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Файл:Clinical nursing practice. Study aid for foreign students of medical university
.pdf
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Fig. 2. Quality Assurance Cycle
Identify key areas. Time, staffing levels and other constraints will
mean that a limited number of key areas can be identified. We suggest below that the four major functions of the nurse are used as a framework.
Within each of these functions, different aspects can be prioritized, depending upon the setting and context in which care is provided.
Set standards. A standard defines an agreed level of performance.
One or more standards are usually agreed and written for each key area.
Select criteria to measure standards. Criteria should clearly specify
the precise levels of performance necessary to satisfy the standard. Criteria
should be achievable, measurable, observable, understandable and
reasonable.
Compare practice with the standard. It should be established when
practice is to be assessed, who assesses it and how.
Identify reasons for any differences between practice and the standard. Many factors influence the quality of care which nurses give to pa-
tients/clients. Where there is a mismatch between actual practice and the
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agreed standard, it is important that the analysis is comprehensive and is
understood by those whose practice is being assessed. This stage should
not be skipped or done superficially. It is particularly important to include
those involved in meeting the standard, as well as their managers, in this
stage.
Take action. Once the reasons for any differences between actual
practice and the agreed standard have been clarified, the team plans for the
changes that are necessary. If these are beyond the team's sphere of influence or if the mismatch is due to the standards being inappropriate or unreasonable, action may be necessary to identify more useful standards.
Review previous stages. An overall review of the quality assurance
process is necessary at a predetermined interval (for example, annually) to
assess whether the previous steps have been completed effectively and if
not, to identify how this can be rectified.
These quality assurance steps need a framework to provide the context for their application. The framework needs to reflect the different dimensions of nursing and health care in order to guide which aspects of
nursing to set standards for. This framework needs to reflect all of the major factors which influence the quality of care delivered, incorporating the
key functions of nursing and including those aspects of care which stakeholders value highly.
Some nurses use the framework provided by the model of nursing
they use, to guide the selection and classification of a nursing standard. For
the purposes of this discussion, it is suggested that the Declaration of Alma
Ata and the Health for All goal, together with the WHO statements of the
nurse's mission and four key functions of the nurse, provide a broad
framework for selecting and describing nursing standards.
The Nurse’s Mission. “The mission of nursing in society is to help
individuals, families and groups to determine and achieve their physical,
mental and social potential, and to do so within the challenging context of
the environment in which they live and work. This requires nurses to develop and perform functions that promote and maintain health as well as
prevent ill health. Nursing also includes the planning and giving of care
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during illness and rehabilitation, and encompasses the physical, mental
and social aspects of life as they affect health, illness, disability and dying.”
Four Major Functions of the Nurse:
1. Providing and managing nursing care.
2. Teaching patients or clients and health care personnel.
3. Acting as an effective member of a health care team.
4. Developing nursing practice through critical thinking and
research.
Nursing standards can be developed and categorized in relation to
each of these major functions.
Exercise. Key functions of the nurse
Think about your current role, or that of your nursing team. Can
you describe your current work within these key functions?
Take a sheet of paper and list some of your activities under each
heading:
• Providing and managing nursing care.
• Teaching patients or clients and health care personnel.
• Acting as an effective member of a health care team.
• Developing nursing practice through critical thinking and
research.
Is there anything that does not seem to fit?
Would you add any other functions or change these at all?
2.8. NURSING STANDARDS
Nursing standards are valid definitions of the agreed and acceptable
quality of nursing care, in a particular setting or context, against which
current nursing practice is judged and evaluated. The development of nursing standards is often described as the second step in the process of defining and measuring the quality of nursing. Standards act as guidelines or
objectives against which we can determine whether or not nursing actions
actually measure up to the predetermined level quality. As in the process
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that Florence Nightingale used, the final steps are the monitoring of actual
practice against expectations and, when necessary taking effective action
to reconcile the two.
2.9. DEVELOPING WRITTEN STANDARDS IN PRACTICE
The way in which a nursing service approaches the issue of developing standards varies according to the particular context and the resources
available to support this. The following case study describes the process in
one health district.
Case Study. The development of written nursing standards within
one district arose partly from interest stimulated by publications, and partly from a local interest in developing tools for describing standards
of care.
Clinical nurses were finding it difficult to explain their concerns
about standards, while nurse managers were aware of the lack of information to help them monitor nursing practice. This district had few resources to train staff and implement a comprehensive quality system. They
also needed a tool which could be applied to several clinical areas
Nurses in this area developed written standards at two levels:
District standards — which are broad statements about the level of
nursing care desirable in all settings within the district and for all types
of clients. They represent an expectation of what constitutes good nursing
care and a target for achievement.
