INTRODUCTION

Quality is rapidly becoming concern to both the consumers and the providers of the services.
In health care, quality is being demanded and expected and provides are judged by the quality
of services and hence, there is a need to sensitize and train nursing personnel to provide
quality care a. we must accept the fact that someone to very satisfied with an individual
product or service performed, while at the same time someone else may be very dissatisfied.
Judging quality depends on an individual’s knowledge and awareness, experiences,
expectations and recognizable standards of quality.

Quality refers to excellence of a product or a service including its attractiveness, lack of

defects, reliability and long-term durability. Quality assurance provides the mechanism to
effectively monitor patient care provided by health care professionals using cost effective
resources. Nursing programs of quality assurance reconcerned with the quantitative
assessment of nursing care as measured by proven standards of nursing practice. Florence
Nightingale introduced the concept of quality in nursing care in 1855 while attending the
soldiers in the hospital during the Crimean war.

It includes all activities related to establishing, maintaining and assuring high quality care for
patients.

DEFINITION:-

Quality assurance in nursing is a process of establishing a target degree of excellence

(standards) for nursing intervention and then taking steps to ensure that each client receives
the agreed upon level of care.

A quality assurance program is an ongoing, systematic process designed to evaluate and

promote excellence in the health care provided to clients. Quality assurance refers to
activities that evaluate, monitor or relate services rendered to consumers. In nursing, the goal
of quality care would be to ensure quality while meeting intended goals.

Quality assurance when viewed simple can be broken down into three basic steps:

1. Criterion or standard is determined.

2. Information is collected to determine if the standard has been met.
3. Educational or corrective action is taken if the criterion has not been met.

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Quality assurance is a judgement concerning the process of care, based on the extent to which
that care contributes to valued outcomes. -Donabedian (1982)
Quality assurance is defining of nursing practice through well-written nursing standards and
the use of those standards as a basis for evaluation on improvement of client care.
-Maker (1998)
Meaning of Quality:-
“Quality is doing the right thing right the first time and doing it better the next time”.
“Quality is defined as the extent to resemblance between the purpose of health care and truly
granted care”.
“Quality refers to the conformance to or variations from pre-established criteria, standards,
policies or procedures.

CONCEPT OF QUALITY ASSURANCE:-

Quality assurance is a dynamic process through which nurses in both academic and clinical
practice assume accountability for quality of care they provide (George, Veigas and Isaac,
1994). It is a guarantee to the society that members of the nursing profession are regulating
services provided by nurses. Kozier (2004) defined quality assurance as the defining of
nursing practice through well written nursing standards as a basis for evaluation on
improvement of client care.
With respect to quality in healthcare, Ovretveit created the definition of quality that states
that the quality of health activities is the complete satisfaction of the needs of those who are
in most need of health services, for the lowest organizational costs, within the given limit and
guidelines of higher administrative bodies and those paying. It also mentions the components
of quality healthcare.
 A high level of professionalism
 Efficient use of resources (human, financial and material)
 The lowest possible risk for the patient
 Patient satisfaction, and
 A (positive) influence on his state of health.
The quality of healthcare attains these demands and, in accordance with existing
knowledge, meets the expectations of the greatest possible utilization with the least
possible risk to the patient’s health and well-being.

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DIMENSIONS OF QUALITY:-
Nursing takes into account three fundamental dimensions: the Profession, Management and
users of health services who should be mutually co-dependent. In doing so, they establish
patient satisfaction as a prime indicator of quality. The eight product quality dimensions are:
performance, features, reliability, conformance, durability, serviceability, aesthetics and
perceived quality. The concept was defined by David A. Garvin, formerly C. Roland
Christensen Professor of Business Administration at Harvard Business School (died 30 April
2017).

Garvin's eight dimensions can be summarized as follows:

1. Performance: Performance refers to a product's primary operating characteristics.

This dimension of quality involves measurable attributes; brands can usually be
ranked objectively on individual aspects of performance.
2. Features: Features are additional characteristics that enhance the appeal of the
product or service to the user.
3. Reliability: Reliability is the likelihood that a product will not fail within a specific
time period. This is a key element for users who need the product to work without
fail.
4. Conformance: Conformance is the precision with which the product or service meets
the specified standards.
5. Durability: Durability measures the length of a product’s life. When the product can
be repaired, estimating durability is more complicated. The item will be used until it
is no longer economical to operate it. This happens when the repair rate and the
associated costs increase significantly.
6. Serviceability: Serviceability is the speed with which the product can be put into
service when it breaks down, as well as the competence and the behavior of the
service person.
7. Aesthetics: Aesthetics is the subjective dimension indicating the kind of response a
user has to a product. It represents the individual’s personal preference.
8. Perceived Quality: Perceived Quality is the quality attributed to a good or service
based on indirect measures.

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MYTHS OF QUALITY:-
 It leads to wasted time and increase workload.
 Quality means more expensive services.
 Quality means goodness, luxury, shininess or weight.
 Quality is intangible and not measureable.
 Quality problems are originated by the workers.
 Quality originates in the quality department.
PURPOSE OF QUALITY ASSURANCE:-
1. To ensure medical surveillance.
2. To ensure population health management through continuous monitoring and evaluation
of the patient care.
3. To ensure the delivery of quality client care.
4. To demonstrate the efforts of the health care providers.
5. To provide technical assistance in correcting systemic deficiencies.
6. To refine existing methods for ensuring optional quality health care.
7. To provide the best possible results.
8. To establish technical assistance and frame effective planning strategies to implement and
monitor quality care by checking and correcting the errors in the health care services.
9. To upgrade the existing system of nursing care, and improve the care to obtain maximum
quality care by conducting evidence-based research activities.
10. To create awareness and popularize the work of nurses in the public, thus improving the
image of nurse by providing quality nursing care.
11. To frame the evaluation process methodically, which helps to attain and improve quality
patient care.

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12. To demonstrate the efforts of the health care provider to deliver quality care.
13. To successfully achieve sustained improvement in health care, as clinics need to design
processes to meet the needs of patients.
14. To design processes well and systematically in order to monitor, analyze and improve
patient outcomes.
15. To ensure that a designed system includes standardized, predictable processes based on
best practices.
16. To set incremental goals as needed.

ELEMENTS OF QUALITY ASSURANCE:-

 Appropriateness- The service or procedure is what the population or individual actually
needs.
 Equity- A fair share is available for all the population.
 Accessibility- Services are not compromised by undue limits of time and distance.
 Effectiveness- Services are achieving the intended benefits for the individual and for the
population.
 Acceptability- Services are provided such as to satisfy the work expectations of patients,
providers and the community.
 Efficiency- Resources are not wasted on one service or patient to the deteriment of
another.
 Structure evaluation- It focuses on the settings in which care is provided to the patient. It
answers the questions like how does the setting affect the quality of care? Structural
standards describe desirable environmental and organizational characteristics such as
equipment and staffing that influence care.
 Process evaluation- It focuses on how the care was provided to the patient. It answers
questions such as the following: Is the care being provided relevant to the patient’s needs?
Is the care being provided appropriate, complete and timely? Process standards focus on
the manner in which the nurse uses the nursing process. Some examples of process criteria
are “check patient’s identification band before giving medication” and perform and record
chest assessment, including auscultation, once per shift”.
 Outcome evaluation- It focuses on visible changes in patient’s health status as a result of
nursing care provided. Outcome criteria are written in terms of patient’s responses or
health status, just as they are for evaluation within the nursing process. For example, ‘How

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 many patient’s undergoing hip repairs develop pneumonia?’ or ‘How many patients who
have a colostomy experience an infection that delays discharge?’

Assuring and Improving Nursing Quality:

Quality assurance is merely a process that incorporates the systematic description,

measurement, evaluation and, when necessary, implementation of measures to improve
quality. This means the systematic and planned implementation of measures in order to
achieve the prescribed requirements for quality.

A distinction must be made from among three concepts: quality assurance, and quality
improvement.

 Quality Assessment-
Quality Assessment is a process which, by employing comparative methods and
selected criteria, we can use to compare healthcare services actually offered and
selected and established criteria and standards. Not until quality has been assessed
can a system of quality assurance be formed, which assists in improving and
attaining the desired goals.
 Quality Assurance-
Quality assurance is not unique, final action, but a lasting process that demands a
constant improvement of the features of products and services.
 Quality Improvement-
Quality improvement is a process that follows the phases of quality assessment
assurance, removes discovered obstacles or problems and raises quality to a higher
level.

