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Файл:Clinical nursing practice. Study aid for foreign students of medical university
.pdf
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be critically reviewed by nurses in those countries and settings. The most
important factor in deciding on the best approach for a particular context is
to use other people's experiences and models to help work out what is
needed in a particular setting.
Exercise. What standards do you want to see in practice?
Review the aspects of clinical practice covered in this chapter.
Look at the examples of standard statements listed below and list those
which you would want to see as standards in your practice setting.
• Nursing people with pain.
All pain management interventions are based on assessment of the
individual’s pain experience.
Patients/clients are offered a range of поп-pharmaceutical pain-
relieving strategies as part of their total pain management.
• Caring for people who have an infectious condition or who are
immuno-suppressed.
Training is given to all new staff in relation to the principles of in-
fection control and clinical guidelines for source isolation.
Nursing care planned for patients in protective isolation includes
measures specifically aimed at preventing or minimizing psychological
distress associated with isolation.
• Tissue viability nursing - the aseptic technique, wound healing
and wound management.
The physical environment is conducive to good hand-washing prac-
tice by nursing staff
Wound management practice is based on a sound understanding of
the principles of wound healing and asepsis.
• Tissue viability nursing — pressure sores.
All patients/clients are individually assessed for their risk of developing pressure sores within four hours of admission or on first contact
with community nursing services, and are re-assessed, undertaken using
a validated risk assessment tool.
Protocols have been developed for selecting the most appropriate
pressure-relieving devices for individual patients/clients.
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• The administration of medication.
A qualified pharmacist is available to nursing staff, for advice, at
all times.
There is a written policy which clearly identifies the conditions under which a nurse may or may not accept a verbal medical order to administer a drug without a written prescription. The policy clearly identifies the action to be taken by the nurse.
What other standards would you want to add?
2.12. WRITING STANDARDS?
Essentially, developing and writing standards involves the following
stages:
1. Establish a standard setting group (the writing of standards is best
undertaken by a group or team of staff)
2. Select the key function for which the standard is to be written. The
key function selected should reflect a major component of your area of
practice, in order that the standards developed are accepted as relevant to
a major part of the job.
3. Write the standard in a logical order — identify the objectives for
the standard, stating explicitly what you intend to achieve. There are a
number of ways of approaching this stage.
One way is to ask the following questions:
• What do nurses want as an outcome? (nurse-centred, nurses’ goals)
• What do people want as an outcome in relation to this function?
(patient/client-centred goals)
Another approach is to answer the questions:
• What is it about this key function that is important?
• What are the major components of this key function?
Having identified a small number of important aspects of the function, the whole standard-setting group can work together throughout on
each standard, or each nurse in the group can construct a statement about
one aspect. The group then discusses each nurse's standard statement and
changes it as necessary.
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4. Agree the criteria which demonstrate the standards and the level of
performance required/desired. Criteria are the detailed indicators of
a standard.
They can be phrased in a number of ways:
• As statements of practice.
• As questions, the answers to which indicate whether or not the
standard has been met.
The standard-setting group may again work either collectively or individually in developing criteria, as for the standard statements.
• Specify the nursing action essential to achieve the objectives.
• Where possible, specify a time frame for each action.
5. Agree the assessment method for each criteria.
6. Review the work done to eliminate ambiguous or irrelevant infor-
mation that cannot be evaluated.
7. Test the new standard for acceptability. Do nurses agree the stand-
ard? Is it based on a sound rationale and understanding of the issues? Is it
realistic, achievable and consistent with the values or philosophy of the
nursing service concerned? and for validity Is it measurable? Is it relevant?
Does it mean the same thing to different nurses?
If all of this sounds a bit daunting, it might be worth remembering
that if you use the nursing process you already have many of the skills
necessary to develop standards. There are a number of similarities between
the process of developing standards and the process of identifying desired
outcomes for care in the nursing process discussed. For example:
• Statements need to be clear and measurable. When planning care
for individuals, you saw that the goals, or statements of desired outcomes,
needed to be clear, meaningful and measurable. Nursing standards need to
follow the same principles. They must be written in such a way that they
are clear and measurable. Standards therefore, need to include criteria
which have meaning to all nurses and that can be measured in some way.
• Statements need to be specific and meaningful to the individual pa-
tient/client or, in the case of standards, to the particular setting. In the section on care planning, you saw how broad outcome statements can be so
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vague as to be meaningless. To be meaningful, they need to be specific to
the individual patient or client.
