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STANDARDS

INTRODUCTION Standard is an acknowledged measure of comparison for quantitative or qualitative value, criterion, or norm. A standard is a practice that enjoys general recognition and conformity among professionals or an authoritative statement by which the quality of practice, service or education can be judged. It is also defined as a performance model that results from integrating criteria with norms and is used to judge quality of nursing objectives, orders and methods. A standard is a means of determining what something should be. In the case of nursing practice standards are the established criteria for the practice of nursing. Standards are statements that are widely recognized as describing nursing practice and are seem as having permanent value. A nursing care standard is a descriptive statement of desired quality against which to evaluate nursing care. It is guideline. A guideline is a recommended path to safe conduct, an aid to professional performance. A nursing standard can be a target or a gauge. When used as a target, a standard is a planning tool. When used as a gauge against which to evaluate performance a standard is a control device. DEFINITION "Standards are professionally developed expressions of the range of acceptable variations from a norm or criterion"-Avedis Donabedian. Standards may be defined as "Benchmark of achievement which is based on a desired level of excellence. TERMINOLOGY CLARIFYING NURSING CARE STANDARDS An objective is a concrete statement of intention, an external goal towards which effort is directed. A criterion is the value free description of variable believed to an indicator of a patient care quality. A norm is the current level of performance of a particular criterion as determined by description study of the target population. A model is a phenomenological analogy used to describe something that cannot be directly observed and about which deeper understanding is sought. A patient problem in an active or potential need, condition or complication, that derives from the patient diagnosis or care and indicates needs for intervention. A nursing problem is difficult situation encountered by care-giver in pursuing nursing goal. A quality improvement is the process of establishing optimum standards of nursing practice and planning or providing care that meets those standards. A nursing order is a prescribed action issued in the form of a command by one nurse to other nursing personnel. Nursing audit is the process of analyzing data about the nursing process or patient outcomes to evaluate the effectiveness of nursing intervention. PURPOSES Communication: provides for sharing a common language with nursing professional which can cross barriers.

Research: The standards provide a framework for further investigation so that current practice is no longer based on intervention. Legal implication: The nursing profession must be self-regulating to maintain credibility as a profession. The courts use professional standards as a yardstick to determine whether hospitals and health care professionals have provided quality patient care according to rationally acceptable standards. Quality assurance: Standards can be used criteria for quality assurance studies to assess the current levels of practice rendered by the health care services provided by the organization or both. Professional accountability: Standards set guidelines for nursing practice providing uniform basis for collecting a information with an established assurance program and or performance appraisal system. Decision making: Standards also help in decision-making and choosing alternatives for delivery of health care, helps in supervision and improving performance. Why are Standards Important?

Outlines what the profession expects of its members. Promotes guides and directs professional nursing practice important for self-assessment and evaluation of practice by employers, clients and other stakeholders. Provides nurses with a framework for developing competencies Aids in developing a better understanding & respect for the various & complimentary roles that nurses have. ( Registered Nurses Association of BC (2003) & the College of Nurses of Ontario (2002) BASIC PRINCIPLES 1. Standards should be designed to achieve a stated purpose. 2. Standards should be based upon clear definitions of professional scope and accountability. 3. Standards should be sufficiently broad and flexible to achieve their objective and at the same time permit freedom for innovation, growth and change. 4. Standards should promote the fullest development of the profession in accordance with its potential social contribution. 5. Standards should promote universal levels of performance and encourage professional identity and mobility. 6. Standards should recognize the equality and interdependence of professions offering essential services. 7. Standards should be formulated according to requirements which facilitate their applicability and use by the profession. CHARACTERISTICS OF STANDARD

Standards statement must be broad enough to apply to a wide variety of settings. Standards must be realistic, acceptable, and attainable. Standards of nursing care must be developed by members of the nursing profession; preferable Nurses practicing at the direct care level with consultation of experts in the domain. Standards should be phrased in positive terms and indicate acceptable performance good, excellence etc. Standards of nursing care must express what desirable optional level is.

