Correlating Nursing Care, Nursing Practice, and Nu rsing Performance Standards by Irene Kane, RN, MSN, and Barbara J. Fickley, RN, MSN, CS
All too often nursing standards have been viewed as
a cumbersome paperwork task with little day-to-day
practical relevance. Using a matrix approach that incorporates nursing role functions and the nursing process, the authors developed a model that provides the basis for job descriptions, pevfomnce appraisals,
peer review, and quality management activities.
N u r s i n g standards of practice, care, and performance have tended to be viewed as a burdensome paperwork task disproportionate to any practical application. This imbalance has existed because the various standards have been developed in isolation from each other and with debatable day-today relevance. When standards correlate with each other, and are integrated into other aspects of nursing responsibilities, they form a meaningful framework from which to direct the course of patient care. Developing such integrated standards became the mission of a small group of nurse administrators, of which the authors were a member. The group first reviewed the pertinent literature and regulatory requirements regarding standards and then brainstormed about desired client outcomes. The standards of psychiatric mental health nursing, created by the American Nurses’ Association (1982),were integrated in order to insure fulfillment of professional responsibilities. The goal was to develop standards that would form the basis for job descriptions, performance appraisals, peer review, and quality improvement activities. Another target goal was to get these standards to correlate with nursing role functions and the nursing process. Linking these concepts was accomplished through the development of a functional matrix model, which also served as a framework for evaluating nursing care activities.
Defining Standards of Practice, Care, and Performance In order to formulate the functional matrix model it was necessary to define and distinguished among the following kinds of standards:
. .
Perspectivesin Psychiatric Care Vol. 28, No. 3, July-Sept,1992
Standards of practice: what the nursing staff must do to provide patient care Standards of cure: what patients can expect to receive from nursing staff Standards of performance: how nursing staff must perform to meet expectations established in the standards of care (Patterson, Kranz, & Brandt, 1986). 27
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Correlating Nursing Care, Nursing Practice, and Nursing Performance Standards
These definitions provided the horizontal axis of the matrix in this model (Table 1). The second step was to translate these descriptions of standards into practical guidelines for nursing care. Role theory and the nursing process provided a context from which to carry out ths phase. Nurses function in multiple roles during their course of care with patients, including: clinical, administrative, research, education, and consultation (Stuart & Sundeen, 1987). These roles, or nursing functions, formed the vertical axis of the matrix of the model (Table 1).
The resulting functional matrix includes a general standard, which is an adaptation of the ANA psychiatric/mental health nursing practice standards (1982). Table 2 outlines the expected standard of practice, care, and performance, and the subsequent rationale.
A Framework for Job Descriptions and Performance Appraisals The standards of performance section of the horizontal axis form the basis of job description and performance
Table 1. Matrix Model for Correlating Standards
Nursing Roles
Standard of Practice
Standard of Care
Standard of Performance Probationary Nurse
Staff Nurse
Psychiatric Nurse
1. Clinical
a) Assessment b) Manning
c) Implementation d) Evaluation
2. Administration
3. Education
4. Research
5. Consultation
28
Perspectivesin Psychiatric Care Vol. 28, No. 3, July-Sept,1992
appraisal responsibhties for the psychiatric nurse (Table 3). The standards are thus utilized a s a link between abstract concepts and the real day-to-day world of practice. In the authors’ setting, the nurse signs a position description and reviews the content during the annual competency evaluation. The nurse receives supervisory feedback around performance relative to standards, and areas of deficit are addressed through learning plans. Expectations for all levels of nurses are thus defined consistently through the modalities of nursing standards, nursing process, job descriptions, and performance evaluations. At the same time, the standards of performance are designed on a continuum to include all levels of nursing staff in existing roles. Since this method provides a consistent framework for all levels of nurses, the chance for discrepancies in nursing care and for expectations of performance is lessened. For example, if a nurse is in the administrative tract, such as an Assistant Nurse Clinical
Manager, the standards remain applicable with a more detailed emphasis in the particular area of concentration. Quality management. Since the standards of practice and care are used as a basis for reviewing the nursing care administered to clients, the functional matrix model facilitates quality management improvement monitoring and evaluation. Documentation is guided by policy and procedures grounded in the standards of practice, care, and performance. In this way, as well as through direct observation, nursing practice can be reviewed by colleagues or the nurse manager. Peer review. The standards also serve as the foundation for the peer review process-that is, nursing practice relative to the standards, as seen through the discerning eye of one’s nurse colleagues, can be assessed. A selected nurse reviews key components of each standard, and the nursing role, in order to share observations with her/lus colleague, in the process of peer review (Table 4).
