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RAJKUMARI AMRIT KAUR COLLEGE OF NURSING, NEW DELHI
Subject: Advanced Nursing Practice Ms. Sunita Thakur
Topic: Standards in General M.N. Final
INTRODUCTION
Standards are an important part of health care and have taken a new prominence in the trend to
address quality of care issues. Standards are important because they are the vehicle by which the
organization translates quality into operational terms and they also allow the organization to
measure its level of quality. Development of standards is a necessary precondition to improve
and sustain quality nursing care. A standard serves to establish norms and states what level of
performance is required to obtain a specific desired outcome. Standards provide protection to the
public by having criteria against which products and the performance of the practitioners can be
assessed. Standards of practice help identify the actual competencies required by the nurses in
routine normal practice. Standards influence the efficiency and effectiveness of performance,
enhance the accountability and ability to assess the performance and improve patient outcome
and satisfaction. Standards should be based on available infrastructure, resources, economic and
social conditions.
MEANING OF STANDARD
The dictionary meaning of standard is: standard is the level of quality or achievement. Another
meaning of standard is, required or agreed level of achievement.
Standard is a measure to serve as a basis of comparison.
In the word STANDARD each letter stands for:
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.
DEFINITION OF STANDARD
A definition by WHO “Standard is a benchmark of achievement which is based on a desired
level of excellence.
Definition by Gillies, D.A. Standard can be defined as a descriptive statement of desired level of
performance against which the quality of structure, process or outcome can be judged.
“A standard is the desirable and achievable level of performance against which actual practice is
compared”.
A standard is an authoritative statement that sets out the legal and professional basis for nursing
practice.
A standard is a model of established practice that is commonly accepted as correct.
DEFINITION OF NURSING STANDARD
Nursing care standard is a descriptive statement of desired quality against which to evaluate
nursing care given to a patient or group of patients.
Nursing standards can be defined as statements that describe the desirable and achievable level
of performance expected of registered nurses in their practice, against which actual performance
can be measured, and serve as a guide to the professional knowledge, skills, and judgment
needed to practice nursing safely. The primary reason for having standards is to promote, guide,
direct and regulate professional nursing practice.
Nursing practice standards are the established criteria for the practice of nursing. A nursing care
standard is a descriptive statement of desired quality against which to evaluate nursing practice.
It is a guideline. A guideline is a recommended path to safe conduct and aid to professional
performance.
PURPOSE OF STANDARDS
The purposes of standards are:
1. To evaluate the quality of nursing practice in any setting.
2. To compare and improve the existing nursing practice.
3. To provide a common base for practitioners to coordinate and unify their efforts in the
improvement or practice.
4. To identify the element of independent function of nursing practices.
5. To provide a basis for planning and evaluating educational program for practitioners.
6. To inform society of our concern for the improvement of nursing practice.
7. To assist the public in understanding what to expect of nursing practice.
8. To assist the employers to understand what to expect of the practitioners.
9. To identify areas for developing core curriculum for practicing nurses.
10. To provide legal protection for nurses.
CHARACTERISTICS OF STANDARDS
The characteristics of standards are:
a. Objective, acceptable, achievable and flexible.
b. Must be framed by the members of the nursing profession.
c. Should be phrased in positive terms like good, excellent, etc.
d. Must be understandable and unambiguous.
e. Must be based on current knowledge and scientific practice.
f. Must be reviewed and revised periodically.
BENEFITS OF NURSING STANDARDS
Standards
 Provide an essential key to organization development.
 Provide legislation for controlling quality.
 Provide means for systematic nursing care.
 Promote better understanding among patient, nursing personnel and other health care
professionals.
 Help in delivering quality patient care.
 Enable achievement of better cost-effectiveness in delivery of care.
 Pave a Code of Practice which establishes good practice in all field
CLASSIFICATION OF STANDARDS
Standards can be classified and formulated into different types of standards used to direct control
nursing actions:
According to the frames of references: These standards are used to direct and control nursing
practice.
A. STRUCTURE STANDARD
B. PROCESS STANDARD
C. OUT COME STANDARD
A. STRUCTURE STANDARD: The structure is related to the frame work that is care
providing system and resources that support for actual provision of care. They include
physical facilities, policies, goals, objectives, number of staff, type of training,
equipment, supplies, administrative set up, budgeting.
The use of standard based on structure implies that if the structure is adequate, reliable
and desirable standard will be met for 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 which are in
observable and measurable terms e.g.,
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 between nurse and client.
In process standard, there is an element of professional judgment, i.e., determining the
quality or the degree of skill. It includes nursing care techniques, procedures, regimens,
process and recording etc.
C. OUT COME STANDARD: Descriptive statement of desired patient care results are
outcome standards because patient’s results are outcome of nursing interventions. Here,
outcome as a frame of reference for setting of standard refers to description of the results
of nursing activity in terms of the change that occur 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. These are related to patient health status, self care ability,
morbidity and mortality status, occurrence of complication, restoration of functions and
change in practices of health personnel.
Second classification of standards may be Normative and Empirical Standards.
 NORMATIVE STANDARDS: These standards are descriptive of practices, which are
considered ideal by authority. These standards describe highest quality of practices. For
example, standards set by professional bodies e.g. set standards for the recruitment of
nurses working in any setting.
 EMPIRICAL STANDARDS: These standards are description of practices which are
actual practice in large number of settings and which are agreed upon and achievable. For
example, standards set by law enforcement bodies and regulatory bodies.
The normative standards describe a higher quality of performance than empirical standards.
Generally professional organization ANA, TNAI promulgate normative standards where as
regulatory bodies INC, MCI promulgate empirical standards.
Standards can also be divided into End and Means Standards
 END STANDARDS: These are patient oriented; they describe the change as desired in a
patient’s physical status or behavior.
 MEANS STANDARDS: These are nursing oriented; they describe the activities and
behavior to achieve ends standards.
PROCESS OF SETTING STANDARDS
The major components of setting standards are:
1. COLLECTIVE JUDGMENT
2. VALUE BASED
3. DYNAMIC VS. STATIC
1. COLLECTIVE JUDGMENT: In health care, standards are developed and maintained
based on collective judgments. These include both organization and management and
standards for clinical/professional practice. The professional groups involved in the
delivery of health care must be the major determinants of their own professional practice
standards. Since hospitals are comprised of many professionals working together to
deliver patient care, it stands to reason that these professional should plays a major role in
determining the standards for organization, management and delivery of care with in the
hospital.
