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RESPONSIBILITY AND
A C C O U N TA B I L I T Y
R E L AT I O N S H I P E T H I C S
Astri Mutiar, M.S
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Responsibility
TANGGUNG JAWAB (RESPONSIBILITY)

• Reliability and trustworthiness. This attribute indicates that the

professional nurse carries out required nursing activities conscientiously
and that nurse’s actions are honestly reported (Koziers, 1983:25).

• Responsibility adalah : Penerapan ketentuan hukum (eksekusi) terhadap

tugas-tugas yang berhubungan dengan peran tertentu dari perawat, agar
tetap kompeten dalam Pengetahuan, Sikap dan bekerja sesuai kode etik
(ANA, 1985).
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Jenis Tanggung Jawab Perawat 3

1. Responsibility to God (tanggung jawab utama terhadap Tuhannya)

2. Responsibility to Client (tanggung jawab terhadap klien dan masyarakat)
3. Responsibility to Colleague (tanggung jawab terhadap rekan sejawat dan
atasan)
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Responsibility to God (tanggung jawab utama terhadap
Tuhannya)

1. Ikhlas melakukan tugas

2. Memfasilitasi klien untuk beribadah kepada Tuhannya.
3. Mengajarkan hikmah sakit kepada klien
4. Melakukan kolaborasi dalam pemenuhan kebutuhan spiritual klien
5. Mengantarkan klien kepada kematian yg damai sesuai dengan kepercayaannya.

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Responsibility to Client (tanggung jawab terhadap klien dan
masyarakat)

• Tanggung jawab perawat erat kaitanya dengan tugas-tugas perawat.

• Dalam pandangan etika keperawatan perawat memilki tanggung jawab

(responsibility) terhadap-tugas tugasnya dengan melihat klien nya sebagai
manusia (humanism).

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Responsibility to Colleague (tanggung jawab terhadap
rekan sejawat dan atasan)

• Memberikan informasi tentang keadaan klien kepada teman sejawat

• Memberikan pengetahuan terhadap perawat yang belum mahir melakukan

tindakan keperawatan

• Menyelesaikan tugas yang sudah dibagi ke dalam tim

• Bersikap adil dan jujur kepada rekan sejawat

• Memberikan teguran bila rekan sejawat melakukan kesalahan atau menyalahi

standar.
Professional Roles & Responsibilities 7

• Autonomy & Accountability

• Caregiver
• Client Advocate
• Educator
• Manager/Clinical Decision Maker
• Communicator
• Collaborator
• Career Development
Autonomy & Accountability 8

• Autonomy is the essential element of professional nursing

• Person is reasonably independent and self-governing in
decision making & practice
• Increased autonomy=Increased responsibility
• Accountability- nurse is responsible professionally & legally
for type & quality of care provided
• Regulated through Standards of Practice and Nurse Practice
Act
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Clinical Decision Maker

• Utilizes critical thinking skills and the
nursing process

• Nursing Process: Assessment,

Diagnosis, Planning, Implementation,
Evaluation
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Client Advocate
• Nurse protects the clients human and legal rights
• Providing information to assist in decision making
 Comforter Role 11

• Caring for client as a

human being
• Role is traditional to
nursing
• Care is directed to
whole person, not just
a body part
• Demonstration of
care and concern
Communicator Role 12

• Role is central to all other roles

• Involves communication with client, family, healthcare team members,
resource people, and the community
• Without clear, concise communication it will be difficult to give effective
care
Teacher/Educator Role 13

• Explains concepts and facts about health, demonstrates procedures,

reinforces learning, determines understanding, and evaluates progress
of learning
• Unplanned or informal education
• Planned or formal education
Professional Accountability 14

• Responsibility that one assumes for their practice

• Obligation to report or account for their actions
• To the profession, public, and themselves
• Begins with preconditions
• Ability
• Responsibility
• Authority
• Ends in accountability
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Accountability (Tanggung Gugat)

The Nurse participates in making decisions and learns to live with these
decisions (Barbara Kozier, Fundamental of Nursing 1983:7, 25,)
Nurses have to be answerable for all their professional activities. They must be able
to explain their professional action and accept responsibility for them.
Three question naturally arise
1. To whom the nurse accountable?
2. For what the nurse accountable?
3. By what criteria is accountable measured ?
1. To whom the nurse accountable? (Kepada siapa tanggung gugat 16

itu ditujukan?)

