Nursing Standards

"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.
Criteria are pre-determined elements against which aspects of the quality of medical service may be compared.

What are Nursing Standards?
All standards of practice provide a guide to the knowledge, skills, judgment & attitudes that are needed to practice safely.
They reflect a desired and achievable level of performance against which actual performance can be compared. Their main purpose is to promote, guide and direct professional nursing practice. (Registered Nurses Association of BC (2003) & the College of Nurses of Ontario (2002)

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)
What is a profession?
Characteristics of a Profession according to Houle (1980)
  1. Concept of mission open to change.
  2. Mastery of theoretical knowledge.
  3. Capacity to solve problems.
  4. Use of theoretical knowledge.
  5. Continued seeking of self-enhancement by its members.
  6. Formal training.
  7. Credentialing system to certify competence.
  8. Creation of subculture.
  9. Legal reinforcement of professional standards.
  10. Ethical practice.
  11. Penalties against incompetent or unethical practice.
  12. Public acceptance.
  13. Role distinctions that differentiate professional work from that of other vocations and permit autonomous practice.
  14. Service to society.
Professionalization of nursing
Professionalization is the process by which an occupation achieves professional status. The status of nursing as a profession is important because it reflects the value society places on the work of nurses and the centrality of this work to the good of society. a profession is characterized by prolonged education that takes place in a college or university. Values, beliefs, and ethics relating to the profession are an integral part of the educational preparation. By definition, a professional is autonomous in decision making and is accountable for his or her own actions. Personal identification and commitment to the profession are strong, and individuals are unlikely to change professions. In contrast, an occupation is characterized by training that may occur on the job for varying lengths of time. The training does not incorporate, as a prominent feature, the values, beliefs, and ethics of the occupation. The workers are supervised, and ultimate accountability rests with the employer. Thus commitment is not always strong, and individuals often changes jobs (Chitty, 1993).
Professional nursing practice involves “specialized skills essential to the performance of a unique, professional role” the two main concepts that are in the forefront of professional nursing and its services ideal are accountability and autonomy.
Accountability is the state of being responsible and answerable for one’s own behavior. The sphere of a nurse’s accountability is to self, the client, the employing agency, and the profession. The standards of clinical nursing practice by ANA and standards of the various specialty nursing practices document the professional nurse’s scope and limits of accountability. By virtue of these standards, society holds nurses and those under their supervision accountable for their actions.
Autonomy in nursing is the freedom and the authority to act independently. It implies control over one’s practice, and it applies to both decisions and actions.
An accountability based governance system is a predominant feature of professional practice models. Responsibility and authority are established in specified processes rather than in particular individuals who, in turn, determine the placement of accountability. The nurse is central to the organization and is supported by major service components such as standards, quality assurance, continuing education, and peer process. Nursing management has no legitimate role in practice-related decisions; rather, management facilitates, integrates, and co-ordinates nursing operations to support the practitioner.

Professional standards and nursing process
Professional standards ensure that the highest level of quality nursing care is promoted. Excellent nursing practice is a reflection of sound ethical standards. Client care requires more than just the application of scientific knowledge. A nurse must be able to think critically, solve problems, and find the best solution for client’s needs to assist clients in maintaining, regaining, or improving their health. Critical thinking requires the use of scientifically based and practice-based criteria for making clinical judgments. These criteria may be scientifically based on research findings or practice based on standards developed by clinical experts and quality improvement initiatives.
Nursing profession and essential components
 Nursing is a helping, independent profession that provides services that contribute to the health of people. Three essential components of professional nursing are care, cure and co-ordination. Caring aspect is rational and requires as nurse to understand the patient’s needs at a level that permits individualization of nursing therapies. To cure is to assist patients in understanding their health problems and to help them to cope. The cure aspect involves the administration of treatments and the use of clinical nursing judgment in determining, on the basis of patient outcomes, whether the plan is effective. Co-ordination of care involves organizing and timing the medical and other professional and technical services to meet the holistic needs of the patient. And often a patient requires many other services simultaneously in order to be well cared for. A professional nurse also supervises, teaches, and directs all of those involved in nursing care. So there are some guidelines are essential to check how the nurses perform professionally and how they exercise the care, cure and co ordination aspects of nursing. As an independent profession, nursing has increasingly set its own standards for practice. This is called standards of nursing care.
Clinical, administrative, and academic experts have developed standards of nursing practice. The most widely accepted one is American Nurses Association (ANA) 2004 within this document there are standards of professional performance and standards of practice.