2. VALUE BASED ASSESSMENT: Standards are set to reflect value. In forming the
standards:
Care must be taken both to ascertain the individuals and society’s values which should
underlying them and then to reflect these values in the standards themselves.
Standards should be based on the responsibility to achieve maximum effectiveness of
area of service delivery through appropriate and efficient use of resources.
3. DYNAMIC VS. STATIC : In the mind of many, standards are seen to be something
which once they are set, is carved in stone. Yet, the contrary is actually true. Standards
are in fact, dynamic in nature and should change to reflect change in the collective
judgment about something or about values placed on it. Within health care, standards
may change due to change in technology, professional practice, economic conditions,
consumer expectations, treatment modalities and life expectations. Thus, after standards
are set, evaluation for their relevance and applicability must commence. If these are not
satisfactory, the standards must be revised, and the process of evaluation begins again.
STEPS OF STANDARD FORMULATION
The steps of standard formulation can be formulated as follows:
 Organize in to small groups of nurses who work in the same field and meet periodically.
 Decide on the area of nursing for which you want to work out standards.
 Review philosophy, purpose and objectives of the institution.
 Review existing nursing care practices, nursing process and identify your client for
nursing service, client’s role and strategies for nursing care services.
 Write the statement considering all the frame of reference giving rationale and criteria in
assessment indicators see that the standards are relevant.
 Discuss them with nursing service administrators to get their approval.
 Device a method for determining achievement of standards. It may be through the use of
criteria checklist for making observation of care given, examining records, self evaluation
checklist, patient’s opinion etc.
 Try out the standards to determine the feasibility.
 The standards are put into practice and quality care is audited.
 Update the standards periodically.
LEVELS OF NURSING STANDARDS
MINIMUM STANDARDS: Representing a level of acceptability below which, in the eyes of
those judging, lies the unacceptable, are the minimum standards.
OPTIMUM STANDARDS: Representing a degree of excellence which may only be achieved by
those who desired and determined to do so.
For example, in a hospital the minimum standard for nosocomial infection may be 7-10 per cent.
Anything above 10 per cent is unacceptable whereas the desired is 3 per cent.
SOURCES OF NURSING CARE STANDARDS
The standards should be based on agreed up achievable level of performance considered proper
and adequate for specific purpose. The standards can be established, developed, reviewed or
enforce by variety of sources as follows:
 Professional organization e.g. T.N.A.I., A.N.A. etc.
 Licensing body’s e.g. statutory bodies like INC, MCI, etc.
 Health institutions / health care agencies.
 Department of institutions e.g. nursing department.
 Patient care units, e.g. I.C.U.
 Government health department at national, state and local level.
 Individual’s e.g. personal standards.
FOCUS OF STANDARDS
Most of the health care standards existing today focus on two aspects.
Organization and Management Standards of Health Care
Clinical Practice Standards
a. ORGANIZATION AND MANAGEMENT STANDARDS: This standard tends to address
the ability of the health care facility to deliver quality care or service.
b. CLINICAL PRACTICE STANDARDS: This standard describes the precise nature of what
should be delivered. Practice standards are formulated by individual professional groups
who work within health care facilities and generally are used to guide those professionals
in ideal way to carry out patient care responsibilities given certain sets of circumstances
and patient diagnosis.
USES OF STANDARDS
Within health care setting, the standards are used in evaluation process:
A. Self Assessment
B. Inspection
C. Accreditation
A. SELF ASSESSMENT: Self assessment implies to be the evaluation of one’s own
performance. In this process, standards may be set by oneself or in collaboration with an
outside agent and then one evaluates how were the standards met or not met. It can be
tremendously valuable in learning experience, especially if there is commitment to
analyzing honestly the strength as well as weakness in performance.
B. INSPECTION: The second evaluation activity which may involve standards is the
inspection. Inspection usually implies some sort of official examination. With in health
care we generally think of inspections as being done by government agents. Those who
inspect most often have a conferred power to do so, which is generally derived from
some form of legislation. These inspections should also have concomitant power to
impose penalty in case of lack of compliance with standards. Inspection is generally not
voluntary and certainly is often fraught with negative connotations in the eyes of those
being inspected. Experience shows us that the standards that are used in the inspection
process may frequently not be determined in consultation with those who will be judged
against them. Care must be taken, that standards should be made jointly. It should be a
joint process.
C. ACCREDITATION: The meaning of accreditation is a process where in standards are set
and compliance with them is measured. The setting of the standards is done through a
consultative process in which consensus among those who will use them is sought
regarding the appropriate level of standards and how compliance with standards will be
judged. Standards are subjected to periodic and ongoing review to ensure their continued
appropriateness. The accreditation process also involve periodic visit from an accreditor
or an accreditation team, which comprise of trained and selected peers who will visit a
facility and determine level of compliance with standards. They may also provide advice
if required and usually visit in three years.
BARRIER AND CONSTRAINTS IN DEVELOPMENT OF STANDARDS FOR
NURSING PRACTICE
I. Related To Policies:
Absence of laid down standards for nursing practice.
Lack of written policies.
Lack of clear cut specific job descriptions.
Lack of political and professional will and support to improve standards.
Absence of policy for having nurses with specialty training to work in specialty care units.
I. Related To Manpower:
Inadequate nurse-patient ratio
Lack of awareness of the concept of standards, sensitivity to the need of standards in nursing
practice.
Lack of supervision and monitoring of nursing services.
Inadequate job descriptions.
Lack of adequately prepared nurse administrators for planning and organizing the nursing
services.
Lack of strategies for regular updating of knowledge and skills.
II. Related To Material Resources:
Lack of equipment and supplies to provide even basic nursing care.
Low quality equipment and supplies.
Lack of training in handling various equipments and resources.
Lack of maintenance and replacement of damaged or condemned equipments.
III. Related To Physical Set Up:
Inappropriate and inadequate physical set up of the hospital.
Shortage of water and electricity supplies, inappropriate drainage and waste disposal facilities.