• Sebagai tenaga perawat kesehatan prawat memiliki tanggung gugat

terhadap klien,

• Sebagai anggota tim perawat memiliki tanggung gugat kepada ketua tim

• Sebagai karyawan rumah sakit, perawat memilki tanggung gugat terhadap

atasan

• Sebagai profesional perawat memilki tanggung gugat terhadap ikatan

profesi dan institusi yang menaunginya
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2. For what the nurse accountable? (Apa saja dari perawat yang 17

dikenakan tanggung gugat?)

Perawat memilki tanggung gugat dari seluruh kegiatan professional dan

tindakan tindakan yang dilakukannya.

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3. By what criteria is accountable measured? (Dengan kriteria apa 18

saja tangung gugat perawat diukur baik buruknya?)

• Ikatan perawat, PPNI atau Asosiasi perawat lainnya menyusun

standar yang memiliki krirteria-kriteria tertentu dengan cara
membandingkan apa-apa yang dikerjakan perawat dengan standar
yang tercantum.

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Relationships

The principle of respect for persons extends to all individuals with whom
the nurse interacts. The nurse maintains compassionate and caring
relationships with colleagues and others with a commitment to the fair
treatment of individuals, to integrity-preserving compromise, and to
resolving conflict.

(American Nurses Association, 2013)

Hubungan Perawat 20

1. Hubungan perawat dengan pasien

2. Hubungan perawat dengan perawat
3. Hubungan perawat dengan tim kesehatan lain

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Hubungan Terapeutik Perawat 21

The therapeutic nurse-patient relationship is a mutual learning experience

and a corrective emotional experience for the patient. It is based on the
underlying humanity of nurse and patient, with mutual respect and
acceptance of sociocultural differences. In this relationship the nurse uses
personal attributes and clinical techniques in working with the patient to bring
about insight and behavioral change.
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Characteristics of the relationship:
The goals of a therapeutic relationship are directed toward achieving the
patient's optimal growth and include the following dimensions:
• Self-realization, self –acceptance, and an increased genuine self-respect.
• A clear sense of personal identity and an improved level of personal
integration.
• An ability to form intimate, interdependent, interpersonal relationships with a
capacity to give and receive love.
• Improved functioning and increased ability to satisfy needs and achieve
realistic personal goals.
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Phases of the Relationship: 24

• It is important to distinguish between social support and

professional support.
• The support requested and ultimately provided should be
within the domain of the nurse's role as a professional
caregiver.
• Four phases of the nurse-patient relationship have been
identified: preinteraction, introductory, or orientation, phase;
working phase; and termination phase.
1. Preinteraction Phase: 25

• The preinteraction phase begins before the nurse's first

contact with the patients. The nurse's initial task is one of
self-exploration.
• The self-analysis of the preinteraction phase is a necessary
task.
• To be effective, nurses should have a reasonably stable self-
concept and an adequate amount of self-esteem. They
should engage in positive relationships with others and face
reality to help patients do the same.
• Other tasks of this phase include gathering data about the
interaction with the patients.
2. Introductory or Orientation 26

• It is during the introductory phase that the nurse and patient first
meet.
• One of the nurse's primary concerns is to find out why the
patient sought help
• An additional task is to establish goal consensus and
collaboration.
• Formulating a contract. The tasks in this phase of the relationship
are to establish a climate of trust, understanding, acceptance,
and open communication and formulate a contract with the
patient.
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Other task