FACTORS AFFECTING QUALITY ASSURANCE:-

1. Lack of resources- Insufficient resources, infrastructure, equipment, consumables, money

for recurring expenses and staff make it possible for output of a certain quality to be
turned out under the prevailing circumstances.
2. Personnel problems- Lack of trained, skilled and motivated employees, staff indiscipline
affect the quality of care.
3. Improper maintenance- Buildings and equipment require proper maintenance for the
efficient use. If not maintained properly, the equipment’s cannot be used in giving nursing

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 care. To minimize equipment down time it is necessary to ensure adequate after sale
service and service manuals.
4. Unreasonable patient and attendants- Illness, anxiety, absence of immediate response to
treatment, unreasonable and uncooperative attitude, in turn, affect the quality of care in
nursing.
5. Absence of well-informed population- To improve quality of nursing care, it is necessary
that the people become knowledgeable and assert their rights to quality care. This can be
achieved through continuous educational program.
6. Absence of accreditation law- There is no organization empowered by legislation to lay
down standards in nursing and medical care so as to regulate the quality of care. It requires
a legislation that provides for setting of a stationary accreditation/vigilance authority to-
 Inspect hospitals and ensure that basic requirements are met.
 Enquire into major incidence of negligence.
 Take actions against health professionals involved in malpractice.
 Lack of incident review procedures.
7. Lack of incident review procedures- During a patient’s hospitalization, incidents may
occur which have a bearing on the treatment and the patient’s final recovery. These critical
incidents may be:
 Delayed attendance by nurses, surgeon, the physician.
 Incorrect medication.
 Burns arising out of faulty procedures.
 Death in the corridor with no nurse/physician accompanying the patient, etc.
8. Lack of goods hospital information system- A good management information system is
essential for the appraisal of quality of care-
 Workload, admissions, procedures and length of stay.
 Activity audit and scheduling of procedures.
9. Absence of patient satisfaction surveys- Ascertainment of patient satisfaction at fixed
points on an ongoing basis. Such surveys carried out through questionnaires, interviews to
by social worker, consultant groups, help to document patient satisfaction with respect to
variables that are-
 Delay in attendance by nurses and doctors.
 Incidents of incorrect treatment.

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10. Lack of nursing care records- Nursing care records are perhaps the most useful source of
information on quality of care rendered. The records-
 Detail of the patient condition.
 Document all significant interaction between patient and the nursing personnel.
 Contain information regarding response to treatment.
 Have the dates in an easily accessible form.
11. Miscellaneous Factors-
 Lack of good supervision.
 Absence of knowledge about philosophy of nursing care.
 Lack of policy and administrative manuals.
 Lack of written job description and job specifications.
 Lack of in-service and continuing educational program.

OBJECTIVES AND GOALS OF QUALITY ASSURANCE IN

NURSING:-
The important objectives and goals are as follows-
 To establish technical assistance and frame effective planning strategies to implement
and monitor quality care by checking and correcting the errors in the health care services.
 To upgrade the existing system of nursing care, and improve the care to obtain maximum
quality care by conducting evidence-based research activities.
 To create awareness and popularize the work of nurses in the public, thus improving the
image of nurse by providing quality nursing care.
 To frame the evaluation process methodically, which helps to attain and improve quality
patient care.
 To demonstrate the efforts of the health care provider to deliver quality of care.
 To successfully achieve sustained improvement in health care, as clinics need to design
processes to meet the needs of patients.
 To design processes well and systematically in order to monitor, analyze and improve
patient outcomes.
 To ensure that a designed system includes standardized, predictable processes based on
best practices.
 To set incremental goals as needed.

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  To ensure quality, nursing care provided by nurses in order to meet the expectations of
receiver, management and regulatory body.
 It also intends to increase the commitment of provider and the management.
 Improves and maintains the patient’s state of health.
 Improves and maintains the patient’s functional abilities.
 Develops the patient’s psychophysical condition or well-being.
 To refine existing methods for ensuring optimal quality health-care.
 To provide technical assistance in correcting systemic deficiencies.
 Helps improve quality of care for patients.
 Assess competence of medical staff, serve as an impetus to keep up to date and prevent
future mistakes.
 Bring to notice of hospital administration the deficiencies and in correcting the causative
factors.
 It helps to exercise a regulatory function.
 Restrict undesirable procedures.

PRINCIPLES OF QUALITY ASSURANCE:-

The principles of quality assurance are as follows-
1. It must be focused on client need- a) external clients (patients and communities), b)
internal clients (health team members).
2. It requires a collaborative effort among all health professionals to measure and improve
care.
3. During planning a coordination is needed to ensure that objectives and activities of each
health professional enhance rather than conceal those of other professionals.
4. Care should be taken to ensure that resource expenditure for quality assurance activities is
appropriate in amount.
5. Key to ensure quality in patient care is accurate assessment of patient care, the key to
successful auditing of care is adequate documentation of care.
6. Effective monitoring of the nursing system operations depend upon receiving feedback
from all parts of the nursing system or process.
7. Evaluation of care will not by itself improve practice rather feedback from all parts of the
nursing system or process.

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8. For an effective quality assurance collective analysis of quality assessment data must be
linked to the decision-making. Focus on data based for decision-making. Decisions about
problem areas and improvements should be based on accurate and timely data and not on
guesses.
9. Focus on systems and processes- By focusing on the analysis of service delivery
processes, inputs, and outcomes, quality assurance approaches allow health team to
develop an in-depth understanding of a problem and provide them with the means to
address its root causes. Later on they can even analyze processes to prevent problems
before they occur.
10. Focus on team approach to problem-solving and quality improvement- Participatory
approach (team) offers high quality technical product. Involving employees in problem-
solving and opportunity improvements bring unique expertise and insight to the quality
improvement efforts. This leads to a thorough problem-analysis and makes development
of feasible solution that is more likely to be accepted and supported and reduces the
possibility of resistance in implementation.
11. It uses data to analyze service delivery.
12. It encourages the use of teams in problem-solving and quality improvement.
13. It uses effective communication to improve service delivery.
14. Quality assurance is a never ending process of creative destruction, with rapid advances in
science and technology and reduced half the life of medical knowledge continuous
updating is essential.
15. The emphasis is on establishing professional excellence patient satisfaction at a reasonable
cost.
16. Quality is not proportionate to the use of sophisticated technology or to be expense
incurred.
17. Motto of fees for service should not be pregnant with the comedy of needles services for a
fee and tragedy of no services if no fee.
18. Technical imperative should not insist on prolonging life at any lost with no consideration
to quality of life.

QUALITY ASSURANCE CYCLE:-

Quality assurance is a continuous, cyclical process that is implemented in a flexible manner

to attain the goals of the specific program. It starts as a strenuous effort, outlining the rules
and regulations as described in the steps below. This model has 10 steps-

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1. Planning- It starts with the planning strategies to be implemented to carry out quality
assurance activities. It begins with researching the past and present status of the
institutional scope in order to determine what kind of services are needed to meet the
goals of the quality assurance process.
2. Framing the standards- All the procedures are framed to meet the standards mentioned
by the Indian Nursing Council and the International Nursing Council so as to meet the
goals of the quality patient care.
3. Providing information about the standards and guidelines- After framing the standards, it
is important to communicate with all the members of the health team who deliver and
clarified any issue encountered in applying the standards should be resolved.
4. Monitoring the quality of care- Monitoring includes evaluating the proper application of
standards as per rules and regulations to identify the extent to which the quality care is
maintained and the desired patient care outcome is obtained.
5. Recognizing the issues and checking for ways of improvement- after completing the
analyses and monitoring the standards survey is done by the nurse manager to identify
the issues that prevent the workers from following the standards. The reasons with
rationale are sorted out after getting the feedback from them by way of complaint books
and regular meeting is done to solve the issues to implement the standards of nursing
care as per the norms.
6. Detailing the prevailing issue- The document on issues should clearly state all the related
problems and analyze how these can be rectified.
7. Team effort- The issues are solved by team effort. Once the problem is identified, it is
analyzed by the team members along with members who are directly involved in the
issue to discuss and find out the solution to the problems identified.
8. Developing root cause analysis- This step follows a standard analytical technique based
on flow charts, system model and cause-effect diagrams through which long methodical
depth analysis is applied to the issues to find their root cause along with the solutions.
This analysis will give a complete understanding of the issues and frame alternatives that
help to resolve the issues and prevent them from appearing in the future.
9. Framing the solutions and interventions for quality improvement- Entire team, after
prolonged analysis, frames the solutions and takes up actions to solve the existing issues
and develop standards to upgrade the nursing care. While framing the solutions, all the
individuals involved in the issues are included. Therefore, the personnel responsible for
root cause of any issue can be identifies and remedy can be planned.