IV. Related To Finance:
Uncertainty for commitment of adequate financial support for development and implementation
of standards for nursing practice at various levels.
REVIEW OF STANDARDS
It is very necessary to review the standards time to time for:
To remove obsolete and unnecessary practices.
To practice according to the new scientific and technological developments.
For patient safety.
LEGAL SIGNIFICANCE OF STANDARDS
Standards of care are very important. 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 from a charge of malpractice, a patient must prove that:
A nurse patient relationship existed such that the nurse owed to the patient a duty of due care.
The nurse deviated from the appropriate standards of care.
The patient’s damages resulted from the nurses deviations from the standard of care.
ROLE OF NURSE ADMINISTRATORS IN DEVELOPING STANDARDS
The expert committee of the WHO project in India which was conducted in RAKCON, in 1999,
on development of standards for nursing practice had discussed the role of nurse administrators
in developing standards for nursing practice.
The role of nurse administrators in developing nursing practice standards are:
 Initiator: Creates awareness or sensitizes the nurses at first and second level leadership
positions on nursing standards.
 Facilitator: She facilitates to develop, implement, monitor and evaluate standards for
nursing practice at all times. Make provision for necessary infrastructure for developing,
implementing, maintenance, monitoring of standards for nursing practice.
Forms a core group for developing, implementing, monitoring and maintaining standards
for nursing practice.
Assures on the job-orientation and in-service education to enhance implementation and
monitoring of standards for nursing practice.
Ensures auditing and reviewing of standards for nursing practice.
 Educator: She as an educator
Gives orientation to nursing personnel regarding the need for standards of nursing
practice.
Stimulates and motivates the nurses to implement and maintain standards of nursing
practice.
Trains core group to develop, implement, monitor, maintain and evaluate the standards
for nursing practice.
 Evaluator: She as an evaluator
Monitors the implementation of standards for nursing practice.
Evaluates the auditing and reviewing process for updating standards of nursing practice.
CONCLUSION
All health care providers will be required to identify standards and show how their own input is
related to achievement of the standards. Nurses will find it necessary to set realistic standards of
nursing care and utilize effective quality control and evaluation methods to ensure that the
standards are achieved and if not, show that appropriate action was taken to change the standard
or change the care to achieve it.
RESEARCH ARTICLES
Westra, B.L. et al. “Nursing Standards to Support the Electronic health record”. Nursing
Outlook. September-October, 2008. 56 (5). Page No. 258-265.
Quality and low cost health care that is free of medical mistakes requires continuity of person-
centric health care information across the life span and health care settings. Interoperable clinical
information systems that rely on the use of multiple standards to support health information
exchange and, in particular, nurse sensitive data, information, and knowledge are key
components to support high quality, safe care. A 2004 Executive order called for a national
health information network and the widespread adaptation of electronic health records (EHRs)
by 2014. While there are numerous standards influencing the exchange of health data, the
primary focus of this article is to synthesize the state-of-the-art in nursing standardized
terminologies to support the development, exchange, and communication of nursing data.
Research exemplars are described for information systems to supports nursing practice using
standardized terminologies and secondary use of standardized nursing data from EHRs for
knowledge development.
Little, B.B. “The use of standards for peer review of online nursing courses: a pilot study”.
Journal of Nursing Education. July, 2009. 48 (7). Page No. 411-415.
This article describes a pilot study on the use of online course standards for peer review of Web-
based nursing courses. A peer review team consisting of a nurse educator and an instructional
designer piloted the use of two sets of online course standards in two RN-to-baccalaureate
nursing course. The college of public health online course standards and the quality matters peer
course review Rubric were used to review the courses. The standards facilitated the peer review
process and supplied important criteria for measuring the quality of the courses. Analysis of the
Rubric scores revealed trends in criteria not met in either course, indicating the need for
educational program improvement and faculty training. The quality matters tool had more
consistent results among peer reviewers and was perceived as easier to use. So the quality
matters standards provided a useful mechanism for benchmarking against higher education
courses throughout the United States.
Miola, J. “Negligence and the legal standard of care: what is reasonable conduct”?. British
Journal of Nursing. June, 2009. 18 ( 12). Page No. 756-757.
Medical negligence has become a big issue for medical Practioners. Fear of the law, and of
litigation, has led to clams of defensive medical practice among doctors and nurses. At the heart
of this lies the legal definition of the standard of care, where the law seeks to determine when
conduct is ‘reasonable’ or ‘unreasonable’. In this article the author clarifies what the law means
by ‘reasonableness’ with respect to nurses, drawing on both the law and the NMC Code.
Furthermore, the article shall demonstrate that the law is not something to be fearful of but,
rather, demands a standard no higher than that of the NMC.
BIBLIOGRAPHY
Nicholls M.E. and Wessells V.G. Nursing standards and Nursing Process. U.S.A. 1977.
Contemporary Publishing, Inc. Wakefield, Massachusetts.
Jernigan, D.K. and Young, A.P. Standards, Job Descriptions, and Performance Evaluations for
Nursing Practice. USA. 1983. Appleton-Century-Crofts. Page No. 9-27.
Basavanthappa, B.T. Nursing Administration, 1st Edition, New Delhi. 2008. Jaypee Brothers
Medical Publishers Private Limited. Page No. 432-449.
RAK College of Nursing. Report on Development of Standards for Nursing Practice. New
Delhi.1999. Ministry of Health and Family Welfare.
Sansburg, R.C. and Swansburg, R.J. Introduction to management and leadership for nurse
managers, Canada, 2002, Jones and Bartlett Publishers, Page No. 520-522.
Gillis, D.A. Nursing management a Systems Approach. U.S.A. 1982. W.B. Saunders company,
1982. Page No. 97-107.
Heidemann, E.G. The Contemporary Use of Standards in Health Care. Geneva.1993. W.H.O.
Page No. 1-30.
Little, B.B. “The use of standards for peer review of online nursing courses: a pilot study”.
Journal of Nursing Education, July, 2009. 48 ( 7 ). Page No. 411-415.
Miola, J. “Negligence and the legal standard of care: what is reasonable conduct”?. British
Journal of Nursing. June, 2009. 18 ( 12). Page No. 756-757.
Westra, B.L. et al. “Nursing Standards to Support the Electronic health record”. Nursing
Outlook. September-October, 2008. 56 (5). Page No. 258-265.