1. To explore the patient's perceptions. Thoughts, feelings, and actions.

2. To identify pertinent patient problems
3. To define mutual, specific goals with the patient.
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3. Working phase:
• Most of therapeutic work is carried out during the working phase. The nurse
and the patient explore stressors and promote the development of insight in
the patient by linking perceptions, thoughts, feelings, and actions.
• These insights should be translated into action and a change in behavior.
They can then be integrated into the individual's life experiences.
• Patients often display resistance behaviors during this phase because it
involves the greater part of the problem-solving process.
• As the relationship develops, the patient begins to feel close to the nurse and
respond by clinging to old defenses and resisting the nurse's attempts to move
forward.
4. Termination phase: 29

• Termination is one of the most difficult but most important

phases of the therapeutic nurse-patient relationship.
• Termination is a time to exchange feelings and memories and
to evaluate mutually the patient's progress and goal
attainment.
• Levels of trust and intimacy are heightened, reflecting the
quality of the relationship and the sense of loss experienced by
both nurse and patient
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Supporting Each Other 31

Case:
Elizabeth had been admitted for further investigation of possible metastases
of her breast cancer as she was unable to care for herself at home. Pictures
that family members brought in showed that she was usually well groomed
and stylish. However, Gladys, her primary care nurse, saw a very different
person. Elizabeth appeared depressed and anxious, refused to bathe and
groom herself and wanted to stay in bed. Gladys felt she should spend some
extra time with Elizabeth, despite her other work also required attention.
Gladys asked Elizabeth if she would like to talk about her fears. The other
women began to cry and then started to talk. She shares her worries for her
health, her appearance and her work and future. Gladys was able to provide
some assurance and some information that Elizabeth needed to reduce her
uncertainty.
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Case:
After 30 minutes, Elizabeth smiled faintly at Gladys and said “Thank you so much.
I really needed to talk. I feel so much better just having gotten things out in the
open. I cant tell you how much I appreciate your taking this time with me. As
Gladys left the room to resume her other duties, she noticed that Elizabeth was
preparing to wash. When she checker in at the end of her shift, Elizabeth was
sitting beside her bed reading. Her hair had been combed and she had put on a
little lipstick. Gladys felt proud, knowing that she had really made a difference.
When giving a report to the oncoming team at change of shift, Gladys’s pride n
having made a difference to Elizabeth was crushed when ,Martha, one of the
incoming nurses, countered, “ It must be nice to have all that time to sit around
gabbing with patients. We’re too busy for that!”. Gladys went from feeling she had
one of her better days in nursing to feeling that may be she did not have her
priorities right.
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• Sometimes nurses contribute to an unhealthy work environment by not
supporting other nurses or even treating them in an abusive manner.
• In fact, the problem has become so prominent that it has been given a
name- lateral, or horizontal, violence *Sheridan-Leos, 2008).
• In the scenario, Gladys felt she had given exemplary care in talking to
Elizabeth and helping her to move past her fear and grief.
• It may be Martha was reacting to the constant pressure in todays fast
paced system to reduce nursing tasks, and was feeling that time she
had once spent talking with patients had not been valued.
• There are many theories about why such violence occurs, but the most
popular suggests that nurses attacks other nurses as a way of dealing
with their own frustrations with hierarchy and powerlessness.
• Ethical (or moral) disengagement: occur if nurses begin to see the
disregard of their ethical commitments as normal.
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Actions 34

• Making an effort to compliment other nurses when their work reflects

ethical commitments of relationship, competence and compassion.
• Supporting student in developing a positive understanding of the
importance of nursing values.
• Standing up for their right to “take the time it takes” to develop the
relationship that are foundational to excellent care
• Actively engaging in mentorship and support of other nurses
• Organizing and participating in peer support groups that help nurses
express their values and find strategies to enact the,
• Become actively involved in encouraging nurses to work to their full
scope, including sharing their vies with the public with policy
developers.
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Supporting The Team 35

Case:
Supporting The Team 36

Case:
• Research has shown that nurses often feel disrespected and undervalued in
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the workplace.
• And inter-professional conflict is a major source of distress.
Actions
• Starting with a belief that the environment can be changes, then supporting one
another in challenging those aspects that impact negatively on the moral community
• Organizing meeting to bring together interested nurses and other care providers to
discuss issues and develop strategies.
• Identifying a leader in the group who wan move strategies forward
• Working consciously to equalize power dynamics
• Seeking support from others, particularly those higher in the organizational structure.
• Organizing workshop to share concern and develop and practice conflict-resolution
skills
• Building in regular evaluation periods to reflect on what has been done and what still
needs doing
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Lateral violence?
• Any inappropriate behavior, confrontation, or conflict-ranging from verbal abuse to
physical and/or sexual harassment