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 10. Implementing and appraising the quality improvement activities- This step needs careful
application of planned strategies that should be done efficiently by the team members. It
involves identifying the needed resources and the time frame to detect who will be the
personnel in-charge for implementing the planned strategies to appraise the quality
improvement activities.

There are some additional steps in quality assurance-

a) Setting standards:-
The nursing profession should have to design standards of nursing practice that are
specific to the patient population served. These standards could serve as the foundation
upon which all other measures of quality assurance are based. An example of a standard
is: Every patient will have a treatment chart.
b) Determining Criteria:-
After standards of performance are established, criteria must be determined that will
indicate if the standards are being met and to what degree they are met. Just as with
standards of care, criteria must be general as well as specific to the individual unit. One
criterion to determine that the standards regarding care plans for every patient are being
met would be: A nursing care plan is developed and written by a nurse within 10 hours of
admission. This criterion, then, provides a measurable indicator to evaluate performance.
c) Data Collection:-
It is the third step in quality assurance. Sufficient observations and random samples are
necessary for producing reliable and valid information. A useful rule is that 10 percent of
the institutional patient population per month should be sampled. The devised tool to
collect data should leave as little room for interpretation by the data collector as possible.
Data collectors need to be taught the purpose of quality assurance along with the
principles of data collection.
Data collection methods include-
 Patient observations and interviews
 Nurse observations and interviews
 Review of charts.
d) Evaluating Performance:-
Various methods can be used to evaluate performance. These include-
 Reviewing documented records
 Observing activities as they take place

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  Examining patients
 Interviewing patients, families, and staff.
Records are the most commonly used source for evaluation because of the relative case of
their use, but they are not as reliable as direct observations. It is quite possible to write in the
patient’s chart activities that were not done or not to record those things that were done.
Further, the chart only indicates that care was provided; it does not demonstrate the quality of
that care. For example, care plan could be checked nursing diagnosis, interventions planned,
and discharge planning.
Making plans for change based on the evaluation: it includes taking the actions for
improving quality care by changing the present scenario and incorporate new policies for the
same.

COMPONENTS OF QUALITY ASSURANCE IN NURSING:-

There are four essential components of quality assurance. They are-
1. Setting program objectives.
2. Promoting quality.
3. Activity monitoring- i) Quality Control, ii) Quality Supervision.
4. Performance assessment- i) Quality review, ii) Quality evaluation, iii) Quality approval.

JCAHO’s 10 steps for Quality Improvement-

 Establish responsibility and accountability.

 Define scope of service for clinical area.
 Develop quality indicators to monitor outcomes and appropriateness of care delivered.
 Establish threshold for evaluation of indicators.
 Collect and analyze data from monitoring activity.
 Evaluate results of monitoring activities to determine the need for change in practice.
 Resolve problems to determine if plan was successful.
 Reevaluate to determine if plan was successful.
 Communicate quality improvement results to organization.

STEPS OF PROCESS IN A QUALITY ASSURANCE PROGRAM:-

According to JCAHO, the following are the steps/guidelines of quality assurance-
Step 1 - Assign Responsibility:

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  Nursing departments and services must assign overall responsibility for their
monitoring and evaluation activities.
 This process oversees all aspects of nursing monitoring and evaluating, assuring that
the activities are comprehensive, effective, uniform and coordinated.

Step 2 – Delineate Scope of Care and Services:

Intended to assure that all nursing activities are considered in monitoring and evaluation:

 Types of patients served.

 Condition and diagnosis.
 Types of nursing staff providing care and services.
 All existing standards of patient care.

Step 3 – Identify Important Aspects of Care and Services:

It is important for nursing staff to remember that important aspects of care are activities of the
department that will be continually monitored and periodically evaluated to determine if care
can be improved or if problems are present. Nursing staff should identify those aspects of
care and services that:

 Occur frequently or affect large numbers of patients.

 Place patient at serious risk (high-risk).
 Have intended in the past to produce problems (problem-prone).

Step 4 – Identify Indicators of outcome:

Indicators are measureable variables related to the structure, process or outcomes of care:

 Structures- Elements that facilitate care (resources, equipment, numbers and

qualification of staff).
 Process- Functions carried out by practitioners (assessment, treatment, planning and
medication administration).
 Outcomes- Includes complications, adverse effects, short and long term results of
treatment.
Step 5 – Establish Threshold for Evaluation:

 Thresholds are accepted levels of compliance with any indicators being measured.
 Thresholds for evaluations are the level or point at which intensive evaluation is
triggered.

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Step 6 – Collect and Organize Data:

Some common data can be found in-

 Patients’ records
 Medication sheets
 Infection control
 Meeting minutes
 Patient surveys
 Incident reports
 Department logs
 Laboratory report
 Direct observation
 Formal evaluation

Step 7 – Evaluate Care:

Once threshold for an indicator is reached, the critical step of evaluation is initiated. The most
important purpose of monitoring and evaluation is to foster overall continuous improvement
in the level of performance.

Step 8 – Take Actions to Solve Problems or Otherwise Improve:

Staff should direct actions towards the root causes and should have an eye toward overall
improvement in the quality of care and services.

Some possible actions if the problem involves deficiencies in systems include-

 Changing communication channels
 Changing organizational structure
 Adjusting staffing or redistributing staff
 Revising job descriptions
 Reallocating resources
 Adding or revising policies and procedures
 Altering the use of equipment
 Purchasing and repairing equipment.
Some possible actions, if the problem involves deficiencies in staff knowledge include-
 Modifying orientation procedures
 Providing focused in-service education
 Providing focused continuing education
 Circulating written policies and procedures or other informational material.
Some possible actions, if the problem involves behavior or performance deficiencies include-
 Revising job descriptions
 Informal counseling

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  Formal counseling
 Changing assignments
 Disciplinary sanctions
 Limiting staff prerogatives relating to patient care
 Transferring to another unit/department
Step 9 – Assess the Effectiveness of Actions:
Monitoring and evaluation does not end when actions are taken. Staff continues to monitor
the aspect of care for future opportunities for improvement, but they must determine whether
actions are taken successfully in improving care or service. If care does not improve within
the expected time, staff should re-examine the aspect of care and take further action.
Step 10 – Communicate Relevant Information to the Organization-Wide Quality Assurance
Program:
It is essential that monitoring and evaluation information be communicated through
established channels. Appropriate dissemination of information helps to assure that quality
assurance activities are coordinated and that knowledge regarding monitoring evaluation and
problem-solving methods is shared.

APPROACHES FOR QUALITY ASSURANCE:-

A. General Approach-
 Credentialing
 Licensure
 Accreditation
 Certification
B. Specific Approach-
 Peer review
 Utilization review
 Evaluation review
 Audit
 Client satisfaction
 Incident review
 Standards

A. GENERAL APPROACH:- It involves large governing official body’s evaluation of a

person’s or agency’s ability to meet established criteria or standards at a given time.

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 i. Credentialing: According to Hinvark (1981), ‘Credentialing is a formal recognition
of professional or technical competence and attainment of minimum standards by a
person or agency’.
Credentialing process has four functional components-
 To produce a quality product.
 To confer a unique identity.
 To protect provider and public.
 To control the profession.
 Principles of Credentialing:
- Credentialing benefits those who are credential in addition to public.
- The legitimate interests of the involved occupation or institution and of the
general public should be reflected in each credentialing mechanism.
- Accountability should be an essential component of any credentialing process.
- A system of checks and balances within the credentialing system assure
equitable treatment for all parties involved.
- Periodic assessments with the potential for sanction are essential components of
an effective credentialing mechanism.
- Objective standards and criteria and persons competent in their use are essential
to the credentialing process.
- Professional identity and responsibility should evolve from the credentialing
process.
- Coordination of credentialing mechanisms should lead to efficiency and cost
effectiveness and avoid duplication.
ii. Licensure: Individual licensure is a contract between the profession and the state in
which the profession is granted control over entry into and exists from the
profession and over quality of professional practice. Licensure of nurses has been
mandates by law since 1903.
iii. Accreditation: Accreditation is the establishment of the status, legitimacy or
appropriateness of an institution program or module of study. Accreditation is
usually for a limited duration at which time re-accreditation procedures come into
operation. In the part of accreditation process primarily evaluated on agency’s
physical structure, organizational structure and personal qualification.