Soni, M. “A study to assess the knowledge and practice of nursing personnel on standards of
nursing practice for selected nursing activities (Thermoregulation and orogastric feeding) with a
view to develop and evaluate the effectiveness of manual on standards of nursing practice in
neonatal care unit for these selected nursing activities in selected hospitals of Delhi”
Unpublished Master of Nursing Thesis, R.A.K. College of Nursing, University of Delhi, May
1999.
www.google.com
www.yahoo.com
www.pubmed.com
EXAMPLE
Standards for nursing practice
Standard Ref. No. - 1
Topic : Basic Nursing care
Subtopic : Eat and drink adequately
Care Group : Hospitalized patients
Unit/Ward : Orthopedic ward
Standard Statements : All Hospitalized patients will receive adequate fluid and nutrition
Prepared By : Professional Organizations
Standard implemented by : Nursing personnel
Standard Audited By : NS/DNS
Standard reviewed By : Committee
STRUCTURE GUIDELINES
The structure guidelines for helping patients eat and drink adequately are:
a. Assess fluids nutritional needs of patient.
b. Evaluate patient’s environment:
 Need for privacy
c. Assess patients readiness to eat
 Need for oral care
 General hygienic needs
 Elimination needs
d. Assess patients ability to eat or need for assistance to take food.
e. Assist with oral hygiene and washing hands.
f. Provide water, soap, and towel for patients hand and face, if needed.
g. Serve prescribed diet.
h. Encourage patient to do as much as possible for self.
i. Remove tray when patient has finished meals.
j. Record amount and type of food consumed.
k. Record intake in intake/output chart.
l. Record any untoward response to diet.
m. Educate patient/relative regarding prescribed diet.
STRUCTURE PROCESS OUTCOME
S1. Nurse with adequate
knowledge on fluid and
nutritional needs of patients.
P1. Nurse assesses fluid and
nutritional needs of patients.
O1. Patient take adequate
amount and type of food and
fluid.
S2. Nurse possess adequate
skill in meeting fluid and
nutritional needs of patients.
P2. Nurse identifies and set priority
in meeting fluid and nutritional
needs.
O2. Patient does not have
any untoward response after
eating.
S3. Devices for serving food
and assisting in eating/feeding
are available in the unit.
P3. Nurse explains the importance of
eating appropriate diet to patient /
family.
O3. Patient express
satisfaction with the food.
S4. Diet as per nutritional
needs of the patient is available
from hospital/home.
P4. Prescribed diet is arranged and
served appropriately.
O4. Patient / relatives
describe appropriate diet
required for him / her.
S5. Diet charts for different
disease condition are available
in the unit or therapeutic diet
charts are available.
P5. Nurse documents quantity of
fluid and food intake.
O5. Amount and type of
fluid and food intake and
any untoward response if
any is recorded correctly.
S6. Structure guideline is
available in the unit.
P6. Any untoward response such as
dislike, nausea, vomiting, gastric
discomfort or diet is documented
and reported by the nurse.
P7. Nurse takes remedial action for
any untoward response.
CHECKLIST ON MEETING FLUID AND NUTRITIONAL NEEDS OF PATIENT
Objective: To assess skill of nurses in meeting fluid and nutritional needs of patient.
S.No
.
Activities Yes No
1. Nutritional need assessed.
2. Identified and prioritized the nutritional need.
3. Explained the need of well balanced diet/diet as prescribed for
specific disease condition.
4. Well balanced diet/prescribed diet provided.
5. Remedial action taken for untoward response if any.
6. Amount of food and fluid intake recorded.
7. Documented and reported any untoward response to diet.
AUDIT FORM
Audit objective: Do all hospitalized patients will receive adequate fluid and nutrition.
TARGET METHOD CODE
NO.
AUDIT CRITERIA YES/NO
Nurse Ask S1 Does the nurse have required level of
knowledge to assess nutritional status of
the patients?
Nurse Ask and
Observe
S2 Does the nurse have the skill to assess
nutritional needs?
Ward Ask and
Observe
S3 Are proper devices available for serving
and eating food?
Ward Observe S4 Is diet available as per the nutritional
need from hospital/home?
Ward Ask and
Observe
S5 Are diet charts for different conditions
available?
Ward Observe S6 Is structured guideline available?
Nurse Observe P1 Dose nurses assess nutritional needs of
patients?
Nurse Ask and
Observe
P2 Does nurse prioritize dietary needs?
Patient Ask P3, O4 Does the patient/relative understand the
need of well balanced diet/prescribed
diet?
Patient Observe and
Ask
P4 Does patient receive the prescribed diet
in clean utensils as per meal schedule?
Nurse Check record P5,O5 Dose nurse record the food and fluid
intake?
Nurse Check record P6,O5 Are untoward responses recorded by
nurse?
Patient Observe and
Ask
O1 Does patient take adequate and
appropriate nutrition?
Patient Observe and
Ask
O2 Does patient experience any discomfort
after eating?
Patient Observe and
Ask
O3 Does patient express satisfaction with
the food?
PATIENT SATISFACTION DATA
INSTRUCTIONS:
Please tick mark ( ) against each of the following items in the column provided.
Satisfied : If the patient is completely satisfied with the nursing care and has no complaints, or
problems then give three score.
Partially Satisfied : If the patient is fairly satisfied with the nursing care and has some complaints
give score two.
Not satisfied : If the patient is not satisfied with nursing care and has number of complaints give
score one.
S.
No.
Statements Satisfied
(3)
Partially
(2) Satisfied
(1) Not
Satisfied
1. Did the nurse assess and prioritize nutritional
needs?
2. Did diet available as per the nutritional needs?
3. Did you receive your food as per diet schedule?
4. Did the nurse provided proper clean utensils for
the serving and eating food?
5. Did your food was adequate and appropriate
according to your nutritional needs?
6. Did you satisfy with your food?
7. Did the nurse record food and fluid intake and
untoward response of food?