Nursing as a profession
Nursing is not simply a collection of specific skills, and the nurse is not simply a person trained to perform specific tasks. Nursing is a profession. No one factor absolutely differentiates a job or a profession, but difference is important in terms of how nurse practice. When one can say a person acts “professionally”, for example, we imply that the person is conscientious in actions, knowledgeable in the subject, and responsible to self and others.
As explained before a profession as have some characteristics, one among this is the profession has a code of ethics and standards.

Standards of Professional Performance
 The ANA Standards of professional Performance describes a competent level of behavior in the professional role, including activities related to quality of care, performance appraisal , education, collegiality, ethics, collaboration, research, and resource utilization, this document serves as objective guidelines for nurses to be accountable foe their actions, their patients, and their peers . the standards provide a method to assure clients that they are receiving high-quality care, that the nurses know exactly what is necessary to provide nursing care, and that measure are I n place to determine whether the care meets the standards.

ANA Standards of professional performance.
Measurement criteria
I: quality of practice
The  registered nurse systematically enhances the quality and effectiveness of nursing practice
1. Demonstrates quality by documenting the application of the nursing process in a responsible, accountable and ethical manner.
2.Uses quality improvement activities to initiate changes in nursing practice and health care delivery system
3.Uses creativity and innovation to improve nursing care delivery
4. Incorporates new knowledge to initiate changes in nursing practice if desired outcomes are not achieved.
5. Participates in quality improvement activities.
II: education
The nurse attains knowledge and competency that  reflects current nursing practice
1. Participates in ongoing educational activities related to clinical knowledge and professional issues.
2.Demonstrates commitment to life long learning
3.Seeks experiences to maintain clinical skills
4.Seeks knowledge and skills appropriate to the practice setting
5. Maintains professional records that provide evidence of competency and lifelong learning.

III: Professional practice evaluation
The nurse evaluates one’s own nursing practice in relation to professional practice standards and guide line, relevant statutes, rules and regulations.
1.Engage in self evaluation on a regular basis
2.Seeks constructive feedback regarding ones own practice
3.Takes action to achieve goals identified during the evaluation process
4.Participates in systematic peer review as  appropriate
5.Practice reflects knowledge of current practice standards, laws and regulations
6.Provides age appropriate care in culturally and ethnically sensitive manner
IV: collegiality
The nurse interacts with and contribute to the professional development  of peers and other health care providers as colleagues
1.Shares knowledge and skills with peers and colleagues
2.Provides peers with feedback regarding their practice
3.Interacts with peers and colleagues
4.To enhance  ones own professional nursing practice
5.Maintains compassionate and caring relationships with peers and colleagues
6.Contributes to an environment that is conductive to clinical education nursing students as appropriate
7.Contributes to a supportive and healthy work environment
V: Collaboration
The nurse collaborates with patient, family, and others in the conduct of nursing practice
1.Communicates with the patient, significant others, and health care providers regarding  patient care and nursing’s role in the provision of care
2.Collaborates with patient, family and others health care providers  in the formulation of overall goals and the plan of care and in the decisions related to care and delivery of services
3.Partners with others to effect  change and generate positive outcomes
4.Document referrals, including provisions for continuity of care, as needed
VI: Ethics
The nurse integrates ethical provisions in all areas of practice
1.Practice is guided by code of ethics for nurses with interpretive statement
2.Maintains therapeutic and professional patient-nurse relationship
3. Delivers care in the manner of that preserves patient autonomy, dignity, and rights.
4.Seeks available resourced in formulating ethical decisions
5.Reports illegal, incompetent or impaired practice
6. Maintain patient confidentiality within legal and regulatory parameters.
VII: Research
 The nurse integrates  research findings in practice
1.Utilize  best available evidence including research findings to guide practice decisions
2.Participates in research activities as appropriate to the nurse’s education and position such as the following:
3.Identifying clinical problems suitable for nursing research
a. Participating in data collection
b. Participating in a unit, organization, or community research committee
c. Sharing research activities with others conducting  research
d. Critiquing research for application  to practice
e. Uses research findings in the development of policies, procedures, and practice guidelines for patient care
f. Incorporates research as a basis for learning
VIII: Resource utilization
The nurse considers factors related to safety effectiveness, cost, and impact on practice in the planning and delivery of nursing services.
1.Evaluates factors related to safety, effectiveness, availability  and cost when practice options would result in the same expected patient outcome
2.Assists the patient and family in identifying and securing appropriate and available services to address health related needs
3.Assigns or delegates tasks as defined by the state nurse practice acts and according to the knowledge and skills of the designated care giver
4.Assigns or delegate tasks based on the needs and condition of the patient, the potential for harm, the stability of the patients condition, the complexity of the task, and the predictability of the outcome
5.Assists the patient and family in becoming informed consumers about the cost ,risks, and benefits of treatment and care

IX: leadership
The nurse provides leadership in the professional practice setting and the profession
1. Engages on team work.
2. Works to create and maintain healthy work environments.
3. Teach others to succeed through mentoring.
4. Exhibits creativity and flexibility during change.
5. Directs coordination of care across settings and care givers.
6. Serves in key roles in the work settings by participating on committees, councils, and administrative.
7. Promotes advancement of the profession.
8. Display the ability to define a clear vision, the associated goals, and a plan to implement and measure progress.
9. Demonstrates energy, excitement and a passion for quality work.
10. Willingly accepts mistakes by self and others, thereby creating a culture in which risk-taking is not only safe, but expected.