Standards must be understandable and stated in unambiguous terms. Standards must be based on current knowledge and scientific practice. Standards must be reviewed and revised periodically. Standards may be directed towards an ideal, ie, optional standards or may only specify the minimal care that must be attained, i.e., minimum standard. And one must remember that standards that work are objective, acceptable, achievable and flexible. ESSENTIAL ELEMENTS In developing standards for nursing, certain essential elements needs to be considered to ensure that the standards: Reflect the values, conditions and goals for advancement of profession. Are based on valid principles. Are designed to help the profession meet the changing health needs to society. Serve as a means for communicating the goals of nursing to the institutions state, members of profession, the public. Include the broad range of practice dimensions in nursing. ESSENTIAL ELEMENTS TO TAKE INTO CONSIDERATION FOR ALL NURSING STANDARDS The need of population for nursing care. The health care delivery system of the country- its organization, types of health care providers and the functions of nurses within the system. A philosophy of nursing which reflects the professions body of knowledge and value, and provides a framework for formulating standards for nursing. Clear definitions of nursing, nurse and other categories of nursing personnel. The scope of nursing practice in the country:

The existence of nurse generalists and or specialists. The distribution of nurses in urban and rural settings. The proportions of nurses required in special areas such as acute acre, long term care and primary health
care.

The existing regulatory mechanisms of nursing education and practice, such as licensure or registration
legislation, nursing practice acts, regulations of health education authorities relating to nursing.

The level of standards.


ESSENTIAL ELEMENTS OF STANDARDS FOR NURSING PRACTICE Standards for nursing practice focus on the individual practitioner are therefore concerned with the role and functions of nurse. This role and function varies in different countries according to national development and health policies and due to emerging degree of professionalism of the nurse and 1. The Nurses: Standard should address "who is the nurse", specifying qualification for practice and requirement for life insure, such as the determination of required competencies at the entry to practice level. The accountability and responsibility of the individual practitioner to consumers and employers is demonstrated by the behaviors of the nurse in carrying out the professional role. Accountability is also shown in the activities of the nurse in relation to the nursing profession and in participating in the

advancement of the profession as well as to the nurse him/ herself as shown by practicing and maintaining through continuing education of high level quality in practice. 2. Nursing Practice: As nursing practice are different in different countries, the various levels of nurses and levels of practice need to be addressed. The regulation of nursing that carries out this function is carried out, will determine the scope of practice. 3. People requiring nursing care: nursing and nurses only exist because people require nursing services. These may be individual families, groups or communities with needs requiring nursing services. 4. The settings for nursing practice: For nursing care to be delivered to people, there needs to be adequate facilities with sufficient resources to carry out safe practice of high quality when this not so, standards will not be maintained. 5. Evaluation of nursing practice: Focus on the practitioner requires standards regarding performance appraisal should be stated whether disciplinary system and or merit or reward system are used. SOURCES OF NURSING CARE STANDARDS It is generally accepted that standards should be based on agreed up achievable level of performance considered proper and adequate for specific purposes. The standards can be established, developed, reviewed or enforced by variety of sources as follows:

Professional organization, e.g. Associations, TNAI. Licensing bodies, e.g. statutory bodies, INC. Institutions/health care agencies, e.g. University Hospitals, Health Centers. Department of institutions, e.g. Department of Nursing. Patient care units, e.g. specific patients' unit. Government units at National, State and Local Government units. Individual e.g. personal standards

CLASSIFICATION OF STANDARDS There are different types of standards used to direct and control nursing actions. 1. Normative and Empirical Standards Standards can be normative or empirical. Normative standards describe practices considered 'good' or 'ideal' by some authoritative group. Empirical standards describe practices actually observed in a large number of patient care settings. Here the normative standards describe a higher quality of performance than empirical standards. Generally professional organizations (ANA/TNAI) promulgate normative standards where as low enforcement and regulatory bodies (INC/MCI) promulgate empirical standards. 2. Ends and Means Standards Nursing care standards can be divided into ends and means standards. The ends standards are patientoriented; they describe the change as desired in a patient's physical status or behavior. The means standards are nursing oriented, they describe the activities and behavior designed to achieve the ends standards. Ends (or patient outcome) standards require information about the patients. A means standard calls for information about the nurses performance. 3. Structure, Process and Outcome Standards