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Indraprashtha Apollo
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Confismile Dental Spa
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New Look Laser Clinic
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Cancer Centre Welfare Home and Research institute (Thakur Pukur)
susrut eye foundation
B.M. Birla Heart Institute
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Dr. L.H Hiranandani Hospital
Wockardt Hospital
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Standards in Nursing

  • 1. RAJKUMARI AMRIT KAUR COLLEGE OF NURSING, NEW DELHI Subject: Advanced Nursing Practice Ms. Sunita Thakur Topic: Standards in General M.N. Final INTRODUCTION Standards are an important part of health care and have taken a new prominence in the trend to address quality of care issues. Standards are important because they are the vehicle by which the organization translates quality into operational terms and they also allow the organization to measure its level of quality. Development of standards is a necessary precondition to improve and sustain quality nursing care. A standard serves to establish norms and states what level of performance is required to obtain a specific desired outcome. Standards provide protection to the public by having criteria against which products and the performance of the practitioners can be assessed. Standards of practice help identify the actual competencies required by the nurses in routine normal practice. Standards influence the efficiency and effectiveness of performance, enhance the accountability and ability to assess the performance and improve patient outcome and satisfaction. Standards should be based on available infrastructure, resources, economic and social conditions. MEANING OF STANDARD The dictionary meaning of standard is: standard is the level of quality or achievement. Another meaning of standard is, required or agreed level of achievement. Standard is a measure to serve as a basis of comparison. In the word STANDARD each letter stands for: 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. DEFINITION OF STANDARD A definition by WHO “Standard is a benchmark of achievement which is based on a desired level of excellence. Definition by Gillies, D.A. Standard can be defined as a descriptive statement of desired level of performance against which the quality of structure, process or outcome can be judged. “A standard is the desirable and achievable level of performance against which actual practice is compared”. A standard is an authoritative statement that sets out the legal and professional basis for nursing practice. A standard is a model of established practice that is commonly accepted as correct.
  • 2. DEFINITION OF NURSING STANDARD Nursing care standard is a descriptive statement of desired quality against which to evaluate nursing care given to a patient or group of patients. Nursing standards can be defined as statements that describe the desirable and achievable level of performance expected of registered nurses in their practice, against which actual performance can be measured, and serve as a guide to the professional knowledge, skills, and judgment needed to practice nursing safely. The primary reason for having standards is to promote, guide, direct and regulate professional nursing practice. Nursing practice standards are the established criteria for the practice of nursing. A nursing care standard is a descriptive statement of desired quality against which to evaluate nursing practice. It is a guideline. A guideline is a recommended path to safe conduct and aid to professional performance. PURPOSE OF STANDARDS The purposes of standards are: 1. To evaluate the quality of nursing practice in any setting. 2. To compare and improve the existing nursing practice. 3. To provide a common base for practitioners to coordinate and unify their efforts in the improvement or practice. 4. To identify the element of independent function of nursing practices. 5. To provide a basis for planning and evaluating educational program for practitioners. 6. To inform society of our concern for the improvement of nursing practice. 7. To assist the public in understanding what to expect of nursing practice. 8. To assist the employers to understand what to expect of the practitioners. 9. To identify areas for developing core curriculum for practicing nurses. 10. To provide legal protection for nurses. CHARACTERISTICS OF STANDARDS The characteristics of standards are: a. Objective, acceptable, achievable and flexible. b. Must be framed by the members of the nursing profession. c. Should be phrased in positive terms like good, excellent, etc. d. Must be understandable and unambiguous. e. Must be based on current knowledge and scientific practice. f. Must be reviewed and revised periodically. BENEFITS OF NURSING STANDARDS Standards  Provide an essential key to organization development.  Provide legislation for controlling quality.  Provide means for systematic nursing care.  Promote better understanding among patient, nursing personnel and other health care professionals.  Help in delivering quality patient care.  Enable achievement of better cost-effectiveness in delivery of care.
  • 3.  Pave a Code of Practice which establishes good practice in all field CLASSIFICATION OF STANDARDS Standards can be classified and formulated into different types of standards used to direct control nursing actions: According to the frames of references: These standards are used to direct and control nursing practice. A. STRUCTURE STANDARD B. PROCESS STANDARD C. OUT COME STANDARD A. STRUCTURE STANDARD: The structure is related to the frame work that is care providing system and resources that support for actual provision of care. They include physical facilities, policies, goals, objectives, number of staff, type of training, equipment, supplies, administrative set up, budgeting. The use of standard based on structure implies that if the structure is adequate, reliable and desirable standard will be met for 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 which are in observable and measurable terms e.g., 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 between nurse and client. In process standard, there is an element of professional judgment, i.e., determining the quality or the degree of skill. It includes nursing care techniques, procedures, regimens, process and recording etc. C. OUT COME STANDARD: Descriptive statement of desired patient care results are outcome standards because patient’s results are outcome of nursing interventions. Here, outcome as a frame of reference for setting of standard refers to description of the results of nursing activity in terms of the change that occur 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. These are related to patient health status, self care ability, morbidity and mortality status, occurrence of complication, restoration of functions and change in practices of health personnel. Second classification of standards may be Normative and Empirical Standards.  NORMATIVE STANDARDS: These standards are descriptive of practices, which are considered ideal by authority. These standards describe highest quality of practices. For example, standards set by professional bodies e.g. set standards for the recruitment of nurses working in any setting.
  • 4.  EMPIRICAL STANDARDS: These standards are description of practices which are actual practice in large number of settings and which are agreed upon and achievable. For example, standards set by law enforcement bodies and regulatory bodies. The normative standards describe a higher quality of performance than empirical standards. Generally professional organization ANA, TNAI promulgate normative standards where as regulatory bodies INC, MCI promulgate empirical standards. Standards can also be divided into End and Means Standards  END STANDARDS: These are patient oriented; they describe the change as desired in a patient’s physical status or behavior.  MEANS STANDARDS: These are nursing oriented; they describe the activities and behavior to achieve ends standards. PROCESS OF SETTING STANDARDS The major components of setting standards are: 1. COLLECTIVE JUDGMENT 2. VALUE BASED 3. DYNAMIC VS. STATIC 1. COLLECTIVE JUDGMENT: In health care, standards are developed and maintained based on collective judgments. These include both organization and management and standards for clinical/professional practice. The professional groups involved in the delivery of health care must be the major determinants of their own professional practice standards. Since hospitals are comprised of many professionals working together to deliver patient care, it stands to reason that these professional should plays a major role in determining the standards for organization, management and delivery of care with in the hospital. 2. VALUE BASED ASSESSMENT: Standards are set to reflect value. In forming the standards: Care must be taken both to ascertain the individuals and society’s values which should underlying them and then to reflect these values in the standards themselves. Standards should be based on the responsibility to achieve maximum effectiveness of area of service delivery through appropriate and efficient use of resources. 3. DYNAMIC VS. STATIC : In the mind of many, standards are seen to be something which once they are set, is carved in stone. Yet, the contrary is actually true. Standards are in fact, dynamic in nature and should change to reflect change in the collective judgment about something or about values placed on it. Within health care, standards may change due to change in technology, professional practice, economic conditions, consumer expectations, treatment modalities and life expectations. Thus, after standards are set, evaluation for their relevance and applicability must commence. If these are not satisfactory, the standards must be revised, and the process of evaluation begins again. STEPS OF STANDARD FORMULATION The steps of standard formulation can be formulated as follows:  Organize in to small groups of nurses who work in the same field and meet periodically.