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 iv. Certification: Certification is usually a voluntary process within the profession. A
person’s educational achievements, experience and performance on examination are
used to determine the person’s qualification for functioning is an identified specialty
area.
B. SPECIFIC APPROACH:- Quality assurances are methods used to evaluate identified
instances of provider and client interaction.
i. Peer review Committee: These are designed to monitor client-specific aspects of
care appropriate for certain levels of care. The audit has been the major tool used by
peer review committee to ascertain quality of care. To maintain high standards, peer
review has been initiated to carefully review the quality of practice demonstrated by
members of a professional group. Peer review is divided into two- i) Centers on the
recipients of health services, ii) Centers on the health professional.
ii. The Audit Process (Stan Hope Han Caster, 2000):
 Follow-up of problem topic study selected.
 Recommendations for correcting deficiencies, explicit criteria selected for
quality care.
 Peer review of all cases not meeting criteria.
 Record reviews.

iii. Utilization review: Utilization review activities are directed towards assuring that
care is actually needed and that the cost appropriate for the level of care provided.
Three types of utilization review are- i) Prospection: It is an assessment of the
necessity of care before giving service, ii) Concurrent: A review of necessity of care
after the care has been given, iii) Retrospective: A review of necessity of care after
the care has been given.
iv. Evaluation studies: three models have been used to evaluate quality, they are-
 Donabedian’s structure-process-outcome model- It includes:
i) Structural evaluation: This method evaluates the setting and instruments
used to provide care such as facilities equipment’s, characteristics of the
administrative organization and qualification of the health providers. The
data for structural evaluations can be obtained from the existing
documents of an agency or from an inspector of a facility.
ii) Process evaluation: This method evaluates activities as they relate to
standards and expectations of health providers in the management of
client care. Data for this can be collected through direct observations of

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 provider encounters and review of records, audit, checklist approach and
the criteria mapping approach are used to establish the client encounter
protocol.
iii) Outcome evaluation: The net changes that occur as a result of health care
or the net results of health care. The data of this method can be collected
from vital statistical records such as death certificates, in person or
telephone client interviews, mailed questionnaires and client records.
 The tracer method- This is a measure of both process and outcome of care. To use
the tracer method, one must identify a volume of client with a particular
characteristic resuming specific health care management. Physicians and nurse
practitioners to identify persons with certain illness such as hypertension, ulcers,
urinary tract infections and to establish criteria for good medical and nursing
management of the illnesses have used the traced method. This method provides
nurses with data to show the differences in outcomes as a result of nursing care
standards.
 The sentinel method- It is an outcome measure for examining specific instances
of client care. The characteristics of this method are-
a. Cases of unnecessary disease, disability deaths are counted.
b. The circumstances surrounding the unnecessary event or the sentinel are
examined in detail.
c. In review of morbidity and mortality are used as an index.
d. Health status indicator such as changes in social, economic, political and
environmental factors are reviewed which may have an effect on health
outcomes.
 Client satisfaction- Client satisfaction can be assessed using person or telephone
interview and mailed questionnaire. Data from client satisfaction surveys are used
to measure structure, process and outcome of care given.
 Incident review- During a patient’s hospitalization several incidents may occur
which have a bearing on the treatment and patient’s final recovery. The critical
incidents may be- i) Delayed attendance by a physician/nurse, ii) Incorrect
medications, iii) Lack of cleanliness and asepsis, and iv) Carelessness in carrying
out nursing procedures, eg., hot and cold applications.
The report should contain the name, age, exact time and place, description of how
it occurred any precaution taken conditions of patient before and after the

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 incident. Since these reports are of legal value it should be written carefully and
importance should be given to all the details and should be filed safely.
v. Standards: Standards is a predetermined baseline conditions or level of excellence
that comprise a model to be followed and practice. Standard is a quantitative or
qualitative measure against which someone or something is judged, compared or
used to service as an example.
The American Nurses Association standard of practice include:
6Standard 1: Data collection
Standard 2: Nursing diagnosis
Standard 3: Goals
Standard 4: Priorities and prescribed nursing approach
Standard 5: Nursing action (Health maintenance)
Standard 6: Nursing action (Maximize health capabilities)
Standard 7: Evaluation
vi. Audit: Audit is a details review and evaluation of selected clinical records in order to
evaluate the quality of nursing care performance by comparing it with accepted
standards.
 Types of Nursing Audits:
 Retrospective audit: This refers to an in-depth assessment of quality after
the patients have been discharged and uses the patients’ charts as the source
of data.
 Concurrent audit: It is an evaluation method to inspect the nursing staff’s
compliance with predetermined standards and criteria while the nurses are
providing care.

MODELS OF QUALITY ASSURANCE:-

A model is merely a graphic presentation of a quality assurance process. It allows all

interested parties an overview of how the district plans on moving the construction
programme from conception to a programme of excellence, meeting the needs of students,
parents, local business and the district.

A quality assurance (QA) program is a methodical, continuous process framed to evaluate

and ascertain the outstanding performance while providing quality care to all patients. This
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model helps to evaluate more number of nurses at a time. Total quality care can be appraised
and the method can be used compare and evaluate the quality care provided by the health care
service agencies across the country.

This is the process of establishing a predetermined degree of excellence for nursing

intervention and taking action to ensure that each receives the level of care as agreed.

Quality assurance model in nursing is developed by Lang and adapted by the American
Nurses Association. The evaluation model is open and circular, indicating a cyclical process
that can be entered at any point association. The evaluation model is open and circular,
indicating a cyclical process that can be entered at any point.

A. A System Model for implementation of Unit-Based Quality Assurance - The

implementation of the unit-based quality assurance program, like that of any other
program, and involve making changes in organizational structure and individual roles. One
method of facilitating and structuring the change process is the system approach in which
the task is broken down into manageable components based on defined objectives.
The basic components of the system are-
1. Input: It can be compared to the present state of the system.
2. Throughput: The throughput to the developmental process.
3. Output: To the finished product.
4. Feedback: It is the essential component of the system because it maintains and nourish
and has growth.
The input can be compared to the present state of the systems, the throughput to the
developmental process and output to the finished product. The feedback is the essential
component of the system because it maintains and nourishes the growth. The
boundaries of the system define its integration in the environment to the other tasks
and goals of nursing department, to the process of nursing science in relation to
evaluation. Their boundaries should be semipermeable so that they allow necessary
information and energy into and out of the change process.

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 Previous Structural Unit based
quality change quality
assurance process assurance program
program improvement

Input Throughput Output

Fig.: System model of Quality Assurance

B. American Nurses Association Model- The ANA has developed quality assurance model in
1977 which has widespread applicability in any healthcare setting and can be used as guide
to implement quality assurance program.
The first step in developing quality assurance program is continuing education. Many staff
nurses and supervisors have not been prepared in the academic setting to develop standards
of practice when a quality assurance program is implemented. The continuing education
needs of all the staff should be ascertained. Quality is not assured if only a small committee
evaluates care and understands quality assurance program.

C. The ANA quality assurance model –

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 Fig: The ANA Quality Assurance Model

The basic components of ANA model are-

1. Identify value: The ANA value identification looks as such issue patient/client, philosophy,
needs and rights from an economics social, psychology and spiritual perspective and values,
philosophy of the health care organization and the providers of nursing services.
2. Identify structure, process and outcome standards and criteria identification of standards
and criteria for quality assurance begins with writing of philosophy and objective of
organization. The philosophy and objectives of an agency serves to define the structural
standards of the agency. Standards of structure are defined by licensing or accrediting
agency. Another standard of structure includes the organizational chart, which shows
supervisory methods, communication patterns, staff patterns and sometimes staff
assignments.
The evaluation of process standards is a more specific appraisal of the quality care being
given by agency care provider. An agency can chose to use the standards of care set forth by
the providers, professional organizations such as the ANA nursing standards or the agency
can use the nursing process and apply it to the activities of the nurses as the activities
correspond to the procedures of care defined by the agency.
The primary approaches for process evaluation include the peer review committee and the
client satisfaction survey. The evaluation of outcome standards reveals the end results of
nursing care. Outcome evaluation is done sentinel survey or tracer method.