• Bullying

• Nurse on nurse aggression and inter-group conflict

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Incivility & Bullying
Workplace incivility/bullying is any negative behavior that demonstrates a lack of regard
for other workers.
It can be displayed in a vast number of disrespectful behaviors including:
• Harassment
• Passive-aggressiveness
• Teasing
• Gossiping
• Purposely withholding business information
• Overruling decisions without a rationale
• Sabotaging team efforts
• Demeaning others
• Verbal intimidation
• Eye rolling
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Incivility & Bullying in the Headlines
Nurse-to-nurse bullying more than just a sore point

Workplace Bullying in Nursing:

Rudeness in Medical
A Problem That Can’t Be Ignored
Settings Could Kill
Patients
Study Finds Nurses
Frequently Being When the Nurse Is a Bully
Bullied at Work

The Price of Incivility

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State of the Science

• One in six nurses (13%) reported being bullied in the past six
months (Sa & Fleming, 2008)

• In a study on workplace bullying, most of the respondents

reported being bullied by a person of authority (Johnson & Rea, 2009)
Nurse to medical or nursing student, radiology tech, or fellow nurses
Physician or manager to nurse or resident
Section chief physician to fellow physician
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State of the Science

• However, incivility and bullying occur

laterally,
top down and bottom up,
among every profession and within every
profession
and at every level of the organization
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State of the Science
• Almost 21% of nursing turnover can be related to bullying (Johnson & Rea, 2009)

• 60% of new RNs who quit their first job in nursing within 6 months report that
it is because of being bullied

• Replacing a nurse can cost up to $88,000 USD (Jones, CB, 2008) Replacing anyone
is too expensive to ignore

• According to a study by the US Bureau of National Affairs, there is a loss of

productivity of $5-6 billion/year in the US due to bullying in the workplace
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State of the Science

• Bullying leads to erosion of professional competence as well as
increased sickness, absenteeism, and employee attrition.
Commitment to work quality and patient satisfaction declines
(Hutchinson et al., 2010b; Johnson, 2009; Chipps & McRury, 2012; Porath & Pearson, 2013)

• Bullying victims may suffer stress-related health problems, such as

nausea, headache, insomnia, anxiety, depression, weight
changes, and alcohol and drug abuse (Townsend, 2012)
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State of the Science

• Those who survive bullying early in their
careers tend to carry their learned behaviors
with them. They accept the bully culture as
part of the job and eventually may choose to
bully others (Townsend, 2012)
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“Bullying has long existed in health care; it

was the ugly secret that no one wanted to talk
about. However, the culture of acceptance
and silence that accompanied it is finally
being broken. The conversation is changing to
focus on creating civil cultures that embrace
collegiality and respect.”
- Edmonson & Bolick, 2015
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Physical/Psychological Manifestations
Common reactions:
• Acute or chronic anxiety
• Depression
• Sleep interruptions
• Fatigue
• Lack of mental focus

Post-traumatic stress disorder:

• An experience that shatters all you had believed in and valued
• Manifestation: Withdrawal, Conversion, Projection
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Effect on Patient Outcomes

• Inattentive health care

• Self-doubt

• Dismissive treatment of patients

• Patients may feel intimidated, embarrassed, or belittled

Approaches 49

• Strategies to eliminate incivility/bullying and to create respectful, civil,

supportive, and safe environments have largely centered on individuals

• However, theory and research establishes incivility/bullying as a

complex interplay of influences from interpersonal, community, and
environmental sources
(McLeroy et al., 1988-Socio-ecological Model)

• Incivility/bullying is a group phenomenon, reciprocally influenced by

the individual, peers, the immediate environment/institution,
community, and society
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Thank you!

Mission 1 Mission 2