BY Mr. MARUDHAR, ASST.PROF. NIMS UNIVERSITY
For more than 100 years, authors have written about the evaluation of nursing practice as a process with minimal elements of –
· Setting standards
· Comparing nursing practice to such standards
· Instituting changes to increase the adherence to the standards
EVOLUTION OF STANDARDS:
The first to write about standards in English language was Florence Nightingale whose notes on nursing what it is and what it is not was first published in England in December 1859. In it she frequently called for change to achieve high standards.
Nightingale developed a multitude of standards of nursing care in the 19th century whether the care was provided by a family member as some one far such service. Notes on nursing have standards regarding.
· Noise and its control around sick.
· Consistency of food and when it should be served.
· Type of bed and mattress to be used, as well as prospects about the bed linens
· Position of the bed in relation to windows so that the patient can look out.
· Cleanliness of the room.
· Personal cleanliness.
Though Nightingale made no comparison between her standards and the existing conditions, within 6 months she reduced the mortality to 2%. In other words a quality assurance as quality control process was used. Much has been done since that time to isolate the concept of setting standards from the larger process of evaluation. Establishing schools of nursing after 1873, was quite an indirect approach in terms of setting standards for practice and meaning improved compliance. Almost two decades after schools of nursing has been established. Efforts were again made to set standards far them. This in turn improved the care of side in the hospitals, because schools of nursing were intimately associated within the hospitals. Eldredge addressed the quality of nursing care in 1932 predominantly in terms of the quality of care given by students in hospitals. She defined quality of nursing care in terms of the quality of care given by students in hospitals. She defined quality of nursing care in terms of outcomes of nursing practice although not in the measurable outcomes used today.
After the World War II the attention was again focused on establishing standards and upgrading nursing care. In the 1950’s as the nursing process emerged, as an identifiable entity with the specific elements evaluation of care was almost always included as a step in nursing process. Orlando identified function, process and principles of professional nursing. She stressed on the evaluation of nursing process. Carrier and Sitzman in 1971 included evaluation as the final point in the six step process of the nursing care plan. In 1973 the ANA legitimized the nursing process. Thus started the era for the evaluation of the nursing profession for better quality care of the patient and quality assurance of the profession itself.
Standard is an established rule as basis of comparison in measuring or finding capacity, quality context and value of objects in the same category. Standard is a broad statement of quality. It is a definite level of excellence as adequately required, aimed at or possible.
Standard is a predetermined baseline condition as level of excellence that comprises a model to be followed and practiced. It is used as a measurement tool.
Professional Standards of Nursing Practice:
Professional standards of nursing practice as established by professional nursing organization exist to guide the nurse in providing case.
“A standard in a model of established practice which has general recognition and acceptance among registered professional nurses and is commonly accepted as correct standards of practice are agreed on levels of competence as determined by the ANA and specially nursing organizations” [ANA – 1996].
“Standards are defined as authoritative statements that describe a common level of care as performance by which the quality of practice can be determined or measured. Standard help define professional practice (Hubes – 1996).
Importance of standards in Nursing :
· It is an authoritative statement by which the quality of nursing practice, service and education can be judged.
· In nursing practice, standards are established criteria for the practice of nursing.
· It is a guideline and a guideline far is a recommended path to safe conduct an aid to professional performance.
· It provides a baseline for evaluating quality of nursing care, increase effectiveness of care and improve efficiency.
· Standard, help supervisors to guide nursing staff to improve performances
· Standards may help to clarify nurses’ area of accountability
· Standards may help nursing to clearly define different levels of care
· Standard is a device for quality assurance as Quality control.
PURPOSES OF STANDARDS:
The purposes of publishing, circulating and enforcing nursing care standards are to
· Improve the quality of nursing
· Decrease the cost of nursing
· Determine the nursing negligence
CHARACTERISTICS OF STANDARDS
1. Statement must be broad enough to apply a wide variety of settings.
2. Must be realistic, acceptable and attainable.
3. Nursing care must be developed by members of the nursing profession.
4. Must be understandable and stated in unambiguous term.
5. Must be based on current knowledge and scientific practice.
6. Must be reviewed and revised periodically.
7. Must be directed towards an optimal standard.
SOURCES OF NURSING CARE STANDARD:
The standard can be established, developed, reviewed as enforced by variety of sources as follows-
· Professional organizations like TNAI
· Licensing bodies IC, MCI, & DCI etc
· Departments of the institution
· Patient care unit
· Government unit at national, state and local government unit
· Individual personal standard
CLASSIFICATION OF STANDARDS:
Koont and Weitrich (1988) have identified the following eight type of standard the most organization must establish.
Physical standard: which include patient activity rating to establish nursing care hours per patient per day.
Cost standard : which includes the cost per patient per day.
Capital standard : which include the review of monitory investments as new program
Revenue standards: which include the revenue per patient day for nursing care
Program standard : which guide the development and implementation of program to meet client needs.
Intangible standards: which include staff development as personnel orientation cost.
Goal standard: which outlines qualitative goal in short and long term planning.
Strategies plan standard: which out lines check point in developing and implementing the organization strategic plan.
NURSING CARE STANDARDS
can be divided into ends and means standards
1. End Standards :
The end standards are patient oriented; they describe the change as desired in a patients physical status or behavior.
2. Mean Standards:
The mean standards are nursing oriented, they describe the activities and behavior designed to achieve end standards.
End standards require information about the patients. A mean standard calls for information about the nurses’ performance.
NURSING CARE STANDARDS can be classified according to frame of references, relating to nursing structure, process and outcome.
1. STRUCTURE STANDARD:
A structural standard involves the setup of the institution. The philosophy, goals and objectives, structure of the organizations, facilitates and equipment and qualifications of employees are some of the components of the structure of the organization. Example, recommended relationship between the nursing department and other departments in a healthy agency are structural standards, because they refer to the organizational structure in which nursing is implemented. It includes people, money equipment, staffing policies etc. The use of standards based on structure implies that if the structure is adequate reliable and desirable, standard will be met as quality care will be given.
2. PROCESS STANDARD
Process standards describe the behaviors of the nurse at the desired level of performance. A process standard involves the activities concerned with delivering patient care. These standards measure nursing action or lade of actions involving patient care. The standards are stated in action verbs that are in observable and measurable terms. Eg : “the patient demonstrates. The focus is on what was planned, what was done and what was communicated as recorded. In process standard there is an element of professional judgment ie determining the quality as the degree of skill. It includes nursing care technique, procedures, regimens, and processes.
3. OUTCOME STANDARDS :
Descriptive statements of desired patient care results are outcome standard, because patients results are outcome of nursing intervention.
An outcome standard measures changes in the patient health status. This change may be due to nursing care, medical care or as a result of variety of services offered to the patient. Outcome standards reflect the effectiveness and results rather than the process of giving care.
Thus structural standards are agency or group oriented, process standards are nurse oriented and outcome.
· Identify structure
· Standards & criteria
· Take action & Evaluate Philosophy
· Job description
· Personal qualification
· Identify strengths & limits
Standards and criteria to evaluate outcome
· Change in clients health states
· Client disposition
· Personnel / client safety
· Client / personnel satisfaction
· Documentation of care effectiveness
· Efficiency of services
· Identify process standards & criteria
· Professional standards application
· Nursing process application
· Nursing procedures
· Client satisfaction
· Personnel performance evaluates
Identify alternative problem Solving choices