The functionality of unit practice councils and its relationship with nurses' accountability: A cross‐sectional study

This study aimed to examine the relationship between perceived unit practice councils' functionality and nurses' accountability in Saudi Arabia.

However, a significant challenge in the research of UPCs is measuring its functionality as several healthcare organizations create UPCs that fit local demands, governance requirements, and patient needs (Fray, 2011).
On the other hand, accountability is a hallmark of the nursing profession. Nursing organizations around the world demand that nurses demonstrate accountability in their daily practice as part of professional and ethical standards. When issues on patient safety and quality of nursing care arise, nurses are expected to be both accountable and responsible for their actions. However, as of yet, there is no standard or consensus definition of accountability (Krautscheid, 2014). Some authors define accountability as a multidimensional concept that pertains to professional expectations of taking responsibility for actions when things go wrong, as societal expectations of performing actions within the boundaries of what society views as acceptable behaviour, as transparency of actions when nurses decide to perform or carry out a task, as outcomebased attitude of evaluating actions according to the value of results (e.g. positive or negative, beneficial or detrimental, etc.), and as strategic-oriented attitude of performing actions with the intent of producing output in the most efficient manner that is based on goals and objectives (Leonenko & Drach-Zahavy, 2016;Wandersman et al., 2016). In consequence, the lack of a standard definition creates problems for nurse researchers and practitioners in the use of accountability as a concept, in measuring the extent and substance of accountability, and in teaching and learning accountability as a professional trait (Krautscheid, 2014).
However, there is a dearth of studies that examined the effectiveness of unit practice councils as a shared governance framework and the relationship between UPCs and nurse accountability resulting in a gap in knowledge on whether or not the implementation of shared governance via UPCs improves the accountability of nurses on the bedside. Studies have shown that when nurses are engaged and empowered to participate in the decision-making processes of the healthcare organization, they are less likely to report poor outcomes on job performance, job satisfaction, patient care, patient safety, and nursing care quality (Abu Mansour & Abu Shosha, 2022;Alrwaihi et al., 2018). Also, it has been suggested that specific issues regarding nurses' accountability are needed to be linked with UPCs, that is, nurses are able to make accountable decisions at different levels. For example, at the clinical-practice level, nurses are held accountable for making decisions regarding nursing care delivery models, quality of care, and performance appraisals. However, at the management-practice level, nurses must participate in managing resources and designing organizations (Moreno et al., 2018).
Results of the study can explicate the role of shared governance on the extent and substance of nurse accountability at the individual and organizational levels, and aid nurse managers, hospital administrators and nurse leaders in creating UPCs whose structures and frameworks have the potential to promote nurse empowerment, enhance nurse capacities, ensure standardization and consistency of practices and promote patient safety and quality of healthcare services (Gerard et al., 2016).
In Saudi Arabia, the exact relationship between UPCs and accountability has not been well addressed in previous literature; therefore, we aim to study the relationship between UPCs and nurses' accountability. The following research questions were specifically addressed: • What are the levels of perceived UPCs functionality and accountability among Saudi Arabian nurses?
• Is there a relationship between UPCs functionality and Saudi Arabian nurses' accountability? 2 | ME THODS

| Research design
The study utilized a descriptive, cross-sectional, correlational design.

| Setting and sampling
The study was performed in multiple sites belonging to a large, tertiary medical complex in Saudi Arabia. The medical complex is made up of four hospitals and seven centres with a total of approximately 1200 beds. Shared governance frameworks were instituted in 2017 via the implementation of unit practice councils. Currently, there are seven UPCs in the medical complex namely (1) scheduler council, (2) heroes' council, (3) informatics council, (4) quality council, (5) educational council, (6) operational council and (7) disaster council.
A convenient sampling technique was used to select nurses with the following inclusion criteria: (1) having at least a bachelor's degree in nursing; (2) having a full-time contract; (3) having at least 1 year of clinical experience; (4) providing direct patient care; (5) willing to participate in the study. However, nurse managers from top management positions were excluded from the study. In total, 160 nurses returned and completed the questionnaires appropriately.

| Accountability index tool
The tool was developed by Specht and Ramler (1994), the tool is composed of 11 items measuring the perceived accountability of nurses using a four-point Likert scale from 'Strongly Disagree = 1' to 'Strongly Agree = 4'. The construct validity of the scale has been confirmed by a previous study (Drach-Zahavy et al., 2018). Also, in this study, Cronbach's α for the total score was 0.88.