Similarly, standards without specific criteria can mean different
things to different people. They are impossible to measure and therefore
are of little use. The effect of writing standards without criteria has been
likened to trying to draw a scale drawing with a ruler that has no measurements marked on it. “The measurements would have to be guessed,
would undoubtedly be wildly inaccurate and they would certainly vary
enormously from one individual to another”.
Just as the goals for one patient/client with a particular need may be
different to those of another, the standards which may be appropriate to
one setting may be inappropriate in another setting. This may be due to
a variety of factors beyond the control of nurses. If nurses are to be held
accountable for achieving standards of care, it is essential that standards
are developed in relation to the context in which they are applied.
• Statements need to be achievable and realistic. Incremental goals
or standards may be more appropriate than ones which seem beyond
reach. When considering how to set achievable and realistic goals for pa-
tient/client care it is often necessary to break down an overall goal into
several stages and to set incremental goals that can realistically be achieved.
This applies equally to the setting of standards. The overall desired quality
of a service is something to be described and striven for. But to develop
standards which cannot be achieved is pointless and demoralizing for those
trying to deliver “good” care in difficult circumstances.
It may be more appropriate to develop standards in an incremental
way. Thus there are accepted and appropriate standards that can realistically be achieved and measured, and which can be reviewed and improved
on. This is particularly important regarding the use of standards in relation
to accountability. Only by being able to state what is the expected or desired standards of a particular nursing service, can nurses je held accountable.
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Exercise. Writing a standard
Look back at the standard statements in the previous exercise. Select one or two that you ticked as applicable and relevant to your area of
practice.
1. Critically review the standard statements, changing them as
necessary to make them really meaningful to your particular practice
situation.
2. Try to develop criteria for the standard, indicating the level of
performance required to meet the standard.
3. For each criteria, identify an appropriate method of measuring
or assessing how far the criteria has or has not been met.
If possible, compare what you have written with some colleagues
who are working through this package.
2.13. MEASURING AND MONITORING STANDARDS
OF NURSING CARE
This subject could take up an entire section of its own. As indicated
above, each of the criteria in a standard should be capable of being assessed, and the method of assessment is usually identified at the time of
writing the standard. Assessing standards of care is a complex process, and
the following text provides only a very brief summary.
To return to the analogy of the ruler, the written standards are the
ruler with which practice is measured or judged. The criteria identified
within the standards are the measurements along the ruler. Obviously the
process of judging the quality of through nursing standards is more complex than this. The word “standards” has both qualitative and quantitative
connotations. There are always tensions between the way in which quantitative aspects of care can be reduced into measurable criteria, while the
more complex interactive aspects of care do not lend themselves to the
same sort of judgements. Studies of the effectiveness of nursing care have
tended in the past to concentrate on the quantitative aspects of nursing.
Any judgement about the more discrete qualitative aspects of nursing are
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highly interpretative in nature, and therefore more complex. The challenge
for the future is to find better ways of describing and judging the quality of
these aspects of care. At present, the process of “measuring” practice still
tends to focus more on those aspects of care which can be measured with
relative ease. Some of the methods used for monitoring or assessing standards are listed below.
Approaches to monitoring or assessing standards of nursing care:
➢ Using a systematic approach to nursing (the nursing process).
➢ Observation of nursing activity.
➢ Audit of nursing records.
➢ Nursing research.
➢ The collection of statistical indices.
➢ Eliciting the views of people who use the nursing service.
➢ Peer review.
➢ Self-assessment.
➢ Critical incident analysis.
➢ Structured review or debriefing session.
➢ Staff and team appraisal systems.
➢ Examining complaints.
➢ Using efficiency measures, such as patient/client duration or fre-
quency of contact.
➢ Assessment by an external assessor.
➢ Inspection visits, for example, by regulating bodies.
➢ 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.
As we saw in the case study, standards can be developed in such a
way that they can be applied to working practices across a whole health
district or within a discrete area of practice. In the same way, quality can
be assessed across a range of different nursing teams, departments and
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specialisms for a particular function or aspect of care, or several aspects of
care may be assessed within one practice setting.
2.14. CONCLUSION
In this section we have explored the issue of defining quality in
health care and in nursing. As nurses, we need to be active in ensuring that
we are involved in all decisions about the quality of health care and in ensuring that we lead developments in defining quality in nursing care. In
doing this, we need to remember actively to involve patients and clients, as
well as the profession, in saying what that quality should be and how it can
be achieved.