Standards can be classified and formulated according to frames of references (used for setting and evaluating nursing care services) relating to nursing structure, process and outcome, because standard is a descriptive statement of desired level of performance against which to evaluate the quality of service structure, process or outcomes. a. Structure Standard A structural standard involves the 'set-up' of the institution. The philosophy, goals and objectives, structure of the organization, facilities and equipment, and qualifications of employees are some of the components of the structure of the organization, e.g. recommended relationship between the nursing department and other departments in a health agency are structural standards, because they refer to the organizational structure in which nursing is implemented. It includes people money, equipment, staff and the evaluation of structure is designed to find out the effectiveness, degree to which goals are achieved and efficiency in terms of the amount of effort needed to achieve the goal. The structure is related to the framework, that is care providing system and resources that support for actual provision of care. Evaluation of care concerns nursing staff, setting and the care environment. The use of standards based on structure implies that if the structure is adequate, reliable and desirable, standard will be met or quality care will be given. b. Process Standard Process standards describe the behaviors of the nurse at the desired level of performance the criteria that specify desired method for specific nursing intervention are process standards. A process standard involves the activities concerned with delivering patient care. These standards measure nursing actions or lack of actions involving patient care. The standards are stated in action-verbs that are in observable and measurable terms.eg: the nurse assesses", "the patient demonstrates". The focus is on what was planned, what was done and what was communicated or recorded. Therefore, the process standards assist in measuring the degree of skill, with which technique or procedure was carried out, the degree of client participation or the nature of interaction between nurse and client. In process standard there is an element of professional judgment determining the quality or the degree of skill. It includes nursing care techniques, procedures, regimens and processes. c. Outcome Standards Descriptive statements of desired patient care results are outcome standards because patients results are outcomes of nursing interventions. Here outcome as a frame of reference for setting of standards refers to description of the results of nursing activity in terms of the change that occurs in the patient. An outcome standard measures change 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. LEGAL SIGNIFICANCE OF STANDARDS Standards of care are guidelines by which nurses should practice. If nurses do not perform duties within accepted standards of care, they may place themselves in jeopardy of legal action. Malpractice suit against nurses are based on the charge that the patient was injured as a consequence of the nurses failure to meet the appropriate standards of care. To recover losses from a charge of malpractice, a patient must prove that:

1. 2. 3. 4.

A patient-nurse relationship existed such that the nurse owed to the patient a duty of due care, The nurse deviated from the appropriate standard of care, The patient suffered damages, The patient's damages resulted from the nurses deviations from the standard of care.

STANDARDS DEVELOPMENT CYCLE Step1. Define and agree. In this step, the goal is to define and agree on several areas and issues that will define the standards. o Clarify the consensus process, both for topic selection and approval o Clarify the approval process for the standards. Step2. Select who should be involved. Identify, at the outset of the process, all stakeholders, I .e, those individuals or groups with a vested interest in the successful development of the standards. Step3. Gather information. In this step, the working group information about the topic under review and other resources that can help define the key elements that should be included in the standards. A flowchart may be developed to better understand the points in the current process requiring the development of standards. Step4. Draft standards. There are several components to drafting standards: o Decide the structure and format of the standards, depending on their purpose. After the format is decided, the working group drafts the standards. o Develop indicators to measure performance according to the standards. o Prior to field testing, the graft standards should be evaluated internally. Step5. Test the standards. Once indicators are developed, the working group must decide whether a field test is needed. Step6. Communicate the standards. Although the standards -setting process might be completed with the approval of the standards, the impact of well- developed standards depends on health care providers using the standards. Standards communication and implementation strategies are critical to achieving healthcare provider performance according to the standards. Suggestions for dissemination of standards - Publish the standards and circulate widely, giving an indication of when they will be revised e.g. 5 years, 10 years. - Institute a series of workshops through branches, work- groups, etc to introduce the standards in appropriate work-places and develop more specific standard at the local level. - Set a future date to seek feedback on the validity and usefulness of the standards and to revise the standards on the basis of this. STANDARDS OF CARE - Recognize that all professions have standards of care. Standards are the minimal level of expertise that may be delivered to the patient; they are a starting point for greater expectation.

