STANDARDS AND NURSING AUDIT: A TOOL FOR QUALITY MANAGEMENT
The discipline of Nursing is an art and science committed to professional excellence and
provision of care to the patients and community by providing highest quality care possible .Quality
of care is determined by identifying the observable characteristics that depict the desired and valued
degree of excellence and the expected, observable variations. The quality of nursing care can be
managed both by evaluating the degree of excellence of results of delivered care and by taking
action for the improvements that in future will result in high degree of care. These two actions
satisfy the public trust that health science professionals continuously search for the means to obtain
the advantageous health /wellness outcomes for them. The standards maintained and the nursing
audit conducted hence, become the important tools for the quality management.
WHAT ARE STANDARDS?
Standard is a quantitative or qualitative measure against which someone or something is judged,
compared or used to service as an example.
Standards are professionally agreed levels of performance, which are achievable, and measurable.
The Oxford dictionary provides several key concepts for the definition of standards. First, it notes
that standards represent a degree of excellence. Second, it suggests that standards serve as a basis of
comparison. Third, it notes that standards are minimum with which a community may be reasonably
content. Finally, a standard is recognized as a model for imitation.
IMPORTANCE OF STANDARD
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. One of
the determinants of profession is that the members of the profession adopt standards of practice of
their calling, establish criterion by which conformance to the standards will be measured and have
the primary responsibility for seeing that the standards are enforced. If the professional group
abdicated its responsibilities, the public may step in and set standard for it.
A nursing care standard is a descriptive statement of desired quality against which is evaluate
nursing care. It is a guideline, a path to safe conduct and an aid to professional performance.
PURPOSE OF STANDARDS
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
1. Objective, acceptable, achievable and flexible.
2. Must be framed by the members of the nursing profession.
3. Should be phrased in positive terms like good, excellent, etc.
4. Must be understandable and unambiguous.
5. Must be based on current knowledge and scientific practice.
6. Must be reviewed and revised periodically.
SOURCE OF NURSING CARE STANDARDS
Standards can be developed, established, reviewed or enforced by:
1) Professional organization like TNAI.
2) Licensing body e.g. INC, statutory bodies.
3) Institutions/Health care agencies.
4) Department of institutions e.g. Nursing Department.
5) Patient care unit e.g. Medical ICU.
6) Government units at national, state and local government units.
7) Individual e.g. personal standards.
LEVELS OF STANDARD: MINIMUM VS OPTIMUM
Minimum standards are generally thought to represent a level of acceptability below which they
eyes on those judging, lies the unacceptable.
While minimum standards are a must to meet, there are other standards which we continually strive
to achieve. These are the desirable or optimal standards, which represent a degree of excellence. 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.
TYPES OF STANDARDS
There are difference types of standard:
1. 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.
2. Standards may be End Means of 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.
FRAMES OF REFERENCE
There are three frames of reference which can be used for setting standards to appraise nursing care
services i.e. structure, process and outcome.
Structure Standards: These are institution oriented and related to care providing system and
resources that support for actual provision of care. They include the following:
Physical facilities, building, etc.
Policies, goals and objectives.
Staffing members: training, qualification, job responsibilities.
Equipment and supplies.
Administrative setup and channel of communication.
Structure standards already exist, though not proved ideal scientifically.
Process Standards: These are nursing oriented and referred to the behavior and actions which a
nurse should carryout. Here focus is on nursing standards technique and procedures e.g. planning,
implementation, nurses interaction, client’s participation, communication and recording. Process
standards help in assessing the degree of skills with which the techniques are performed, the degree
of client involvement, and interaction between nurse and client. Thus, it implies professional
judgment in determining quality of nursing care/skills.
Nurse prepares appropriate written nursing care plan for the patient, which includes identification
Personal needs, disease related needs and therapy needs.
Nursing actions: Assessment , Diagnosis , Outcome identification etc.
Implementation of actions.
Evaluation of the results or effectiveness of nursing actions taken.
Professional Performance: Performance appraisal , Education , Ethics, Research .
Outcome Standards: These are patient centered or client centered. These are the description
statement of result of care for the patient and can be both qualitative and quantitative. Outcome
standards are related to patient’s health status, such as:
Self-care or disability.
Morbidity or mortality status.
Non-occurrence of complication and restoration of body functions, etc.
The results of outcome standards may be positive or negative. If one discovers that outcomes are
not according to the expectation, then one needs to scrutinize the structure and process standards
e.g. patients developing infections postoperatively, explore the causes and take remedial actions
STEPS OF STANDARD FORMULATION
1. Organize into small groups of nurses who work in the same field and meet periodically.
2. Decide on the area of nursing practice for which you want to work out standards.
3. Review philosophy, purposes and objectives of institution.
4. Review existing nursing care practices, nursing process and identify your client for nursing
service, client’s role and strategies for nursing care services.
5. Write the statements considering all the frame of reference giving rationale and criteria i.e.
assessment indicators see that standards are relevant.
6. Discuss them with nursing service administrators to get their approval.
7. Devise 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;
patients’ opinion, etc.