  • 5.  Decide on the area of nursing for which you want to work out standards.  Review philosophy, purpose and objectives of the institution.  Review existing nursing care practices, nursing process and identify your client for nursing service, client’s role and strategies for nursing care services.  Write the statement considering all the frame of reference giving rationale and criteria in assessment indicators see that the standards are relevant.  Discuss them with nursing service administrators to get their approval.  Device a method for determining achievement of standards. It may be through the use of criteria checklist for making observation of care given, examining records, self evaluation checklist, patient’s opinion etc.  Try out the standards to determine the feasibility.  The standards are put into practice and quality care is audited.  Update the standards periodically. LEVELS OF NURSING STANDARDS MINIMUM STANDARDS: Representing a level of acceptability below which, in the eyes of those judging, lies the unacceptable, are the minimum standards. OPTIMUM STANDARDS: Representing a degree of excellence which may only be achieved by those who desired and determined to do so. For example, in a hospital the minimum standard for nosocomial infection may be 7-10 per cent. Anything above 10 per cent is unacceptable whereas the desired is 3 per cent. SOURCES OF NURSING CARE STANDARDS The standards should be based on agreed up achievable level of performance considered proper and adequate for specific purpose. The standards can be established, developed, reviewed or enforce by variety of sources as follows:  Professional organization e.g. T.N.A.I., A.N.A. etc.  Licensing body’s e.g. statutory bodies like INC, MCI, etc.  Health institutions / health care agencies.  Department of institutions e.g. nursing department.  Patient care units, e.g. I.C.U.  Government health department at national, state and local level.  Individual’s e.g. personal standards. FOCUS OF STANDARDS Most of the health care standards existing today focus on two aspects. Organization and Management Standards of Health Care Clinical Practice Standards a. ORGANIZATION AND MANAGEMENT STANDARDS: This standard tends to address the ability of the health care facility to deliver quality care or service. b. CLINICAL PRACTICE STANDARDS: This standard describes the precise nature of what should be delivered. Practice standards are formulated by individual professional groups who work within health care facilities and generally are used to guide those professionals in ideal way to carry out patient care responsibilities given certain sets of circumstances and patient diagnosis.
  • 6. USES OF STANDARDS Within health care setting, the standards are used in evaluation process: A. Self Assessment B. Inspection C. Accreditation A. SELF ASSESSMENT: Self assessment implies to be the evaluation of one’s own performance. In this process, standards may be set by oneself or in collaboration with an outside agent and then one evaluates how were the standards met or not met. It can be tremendously valuable in learning experience, especially if there is commitment to analyzing honestly the strength as well as weakness in performance. B. INSPECTION: The second evaluation activity which may involve standards is the inspection. Inspection usually implies some sort of official examination. With in health care we generally think of inspections as being done by government agents. Those who inspect most often have a conferred power to do so, which is generally derived from some form of legislation. These inspections should also have concomitant power to impose penalty in case of lack of compliance with standards. Inspection is generally not voluntary and certainly is often fraught with negative connotations in the eyes of those being inspected. Experience shows us that the standards that are used in the inspection process may frequently not be determined in consultation with those who will be judged against them. Care must be taken, that standards should be made jointly. It should be a joint process. C. ACCREDITATION: The meaning of accreditation is a process where in standards are set and compliance with them is measured. The setting of the standards is done through a consultative process in which consensus among those who will use them is sought regarding the appropriate level of standards and how compliance with standards will be judged. Standards are subjected to periodic and ongoing review to ensure their continued appropriateness. The accreditation process also involve periodic visit from an accreditor or an accreditation team, which comprise of trained and selected peers who will visit a facility and determine level of compliance with standards. They may also provide advice if required and usually visit in three years. BARRIER AND CONSTRAINTS IN DEVELOPMENT OF STANDARDS FOR NURSING PRACTICE I. Related To Policies: Absence of laid down standards for nursing practice. Lack of written policies. Lack of clear cut specific job descriptions. Lack of political and professional will and support to improve standards. Absence of policy for having nurses with specialty training to work in specialty care units. I. Related To Manpower: Inadequate nurse-patient ratio Lack of awareness of the concept of standards, sensitivity to the need of standards in nursing practice. Lack of supervision and monitoring of nursing services.
  • 7. Inadequate job descriptions. Lack of adequately prepared nurse administrators for planning and organizing the nursing services. Lack of strategies for regular updating of knowledge and skills. II. Related To Material Resources: Lack of equipment and supplies to provide even basic nursing care. Low quality equipment and supplies. Lack of training in handling various equipments and resources. Lack of maintenance and replacement of damaged or condemned equipments. III. Related To Physical Set Up: Inappropriate and inadequate physical set up of the hospital. Shortage of water and electricity supplies, inappropriate drainage and waste disposal facilities. IV. Related To Finance: Uncertainty for commitment of adequate financial support for development and implementation of standards for nursing practice at various levels. REVIEW OF STANDARDS It is very necessary to review the standards time to time for: To remove obsolete and unnecessary practices. To practice according to the new scientific and technological developments. For patient safety. LEGAL SIGNIFICANCE OF STANDARDS Standards of care are very important. 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 from a charge of malpractice, a patient must prove that: A nurse patient relationship existed such that the nurse owed to the patient a duty of due care. The nurse deviated from the appropriate standards of care. The patient’s damages resulted from the nurses deviations from the standard of care. ROLE OF NURSE ADMINISTRATORS IN DEVELOPING STANDARDS The expert committee of the WHO project in India which was conducted in RAKCON, in 1999, on development of standards for nursing practice had discussed the role of nurse administrators in developing standards for nursing practice. The role of nurse administrators in developing nursing practice standards are:  Initiator: Creates awareness or sensitizes the nurses at first and second level leadership positions on nursing standards.  Facilitator: She facilitates to develop, implement, monitor and evaluate standards for nursing practice at all times. Make provision for necessary infrastructure for developing, implementing, maintenance, monitoring of standards for nursing practice.
