contradictory and perhaps unhelpful to good nursing practice. The next section of this paper attempts to bring some clarity to the discussion by sum-marising theories and research pertaining to the issue of accountability.
Administrative, managerial or bureaucratic accountability were historically seen as the same thing, arising by virtue of a person’s location within a hier-archy in which a superior calls to account a subordinate for the performance of delegated duties.
These aspects of accountability were evident in the structural analysis of Batey & Lewis, who argued that authority and therefore accountability was tied to position. However, Sinclair (p. 227) suggested that recent public sec-tor reforms had led to a distinction between administrative and managerial accountability. Managerial accountability was seen as monitoring inputs and outputs or outcomes while administrative accountability was seen as being concerned with monitoring the processes by which inputs are transformed.
In effect this fits the distinction between what Hood (1995) called New Public Management (NPM) and the pre-existing doctrines of public accountability and administration (Progressive Public Administration).
Sinclair suggested that professional accountability involved the sense of duty that one has as a member of a professional or expert group. However, this professional accountability was given very different meanings by differ-ent CEOs. For some CEOs professional accountability meant being the top professional in an agency dominated by a particular professional group; for others it meant being a professional administrator or manager; while for others being professionally accountable involved representing the professional values of the agency workforce to a sceptical government or community.
Little mention was made of the fundamental idea of giving an account for action to a group of peers or to a professional association.
Personal accountability was described as fidelity to personal conscience in basic values such as respect for human dignity and acting in a manner that accepts responsibility for affecting the lives of others. Ultimately this was seen to rest on an internalised set of moral or ethical values. However, each of these forms could be articulated within two different discourses, struc-tural and personal. Within a strucstruc-tural discourse accountability was an objectified feature of a contract or position: accountability was not prob-lematic but could be ‘delivered to’ and ‘extracted from’ others by following procedure (Sinclair, 1995, p. 232). Again, this could be seen to be akin to the Batey & Lewis stance. However, within a personal discourse account-ability was something that CEOs uphold and fear, something about which they feel both anguish and attachment as a moral practice (Sinclair, 1995, p. 232). Curiously enough this seems to be more characteristic of the Batey
& Lewis empirics.
Sinclair develops the idea that there is a fundamental duality to the con-cept of accountability through her distinction between a structural and an individual discourse. However, this duality is not well explained or defined and needs further work. Munro & Mouritson (1996) explore the idea of duality by suggesting that accountability should be understood as a broad concept that extends beyond formal accounts to embrace concepts of how individuals give account of and for their daily lives and, in doing so,
Accountability 27
produce and reproduce their individual and collective identities. To further explore the idea of accountability it is necessary to consider separately these two different elements or discourses of accountability.
Munro & Mouritson (1996, p. 3) suggest that the structural perspective on accountability focuses on the measurement of individual performance, issues of target, output and control, establishment of centres of calculation and the creation of visibilities. Roberts (1991, 1996) called this an individualising or hierarchical accountability and associated it with what Habermas calls
‘purposive rational action’ or ‘work’ and Foucault’s notions of disciplinary power. Roberts (1996) argued that this individualising accountability is maintained by the formal structures of organisations, that it obscures the inter-dependent nature of organisational life and that it is destructive to ‘the self ’.
This structural or individualising understanding of accountability was a major theme evident in Watson (1995), clearly emerging from the earlier Batey &
Lewis and Lewis & Batey understanding, as he acknowledges in his intro-ductory chapter.
Munro & Mouritson (1996, p. 3) associate the second or individual dis-course of accountability with the work of psychologists and sociologists who represent accountability as the capacity to give an account, explanation or reason. It was this understanding of accountability that characterised Tilley’s (1995) discussion of accounts, accounting and accountability in psychiatric nursing. This sense of duality was also explored in the context of nursing by Ryan (1997, p. 118), who suggested that nurses were like amphibians in that they ‘inhabit simultaneously two worlds: the world of artificial organ-isations and the world of natural persons’.