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3. Select measurement needed to determine degree of attainment of criteria and standards.
Measurements are those tools used to gather information or data, determined by the
selections of standards and criteria. The approaches and techniques used to evaluate
structural standards and criteria are:
 Nursing audit
 Utilization review
 Review of agency document
 Self studies
 Review of physical facilities

The approaches and techniques for the evaluation of process standards and criteria are:

 Peer review
 Client satisfaction survey
 Direct observation
 Questionnaire
 Interview
 Written audits
 Videotapes

The evaluation approaches for the outcome standards and criteria are:

 Research studies
 Client satisfaction surveys
 Client classification
 Admission, readmission
 Morbidity data
4. Make interpretations: The degree to which the predetermined criteria are met is the bases
for interpretation about the strengths and weakness of the program. The rate of compliance
is compared against the expected level of criteria accomplishment.
5. Identify course of action: If the compliance level is above the normal or the expected level,
there is great value in conveying positive feedback and reinforcement. If the compliance
level is below the expected level. It is essential to improve the situation.
6. Choose action: Usually various alternative while considering the environmental context and
the availability of resource.

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7. Take action: It is important to firmly establish accountability for the action to be taken. It is
essential to answer the question of who will do, what and when. This step then conclude
with the actual implementation of the proposed course of action.
8. Re-evaluate: The final step of quality assurance process involves an evaluation of the result
of the action.

FRAMEWORK FOR QUALITY ASSURANCE:-

a. Maxwell (1984): Maxwell recognized that, in a society whole resources are limited, self-
assessment by health care professionals is not satisfactory in demonstrating the efficiency
of a service. The dimensions of quality he proposed are-
 Access to service
 Relevance to need
 Effectiveness
 Equity
 Social acceptance
 Efficiency and Economy
b. Wilson (1987): Wilson considers four essential components to a quality assurance
program. These are-
 Setting objectives
 Quality promotion
 Activity monitoring
 Performance assessment
c. Lang (1976): This framework has subsequently been adopted and developed by the ANA.
The stages includes-
 Identify and agree values
 Review literature
 Analyze available programs
 Determine most appropriate program
 Establish structure, plans, outcome criteria and standards
 Evaluate current levels of nursing practice
 Identify and analyze factors contributing to results

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  Select appropriate actions to maintain or improve care
 Implement selected actions
 Evaluation

NEW TRENDS IN QUALITY ASSURANCE PROGRAMS:-

 Quality council- A body of senior managers representing the main functional areas and
departments within a firm.
 Standards of care- Standards of care or standards of nursing care are general quidelines
that provide a foundation as to how a nurse should act and what he or she should and
should not do in his/her professional capacity.
 Concurrent monitoring- Continuous review and supervision.
 Interdisciplinary quality assurance
 Automation of late sources
 Performance appraisal

FUNCTIONS OF NURSE IN QUALITY ASSURANCE:-

A. Role of Nursing Administrator in Quality Assurance Programme-

1. Initiator
2. Facilitator
3. Leader
4. Coordinator
5. Educator
6. Evaluator
B. Role of a Clinical Nurse in Quality Assurance-
 Test sets of patient health/wellness outcome criteria for validity and reliability.
 When outcomes are not at the desired level, search for activities that will assist
patients to realize the desired benefits.
 Teach the methods for developing and applying patient health/wellness outcome
criteria to staff and head nurses and to students in educational programmes.
 Work with physicians and members of other disciplines to initiate health review.
C. Role of Director of Nursing Service-
 Make a commitment to the necessity, importance, and urgency of implementing a
quality assurance review program.

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  Create or guide the development of a protocol that enables expert nurse peer panels to
be organized and to proceed productively.
 Teach staff nurses, head nurses and clinical nurse specialists how to develop and
apply sets of patient health/wellness outcome criteria, and how to connect nursing
activities to specific outcomes, and how to evaluate cost effectiveness.
 Create the nursing quality assurance review system and assemble the resources.
 Monitor the reported results, support or direct implementation or changes that will
secure a higher degree of effectiveness or efficiency, and make reports to appropriate
internal bodies.
 Participate with other administrators and clinicians in decisions about reports to
external quality monitoring and control bodies, and provide reports.
 Serve with other administrators and clinicians in evaluating institutional effectiveness
and efficiency in meeting the health needs of the population in the service area.

Other functions may include-

1. Encourage team members to be actively involved in the quality process.

2. Implement quality control.
3. Communicates standards of care to team members.
4. Assess appropriate source of information.
5. Evaluate quality assurance activities.
6. Assist in the planning and organization of quality assurance program.
7. Assume the authority, responsibility of directing the program.
8. Assist in developing annual auditing schedule.
9. Attend and participate in workshops and seminars.
10. Develop and implement appropriate plans of action to correct deficiencies.

QUALITY TOOLS:-

 Chart audits- It is the most common method of collecting quality data using charts as
quality assessment tool.
 Failure mode and effect analysis (prospective view)- It is a tool that takes leaders through
evaluation of design weaknesses within their process, enable them to prioritize
weaknesses that might be more likely to result in failure (errors) and, based on priorities
decide where to focus on process redesign aimed at improving patient safety.

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 Root-cause analysis (retrospective view)- It is sometimes called a fishbone diagram, used
to retrospectively analyze potential causes of a problem or sources of variation of a
process. Possible causes are generally grouped under four categories-people, materials,
policies and procedures and equipment.
 Flow charts- these diagrams that represent the steps in a process.
 Pareto diagrams- It is used to illustrate 80/20 rule, which states that 80% of all process
variation is produced by 20% of items.
 Histograms- It uses a graph rather than a table of number to illustrate the frequency of
different categories of errors.
 Run charts- These are graphical displays of data over time. The vertical axis depicts the
key quality characteristics, or process variable. The horizontal axis represents time. Run
charts should also contain a center line called median.
 Control charts- These are graphical representations of all work as processes, knowing
that all work exhibit variation; and recognizing, appropriately responding to, and taking
steps to reduce unnecessary variation.

QUALITY ASSURANCE METHODS:-

The purpose of a nursing quality assurance programme is to measure and improve the quality
of patient care delivered in the organization.

The following are some of the important methods used-

1. Nursing Audit: It is a procedure to appraise the quality of nursing care through which the
evaluation of nursing care plan or processes is made, which ultimately reflects the quality
care given as recorded in the patient care record.
2. Peer review: A process by which nurses evaluate one another’s job performance against
accepted standards.
3. Patient care profiles analysis: The analysis of longitudinal or cross-sectional
complications in data on patients with a particular diagnosis or problem.
4. Quality circles: a quality circle is a small group of 5-15 employees who perform similar
work and meet for an hours each week to solve problems related to their work.
5. Patient satisfaction: Patient satisfaction is used as one of several indicators of quality.

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 NURSING AUDIT

Nursing audit is an evaluation of nursing service. It was introduced by Industrial concern.

The report of nursing audit of the hospital, published in 1955, related to the planning,
delivery and evaluation of care. It determines its effectiveness, and any area needing
improvement and whether the planned care was given.

Quality in product services, is the demand of the day as per a famous statement. You cannot
insert quality into product; quality must be built into the product as service. The level of
quality is determined at the point of service, which is experienced and perceived by the
clients and reflected through the audit process.

History of nursing audit :-

First report of nursing audit of the hospital published in 1955. For the next 15 years, nursing
audit is reported from study or record on the last decade. The program is reviewed from
record nursing plan, nurse’s notes, patients’ condition. Nursing care before 1955, very little
was known about concept of nursing audit. George Groward a physician was the first one to
pronounce the term medical audit in 1918. Ten years later, Thomas R. Pondon HD
established a method of medical audit based on procedures used by financial account. The
18th report of nursing audit of the hospital published in 1995. The world trend of professional
accountability to an enlightened public can no longer be ignored by nursing.

Quality of nursing is different to measure both qualitatively and quantitatively but is

possible. Nursing audit makes an important component of medical audit. Increase in public
awareness of their rights of safety and high cost of medical treatment necessitates that the
nurses become more and more accountable for the care they deliver. The word “AUDIT”
comes from the Latin word “AUDITUS” meaning a hearing. It originally meant the hearing
of the facts and arguments about a situation to determine the truth.

MEANINGS :-

1. Quality :- A judgement of what constitutes good or bad.

2. Audit :- A systematic and critical examination to examine or verify.
3. Nursing audit :- (a) It is the assessment of the quality of nursing care.
(b) Uses a record as an aid in evaluating the quality of patient care.

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4. Medical Audit :- The systematic, critical analysis of the quality f medical care, including
the procedures for diagnosis and treatment, the use of resources, and the resulting outcome
and quality of life for the patient.

DEFINITION :-

According to Elison, “ Nursing audit refers to assessment of the quality of clinical nursing”.

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.

According to Ganong & Ganong :- Nursing audit is a method for assuring documentation of
the quality of nursing care in keeping with the standards of the agency, thenursing
department, and the professional, governmental and accrediting groups.