Table 2. Standards and Rationale Clinical (Assessment)
Clinical (Administration)
Standard of Practice
Standard of Practice
The professional nurse must systematically and continuously collect and assess data in collaboration with the multidisciplinary team to provide therapeutic care for the patient.
The professional nurse is actively involved in the clinical management, coordination, and evaluationof individual patient care, patient groups, and the therapeuticmilieu. This adminis tration process is monitored through peer review, clinical supervision, consultation, and other quality improvement procedures.
Standard of Care The patient participates in assessing strengths and needs on an ongoing basis.
Standard of Care
Standard of Performance
The patient merits a skillfully structured and monitored program of nursing care.
The nurse assesses each patient utilizing the nursing process from admission through discharge.
Standard of Performance
Rationale
The nurse utilizes clinical administrative skills in assuring quality nursing care with the individual patient, patient groups and within the therapeutic milieu.
Assessment is a nurse-patient participatory process that continues through all phases of nursing/patient care. It consists of an accurateand comprehensivecollection of pertinent information, including admission procedures, nursing assessment tool, patient orientation to the unit, and ongoing monitoring of patient status.
Perspectivesin Psychiatric Care Vol. 28, No. 3, July-Sept.,1992
Rationale Psychiatric mental health nursing involves the utilization of clinical administrativeskills to ensures our providing patients with excellent nursing care..
29
Correlating Nursing Care, Nursing Practice, and Nursing Performance Standards
Table 3. Standards for Job Description and Performance Appraisal I. Clinical Assessment Standards of Practice
Standards of Care
Standards of Performance
The Nurse:
The Patient (or significant other):
Psychiatric Nurse:
1. Completes the nursing admission procedure within 8 hrs of admission: a. Greets the patient. b. Assesses patient's tolerance for admission procedures. c. Gathers information as outlined on assessment form. d. Orients patient and sigruhcant others to hospital environment; assists in adjustment.
1. Participates in the admission process: a. Is introduced to the hospital, treatment, and staff in a courteous, dignified, and respective manner. b. Participatesin the admission procedure to the best of his/her ability. c. Obtains specific information about the milieu.
1. Utilizes the requisite policy and procedure for completing the initial admission process: a. Communicates with the patient at the patienfs level of understanding. b. Evaluates current status of the patient, prioritizes immediate needs, and utilizes information for patient care plan for long-term planning. c. Involves the patient in the mutual-sharing process; interprets this information for the patient in logical manner; anticipates the patienfs concerns and questions.
2. Obtains information to develop a holistic picture of the patient from which the therapeutic process evolves.
2. Participates in giving relevant information that contributes to the development of a holistic picture.
2. Synthesizes the pertinent patient information in order to discuss immediate and long-range goals of the treatment plan.
3. Assesses information systematically and objectively on a regular basis according to the categories of the treatment plan.
3. Meets regularly with the primary/ associate nurse to provide and receive feedback.
3. Utilizes past experience and theoretical knowledge to report subtle verbal and nonverbal behaviors.
4. Communicatesassessment data to the assigned treatment team members through multidisciplinary team meetings, shift reports, case conferences, patient rounds, progress notes.
4. Understands that vital assessment information is communicated to all pertinent staff.
4. Develops a collegd role in patient information-sharingmeetings and provides assessment recommendations for changes in the treatment plan.