Standards of care
The standards of care in the ANA nursing: Scopes and Standards of practice (2004) describe a competent level of nursing care. The levels of care are demonstrated through the nursing process. The nursing process is the foundation of clinical decision making and includes all significant actions taken by nurses in providing care to clients. Within these are the nursing responsibilities for diversity , safety, education, health promotion, treatment , self care, and planning for the continuity of care. Standards of care are important if a legal dispute arises over whether a nurse practiced appropriately in a particular case.

ANA Standards of practice
Measurement criteria
I. Assessment
The nurse collects comprehensive data pertinent to the patients health or situation
  1. Collects data in a systematic and ongoing process.
  2. Data collection involves the patient, significant others, and health care providers, when appropriate
  3. Priorities data collection activities based on the patients immediate condition or needs determine the priority of data collection
  4. Collects pertinent data using appropriate assessment techniques
  5. Document relevant data in a retrievable form
2. Diagnosis: The nurse analyzes the assessment data to determine the diagnoses or issues
  1. Derives diagnoses from the assessment data
  2. Validates the diagnoses with patient, significant others, and health care providers ,when possible.
  3. Documents diagnoses in a manner that facilitates the determination of expected outcomes and plan of care
3.Outcomes identification:
The nurse identifies expected outcomes for a plan individualize to the patient or the situation

  1. Derieves outcomes from the diagnoses
  2. Formulates outcomes mutually with the patient and the health care providers, when possible.
  3. Outcomes are culturally appropriate and realistic in relation to the patients present and potential capabilities
  4. Defines  expected outcomes in terms of the patient, patient values, ethical considerations, environment, or situation with such consideration as associated risks , benefits , costs, current scientific evidence, and clinical expertise when formulating expecting outcomes.
  5. Outcomes are attainable in relation to resources available to the person
  6. Outcomes include a time estimate for attainment for expected outcome.
  7. Outcomes provide direction for continuity of care
  8. Modifies expected outcomes based on changes in the status of the patient or evaluation of the situation.
  9. Documents outcomes as measurable goals.
4:Planning: The nurse develops a plan that prescribes strategies and alternatives to attain expected out comes

  1. The plan is individualized to the patient and patients condition or needs
  2. Develops the plan with the patient, significant others, and health care providers, when appropriate.
  3. Includes strategies within the plan that address each of the identified diagnosis or issues, which may include strategies for promotion and restoration of health and prevention of illness, injury, and disease.
  4. Provides for continuity within the plan.
  5. Incorporates an implementation pathway or timeline within the plan.
  6. Utilizes the plan to provide direction to other members of the health care team.
  7. Defines the plan to reflect current status , rules, and regulations and standards.
  8. Integrates current trends and research affecting care in the planning process.
  9. Considers the economic impact of the plan.
  10. Uses standardized language or recognized terminology to document the plan.
The nurse implements the identified plan of  care

1.Interventions are consistent with the established plan of care
2.Implements interventions in a safe and appropriate manner,
documents interventions
3. Utilizes evidence –based interventions and treatments specific to the diagnosis or problem.
4.Collaborates with nurse colleagues to implement the plan
5.Utilizes community resources and systems to implement the plan
5A:Co-ordination of care. The registered nurse coordinates care delivery.

5B:Health teaching and health promotion

5C:consultation:the advanced practice registered nurse and the nursing role specialist provide consultation to influence the identified plan, enhance the abilities of others and effect change. 

5D:Prescriptive Authority and Treatment :the advanced practice registered nurse uses prescriptive authority, procedures, referrals, treatments, and therapies in accordance with state and federal laws and regulations.

The nurse evaluates progress towards attainment of outcomes
1.Coordinates implementation of the plan.
2.Documentation of the care.

1.Provides health teaching that address such topics as healthy lifestyles , risk reducing behaviors, developmental needs, activities of daily living, and preventive self-care.
2. Uses health promotion and health teaching methods appropriate to the situation and the patient’s developmental level, learning needs , readiness, ability to learn , language preference , and culture.
3. Seeks opportunities for feedback and evaluation of the effectiveness of the strategies used .
1.Synthesizes clinical data, theoretical frameworks, and evidence when providing consultation.
2.Facilitates the effectiveness of a consultation by involving the patient in decision-making and negotiating role responsibilities.
3.Communicates consultation recommendations that facilitates change.