According to Phaneuf (1976) :- A method for evaluating quality of care through appraisal of
nursing process as it is reflected in the patient care records for discharged patients.

CONCEPT OF NURSING AUDIT:-

Nursing audit mainly comprises of –

1. Debit- Debit is all negative activities in nature, e.g., Hospital infection.

2. Credit- Credit mainly involves all positive activities in nature, e.g., Satisfaction of
care.
 Debit items of Nursing Audit:
 Death of the client not justifiable as otherwise could have been prevented.
 Complications due to the neglect of nursing care.
 Complications of diseases leading to morbidity.
 Hospital-borne infection.
 Errors in treatment.
 Clients discharged against medical advice.
 Absence of total client care.
 Lack of application of nursing process.
 Credit items of Nursing Audit:

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  Number of recovered patients.
 Shortened stay in the hospital.
 Expansion of health knowledge in client population.
 Research as need for problem-oriented care approach.
 Regular follow-up in the community.
 Good nurses record.

OBJECTIVES:-

1. To justify the cost increased on human and material resources.

2. To study the quality of patient care against defined criteria.
3. To take remedial action towards cost effectiveness.
4. To assess the competence of nursing staff and serve to keep up to date knowledge and
prevent repeated mistakes.

PURPOSE OF NURSING AUDIT :-

1. Evaluating nursing care given.

2. Achieving deserved and feasible quality of nursing care.
3. Stimulates to better health.
4. Focusing on care provided and not on care provider.
5. Contributing to research.
6. Necessitating adequate documentation of nursing care provided to the client through
the entire nursing process.
7. Directing attention to the design and utility of the charting record.
8. Encouraging the use of the problem oriented nursing system.
9. Supporting and becoming an integral part of nursing by objective program.
10. Facilitating the co-operative planning and delivery of client care by physician and
nursing employees.
11. Increasing the priority for results oriented performance evaluation program for
nursing service employees.
12. Enriching and providing the direction to in-service education effects.
13. Providing specific management technique in carrying out evaluation and control
function.
14. Identifying ways to improve patient care.

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 15. Providing meaningful ways for nursing staff members to participate and achieve
career growth.

ESSENTIAL CHARACTERISTICS OF NURSING AUDIT:-

1. Written standards of care against which to evaluate nursing care.

2. Evidence that actual practice was measured against such standards.
3. Examination and analysis of findings.
4. Evidence of corrective action being taken.
5. Evidence of effectiveness of corrective action.
6. Appropriate recording of the audit program.

METHODS OF NURSING AUDIT:-

There are two methods-

1. Retrospective View: This refers to an in-depth assessment of the quality after the
patient has been discharged, to have the patient’s chart as the source of data.
Retrospective audit is a method for evaluating the quality of nursing care by
examining the nursing care as it is reflected in the patient care records for discharged
patients. In this type of audit, specific behaviour are described then they are converted
into questions and the examiner looks for answers in the record. For example, the
examiner looks through the patient’s records and asks-
 Was the problem solving process used in planning nursing care?
 Whether patient data collected in a systematic manner.
 Was a description of patient’s pre-hospital routines included?
 Were the laboratory test results used in planning care?
 Did the nurse perform physical assessment? How was information used?
 Were nursing diagnosis stated?
 Did nurse write nursing orders? And so on.
2. The Concurrent Review: This refers to the evaluation conducted on behalf of the
patients who are still undergoing care. It includes assessing the patient at the bedside
in relation to pre-determined criteria, interviewing the staff responsible for this care
and reviewing the patient’s record and care plan.

AUDIT COMMITTEE:

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Before carrying out an audit, an audit committee should be formed, comprising a minimum of
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
than10 patients each month and that the auditor should have the ability to carry out an audit
in about 15 minutes. If there are less than 50 discharges per month, then all the records may
be audited, if there are large number of records to be audited, then an auditor may select 10
percent of discharges.

 Nursing Auditor: The choice of nursing auditors depends upon whether the type of
nursing audit to be undertaken is internal and external accordingly.
a) Internal auditors- The nursing experts from within the hospital are deputed for
internal audit and the auditing is done within agency or hospital.
b) External auditors- The nursing and medical administration from the ministry,
other agency or professional association like TNAI undertake the nursing audit in
desired agency of a hospital.
Training for auditors should include the following-
 A detailed discussion of the seven components.
 A group discussion to see how the group rates the care received using the notes of a
patient who has been discharged, these should be anonymous and should reflect a
total period of care not exceeding two weeks in length.
 Each individual auditor should then undertake the same exercise as above. This is
followed by a meeting of the whole committee who compare and discuss its findings,
and finally reach a consensus of opinion on each of the components.

AUDIT CYCLE:

SET STANDARDS

IMPLEMENT CHANGE OBSERVE PRACTICE

COMPARE WITH

33
 STANDARDS

FIG: AUDIT CYCLE.

AUDIT REPORTS:-
 The audit objective.
 The name of auditors.
 Date of the audit.
 The audit methods used, sample size and time frame.
 The findings in relation to criterion.
 Selected comments from questionnaires and suggestions for improvement.
AUDIT AS A TOOL FOR QUALITY CONTROL:-
As audit is systematic 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 more frequently used in quality control
include outcome, process and structure audits.
 Outcome Audit- Outcomes are the end results of care, the changes in the patient’s
health status and can be attributed to delivery of healthcare services. Outcome audits
determine what result if any, occurred as a result of specific nursing intervention for
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 of hospital stay.
 Process Audit- Process audits are used to measure the process of care or how the care
was carried out. Process audit is task-oriented and focuses on whether or not practice
standards are being fulfilled. These audits assumed that a relationship exists between
the quality pf the nurse and quality of care provided.
 Structure Audit- Structure audit monitors the structure or setting in which the 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.

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ADVANTAGES OF NURSING AUDITS:-

i. It can be used as a method of measurement in all areas of nursing.

ii. Scoring system is fairly simple.
iii. Results are easily understood.
iv. Assesses the work of all those involved in recording care.
v. May be a useful tool as a part of a quality assurance program in areas where
accurate records of care are kept.
vi. It gives a biographical index of quality of nursing each patient has achieved.
vii. Patient is assured of good services.
viii. It will give valuable and pertinent information for the staff, improvement in
quality of nursing as well as strength and weaknesses in nursing service re
revealed.
ix. It will lead to better cooperation and communication among the nurses and the
health team members as a result of improved quality of nursing notes.
x. It will help each professional nurse for her self-evaluation.
xi. It helps the administration for better planning through nursing audit. It enables the
nurse administrator to uncover the inefficient service and point the ways to
elevation of standards.
xii. It will reduce the incidence of medico-legal complications arising out of
incomplete or inaccurate records maintained by the nurses.
xiii. It will broaden and strengthen nursing service in the hospital. It may rovide data
needed to effect required changes in health care system.

DISADVANTAGES OF NURSING AUDITS:-

i. Appraises the outcomes of the nursing process, so it is not so useful in areas where
the nursing process has not been implemented.
ii. Many of the components overlap making analysis difficult.
iii. It is time consuming.
iv. Requires a team of trained auditors.
v. Deals with a large amount of information.
vi. Only evaluates record keeping.
vii. It is considered as a source of punishment by the professional group.
viii. It is only served to improve the documentation not the nursing care.

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UTILIZATION OF RESULTS OF NURSING AUDIT:-

 For Nursing Care Services-

 Modifying nursing care plans and the nursing care process, including discharge
planning for selected patient population.
 Implementing a program for improving documentation of nursing care through
improved charting policies, methodologies and forms.
 Focusing supervisory attention upon areas of weakness identified, such as one
particular nursing unit or specific employee.
 Focusing of nursing rounds and team conferences.
 Designing responsible orientation and in-service education programs.
 Gaining administrative support for making changes in resources including personnel.
 Using the evaluation based on nursing audit criteria to focus staff attention on
individual patient outcome.
 For Nursing Administrator-
 Provide evaluation of particular program such as orientation of personnel or
establishment of patient teaching program.
 Support requests for accreditation or for financing of a particular program.
 Serve as a basis for planning new programs or program changes.
 Serve to identify areas of strength and weakness in the total nursing programs, in
specific areas of the program, and in various settings in which a program exists.
 Determine the influence of varied staffing patterns.
 It may be used as data in cost-effectiveness status.
 For Supervisor and Head Nurse-
 Identify the areas of needed patient care improvement.
 Provide basis for planning in-service education program.
 Identify teaching/supervision needs of staff members who give direct care to patients.