5. Conducts assessments of the patient's
5. Participates in assessment of learning needs.
5. Discriminatespatient's learning needs according to willingness to learn.
6. Conducts assessment information to the treatment team to begin the discharge planning.
6. Understands preliminary discharge plans based upon assessment.
6. Formulates issues from assessment informationrelevant to adequate discharge planning. Summarizes information to the treatment team.
7. Documents accurate and complete assessment information in the medical record.
7. Merits a medical record that reflects accurate, continuous and complete assessment information.
7. Documents factual, organized assessment information utilizing accurate terminology.
learning needs.
30
Perspectives in Psychiatric Care Vol. 28, No. 3, July-Sept,1992
summary This model of standards offers a framework from which nursing care activities revolve, creating a balanced wheel of interrelated concepts. Each concept defines expectations for daily nursing actions, performance responsibilities, and role aspirations. This model is made available to nursing staff during orientation.The concepts form a progressive wheel of efficient, correlated parts; each adds value to the other. The resulting sum provides the needed balance between burdensome paperwork and relevant resources for day-today practice.
Acknowledgement. The authors would like to thank Carole Taylor, RN, MSN, and Margaret Lunn, RN, MPH, for their participation in the early stages of the project. References American Nurses Association (1982). Standards of psychiatric and mental health nursing practice. Kansas City, M O Author.
Pattason, C., Kranz, D., & Brandt, B. (1986).A gulde to ICAH nulsiny .ruice standards. Chicago:Joint Commission on Accreditation of Hospitals.
Stuart,G., & Sundeen, S. (1987). Principles and practice of psychiatric nursing. St. Louis: Mosby.
Table 4. Peer Review Tool Observations
Suggestions
Assessment: Plan: Intervention: Evaluation:
Patient Focused Nursing Implementation: Professional Communication and Reporting Skills: Administrative: Education:
Consultation: Research
Pempectivesin Psychiatric Care Vol. 28, NO.3, Juiy-Sept,1992
31
All too often nursing standards have been viewed as
a cumbersome paperwork task with little day-to-day
practical relevance. Using a matrix approach that incorporates nursing role functions and the nursing process, the authors developed a model that provides the basis for job descriptions, pevfomnce appraisals,
peer review, and quality management activities.
N u r s i n g standards of practice, care, and performance have tended to be viewed as a burdensome paperwork task disproportionate to any practical application. This imbalance has existed because the various standards have been developed in isolation from each other and with debatable day-today relevance. When standards correlate with each other, and are integrated into other aspects of nursing responsibilities, they form a meaningful framework from which to direct the course of patient care. Developing such integrated standards became the mission of a small group of nurse administrators, of which the authors were a member. The group first reviewed the pertinent literature and regulatory requirements regarding standards and then brainstormed about desired client outcomes. The standards of psychiatric mental health nursing, created by the American Nurses’ Association (1982),were integrated in order to insure fulfillment of professional responsibilities. The goal was to develop standards that would form the basis for job descriptions, performance appraisals, peer review, and quality improvement activities. Another target goal was to get these standards to correlate with nursing role functions and the nursing process. Linking these concepts was accomplished through the development of a functional matrix model, which also served as a framework for evaluating nursing care activities.
Defining Standards of Practice, Care, and Performance In order to formulate the functional matrix model it was necessary to define and distinguished among the following kinds of standards:
. .
Perspectivesin Psychiatric Care Vol. 28, No. 3, July-Sept,1992
Standards of practice: what the nursing staff must do to provide patient care Standards of cure: what patients can expect to receive from nursing staff Standards of performance: how nursing staff must perform to meet expectations established in the standards of care (Patterson, Kranz, & Brandt, 1986). 27
~
~
Correlating Nursing Care, Nursing Practice, and Nursing Performance Standards
These definitions provided the horizontal axis of the matrix in this model (Table 1). The second step was to translate these descriptions of standards into practical guidelines for nursing care. Role theory and the nursing process provided a context from which to carry out ths phase. Nurses function in multiple roles during their course of care with patients, including: clinical, administrative, research, education, and consultation (Stuart & Sundeen, 1987). These roles, or nursing functions, formed the vertical axis of the matrix of the model (Table 1).