| Ethical consideration and data collection procedures
The study was reviewed and approved by the Institutional Review Board (IRB) of 'REDACTED' and 'REDACTED'. Participation in the study was voluntary, an online informed consent was sought from participants prior to data collection, and the participants provided the consent by agreeing to proceed to the survey. Due to the COVID-19 restrictions, data were collected online between February 2021 and May 2021. Google Form was created and the link to the form was shared with nurse managers in each department, and then, they forwarded that link with nurses.

| Data analysis
Statistical analyses were performed using SPSS Software version 24 (McCormick & Salcedo, 2017). Descriptive analysis was used to summarize sample characteristics. Inferential analyses were used to test the relationship between UPCs and nurses' accountability.
Descriptive and inferential statistics were performed to analyse the data. The Statistical Package for the Social Sciences (SPSS) Version 24 was used. Means and standard deviations, wherever applicable, were calculated for the demographic characteristics of the participants. Pearson's r was calculated to determine any relationship between the variables. Internal consistency reliability was evaluated using Cronbach's α for each of the scales used for data collection in this study. A significance level of p < 0.05 was set a priori for all analyses.

| Nurses' background variables
The study consisted of 160 participants. The majority of the participants were female (n = 111, 66.4%). More than half of the participants were more than 35 years old (n = 83, 51.9%). The sample primarily consisted of registered staff nurses (n = 111, 69.4%).
Almost 84% of the participants had a Bachelor's degree (n = 134, 83.8%) while one had a doctorate. In terms of length of experience as a registered nurse, 27 participants (16.9%) had less than 5 years of experience, 34 (21.3%) had 6-10 years of experience, 34 (21.3%) had 11-15 years of experience, and 65 (40.6%) had more than 15 years of experience. Most of the participants had either 1-5 years (n = 53, 33.1%) or more than 10 years (n = 65, 40.6%) of working experience in the research setting (Table 1).

| Nurses' perceptions of UPCs functionality
Unit practice council functionality was measured using the tool by Ojeda et al. (2014). The mean score was 58.3 which meant that nurses perceived a moderate level of UPCs functionality. As presented in Table 2

| Nurses' accountability levels
As shown in Table 3, the mean score of nurses' level of accountability was 36.8 which meant high levels of being accountable. The highest-scoring item was being accountable to patients (M = 3.44, SD = 0.5) while the lowest-scoring item was holding peers accountable for their actions (M = 3.23, SD = 0.7).

| Correlations between study variables
The study examined whether there is a significant relationship be- to conceptualize, design, plan and implement initiatives and projects that can be translated and influential to actual patient care (Giambra et al., 2018;Wong et al., 2013). Actions by UPCs should be felt by nurses and patients as they are the primary stakeholders of UPC functionality.
There are areas of UPC functionality worth commending as nurses managed to demonstrate high scores in these items. The onus is for UPCs to implement strategies that can sustain the measured high scores over time.
First, participants believed that UPCs empower them and help them to make decisions. Decision making is a vital element for a professional and healthy working environment. This finding is supported by the study of Barden et al. (2011), as they found that shared governance provides a context where nurses are involved in decision-making processes which increased nurses' satisfaction and improved patients' outcomes.
Second, knowing the people who are part of UPCs and knowing how to contact them suggests that there is an existing communication link between staff nurses and UPCs, and UPCs are not detached and alienated from nursing personnel. In her study, Wessel (2012) found that nurses' communications with their peers and managers inspire them to lead change and facilitate the group decision-making process.
Lastly, participants expressed interest in knowing the initiatives of UPCs. In turn, UPCs should take advantage of such interest by bolstering information dissemination about current and planned projects, inviting staff nurses to monthly discussion fora and meetups, and encouraging participation in projects and initiatives that nurses find most appealing. By making the most of the interests expressed by nurses, UPCs increase their effectiveness in increasing nurse engagement and participation.
As established in the review of literature, accountability is a concept that is widely accepted in the nursing profession but is poorly defined, thereby limiting the number of researches done on the topic (Krautscheid, 2014). Moreover, some studies have shown that nurses tended to link the concept of accountability with self-incrimination since nurses were expected to take the blame when a mistake happens to a patient, and challenging the status quo of the healthcare organization since nurses are expected to go against the practice of peer and colleagues (Leonenko & Drach-Zahavy, 2016). Therefore, it is not surprising that the dimension of accountability nurses had the lowest score in was holding their colleagues accountable for the care that they deliver. This is problematic, though, since one of the roles nurses are expected to perform is that of the patient's advocate in terms of keeping the patient safe, preventing harm from reaching the patient, and acting on the patient's best interests (Choi et al., 2014). If nurses were reluctant to point out mistakes or problems that they have with the way their colleagues deliver nursing care, poor performance, worse patient outcomes, poor patient and family satisfaction, adverse events, avoidable deaths, and breaches in patient safety can potentially and negatively proliferate (Vermeir et al., 2015). Several high-profile cases that resulted in a significant extent of patient harm and volume of avoidable deaths such as that of the Mid Staffordshire Hospital and Furness General Hospital in the UK was borne out of complacency from the nursing staff to call each other when poor practice was observed, and to have key staff and management personnel accountable for their actions (Newdick & Danbury, 2015;Wise, 2015).
Nonetheless, nurses had overall high scores for accountability, especially for dimensions pertaining to personal accountability for their actions in following and implementing standards of care, monitoring standards of care, delivering nursing care to their patients, keeping their knowledge and skills up-to-date with current evidence, preparing their patients for discharge, and responding to any complaint arising from the patient and their families. The high scores highlight nurses' acknowledgement of the value of accountability in patient safety, prevention of harm, and quality of service delivery (Rubio-Navarro et al., 2020). If nurses recognize that they are accountable for the results of their actions, they have the potential to 4726 | ABU DAWASS et al. create situations that protect their patients from injury and promote their health and well-being.
A significant positive moderately strong relationship was found between UPC functionality and accountability, suggesting that nurses working with UPCs with high functionality tend to demonstrate higher levels of accountability. The relationship implies that a functional UPC has the potential to positively impact the way nurses take accountability for their actions, especially since the core of UPCs is the promotion of safe and quality patient care through empowerment, engagement and participation. In turn, high levels of accountability among nurses' feedback to the UPCs, providing information on areas of service delivery that require improvement and areas that are already being performed to standard and will only need to be sustained.