Local standards — which are specific to a particular setting and
are defined by the nurses in that setting. Each standard specifies the type
of patient or client to whom the standard applies and the date by which it
is to be achieved and reviewed, taking into account the needs and resources available. These standards spell out a level of care which nurses
in that setting commit themselves to achieving within the specified period.
Once achieved, the standard is reviewed and may either be restated or reset at a different level.
The job of developing standards was designed to be absorbed into
each individual's work and to build on the skills nurses had already devel-
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oped in using the nursing process and writing care plans. Each senior nurse
was asked to work with their staff to produce two written standards of care
applicable to the particular area of practice.
The nurses used meetings to explain the ideas and they distributed
locally developed information packs which described the philosophy of
nursing in the district, the arrangement of standards under topic headings,
such as individualized care, independence and involvement, to reflect the
philosophy of care; the principles of setting and using standards and the
particular framework (structure, process, outcome) that had been used (fig. 3).
Fig. 3. Standards for Nursing
Nurses have gone on to use the local standards to identify deficiencies in the provision of care (structure), performance (process) and the outcomes of care. They have also used the standards to compare the service
actually provided with the service required by a particular client group.
The written standard provides a tool for nurses to use, at ward level or in
the community, to identify clearly what they need to have and what they
need to do in order to provide acceptable care which leads to satisfactory
outcomes. It also appears that the writing and agreeing of standards has
helped those involved to examine and try to change their own practice. For
example, nurses working at night wrote a standard of care about providing
an acceptable level of privacy for their patients/clients.
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2.10. WHAT DO STANDARDS LOOK LIKE?
Many standards set for a nursing service relate to clinical procedures
and practice, they tend to be written in the form of principles of nursing
practice or clinical guidelines. The clinical nursing procedure guidelines,
described in the later sections of this chapter, are examples of these. Some
authors suggest that nursing procedure guidelines are not the same as
standards, and that it is necessary to develop standards for all nursing procedures.
The example below relates to discharge planning for hospital patients
in order to achieve continuity of nursing care. It illustrates the approach
taken by the district in the case study above. The approach they use is explained in more detail later.
Example
Standard Statement
Each patient's discharge or transfer is carried out in accordance with his [sic]
needs and abilities and wishes
Structure criteria
Process criteria
Outcome criteria
The nurse has a local
knowledge of services
available
The nurse includes
in the nursing record
[the following
information]:
- assessment of factors
affecting discharge;
- the views of patient
and relatives;
- home circumstances
A discharge plan
is completed for each
patient (example continues
on the next page)
Reference: resource book
of services available
to each ward.
The nurse plans
preparation for discharge
and sets goals
for discharge with patient
and relatives
The support services
detailed in the plan
are arranged
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Structure criteria
Process criteria
Outcome criteria
The nurse knows how
to contact the senior nurse
(community liaison) for
advice and the patient's...
[community] nurse for
exchange of information
The nurse coordinates
arrangements for transfer
and the support services
required
The patient's discharge
and aftercare
is in accordance with his
[sic] individual needs
The policy for discharge
arrangement...is available
on the ward
The nurse provides
teaching time and written
instructions for each
patient...being discharged
The patient and/or relative
achieve the discharge
goals [and] can explain
the discharge instructions
A nursing history form,
which includes the details
of family and home
circumstances and
a format for discharge
planning, is available
for each patient
The nurse evaluates
the pre-discharge teaching
Reduction in the number
of complaints related
to discharge, transfer
and arrangements
for aftercare
Standards are usually collected together in each particular setting and
indexed so that those using them can access them easily and know what is
expected of them.
2.11. WHERE TO BEGIN
Existing standards. You probably already have a number of written
standards, such as official guidelines on staffing levels, a code of conduct,
policies on drug administration and storage, specific ward learning outcomes for nursing students and procedure manuals based on research findings. They may not be up to date, or all be written in the same way, or
stored in one place or even called standards. Nevertheless they are agreed
standards which guide nursing practice in your setting. In addition, there
will be many unwritten or unofficial standards that operate. Some of these
may be dictated by the nurse in charge or manager, some may be shared
standards which all nurses agree with and work to, others will be your own
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personal standards against which you judge your own practice and that of
others.
All of these provide you with a starting point for discussion about
what standards are and what the benefits might be of trying to develop
agreed standards in support of your role and responsibilities.