 For Staff Nurse-

 Provide self-examination of care in their specific nursing unit or settings.
 Identify particular types of care in which practice may be improved merely by
increased attention and consciousness.

36
  Identify types of care in which improvement will depend on the staff’s acquiring
additional knowledge and skill.

QUALITY ASSURANCE IN NURSING: STANDARDS:

Introduction:-

A standard is a means of determining what something should be. In the case of nursing
practice standards are the established criteria for the practice of nursing. Standards are
statements that are widely recognized as describing nursing practice and are seem as having
permanent value.

Meaning of Standards:-

A level of quality or attainment.

Definition of Standard:-

According to ANA, “A standard is described as a criterion used by general agreement as

acceptable level of practice or an established norm.

Definition:-

A nursing care standard are descriptive statements that effect the nature of current nursing
practice, current knowledge and current quality of nursing care. As such, they are means of
establishing accountability or nursing care rendered by the professional nurse.

Characteristics of standards:-

i. Standard statement must be broad enough to apply to a wide variety of settings.

ii. Standards must be realistic, acceptable and attainable.
iii. Standards of nursing care must be developed by members of the nursing profession.
iv. Standards should be phrased in positive terms and indicate acceptable performance like
good, excellent, etc.
v. Standards of nursing care must express what desirable optional level is.
vi. Standards must be understandable and stated in unambiguous terms.
vii. Standards must be based on current knowledge and scientific practice.
viii. Standards may be directed towards an ideal, i.e., optional standards or may only specify
the minimal care that must be attained, i.e., minimum standard.

37
ix. One must remember that standards that work are objective, acceptable, achievable and
flexible.

Purpose of Standards:-

1. Communication:- Communication provides for sharing a common language with nursing

professional which can cross barriers.
2. Research:- The standards provide a framework for further investigation, so that current
practices are no longer based on intention “word of mouth” but are derived from theory
developed by authorities with the nursing profession.
3. Legal implications:- The nursing profession must be self-regulating to maintain credibility
as a profession. The courts use the professional standards “as a yard stick” to determine
whether hospitals and health care professionals have provided quality patient care
according to rationally acceptable standards.
4. Quality assurance:- Standards can be used as the criteria for quality assurance studies to
assess the current levels of practice rendered by the health care services provided by the
organization.
5. Professional Accountability:- Standards set guidelines for nursing practice, providing
uniform basis for collecting a convocation with an established assurance programme and
or performance appraisal system.
6. Decision-making:- Standards also help in decision making and choosing alternatives for
delivering of health care, and helps in supervision and improving performance.

Sources of Nursing Care Standards:-

i. Professional organizations, e.g., Associations like TNAI.

ii. Licensing bodies, e.g., statutory bodies like INC.
iii. Institutions/Healthcare agencies, e.g., University hospitals, Health Centres.
iv. Department of Institutions, e.g., Department of Nursing.
v. Patient Care Units, e.g., specific patients’ unit.
vi. Government units at National, State and Local Government units.
vii. Individual, e.g., personal standards.

Classification of Standards:-

1. Normative Standards:- It describes practices considered good or ideal by some

authoritative group. Ideal sides are set by authoritative group.

38
 2. Empirical Standards:- It describes practices actually observed in a large number of
patient care setting. Here, the norm active standards describe a higher quality of
performance than empirical standards. Generally, professional organizations
(ANA/TNAI) promulgate normative standards whereas law enforcement and
regulatory bodies (INC/MCI) promulgate empirical standards.
3. The Ends Standards:- These are patient oriented. They describe the change as desired
in a patient’s physical status or behaviour.
4. The Means Standard:- These are nursing oriented. They describe the activities and
behaviour designed to achieve the ends standard. Ends or patient outcomes standards
require information about the nurses’ performance.

Classification of Standards according to Frame of References:-

1. Structure standard.
2. Process standard.
3. Outcome standard.

TOTAL QUALITY MANAGEMENT:

Definition of Total Quality Management:-

Quality management is defined as a management philosophy concerned with people and

work processes that focuses on customer satisfaction and improves organizational
performance.

Principles:-
The principles were set in 1990 by a small group of experts. a key universal principles of
Total Quality Management are-
1. Customer focused organization- Like any organization, every private and/or public
healthcare organization, when providing healthcare services, must respect the
customer centered approach. This approach is an important objective in the
development of public and private services as it constitutes one of the main drivers
for healthcare services reforms. Customers are the ones for whom such
organizations exist and their needs, demands and expectations must be paid special
attention. Hence, healthcare services must be designed and developed according to
the requirements, needs and expectations of the customers (patients/clients), thus
taking into account all the requirements of the healthcare environment as well as
the entire society.
2. Leadership- Another novelty brought with a new version of the ISO 9001 - leadership
is crucial for the management of the healthcare organizations and the quality

39
 management system of those organizations that adopted customer centred
approach. Leaders have the role to inspire, promote and support the organizational
culture of quality. Doctors are not the only ones who contribute to the healthcare
service quality. According to the same authors, the quality improvement is equally
contributed by doctors and managers - doctors in the field of their professional
practice and managers in the field of quality and safety of all the services provided by
the healthcare.
3. Involvement of people- Customers are not the only group whose needs and
requirements should be met. ''Adequate worth must also be provided to employees,
local and global community, investors and society in general, in terms of both
financial and non-financial aspects of a company's performance''. Therefore,
defining the healthcare service, often, requires the identification of needs,
expectations and requirements of all the stakeholders and interested parties that, in
addition to the service provider and health insurance, include customer (patient/
client) as well as the physician and doctor.
4. Process approach- In recent times, the majority of authors agree that healthcare
services require the implementation of integrated and multidisciplinary processes
that unite different functions, clinical specialist activities as well as the variety of
providers of healthcare services. When it comes to understanding the process
orientation, it is necessary to understand some of the basic concepts that it carries with
it. For instance, it is necessary to introduce new roles, such as the owner, the bearer
and the executor of the process. It is necessary to introduce systems of evaluation
and rewarding that will be based on the achieved results of the process and not on
the results achieved within the individual organizational units.
5. System approach to management.
6. Continual improvement.
7. Factual approach to decision-making.
8. Mutually beneficial supplier relationships.

RISK MANAGEMENT (RM):

 In essence, risk management can be explained as a set of techniques, actions, plans
and synchronized activities designed to help practitioners assess, monitor, prevent or
mitigate any life- or quality-threatening factors and risks. An effective risk
management process is based on several key steps. They begin from the process of
comprehending the nature of the risk, go through determining its possible effects and
reach stages when practitioners involved take actions to eliminate and mitigate the
identified risk.

 Precisely, the steps include:

o Methodical adoption of core management policies;

40
 o Risk Communicating – where decision makers, regulatory authorities, patients
and other personnel involved share information about the nature, consequences,
control, acceptability or any other relevant aspects

o Risk documentation;

o Consulting;

o Setting up the context and planning of resources required for the management of
risks;

o Finding, categorizing, analyzing, assessing, describing, treating, monitoring and

reviewing risks;

Mitigating the risk depends on the level of the risk itself. What’s important then is to
carefully review the risk and find out if it is within the acceptable levels. That will help
practitioners make an informed decision as to whether the issue can be reduced or eliminated
completely. Another key process here is to share information across departments and teams.
The clearer communication is established, the better and quicker the whole process will run.
However, it’s not just questions and procedures which deliver effective risk management.
Having well-prepared and trained personnel is what promises successful risk management as
well.

In this regard, Clinical Risk Managers (CRM) should be familiar with available techniques,
methodologies, and the best possible analytical tools in order to conduct appropriate risk
management. 

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 FUTURISTIC NURSING

INTRODUCTION:-
Future is full of mystery, no one can guess, predict about the future and actual of future may
differ from the prediction. But one can be successful in future by systemic planning,
maximum implementation of planning as the future is based on the past and present. Many
new trends in nursing are likely to develop in the near future. Some can be predicted with
certainty, while others may be unexpected. These trends of the future will result from very
rapid changes taking place to make a constant effort to keep informed through all available
sources. It is the only way which will present and what may come about in the near future.
Futuristic means ‘expecting the future’. Futuristic nursing implies expectation of changes in
different areas of nursing profession in future and creating a preferred future for nursing
based on what we today are and using challenges as stepping stones for creating a desired
future.