- Standards of care may be internally or externally set. The nurse is responsible for both categories of standards, those set by forces outside of nursing and those set by the role of nursing. - Standards of care can be found in the following: The state nurse practice act. Published standards of professional organizations and specialty practice groups, such as the American Association of Critical Care Nurses or the Association of Operating Room Nurses. Federal agency guidelines and regulations. Hospital policy and procedure manuals the nurses job descriptions. - The nurse is accountable for all standards of care as they pertain his/ her profession. To remain competent and skillful the nurse is encouraged to read professional journals and to attend pertinent, continuing education and in service program. - Standards of care are determined for the judicial system by expert witnesses. Such people testify to the prevailing standards in the community- a standard that all nurses are accountable for matching and exceeding thus ensuring that patients receive quality, competent nursing care. STANDARDS FOR EVALUATING THE CONTROLLING FUNCTION OF NURSING ADMINISRATION OF A DIVISION, SERVICE OR UNIT 1. An evaluation exists and is used for each nursing department, service or unit. 2. Each evaluation plan is specific to the needs and activities of the individual department, service or unit. 3. Evaluation findings are given in immediate feedback to subordinate nursing personnel. 4. Standards are accurate, suitable and objective. 5. Standards are flexible and work when changes are made in plans and when unforeseen events and failures occur. 6. Standards mirror the organizational pattern of the nursing division, service or unit. 7. Standards are economical to apply and do not produce unexpected results or effects. 8. Nursing personnel know and understand the standards. 9. Application of standards results in the correction of deficiencies. STANDARDS FOR EVALUATION OF PHILOSOPHY STATEMENTS OF THE NURSING DIVISION, DEPARTMENT, SERVICE OR UNIT 1. A written statement of philosophy should exist for the nursing division and each of its units. 2. A written statement of philosophy should be developed in collaboration with nursing employees, the consumers and health care workers. 3. Nursing personnel should share in an annual (or more frequent) review and revision of written statement of philosophy. 4. The written statement of philosophy should reflect these beliefs or values: a) The meaning of the clinical practice of nursing.

b) Recognition of rights of individuals and of the responsibility of nursing personnel to serve as advocates for those rights. c) Selective other statements about humanity, society, health, nursing, nursing process and self- care relevant to external forces (community, law) and internal forces(personnel, clients, material resources, etc ), research, education and family as are deemed to accomplishing the mission of the division and each of its units. 5. The nursing philosophy should support the philosophy of the organization as expressed at all levels above the nursing division. 6. The statement of philosophy should give direction to the achievement of the mission. STANDARDS FOR EVALUATION OF STATEMENTS OF OBJECTIVES FOR A NURSING DIVISION, DEPARTMENT, SERVICE OR UNIT 1. The objectives for the nursing division, department, services or unit should be in written form. 2. The objectives should be developed in collaboration with the nursing personnel who will assist in achieving them. 3. Nursing personnel should share in an annual (or more frequent) review and revision of the written statements of objectives. 4. The written statement of objectives should meet these qualitative and quantitative criteria: a) They operationalize the statements of mission and philosophy; they can be translated into actions. b) They can be measured or verified. c) They exist in a hierarchy or prioritized sequence. d) They are clearly stated. e) They are realistic in terms of human and physical resources and capabilities. f) They direct the use of resources. g) They are achievable (practical). h) They are specific. i) They indicate results expected from nursing efforts and activities; the ends of management program. j) They show a network of desired events and results. k) They are flexible and allow for adjustment. l) They are known to the nursing personnel who will use them. m) They are quantified wherever possible.

n) They exist for all positions. STANDARDS FOR EVALUATION OF MANAGEMENT PLAN OF NURSING DIVISION, DEPARTMENT, SERVICE OR UNIT 1. The written management plan should operationalize the strategic goals of the organization as well as the objectives of the nursing division, department, service or unit. It should specify activities or actions, persons responsible for accomplishing then and target dates or time frames as well as providing for evaluation of program. Each activity or action should be listed in problem-solving or decision making format, as appropriate. 2. The management plan is personnel to the incumbent, who should select the standards for developing, maintaining and evaluating it. The nursing manager should solicit desired output from appropriate nursing persons and others. 3. The actions listed should reflect planning for: a) Nursing care programs to ensure safe and competent nursing services to clients: i. The nursing process including data gathering assessment, diagnosis, goal setting and prescription, intervention and application, evaluation, feedback, change and accountability to the consumer. ii. A process and outcome audit. iii. Promotion of self-care practice. b) Establishment of policies and procedures for employing competent nursing personnel: recruitment, selection, retention and promotion based on individual qualification and capabilities without regard to race, national origin, creed, color, sex, age. c) Integration of nursing care programs into the total program of health care organization and community through community participation in professional and service activities and credentialing of individuals in organizations including nursing organizations. d) A budget that is evaluated and revised as necessary.

PRESENTATION ON STANDARDS

SUBMITTED TO: Respected Mrs. Manoshanthini Reader SGRDCON, Hoshiarpur.

SUBMITTED BY: Amrinder Kaur MSc.(N) 2nd Year. Roll No-1.