Exercise. Existing standards
Using the four major functions of the nurse as headings, try to compile a list of all of the existing quality standards that guide or direct practice in your work setting.
In relation to each one, identify the following information:
• Which key function(s) the standard relates to the source of the
standard
• The status of the standard (for example whether it is custom and
practice in a particular area, a personal standard or a legal requirement)
• How you and other nurses know if you are meeting the required
standard — what mechanism is there for monitoring the standards and for
providing you with feedback?
Learning from the experience (and mistakes) of others. One important principle when developing standards is that the nurses who will be
expected to meet the standards should be involved in the process as much
as possible. Top-down approaches, where standards are developed in isolation from practice, perhaps by nurse managers and nurse educators, are not
as successful as those that involve staff in the process. Obviously the skills
and resources of nurse managers and educators should be used to help in
the process, but they should be used to facilitate and support, rather than to
direct or control the process. It is also important to remember to make
standards holistic in relation to all aspects of nursing, in order to ensure
that the more qualitative issues in nursing, such as interpersonal and communication skills, are incorporated and evaluated.
The development of research-based nursing standards can be an important mechanism to encourage the application of research findings to
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practice. The implementation of nursing research in practice demands skill
in critically evaluating research findings. At present, it is both unrealistic
and unnecessary to require all nurses to possess these skills. Identifying
nursing standards which incorporate and therefore apply research findings
is a far more realistic approach, which encourages shared, rather than individual understanding of the rationale for practice.
In trying to develop standards, it is important not to dismiss or reject
existing knowledge which may not have been gained recently or where
there are no applicable research findings. It can be tempting to concentrate
on developing standards only in areas where there is new knowledge or an
abundance of research findings. This is perhaps one of the limitations of
this chapter; each of the aspects of nursing described has been selected in
order to highlight the existence of a considerable research base for nursing
practice. But in discussing nursing standards it is important to look at how
to develop standards in the areas where our practice still draws heavily either on tradition or on the procedures and theoretical underpinnings of other disciplines. Knowledge and practice drawn from other disciplines needs
to be evaluated carefully in terms of rationale, but in reality it is unlikely
that nurses could evaluate all of underlying theoretical perspectives and research. The application of research-based knowledge is important in improving care but there are many issues in nursing where our knowledge is
incomplete or where research may ultimately have little to offer.
Finally, but perhaps most importantly, experience suggests that although developing and writing nursing standards can be difficult and challenging, it is essentially a learning process in its own right. Developing and
monitoring standards of care can help us to fulfil our nursing functions by
demanding critical thinking and reflection on our practice. Nurses are
more likely to be enthusiastic about developing and achieving standards if
they are active participants in the process and if learning and professional
development are intrinsic to that process.
Considering existing frameworks (or criteria) for developing
standards. There are a number of frameworks used for developing stand-
ards. Much of the current literature in nursing suggests that the Donabedi-
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an approach to developing standards and criteria is suitable for evaluating
nursing, but this approach is not without problems and has been criticized
by a number of authors for being unnecessarily clumsy and timeconsuming. Dunne describes the three approaches identified by Donabedian in his review of the evaluation of medical care as follows:
1. Structure standards. These are concerned with the regulation of
nursing practice and include the organization of nursing services, recruitment, selection, manpower establishments, the provision of necessary
equipment and buildings and all of the statutory and legal requirements.
They tend to indicate minimum expectations or levels of service, for ex-
ample, “there will be at least one first level qualified nurse on duty on the
ward at all times”.
2. Process standards. These look specifically at nursing actions and
define the quality of the implementation of nursing care. Process standards
should be developed for all nursing interventions or procedures.
3. Outcome criteria. These specify the patient or client's response to
planned care — the expected change in a patient/client's condition following nursing intervention is an outcome standard.
Outcome standards frequently include some measure of the patient/
client's satisfaction with care. Many authors define a fourth category:
4. Content standards. These describe the nature of nursing that is
communicated to other groups or disciplines and the basis of nursing decisions, for example, information that must be recorded in nursing notes and
reported to the multidisciplinary team, communication and teaching of patients/clients and their families or friends.
Once again, as we saw in relation to the use of nursing models in
practice, many of the approaches described in the literature may be useful
in encouraging us to look critically at our own situations but they may not
be directly applicable to different settings or countries. For example, the
Donabedian approach arose from a study to evaluate the quality of medical
care in the United States. Although it has been adopted as a framework by
nurses in other countries (for example by the Royal College of Nursing in
the United Kingdom), its applicability to each country or setting needs to
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