| Implications and recommendations
As discussed, the significance of accountability in practice cannot be overstated. The need to be accountable acts as a safeguard for patients because nurses bear in mind that all their actions in providing nursing care require a rationale that is rooted in evidence, and that mistakes and poor performance have critical ramifications for their ability to practice the profession in the future. Likewise, UPC functionality seems to positively influence the level of nurse accountability, which means that UPCs need to be able to function and perform within expectations and that initiatives and projects need to be felt by patients and staff nurses. More importantly, results are significant in that they have the potential to directly affect actual bedside practice, with the overall goals of both UPC functionality and nurse accountability being the promotion of patient safety, achievement of target patient outcomes, and better workforce well-being.
The results of the study emphasize the importance of teaching accountability at an early stage of nurses' undergraduate education.
This attitude is critical in ensuring the integrity of care received by patients and the quality of service provided by nurses. In addition, the study has laid the groundwork for examining UPC functionality and its links with nurse accountability. With the scarcity of high-quality evidence on both variables, future studies can look closer at the dimensions that compose UPC functionality and nurse accountability and identify factors that may predict and influence its measurement.
In view of the findings of the study, the following recommendations are made: • Develop programs and strategies that will target the improve-

| CON CLUS ION
The findings of the study demonstrated moderate levels of UPC functionality and high levels of nurse accountability, though nurses scored low on recalling when the last UPC meeting was held, enumerating UPC initiatives that have been implemented in their workplaces, and holding colleagues accountable for their actions. Nurses working with highly functional UPCs have high levels of nurse accountability. Many organizations have applied some principles of shared governance, but the reach to full potential depends on many personal and organizational factors. Nursing leaders need to continuously develop strategies to empower nurses and reinforce their sense of responsibility and accountability to be an essential element in healthcare systems.

AUTH O R CO NTR I B UTI O N S
MAD and HK: Planned and designed the study. MAD and MJ carried out the data collection. MAD, HK and AR contributed to the interpretation of the results. All authors discussed the results and contributed to the final manuscript.

ACK N O WLE D G E M ENTS
The authors acknowledge the support from Zarqa University and King Fahad Medical City.

FU N D I N G I N FO R M ATI O N
None to declare.

CO N FLI C T O F I NTE R E S T S TATE M E NT
The authors have no conflicts of interest to declare that are relevant to the content of this article.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

R E S E A RCH E TH I C S CO M M IT TE E A PPROVA L
Ethical approval from Zarqa Universty has been obtained (#12/2021).