Roberts (1991, 1996) referred to this second discourse or world of natural persons as socialising accountability, which he associates with what Habermas called ‘communicative action’ or ‘interaction’ and the concept of the constitution of the self found in the work of Foucault (1979), Merleau-Ponty (1962) and Mead (1934). Roberts (1996) argues that socialising accountability plays a key role in making the self visible both to self and to others. The self of the child is constructed in being held to account or being called to account by others. For Mead the attitude of others makes the self visible and acts as the mirror in which the self is discovered. Roberts (1996, p. 44) brings these ideas together with the statement that:
. . . the self is discovered only in the process of being called to account by others. Accountability in confronting self with the attitudes of others comes thereby both to address, confirm and shape the self. To be held to account by others has the effect of sharpening and clarifying our sense of self.
These definitions assist to better understand this duality present in Sinclair (1995). However, this quotation from Roberts represents a funda-mental mistake made in much of the literature. Accountability is only seen as being held or called to account. This focus is also evident in the work of 28 Accountability and Clinical Governance in Nursing
other authors such as Hoskin & Macve (1986, p. 124), who describe being accountable as ‘the state of being liable to answer for one’s conduct’.
However, this imports a power relationship, a relationship characteristic of a hierarchical context of domination. While this might characterise an individualising or hierarchical accountability it effectively eliminates the possibility of a socialising accountability where accounts might be given freely and thereby facilitate the construction of the self (Starkey & McKinlay, 1998, p. 239). While much of accountability can be seen as an extension of power relationships and therefore as a form of control, a free act of giving an account offers the possibility of something different.
Jacobs & Walker (2000) suggest that it is necessary to reorientate our understanding of accountability by acknowledging that accounts might also be freely given. This draws another distinction between an individualising or structural accountability, where an account is required (and therefore is a form of power or domination), and a socialising or individual account-ability, where an account is freely given (and therefore does not represent an explicit power relation).
Jacobs & Walker draw on Foucault’s ideas on governmentality and tech-nologies of the self, centrally concepts of self-examination and confession (Foucault, 1980, p. 163), to develop this idea of the socialising or indivi-dual accountability. They call it accounting for the self. Just prior to his death Foucault revisited the themes of accountability, examination and the con-struction of the self, significantly revising and extending his work on these subjects. He suggested that his earlier statements on asylums and prisons focused too heavily on techniques of domination and had tended to repres-ent power and governmrepres-entality in an over-simplistic light (Foucault, 1988, p. 19). It is this kind of understanding which has tended to dominate the thinking on accountability.
However, Foucault argued that the technologies of examination and con-fession enabled people to construct and transform themselves (Bernauer, 1987, p. 53; Foucault, 1985, pp. 63, 70). Therefore the most fundamental distinction between the different discourses of accountability is between an accountability required and an accountability freely given. The first is a technology of dom-ination while the second is about constructing the self. The first raises a series of questions about issues of power and visibility. As a form of disciplinary power structures of accountability have the potential to create new patterns of visibility, make institutional boundaries less opaque and enable the local to become visible to the centre. Therefore questions need to be asked about who, what and how:
Just who is made visible to whom? Are the patterns of visibility symmet-rical or otherwise? Can only the centre observe the local? Or can the local also observe the centre? Equally what emphasis is placed on the forging of a visibility within the system of public administration, as compared to the creation of an external account? (Hopwood, 1984, p. 182) Accountability 29
However, accounting for the self raises different kinds of questions. How do these accounts serve to enable the individual to make sense of their world, including their sense of self in the world (Munro & Mouritson, 1996, p. 6)?
How are these accounts developed and how are they linked to practices or technologies such as confession and examination? It is with these questions in mind that I turn to a discussion of the nature of accountability in the organ-isational and institutional context of the NHS and the clinical governance initiative.