Quality Assurance in Nursing: Standards


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 recognised 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.
Characteristics of Standard
  • Standards statement must be broad enough to apply to a wide variety of settings.
  • Standards must be realistic, acceptable, attainable.
  • Standards of nursing care must be developed by members of the nursing profession; preferable
  • nurses practising 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.
  • Standardsof nursing care must express what is desirable optional level.
  • 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,ie, minimum standard.
  • And one must remember that standards that work are objective, acceptable, achievable and flexible.
Purposes of Standards
  • Setting standard is the first step in structuring evaluation system. The following are some of the purposes of standards.
  • Standards give direction and provide guidelines for performance of nursing staff.
  • Standards provide a baseline for evaluating quality of nursing care
  • Standards help improve quality of nursing care, increase effectiveness of care and improve efficiency.
  • Standards may help to improve documentation of nursing care provided.
  • Standards may help to determine the degree to which standards of nursing care maintained and take necessary corrective action in time.
  • Standards help supervisors to guide nursing staff to improve performance.
  • Standards may help to improve basis for decision-making and devise alternative system for delivering nursing care.
  • Standards may help justify demands for resources association.
  • Standards my help clarify nurses area of accountability.
  • Standards may help nursing to define clearly different levels of care.
Major objectives of publishing, circulating and enforcing nursing care standards are to:
1. improve the quality of nursing care,
2. decrease the cost of nursing, and
3. determine the nursing negligence.
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 organisation, e.g. Associations, TNAI,
  • Licensing bodies, e.g. Statutory bodies, INC,
  • Institutions/health care agencies, e.g.  University Hospitals, Health Centres.
  • 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 organisations (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 patient-oriented; they describe the change as desired in a patient's physical status or behaviour. The means standards are nursing oriented, they describe the activities and behaviour 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 organisation, facilities and equipment, and qualifications of employees are some of the components of the structure of the organisation, e.g. recommended relationship between the nursing department and other departments in a health agency are structural standards, because they refer to the organisational 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 behaviours 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 is 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 judgement 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  patient's 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.
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. a patient-nurse relationship existed such that the nurse owed to the patient a duty of due care,
  2. the nurse deviated from the appropriate standard of care,
  3. the patient suffered damages,
  4. the patient's damages resulted from the nurses deviations from the standard of care.
Quality assurance is to provide a higher quality of care. It is necessary that nurses develop standards of patient care and appropriate evaluation tools, so that professional aspects of nursing involving intellectual and interpersonal activities. Quality will be ensured and attention will be given to the individual needs and responses to patients.The formulation of standards is the first step towards evaluating the nursing care delivery. The. standards serve as a base by which the quality of care can be judged. This judgement may be according to a rating or other data that reflect the conformity of existing practice with the established standards. The standards must be written, regularly reviewed and well-known by the nursing staff.
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