'Accountability matters'. Nurses' accountability enactment for consumer involvement in care planning in one Australian inpatient unit

Author: Josephien Rio

Rio, Josephien, 2019 'Accountability matters'. Nurses' accountability enactment for consumer involvement in care planning in one Australian inpatient unit, Flinders University, College of Nursing and Health Sciences

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Policy rhetoric promotes the use of care planning processes to empower consumers in the active management of their own recovery, however mental health consumers continue to re-present to our services with low levels of wellbeing, mental and physical health challenges and a reduced life expectancy. Evidence suggests that care plans are not routinely created, discussed or updated. My thesis is that the lack of meaningful care plan discussion between mental health professionals and consumers is influenced by and is the outcome attributable to a failure of accountability enactment.

The aim of this study is to explore how the management of accountability impacts on the development and use of care plans by mental health nurses and to examine if there is a relationship between a unit culture of accountability and consumer involvement in the development of care plans by these nurses.

A focused ethnography involving mental health nurses and other health professionals was undertaken in one inpatient unit of an Australian psychiatric hospital from August 2015 until February 2016. Data from in-depth semi-structured interviews with 12 nurses and 6 months of non-participant observation of multidisciplinary meetings and clinical handovers were analysed using the theory of accountability, the role of the mental health nurse and care planning in the inpatient unit.

The unit environment was found to be medicalised with attention to acute treatments and risk management that was driven by a focus on reducing the length of stay rather than recovery. Nurses felt their role was diminished, with their decision making and accountability enactment directed to medical management. As a result nurses forewent commitments regarding consumer involvement in care plan developments and therefore the provision of high quality therapeutic engagement.

My original contribution to knowledge is that a lack of meaningful consumer engagement by mental health nurses occurs through non-fulfilment of accountability obligations. Despite the use of organisational processes such as mental health service accreditation and auditing to ensure accountability, unless individual nurses include consumers in development and maintenance of their care plans then quality oriented care will be absent. It is this therapeutic engagement in the processes of care plan development and subsequent advocacy, which forms the basis of accountability enactment that can facilitate recovery. I argue that therapeutic engagement with the consumer is a key role of mental health nurses that needs to be reinvigorated.

The care plan and the recovery model are intrinsically linked and for the care plan to succeed and become an integral part of everyday mental health practice, the recovery model needs to be embedded in routine practices within mental health services. Beyond the rhetoric of consumer recovery outlined in policies, this requires attention to the culture of the work environment, how nurses weigh up the factors that drive the current service approaches and how these influence mental health nurses’ decisions about their practice.

Keywords: accountability, care plans, care planning, mental health nursing, recovery

Subject: Nursing thesis

Thesis type: Doctor of Philosophy
Completed: 2019
School: College of Nursing and Health Sciences
Supervisor: Emeritus Professor Jeffrey Fuller