8. Determine validity by giving to the experts. Try out the standards to determine the feasibility.
9. The standards are put into practice and quality care is audited.
10. Updating of standards periodically with continuous renewal.
LEVELS OF STANDARD SETTING
There are four levels of standard setting:
National and state level
HOW ARE STANDARDS USED?
Mainly in health care settings, standards are used in:
1. Self-assessment: It is the evaluation of one’s own performance. Standards may be set by oneself
or in collaboration with an outside agent and evaluate how well the standards are met.
2. Inspection: It usually implies some sort of official examination. Those who inspect most often
have a conferred power to do so.
3. Accreditation: It is a process where in standards would depend on whether they are used in an
ongoing process. Set standards should be observable, attainable and measurable. They are to be
compared to actual practices. Identify the strength and weaknesses, take actions to correct
deficiencies, review the effectiveness of those actions through an audit protocol derived from
The success of standard would depend on whether they are used in an ongoing process. Set
standards should be observable, attainable and measurable. They are to be compared to actual
practices. Identify the strengths and weaknesses, take actions to correct deficiencies, review the
effectiveness of those actions through an audit protocol derived from the standard.
Nursing services are necessary for virtually every client seeking care of any type, including health
promotion, diagnosis and treatment. With the changing trends in the health care delivery, the role of
the nurse manager is becoming critical to effective, quality patient care. Nursing can no longer
ignore the world trend of professional accountability to an enlightened public. We as nurses, when
we talk about “quality nursing”, need to know our deficiencies and admit them to our peers.
Remedial steps needs to be taken only by such self-regulation we can retain our identity with the
health professional as true partners.
1. Audit: A systematic and critical examination to examine or verify.
2. According to Elison “Nursing audit refers to assessment of the quality of clinical nursing”.
3. According to Goster Walfer:
(a) Nursing audit is an exercise to find out whether good nursing practices are followed.
(b) The audit is a means by which nurses themselves can define standards from their point of view
and describe the actual practice of nursing.
4. Nursing audit is defined as the evaluation of nursing care in retrospect through analysis of
nursing records. It is a systemic format and written appraisal by nurses of the quality of content
and the process of nursing service from the nursing records of the discharged patient.
BRIEF HISTORY OF AUDIT
Nursing audit is an evaluation of nursing service. Before 1955, very little was known about the
concept. It was introduced by the industrial concern and the year 1918 was the beginning. George
Grower, pronounced the term physician for the first time medical audit. Ten years later Thomas R.
Pondon M.D. established a method of medical audit based on procedures used by financial account.
He evaluated the medical care by reviewing the medical records.
First report of nursing audit of the hospital was published in 1955. for the next 15 years, nursing
plan, nurses role, and patient condition and nursing care.
Audit is reports from study or records on the last decade. The program is reviewed from record
PURPOSES OF NURSING AUDIT
1. Evaluation: Evaluating the nursing care given.
2. Achieve deserved and feasible quality of nursing care.
3. Verification: Stimulant to better records.
4. Focuses on care provided and not on care provider.
5. Contributes to research.
6. Review of professional work or in other words the quality of nursing care i.e. we try to see how
far the nurses have confirmed to the norms and standards of nursing practice while taking care
7. It encourages followers to be actively involved in the quality control process and better records.
8. It clearly communicates standards of care to subordinates.
9. Facilitates more efficient use of health resources.
10. Helps in designing response orientation and in-service education programme.
METHODS OF NURSING AUDIT
There are two methods:
a) Retrospective View: This refers to an in-depth assessment of quality after the patient has been
discharged, and uses the patient’s chart as the source of data.
b) Concurrent Review: This refers to the evaluations conducted on behalf of patients who are still
undergoing care. It includes assessment the patient at bedside in relation to pre-determined
criteria, interviewing the staff responsible for his care and reviewing the patient record and care
ESSENTIAL CHARACTERISTICS OF NURSING AUDIT: There should be:
Written standards of care against which to evaluate nursing care.
Evidence that actual practice was measured against such standards, sharing a percent
Examination & analysis of findings.
Evidence of corrective action being taken.
Evidence of effectiveness of corrective action.
Appropriate reporting of the audit programme.
PROCESS OF NURSING AUDIT:
A. Set the key criteria (item): It should be measurable against identified values, set
standard & in terms of desired patient outcome. Methods to develop criteria are:
1. Define patient population.
2. Identify a time framework for measuring outcomes of care.
3. Identify commonly recurring problems presented by the defined patient population.
4. State patient outcome criteria.
5. State acceptable degree of goal achievement.
6. Specify the source of information.
B. Prepare Audit Protocol keeping in mind Audit Objectives, Target groups, Method of
information gathering (by asking, observing, checking records), Criterion you are measuring,
identify the time framework for measuring outcome of care, identify commonly recurring
nursing problems, State acceptable of goal achievement.
C. Design the type of tool: Quality assurance must be a priority.
(a)Those responsible must implement a program not only a tool.
(b) A co-coordinator should develop and evaluate quality assurance activities.
(c) Roles and responsibilities must be delivered.
(d) Nurses must be informed about the process and the results of the program.
(e) Data must be reliable.