The resulting functional matrix includes a general standard, which is an adaptation of the ANA psychiatric/mental health nursing practice standards (1982). Table 2 outlines the expected standard of practice, care, and performance, and the subsequent rationale.
A Framework for Job Descriptions and Performance Appraisals The standards of performance section of the horizontal axis form the basis of job description and performance
Table 1. Matrix Model for Correlating Standards
Nursing Roles
Standard of Practice
Standard of Care
Standard of Performance Probationary Nurse
Staff Nurse
Psychiatric Nurse
1. Clinical
a) Assessment b) Manning
c) Implementation d) Evaluation
2. Administration
3. Education
4. Research
5. Consultation
28
Perspectivesin Psychiatric Care Vol. 28, No. 3, July-Sept,1992
appraisal responsibhties for the psychiatric nurse (Table 3). The standards are thus utilized a s a link between abstract concepts and the real day-to-day world of practice. In the authors’ setting, the nurse signs a position description and reviews the content during the annual competency evaluation. The nurse receives supervisory feedback around performance relative to standards, and areas of deficit are addressed through learning plans. Expectations for all levels of nurses are thus defined consistently through the modalities of nursing standards, nursing process, job descriptions, and performance evaluations. At the same time, the standards of performance are designed on a continuum to include all levels of nursing staff in existing roles. Since this method provides a consistent framework for all levels of nurses, the chance for discrepancies in nursing care and for expectations of performance is lessened. For example, if a nurse is in the administrative tract, such as an Assistant Nurse Clinical
Manager, the standards remain applicable with a more detailed emphasis in the particular area of concentration. Quality management. Since the standards of practice and care are used as a basis for reviewing the nursing care administered to clients, the functional matrix model facilitates quality management improvement monitoring and evaluation. Documentation is guided by policy and procedures grounded in the standards of practice, care, and performance. In this way, as well as through direct observation, nursing practice can be reviewed by colleagues or the nurse manager. Peer review. The standards also serve as the foundation for the peer review process-that is, nursing practice relative to the standards, as seen through the discerning eye of one’s nurse colleagues, can be assessed. A selected nurse reviews key components of each standard, and the nursing role, in order to share observations with her/lus colleague, in the process of peer review (Table 4).
Table 2. Standards and Rationale Clinical (Assessment)
Clinical (Administration)
Standard of Practice
Standard of Practice
The professional nurse must systematically and continuously collect and assess data in collaboration with the multidisciplinary team to provide therapeutic care for the patient.
The professional nurse is actively involved in the clinical management, coordination, and evaluationof individual patient care, patient groups, and the therapeuticmilieu. This adminis tration process is monitored through peer review, clinical supervision, consultation, and other quality improvement procedures.
Standard of Care The patient participates in assessing strengths and needs on an ongoing basis.
Standard of Care
Standard of Performance
The patient merits a skillfully structured and monitored program of nursing care.
The nurse assesses each patient utilizing the nursing process from admission through discharge.
Standard of Performance
Rationale
The nurse utilizes clinical administrative skills in assuring quality nursing care with the individual patient, patient groups and within the therapeutic milieu.
Assessment is a nurse-patient participatory process that continues through all phases of nursing/patient care. It consists of an accurateand comprehensivecollection of pertinent information, including admission procedures, nursing assessment tool, patient orientation to the unit, and ongoing monitoring of patient status.
Perspectivesin Psychiatric Care Vol. 28, No. 3, July-Sept.,1992
Rationale Psychiatric mental health nursing involves the utilization of clinical administrativeskills to ensures our providing patients with excellent nursing care..