1.prescribes evidenced-based treatments , therapies, and procedures considering the patient’s comprehensive health care needs.
2.presribes pharmacological agents based on a current knowledge of pharmacology and physiology and based on clinical indicators, the patient’s status needs , and the results of diagnostic and laboratory tests.
3.Evaluates therapeutic and potential adverse effects and potential adverse effects of pharmacological and non pharmacological treatment.
4.Provides patients with information about intended effects and potential adverse effects of proposed prescriptive therapies.
5.Provides information about costs, alternative treatments and procedures , as appropriate.
1.Evaluation is systematic, ongoing and criterion-based
2.Involves the patient, significant others ,and the health care providers in the evaluation process, when appropriate
3.Uses ongoing assessment data to revise diagnoses, outcomes
and plan of care as needed
4.documents revisions in diagnoses, outcomes, and the plan of care
5. evaluates the effectiveness of interventions in relation to outcomes.
6.Documents the patients response to interventions 

Code of ethics
Nursing has a code of ethics that defines the principles by which nurse provide care to their clients. In addition, nurses incorporate their own values and ethics into practice. The code of ethics for nurses with interpretive statements provides a guide for carrying out nursing responsibilities that provide quality nursing care and provides for the ethical obligations of the profession.

Standard nursing care: An Asset 
In order to ensure quality care the nursing care needs some standards. Standards are degree of excellence. The aim of standard nursing care is to support and contribute to excellent practices. The role of nurse is constantly changing to meet the growing needs of health services.

  • Plan
  • Holistic Approach
  • Appropriate Diagnosis
  • Realistic Goal
  • Selecting Appropriate Media
  • Quality Care rather than quantity
  • Economize Time, Material, Energy
Types of standard care
  • Structure -- Things we use
  • Process -- Things we do
  • Outcome -- The result
Characteristics of standard care
  • Dynamic
  • Reflects Changes
  • Not Static
Brief description of methods and procedure
S - Successful termination of helping relationship for client.
T - To have clear idea or conception of the distinct goal, nursing the patient and health needs of society.
A - Assertive planning.
N - Nature of client nurse interaction.
D - Directing others.
A - Analytical thinking.
R - Respect status and policies.
D - Data collection in accordance with goal.
Standard: Nursing practice requires that a conceptual model for nursing be the basis for the independent part of that practice.
Elements: Nurses are required to have clear idea or conception of the distinct goal nursing, the patient, the health needs of the society, the source of client difficulty, the focus, and modes of nursing intervention and the expected consequences of nursing activities.
Standard: Nursing practice requires the effective use of the nursing process.
Elements: Nurses are required to collect data in accordance with their conception of the goal of nursing, client, the source of client difficulty, the four and modes of intervention conceptual models for nursing.
Standard: Nursing practice requires that the helping relationship be the nature of client nurse interaction.
Elements: Nurses are required to increase the likelihood that the client will perceive the health service experience as understandable, manageable and meaningful at the outset.
Nurses are required to ensure a successful termination of the helping relationship.
Standard: Nursing practice requires nurses to fulfill professional responsibilities.
Elements: Nurses are required to respect status and policies relevant to the profession and the practice setting. Nurses are required to comply with the code of ethics of their profession. Nurses are required to function as members of a health team.
Standard in Nursing Practice
Professional Responsibilities
  • Health team member
  • Ethics
  • Policies
  • Health needs of society
  • Nursing intervention
Effective use of nursing process
  • Data collection
  • Diagnosis
  • Goal
  • Intervention
  • Evaluation
  • Setting standards
  • Planning individual patient care
  • Monitoring and evaluating patient and environment
  • Coordinating services to the patient
“Nursing Standards of Care” pertain to professional nursing activities that are demonstrated by the nurse through the nursing process. These involve assessment, diagnosis, outcome identification, planning implementation, and evaluation. The nursing process is the foundation of clinical decision making and encompasses all significant action taken by nurses in providing care to all consumers. While “Nursing Standards of Professional Performance” describe the roles of all professional nurses, there are many other responsibilities that are hallmarks of professional nursing. These nurses should be self-directed and purposeful in seeking necessary knowledge and skills to enhance career goals. Other activities-such as membership in professional organizations, certification in specialty or advanced practice, continuing education and further academic education, are desirable methods of enhancing the nurse’s professionalism. Accountability for one’s practice as a professional rests with the individual nurse.

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