share accountability for
staff nurses’ job satisfaction? Staff
nurses must ask why they accept the
prevailing rhetoric: Is it because they
like their current roles and prefer that
managers assume the accountability?
JONA • Vol. 34, No. 3 • March 2004
Managers must ask the same question:
Do they like their roles as boss?11
Nurse managers and administrators must acknowledge their ethical accountability for professional practice
environments within a model of shared
accountability. Educators must assure
that students understand their ethical
imperative to embrace the ANA Code
of Ethics and attendant roles as professionals in fostering professional practice environments. Teaching strategies
related to team building must foster
“followership” and individual accountability for cohesive teams and
work groups. Nurse researchers must
recommend strategies that promote
shared accountability.
Finally, each professional nurse
should purposefully reflect upon the
intent and essence of the Code of
Ethics and the insidious erosion of individual professional accountability
posed by misguided entitlement. All
nurses must question the extent to
which their failure to confront this prevailing rhetoric perpetuates misguided
entitlement. When a person chooses to
become a professional nurse, he or she
accepts the responsibility to uphold the
values of the profession: A powerful,
poignant incentive to confront misguided entitlement. During a previous
nursing shortage, shared accountability was achieved as work outcomes
were clarified, compensation was tied
to performance, and authority was delegated proportionate to employee
readiness for decision-making power.5
Currently, acute care facilities are
implementing shared leadership models. These models are nursing management models that support and expect
staff nurse input into decisions that affect their practice, work environments,
professional development, and self-fulfillment. These models, based upon
the pillars of accountability, partnership, equity, and ownership, empower, support, and expect staff
nurses to act autonomously at the
point of service.11,12
One organization reports using a
shared leadership council to create and
maintain a relationship-based environment that supports peer-to-peer ac-
countability, retention, and staff nurse
job satisfaction. This shared leadership
model embraces the principle of shared
work, sharing the accountability to
create and maintain healthy work relationships, provide quality care, and
continuous learning.11
Another organization uses a
shared leadership model based in part
on motivational and self-efficacy theory. Staff nurses receive education that
promotes development of critical leadership qualities, including change facilitation, decision making, and negotiating win-win solutions to achieve
improved patient and staff nurse outcomes.12
Connors et al13 developed a
model based upon the lesson Dorothy
and companions learned on their journey to Oz: People hold within
themselves the power to rise above
their circumstances. With this model,
staff nurses and managers jointly
take a proactive stance, acknowledge
shifted accountabilities, and commit
to sharing accountability for work
environments and job satisfaction.
Specific strategies include seeking
and using feedback, focusing on
what must and can be changed, and
embracing stewardship, a sense of
ownership for a professional work
environment.13
CONCLUSION
Less than 2 decades ago, nurse managers were advised to stop babying
nurses and refining parenting leadership to a high art. These managerial actions purportedly prevented cohesive
teams and fostered codependency and
oppressive conditions in nursing.14,15
Today, staff nurses are reportedly
ready to create work environments
that support them as accountable,
knowledgeable workers.11,15 Will failure
to support this readiness promote psychologically disempowering work environments and more deeply embed
misguided entitlement? Will staff
nurses assume their ethical accountability for job satisfaction and supportive work environments if repeatedly
told it is the manager’s responsibility or
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IN MY OPINION
managers must “do something in order
to get them to?”
These are critical questions worthy of consideration and dialogue. The
pervasive and almost religious belief
in and dependence upon leaders to
bring valued outcomes into the
workplace must be replaced with
shared accountability. Creating preferred conditions of employment is
not a solo or spectator sport. The
specialness of professional nurses
must be validated through strategies
that promote professionalism rather
than misguided entitlement, beginning with shared accountability
for job satisfaction.
REFERENCES
1. Shader K, Broome M, Broome C,
West M, Nash M. Factors influencing
satisfaction and anticipated turnover
for nurses in an academic medical
116
2.
3.
4.
5.
6.
7.
8.
center. J Nurs Adm. 2001;31(4):210216.
Ingersoll G, Olsan I, Drew-Cates J,
DeVinney B, Davies J. Nurse job satisfaction, organizational commitment,
and career intent. J Nurs Adm.
2002;32(5):250-263.
Laschinger H, Wong C, McMahon L.
Leader behavior impact on staff nurse
employment, job tension and work effectiveness. J Nurs Adm. 1999;29(5):
28-39.
Kerr N. The Behavioral Manifestations
of Misguided Entitlement. Kansas City:
University of Kansas; 1992.
Gamble D, Kee H. Out of entitlement. J
Nurs Adm. 1993;23(9):58-64.
American Nurses Association (ANA).
Code of Ethics for Nurses with Interpretive Statements. Washington, DC:
American Nurses Association; 2001.
Manthey M. What do Enron and nursing have in common? Nurse Leader.
2003;(1):33-36.
Apker J, Fox D. Communication: improving RNs’ organizational and pro-
9.
10.
11.
12.
13.
14.
15.
fessional identification in managed
care hospitals. J Nurs Adm. 2002;
32(2):106-114.
Brandon N. Taking Responsibility.
New York: Simon and Schuster;
1996.
DePree M. Leadership Jazz. New
York: Dell Publishing; 1993.
Walker J. Developing a shared leadership model at the unit level. J Perinatal Neonatal Nurs. 2001;15(1):2639.
George V, Burke L, Rodgers R, et al.
Developing staff nurse leadership behaviors in professional nursing practice. Nurs Admin Q. 2002;26(3): 4459.
Connors R, Smith T, Hickman C. The
Oz Principle. Englewood Cliffs: Prentice Hall; 1994.
Manthey M. From ‘mama management’ to team spirit. Nurs Manager.
1990;21(1):20-21.
Porter-O’Grady T. Is shared governance still relevant? J Nurs Adm.
2001;31(10):468-473.
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