29
Correlating Nursing Care, Nursing Practice, and Nursing Performance Standards
Table 3. Standards for Job Description and Performance Appraisal I. Clinical Assessment Standards of Practice
Standards of Care
Standards of Performance
The Nurse:
The Patient (or significant other):
Psychiatric Nurse:
1. Completes the nursing admission procedure within 8 hrs of admission: a. Greets the patient. b. Assesses patient's tolerance for admission procedures. c. Gathers information as outlined on assessment form. d. Orients patient and sigruhcant others to hospital environment; assists in adjustment.
1. Participates in the admission process: a. Is introduced to the hospital, treatment, and staff in a courteous, dignified, and respective manner. b. Participatesin the admission procedure to the best of his/her ability. c. Obtains specific information about the milieu.
1. Utilizes the requisite policy and procedure for completing the initial admission process: a. Communicates with the patient at the patienfs level of understanding. b. Evaluates current status of the patient, prioritizes immediate needs, and utilizes information for patient care plan for long-term planning. c. Involves the patient in the mutual-sharing process; interprets this information for the patient in logical manner; anticipates the patienfs concerns and questions.
2. Obtains information to develop a holistic picture of the patient from which the therapeutic process evolves.
2. Participates in giving relevant information that contributes to the development of a holistic picture.
2. Synthesizes the pertinent patient information in order to discuss immediate and long-range goals of the treatment plan.
3. Assesses information systematically and objectively on a regular basis according to the categories of the treatment plan.
3. Meets regularly with the primary/ associate nurse to provide and receive feedback.
3. Utilizes past experience and theoretical knowledge to report subtle verbal and nonverbal behaviors.
4. Communicatesassessment data to the assigned treatment team members through multidisciplinary team meetings, shift reports, case conferences, patient rounds, progress notes.
4. Understands that vital assessment information is communicated to all pertinent staff.
4. Develops a collegd role in patient information-sharingmeetings and provides assessment recommendations for changes in the treatment plan.
5. Conducts assessments of the patient's
5. Participates in assessment of learning needs.
5. Discriminatespatient's learning needs according to willingness to learn.
6. Conducts assessment information to the treatment team to begin the discharge planning.
6. Understands preliminary discharge plans based upon assessment.
6. Formulates issues from assessment informationrelevant to adequate discharge planning. Summarizes information to the treatment team.
7. Documents accurate and complete assessment information in the medical record.
7. Merits a medical record that reflects accurate, continuous and complete assessment information.
7. Documents factual, organized assessment information utilizing accurate terminology.
learning needs.
30
Perspectives in Psychiatric Care Vol. 28, No. 3, July-Sept,1992
summary This model of standards offers a framework from which nursing care activities revolve, creating a balanced wheel of interrelated concepts. Each concept defines expectations for daily nursing actions, performance responsibilities, and role aspirations. This model is made available to nursing staff during orientation.The concepts form a progressive wheel of efficient, correlated parts; each adds value to the other. The resulting sum provides the needed balance between burdensome paperwork and relevant resources for day-today practice.
Acknowledgement. The authors would like to thank Carole Taylor, RN, MSN, and Margaret Lunn, RN, MPH, for their participation in the early stages of the project. References American Nurses Association (1982). Standards of psychiatric and mental health nursing practice. Kansas City, M O Author.
Pattason, C., Kranz, D., & Brandt, B. (1986).A gulde to ICAH nulsiny .ruice standards. Chicago:Joint Commission on Accreditation of Hospitals.
Stuart,G., & Sundeen, S. (1987). Principles and practice of psychiatric nursing. St. Louis: Mosby.
Table 4. Peer Review Tool Observations
Suggestions
Assessment: Plan: Intervention: Evaluation:
Patient Focused Nursing Implementation: Professional Communication and Reporting Skills: Administrative: Education:
Consultation: Research
Pempectivesin Psychiatric Care Vol. 28, NO.3, Juiy-Sept,1992
31