Developing and using a system for assessing or assuring the quality
of nursing is now becoming an integral part of the day-to-day work of
nurses. The process does not need to be intimidating or difficult, it can be
built on existing good practice and it can have an important role in making
us more effective and in improving our job satisfaction. We have seen how
the development and application of nursing standards helps to describe acceptable practice, determine resource needs, and foster the application of
research findings and the accountability of nurses. The discussion has been
located within the context of current developments in nursing and the European strategy for Health for All.
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3. NURSING PEOPLE WITH PAIN
3.1. INTRODUCTION
In this section you will explore developments in nursing related to:
• The assessment of the person experiencing pain.
• How nursing people with pain can be improved through the use of
pain assessment tools.
• Reducing pain and anxiety in children.
The learning objectives for this section are:
1. To increase your understanding of the factors which influence
people's experiences of pain.
2. To be able to use the assessment tool described, to assess a person
experiencing pain.
3. To have developed your knowledge of how psychological ap-
proaches can be used by nurses to reduce pain and distress for children.
Definition. Pain is not a simple sensation but a complex phenomenon
having both a cognitive (physical) and an affective (emotional) component. It is a wholly subjective experience. There are no objective measures
of how much pain a person is experiencing. Our experience of pain is influenced by personal and cultural factors as much as by any biological
process. Humanity has tried to understand and relieve pain in terms of religion, philosophy and medicine for centuries. Pain is a major reason for
people making contact with the health care system. People seek relief for
pain from medicine and a variety of other sources.
Pain has been identified as one of the priorities of nursing research
and development. Recognition and acceptance of the nature and the subjectivity of the experience of pain has in itself been a significant development in nursing's understanding of and responses to people in pain.
Pain is a distressing feeling often caused by intense or damaging
stimuli.
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Exercise
Spend a few minutes listing the different experiences of pain that you
personally have had. Now look at your list and try to say which pain was
the worst and what made the pain a problem?
Now try to work out what factors influence what we see as “worst”
in terms of experience of pain. For example, was it because of your perception of the seriousness of a particular pain? Was it the intensity of the
pain, or the duration of the pain? Was it because of how much the pain
was linked to emotional distress, loss or fear; or was it because it interfered with the ability to be independent and continue with your daily life?
Have there been occasions when you have tried to ignore pain? If so, what
were the factors which made this necessary?
Refer to your list as you work through this section and consider the
material presented in relation to your understanding of your own experiences of pain.
3.2. BACKGROUND INFORMATION
Pain is probably the most common symptom of illness. It is a biologically protective mechanism, a warning signal which may be triggered by a
vast range of stressors. Most people recognize pain as a warning sign,
meaning that there is some threat or danger to health and well-being.
When we experience pain, it is also part of the natural protective response that makes us want to relieve the pain in some way. Pain becomes a
problem when it interferes with the person's ability to carry out normal activities or when the person experiencing it feels that it is unbearable in intensity or duration.
Acute pain is usually useful as a protective mechanism; chronic pain
by contrast is useless in terms of biological protection. Harmful or potentially harmful pain exists when the pain serves no useful function and may
contribute to serious pathological responses, such as neurogenic shock,
which may result in death if unrelieved. The extreme pain reflexes following a massive injury or bum, surgery and extreme anxiety are examples of
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harmful pain which must be relieved as a major priority if it is not to cause
serious harm to the person experiencing it.
The normal state is to be pain free and this is usually the goal we aim
for, for ourselves and those we care for. There are, however, occasions
when freedom from pain is not desired by the person experiencing it. For
some people, damage to the nervous system can interfere with or prevent
the protective warning signal which pain provides. This can present more
danger for the person than the experience of pain would. For example, the
person who is unconscious will have a reduced perception of pain and will
not be able to respond protectively to painful stimuli; the person who is
paralyzed may have no perception of pain affecting anything below the
level of the paralysis. Alternatively, some conditions may cause heightening of the pain response, which may make everyday activities excruciatingly painful.
There are three forms of pain:
• Phasic pain.
• Acute pain.
• Chronic pain.
Phasic pain. This is pain of short duration which occurs at the onset
of injury.
Acute pain. This is provoked by tissue damage which persists for
variable periods of time until healing takes place. The distinguishing characteristics of acute pain are that:
a) It subsides as healing takes place — it has a predictable end.
b) It is of brief duration, less than six months.
Chronic pain. This is pain which persists beyond the period of time
required for healing. Although distinct emotional states appear to be associated with acute pain, chronic pain has the greatest potential for negatively affecting the psychological well-being of the person. Physical, psychological and social problems become more complex in the presence of pain.
Holistic assessment of the person experiencing chronic pain is therefore
essential if we are to understand their experience and find ways of helping
to manage their pain.
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