Introduction -

Nursing has come a long way as a profession since the days when Florence Nightingale
established basic standards for education of nurses. In 1893, Lysta E Gretter led a
committee of nurses in the development of "the Florence Nightingale Pledge". This was an
effort to identify a set of ethical behaviour by which nurses could be judged. Standards
reflect the actual situation and can be tailored to most specific situation. Standards for
nursing practice help to fulfil the profession's obligations to provide quality nursing
services to clients. They are essential to a professional nurse.

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. A nursing care standard is a descriptive statement of desired quality
against which is evaluating 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 employers to understand what to expect of Practitioners.
 9. To identify areas for developing core curriculum for practicing nurses.
10. To provide legal protection for nurses.

Characteristics of standards
Objective, acceptable, achievable and flexible. Must be framed by the members of the
nursing profession. Should be phrased in positive terms like good, excellent, etc. Must be
understandable and unambiguous. Must be based on current knowledge and scientific
practice. 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. Licensing body e.g. INC, statutory bodies.
Institutions/Health care agencies.
2. Department of institutions e.g. Nursing Department. Patient care unit e.g. Medical
ICU.
3. Government units at national, state and local government units.
4. Individual e.g. personal standards.

Types of standards : 

1. 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, standards for the recruitment of
nurses working in any setting.
2. 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.
3. End standards: These are patient oriented; they describe the change as desired in a
patient’s physical status or behaviour.
4. Means Standards: These are nursing oriented; they describe the activities and
behaviour to achieve ends standards.

Frames of reference for standards

1. 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. Recording system. Budgeting.
Structure standards already exist, though not proved ideal scientifically.

2. Process Standards: These are nursing oriented and referred to the behaviour and
actions which a nurse should carry out. 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 of: Personal
needs, disease related needs and therapy needs. Nursing actions: Assessment ,
Diagnosis , Outcome identification etc. Resources. Implementation of actions.
Evaluation of the results or effectiveness of nursing actions taken. Professional
Performance: Performance appraisal , Education , Ethics, Research .

3. 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 accordingly.
Evaluation of nursing care by structure, process and outcomes:

Focus of Evaluation What to Assess Information Sources

methods, Tools
Structure e.g. physical facilities, e.g. observation e.g. nursing
equipment and checklist, personnel, nursing
supplies, staffing questionnaire, service unit, physical
number, qualification, interview, review of plant, management
policies, organizational records & reports personnel, records
objective and document. and reports.
Process e.g. the performance e.g. observation, task e.g. client/patient
of the nursing analysis, activity records, nursing
personnel. Nursing studies, review of personnel.
activities in terms of records & reports
adequacy, and document.
appropriateness and
quality of care.
Outcome End result or effected Observation, e.g. client/patient
of the care in terms of interviews, nursing records
effectiveness and audit, review of
efficiency .e.g. records & reports
Change in health status and document.
of client. Change in self
care status. Client
 satisfaction.

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.
9. Try out the standards to determine the feasibility.
10. The standards are put into practice and quality care is audited.
11. Updating of standards periodically with continuous renewal.

Levels of standard setting

There are four levels of standard setting:
1. National and state level,
2. Community level ,
3. Institution level,
4. Department 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. Inspection: It usually implies some sort of official examination.
Those inspecting most often have a conferred power to do so.
2. 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 standard.
NAME OF THE HOSPITAL: DEPARTMENT:
NURSING

WORK INSTRUCTION OF NURSING DOCUMENT NO:

PROTOCOL FOR ANTENATAL CARE :

Abdominal palpation:

Aim:

To estimate gestational age, monitor fetal growth and accurately identify lie,
presentation and position of the fetus.

Structure :

1. Midwifery- trained personnel have been trained in the correct procedure for
conducting abdominal palpation

2. Essential equipment such as tailor's measure tape and fetal stethoscope is

available and in good working condition.

3. A culturally appropriate place is available which allows privacy to conduct the

abdominal palpation.

4. Pregnancy records are in use

5. A fully operational referral system is in place for the pregnant women identified as
at risk or who develops complication to receive appropriate care and treatment.

Process:

Midwifery trained personnel must:

1. Carry out abdominal palpation at every antenatal visit

2. Ask the pregnant women prior to the palpation how she feels, if the baby is
moving and when her last menstrual cycle occur or the date she felt the baby first
moved.
3. Ensure the place for conducting palpation provides the pregnant women with
privacy

4. Prior to an abdominal palpation ask the pregnant women to empty her bladder

5. Lay the pregnant women on her back with upper part of her body supported with
cushions. Never lie a pregnant women flat on her back as the heavy uterus may
compress the main blood vessels returning to the heart and cause fainting (supine
hypotension)

6. Inspect the abdomen for scar, previous stretch mark, signs of over distension/
other signs of multiple pregnancy such as fetal parts felt to fetal heads palpated,
excessive or reduced amount of amniotic fluid. Record findings and refer for
institutional deliveries. If the women had a previous caesarean section or there are
signs of excessive or reduced amniotic fluid or multiple pregnancy.

7. Estimate gestational age and assess the fetal growth. After 24 weeks of pregnancy
the most effective way to estimate gestational age is to use a tailor's tape measure.

8. Using the measuring tape, measure from the upper border of the symphysis pubis
to the top of the fundus. Record the measurement in centimeters. If measurement is
different from calculated weeks by more than 3 c.m. or there is no growth or poor
growth from the last examination, refer for further investigation.

9. Gently palpate the abdomen to assess the lie of the fetus

10. Using two hands palpate the abdomen and pelvic area to identify the presenting
part

11.  After 37 weeks especially in primi gravida assess the fetal head is engaged. If
not, ask the pregnant women to sit/ stand up and see if the head can be made to fit
in to the pelvis. If the head will not going to the pelvis refer to the first referral unit/
hospital.

12.  Identify where the fetal back is and listen to the fetal heart sound

13.  Discuss all findings with the pregnant women, her husband/ accompanying
family members

14.  Record all findings accurately. Reveal all findings and if any deviations are found
refer to the first referral unit/ hospital for most specialized investigation as
appropriate.
Approved By 1. Issue No:
2.
Issued by: Rev No:
Document
Issue date: Rev Date:

STANDARD AND PROTOCOL

Subject : Nursing Administration

submitted by
SARBANI SARKAR
m.sc nursing ,final year
college of nursing
Medical college & hospital