  • 8. Forms a core group for developing, implementing, monitoring and maintaining standards for nursing practice. Assures on the job-orientation and in-service education to enhance implementation and monitoring of standards for nursing practice. Ensures auditing and reviewing of standards for nursing practice.  Educator: She as an educator Gives orientation to nursing personnel regarding the need for standards of nursing practice. Stimulates and motivates the nurses to implement and maintain standards of nursing practice. Trains core group to develop, implement, monitor, maintain and evaluate the standards for nursing practice.  Evaluator: She as an evaluator Monitors the implementation of standards for nursing practice. Evaluates the auditing and reviewing process for updating standards of nursing practice. CONCLUSION All health care providers will be required to identify standards and show how their own input is related to achievement of the standards. Nurses will find it necessary to set realistic standards of nursing care and utilize effective quality control and evaluation methods to ensure that the standards are achieved and if not, show that appropriate action was taken to change the standard or change the care to achieve it. RESEARCH ARTICLES Westra, B.L. et al. “Nursing Standards to Support the Electronic health record”. Nursing Outlook. September-October, 2008. 56 (5). Page No. 258-265. Quality and low cost health care that is free of medical mistakes requires continuity of person- centric health care information across the life span and health care settings. Interoperable clinical information systems that rely on the use of multiple standards to support health information exchange and, in particular, nurse sensitive data, information, and knowledge are key components to support high quality, safe care. A 2004 Executive order called for a national health information network and the widespread adaptation of electronic health records (EHRs) by 2014. While there are numerous standards influencing the exchange of health data, the primary focus of this article is to synthesize the state-of-the-art in nursing standardized terminologies to support the development, exchange, and communication of nursing data. Research exemplars are described for information systems to supports nursing practice using standardized terminologies and secondary use of standardized nursing data from EHRs for knowledge development. Little, B.B. “The use of standards for peer review of online nursing courses: a pilot study”. Journal of Nursing Education. July, 2009. 48 (7). Page No. 411-415. This article describes a pilot study on the use of online course standards for peer review of Web- based nursing courses. A peer review team consisting of a nurse educator and an instructional designer piloted the use of two sets of online course standards in two RN-to-baccalaureate nursing course. The college of public health online course standards and the quality matters peer course review Rubric were used to review the courses. The standards facilitated the peer review process and supplied important criteria for measuring the quality of the courses. Analysis of the
  • 9. Rubric scores revealed trends in criteria not met in either course, indicating the need for educational program improvement and faculty training. The quality matters tool had more consistent results among peer reviewers and was perceived as easier to use. So the quality matters standards provided a useful mechanism for benchmarking against higher education courses throughout the United States. Miola, J. “Negligence and the legal standard of care: what is reasonable conduct”?. British Journal of Nursing. June, 2009. 18 ( 12). Page No. 756-757. Medical negligence has become a big issue for medical Practioners. Fear of the law, and of litigation, has led to clams of defensive medical practice among doctors and nurses. At the heart of this lies the legal definition of the standard of care, where the law seeks to determine when conduct is ‘reasonable’ or ‘unreasonable’. In this article the author clarifies what the law means by ‘reasonableness’ with respect to nurses, drawing on both the law and the NMC Code. Furthermore, the article shall demonstrate that the law is not something to be fearful of but, rather, demands a standard no higher than that of the NMC. BIBLIOGRAPHY Nicholls M.E. and Wessells V.G. Nursing standards and Nursing Process. U.S.A. 1977. Contemporary Publishing, Inc. Wakefield, Massachusetts. Jernigan, D.K. and Young, A.P. Standards, Job Descriptions, and Performance Evaluations for Nursing Practice. USA. 1983. Appleton-Century-Crofts. Page No. 9-27. Basavanthappa, B.T. Nursing Administration, 1st Edition, New Delhi. 2008. Jaypee Brothers Medical Publishers Private Limited. Page No. 432-449. RAK College of Nursing. Report on Development of Standards for Nursing Practice. New Delhi.1999. Ministry of Health and Family Welfare. Sansburg, R.C. and Swansburg, R.J. Introduction to management and leadership for nurse managers, Canada, 2002, Jones and Bartlett Publishers, Page No. 520-522. Gillis, D.A. Nursing management a Systems Approach. U.S.A. 1982. W.B. Saunders company, 1982. Page No. 97-107. Heidemann, E.G. The Contemporary Use of Standards in Health Care. Geneva.1993. W.H.O. Page No. 1-30. Little, B.B. “The use of standards for peer review of online nursing courses: a pilot study”. Journal of Nursing Education, July, 2009. 48 ( 7 ). Page No. 411-415. Miola, J. “Negligence and the legal standard of care: what is reasonable conduct”?. British Journal of Nursing. June, 2009. 18 ( 12). Page No. 756-757. Westra, B.L. et al. “Nursing Standards to Support the Electronic health record”. Nursing Outlook. September-October, 2008. 56 (5). Page No. 258-265. Soni, M. “A study to assess the knowledge and practice of nursing personnel on standards of nursing practice for selected nursing activities (Thermoregulation and orogastric feeding) with a view to develop and evaluate the effectiveness of manual on standards of nursing practice in neonatal care unit for these selected nursing activities in selected hospitals of Delhi” Unpublished Master of Nursing Thesis, R.A.K. College of Nursing, University of Delhi, May 1999. www.google.com www.yahoo.com www.pubmed.com
  • 10. EXAMPLE Standards for nursing practice Standard Ref. No. - 1 Topic : Basic Nursing care Subtopic : Eat and drink adequately Care Group : Hospitalized patients Unit/Ward : Orthopedic ward Standard Statements : All Hospitalized patients will receive adequate fluid and nutrition Prepared By : Professional Organizations Standard implemented by : Nursing personnel Standard Audited By : NS/DNS Standard reviewed By : Committee STRUCTURE GUIDELINES The structure guidelines for helping patients eat and drink adequately are: a. Assess fluids nutritional needs of patient. b. Evaluate patient’s environment:  Need for privacy c. Assess patients readiness to eat  Need for oral care  General hygienic needs  Elimination needs d. Assess patients ability to eat or need for assistance to take food. e. Assist with oral hygiene and washing hands. f. Provide water, soap, and towel for patients hand and face, if needed. g. Serve prescribed diet. h. Encourage patient to do as much as possible for self. i. Remove tray when patient has finished meals. j. Record amount and type of food consumed. k. Record intake in intake/output chart. l. Record any untoward response to diet. m. Educate patient/relative regarding prescribed diet. STRUCTURE PROCESS OUTCOME S1. Nurse with adequate knowledge on fluid and nutritional needs of patients. P1. Nurse assesses fluid and nutritional needs of patients. O1. Patient take adequate amount and type of food and fluid. S2. Nurse possess adequate skill in meeting fluid and nutritional needs of patients. P2. Nurse identifies and set priority in meeting fluid and nutritional needs. O2. Patient does not have any untoward response after eating. S3. Devices for serving food and assisting in eating/feeding are available in the unit. P3. Nurse explains the importance of eating appropriate diet to patient / family. O3. Patient express satisfaction with the food.