(f) Adequate orientation of data collection is essential.
(g) Quality data should be analyzed and used by nursing personnel at all levels.
D. Plan and implement the tool: What is to be evaluated? Who is going to collect the
information? How many sample in the target group? Time period? Required and so on.
E. Recording/Analysis, Concluding: Record the information, Analyze the information, Make
a summary, Compare with set standard, Conclusion.
F. Using results : The results aid to modify nursing care plans & the nursing care process,
including discharge planning, for selected patient outcome, implementing a program for
improving documentation of nursing care through improved charting policies,
methodologies & forms, focusing of nursing rounds & team conferences. Focusing
supervisory attention upon areas of weakness identified, such as one particular nursing unit
or specific employees. Designing responsive orientation & in-service education programs.
Gaining administrative support for making changes in resources, including personnel.
ADVANTAGES OF NURSING AUDIT
(1) Can be used as a method of measurement in all areas of nursing.
(2) Seven functions are easily understood.
(3) Scoring system is fairly simple.
(4) Results easily understood.
(5) Assesses the work of all those involved in recording care.
(6) May be a useful tool as part of a quality assurance programmed in areas where accurate records
of care are kept.
(7) Enables the professional group to highlight the deficiencies and how good they are in giving
(8) Better planning can be done.
(9) Helps in re-allocation of resources.
10) Administrators are also sure that patients are getting quality care.
(ii) Appraises the outcomes of the nursing process, so it is not so useful in areas where the
nursing process has not been implemented.
(iii) Many of the components overlap making analysis difficult.
(iv) It time consuming.
(v) Requires a team of trained auditors.
(vi) Only evaluates record keeping. It only serves to improve documentation, not nursing care.
(vii) Medical legal importance.
(viii) The professionals feel that they will be used in court of law as any document can be called
for in court of law.
(ix) Deals with a large amount of information.
PREREQUISITES OF NURSING AUCIT
1. Audit Committee: Before carrying out an audit, an audit committee should be formed which
consists of fair and impartial members including senior nurses as members to do nursing audit.
This committee should comprise of minimum five members who are interested in quality
assurance, are clinically competent and able to work together in a group. It is recommended that
each member should review not more than 10 patients each month and that the auditor should
have the ability to carry out an audit in about 15 minutes. It there are less than 50 discharges per
month, all the records may be audited. If there are large numbers of records to be audited, an
auditor may select 10 per cent of discharges.
2. The impetus must come from the nursing staff themselves, realizing the benefits to the patients
3. A good system of nursing record keeping.
AUDIT AS A TOOL FOR QUALITY CARE
An audit is systemic and official examination of a record, process or account to evaluate
performance. Auditing in health care organization provides managers with a means of applying
control process to determine the quality of service rendered. Nursing audit is the process of
analyzing data about the nursing process of patient outcomes to evaluate the effectiveness of
nursing interventions. The audits most frequently used in quality control include outcome process
and structure audits.
1. Outcome Audit: Outcomes are the end results of care; the changes in the patient’s health status
and can be attributed to the delivery of health care services. Outcome audits determine what
results if any occurred as result of specific nursing intervention for the clients. These audits
assume the outcome accurately and demonstrate the quality of care that was provided. Examples
of outcomes traditionally used to measure quality of hospital care include mortality, its
morbidity, and length to hospital stay.
2. Process Audit: Process audits are used to measure the process of care or how the care was
carried out. Process audit it task oriented and focuses on whether or not practice standards are
being fulfilled. These audits assume that a relationship exists between the quality of the nurse
and quality of care provided.
3. Structure Audit: Monitors the structure or setting in which patient care occurs, such as the
finances, nursing service, medical records and environment. This audit assumes that a
relationship exists between quality care and appropriate structure. These above audits can occur
retrospectively, concurrently and prospectively.
ROLES AND FUNCTIONS OF NURSE MANAGER FOR EFFECTIVE QUALITY CARE:
(1) Encourages followers to be actively involved in the quality control process.
(2) Clearly communicates standards of care to subordinates.
(3) Encourages the setting of high standards to maximize quality instead of setting minimum safety
(4) Implement quality control proactively instead reactively.
(5) Uses control as a method of detraining why goals were not met.
(6) Is positively active in communicating quality control finding.
(7) Acts as a role model for followers in accepting responsibility and accountability for nursing
(i) In conjunctions with other personnel in the organization establishes clear cut, measurablke
standards of care and determines the most appropriate method for measuring if those
standards have been met.
(ii) Selects and uses process, outcome and structure audits appropriately as quality control tools.
(iii) Assesses appropriate sources of information in data gathering for quality control tools.
(iv) Determines discrepancies between care provided and unit standards and seeks further
information regarding why standards were not met.
(v) Uses quality control findings as a measure of employee performance and rewards, coaches,
counsels, or disciplines employees accordingly.
(vi) Keeps abreast of current government and licensing regulations that affect quality control.
In the new era, with the changing concepts in the health care delivery, the nurse manager role ;is
becoming critical to effective qualities patient care. Nursing audit is on one of the important tools to
provide quality-nursing care services to the clients and maintain professional accountability.