  • 11. S4. Diet as per nutritional needs of the patient is available from hospital/home. P4. Prescribed diet is arranged and served appropriately. O4. Patient / relatives describe appropriate diet required for him / her. S5. Diet charts for different disease condition are available in the unit or therapeutic diet charts are available. P5. Nurse documents quantity of fluid and food intake. O5. Amount and type of fluid and food intake and any untoward response if any is recorded correctly. S6. Structure guideline is available in the unit. P6. Any untoward response such as dislike, nausea, vomiting, gastric discomfort or diet is documented and reported by the nurse. P7. Nurse takes remedial action for any untoward response. CHECKLIST ON MEETING FLUID AND NUTRITIONAL NEEDS OF PATIENT Objective: To assess skill of nurses in meeting fluid and nutritional needs of patient. S.No . Activities Yes No 1. Nutritional need assessed. 2. Identified and prioritized the nutritional need. 3. Explained the need of well balanced diet/diet as prescribed for specific disease condition. 4. Well balanced diet/prescribed diet provided. 5. Remedial action taken for untoward response if any. 6. Amount of food and fluid intake recorded. 7. Documented and reported any untoward response to diet. AUDIT FORM Audit objective: Do all hospitalized patients will receive adequate fluid and nutrition. TARGET METHOD CODE NO. AUDIT CRITERIA YES/NO Nurse Ask S1 Does the nurse have required level of knowledge to assess nutritional status of the patients? Nurse Ask and Observe S2 Does the nurse have the skill to assess nutritional needs? Ward Ask and Observe S3 Are proper devices available for serving and eating food? Ward Observe S4 Is diet available as per the nutritional need from hospital/home? Ward Ask and Observe S5 Are diet charts for different conditions available? Ward Observe S6 Is structured guideline available? Nurse Observe P1 Dose nurses assess nutritional needs of
  • 12. patients? Nurse Ask and Observe P2 Does nurse prioritize dietary needs? Patient Ask P3, O4 Does the patient/relative understand the need of well balanced diet/prescribed diet? Patient Observe and Ask P4 Does patient receive the prescribed diet in clean utensils as per meal schedule? Nurse Check record P5,O5 Dose nurse record the food and fluid intake? Nurse Check record P6,O5 Are untoward responses recorded by nurse? Patient Observe and Ask O1 Does patient take adequate and appropriate nutrition? Patient Observe and Ask O2 Does patient experience any discomfort after eating? Patient Observe and Ask O3 Does patient express satisfaction with the food? PATIENT SATISFACTION DATA INSTRUCTIONS: Please tick mark ( ) against each of the following items in the column provided. Satisfied : If the patient is completely satisfied with the nursing care and has no complaints, or problems then give three score. Partially Satisfied : If the patient is fairly satisfied with the nursing care and has some complaints give score two. Not satisfied : If the patient is not satisfied with nursing care and has number of complaints give score one. S. No. Statements Satisfied (3) Partially (2) Satisfied (1) Not Satisfied 1. Did the nurse assess and prioritize nutritional needs? 2. Did diet available as per the nutritional needs? 3. Did you receive your food as per diet schedule? 4. Did the nurse provided proper clean utensils for the serving and eating food? 5. Did your food was adequate and appropriate according to your nutritional needs? 6. Did you satisfy with your food? 7. Did the nurse record food and fluid intake and untoward response of food?
  • 13. AccreditedBest HospitalsNetwork in India Bangalore Apollo Bangalore Columbia Asia Wockhardt Hospital Sagar Apollo Hospital Manipal Hopsital Narayan Hrudalya Wockhardt Heart Institute NU Hospital Vignesh Dental Speciality Centre Netradhama Super Specialty Eye Hospital Indus Valley- Ayurvedic Centre Delhi Indraprashtha Apollo Max Healthcare Fortis Healthcare Artemis Hospital Confismile Dental Spa Kairali Ayurvedic centre New Look Laser Clinic Venu Eye Institue and Research Centre Kolkata AMRI Hospital Apollo Hospital Wockhardt Hospital CMRI Hospital Deusan Hospital B P Poddar Hospital Ruby General Hospital Columbia Asia Cancer Centre Welfare Home and Research institute (Thakur Pukur) susrut eye foundation B.M. Birla Heart Institute Rabindranath Tagore International Institute of Cardiac Sciences Mumbai Dr. L.H Hiranandani Hospital Wockardt Hospital Fortis Healthcare Jupiter Hospital Evovle Medspa Kenia Dental Clinic Dr. Kadalis Dental Clinic Kenia Eye Clinic Aditya Jyot Hospital Kairali Ayurvedic Clinic Goa Apollo Victor Hospital
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