FUTURE SCENARIOS:-
Scenarios are forecasts, ‘a model of an unexpected or supposed sequence of events’. They
raise awareness of the wide range of possible implications of external forces, sensitize people
to potential threat and opportunities, and allow examination of alternative options for action.
Four scenarios describe different potential picture of the health care delivery system at the
start of 21st century are:
 Business as usual scenario: It assumes continues technological ingenuity, sophisticated
communication. Advances in biomedical knowledge and technology make it possible to
forecast, prevent and manage illnesses earlier and more successfully. In this scenario
nursing education could be highly individualized through the use of the computers.

42
 Hard times scenario: This scenario assumes that times are tough for the economy as a
whole and for health care. As unemployment increases, pressure is placed on the federal
government to provide basic package of care and nursing care of acutely ill-patient
would be important in this scenario.
 Buyer’s market scenario: In this scenario responsibility for health and health care has
been returned to the consumer. This scenario offers real potential for nursing to achieve
greater power and influence as compared to present situation. By assessing consumers
directly, nurses would have a major role in promoting health consumers to promote
individual, family and community health.
 Healthy healing communities’ scenario: This scenario involves a focus on “healing the
body, mind and spirit of individuals and communities”. Nurses would be full partners
with people in this scenario, helping people with self-care and providing informed
decision-making. Older persons would be valued and would be cared for at home.

RAPID CHANGES IN HEALTHCARE TECHNOLOGY AND THERAPIES:-

It likely means continued lowered cute care stays. Driving forces include increasingly
sophisticated surgical technologies that are less invasive and promote quicker healing. New
therapies may reduce sick time, hopefully even in areas, such as cancer, HIV/AIDS and
genetic disorders. However, as those technologies have prolonged the life span, reduced
mortality has changed fatal illnesses into more chronic illness, which may still require care
and control. The growth of telemedicine, telenursing, and telehealth will also change the way
we function, and they have great potential and challenges for the development of new nursing
roles. With lowered acute care stays, many more people will require care in their own
communities. Nurses need to be better prepared to work within this are: financial issues of
care provision need to be addressed and nurses need to be better prepared to work with
chronic care needs.

CHANGES IN HEALTHCARE PRACTICES:-

Demonstrable shifts are occurring in the causes of mortality from infectious diseases and
chronic diseases. For example, AIDS and related illnesses are the major cause of death.
Obesity is also the predisposing cause of number of illnesses due to unhealthy dietary habits,
lack of exercise and stress. These kinds of health problems are especially suited to nursing
expertise in care:

43
 Nurse will play an increasingly important role in educating people about wellness and self-
care.
 Nurse will play an instrumental role in educating the public about how to be involved in
the development of sound public policies concerning these issues.
 Nurse will become politically active as voter, campaign worker and political candidate.
 Nurse will also assume leadership qualities in helping people and prevent illnesses.
 The health care delivery system will be completely restructures in the near future. The
challenge for nursing would be to gain autonomy within the system. For this, nurses would
need quality with other health professionals, which can be accomplished only through
comparable education qualifications and an equivalent allocation of authority.

MODERN NURSING:-
The art of using latest technology and science to promote quality of life as defined by patients
and families throughout their life experiences from birth to the end of life.

ASPECTS OF FUTURISTIC NURSING:-

Futuristic nursing can be classified in terms of nursing education, practice, research,
administration, and all the four components which might occur in the years to come.

 Nursing education-

Future directions for nursing Education In 1993, three major organizations issued statements
and reports about nursing education for the twenty first century. Their reports addressed the
new directions of nursing education needed to take in the future. Although the three
organizations advocated somewhat different approaches and strategies, several common
themes emerged in their reports common emphasis included the following eight points.
These eight areas of emphasis remain as important today as they were first identified in
1993.
1. Schools should recruit diverse students and facilities that reflect the multicultural nature of
society.
2. Curricula and learning activities should develop student’s critical thinking skills.
3. Curricula should emphasize student’s abilities to communicate from interpersonal families
and inter disciplinary colleagues.

44
4. The number of advanced practice nurses should be increased and curricula should
emphasize health promotion and health maintenance skills for all nurses.
5. Emphasis should be placed on community–based care increased accountability state of the
art clinical skills and increased information management skills.
6. Cost effectiveness of care should be focus in nursing curricula.
7. Faculty should develop programme that facilitate programme articulation and career
mobility.
8. Continuing faulty development activities should support excellence in practice teaching
and research.
Nursing education has moved ahead from what it was in the beginning to what it
is, B. Sc, PB BSc, MSc, PhD and the post- doctoral programmes. There are numerous
websites which gives the number of Universities, nursing colleges and programmes in India.
It has become mandatory to update oneself to be in a position to complete in a country of
numerous opportunities and to keep abreast with the changes in education and technology.
In the future, more than ever, nurses will need a broad-based education, assertiveness skills,
technical competence, and the ability to deal with rapid change. The knowledge and
technology used in providing nursing care will continue to increase, as will nurses’ need for
skill and ability in:
 Intensively acute aspects of care.
 Diagnostics and decision-making.
 Client teaching.
 Coordination and delegation to less-skilled workers.

 Nursing service-

It has provided leadership opportunities and these have to be chanelised appropriately to get
the things done for the benefit of the patient and provide quality health care that is affordable
by the patient with the advent of specialist. Nurses as pain control nurse, infection control
nurse, skin care nurse and diabetic educator nurse have a wide range of expanded roles. This
also involves proper use the nurses’ time in providing health care services rather than being
caught up in the web of looking into only the environmental factors of the agency.
The advancements in telemedicine will change the way nurses function, and lead to the
development of new nursing roles. As consumers become more educated about health

45
promotion, there will be an elevated demand for quality care and alternative and
complementary healthcare choices.
Nurses will be involved in decisions regarding helping patients seek alternative therapy
solutions. Nursing practice will expand to include education about alternative therapy
choices.
 Achievements in medicine has resulted in longer life expectancies and changes in views
on end-of-life and palliative care. The promotion of advanced directives, organ donation,
and comfort measures for the terminally ill will lead to elevation in hospice care
providers. Care modalities, which include pain management, spiritually assessment and
bereavement counselling will be incorporated into health care organizations and nursing
education curriculums. In the future freed from endless paperwork, they will have much
time to devote to patients.
 Nurses will spend considerably more time as health teachers. Since the entire population
of the country is becoming much better educated, most patients will be able to act as
intelligent collaborators in their health care instead of as passive recipients of attention.
 The relationship between physicians and nurses will take on new dimensions. As nurses
become better educated, the knowledge gap between nurses and physicians will decrease.
As a result, nurses will be capable of working as close collaborators with the physicians
on the clinical designs of patient care.
 In the future all the nurses will be expected to have clinical investigative ability.
Relatively few nurses will be full-time researchers, but application of the scientific
method to problems of practice will be common place. The clinical management of each
and every patient will take the form of a mini-research design.
 Nurses and physicians will collaborate in programs to prevent illness and maintain health
rather than seek patients only when they are ill. Advanced technology will enable
patients to receive much of their care in their homes. Telemetry, sensoring devices and
the richer preparation of providers will make this feasible. This development too will
require that nurses be prepared at much higher levels because they will be working as
solo practitioners in the patient’s home.
On site Nurse in Senior Housing- Many senior don’t need round the clock nursing care, but
do need some nursing supervision. Senior housing communities often have an on-site nurse
who is available in case of an emergency. The nurse on site will also often consult with
doctors to help and manage any medical care that they need.

46
Regents Blue Ribbon Task Force on the future of Nursing- In April 2001, New York
State Board of Regents named a Blue Ribbon Task Force on Future of the Nursing, chaired
by Regent Diane. The Regents Blue Ribbon Task Force has a critical role in addressing the
current nursing shortage, solutions to the problem and the long term future of nursing. The
leaders from education, health care government were the members of the Task Force. The
task force has released their findings and recommendations for resolving those looming
health care crises.

 The task force recommends the following solutions to the nursing shortage.

Recruitment- Expand the nursing workforce by recruiting additional numbers of men, non-
practicing nurses and recent high school graduates.
Education- Provide additional academic and financial support systems to increase and pool
of nursing school graduates and creates career leaders.
Technology- Increase the application of labor saving technology to eliminate unnecessary,
duplicative paper work and communication of patient information, thereby improving
workplace conditions.
Data Collection- Develop a reliable central source of data on the future need for nurses in the
workforce upon which employers, policy makers, researchers and legislators may base pubic
policy and recourse allocations.
Clarify existing laws and regulations (Scope of practice for Nurses)- Issue practice
guidelines to clarify the legal scope of practice of nursing including those tasks which do not
require licensure. These guidelines will reaffirm the individual practitioner’s responsibility
for patient care.

 Nursing administration-

It involves making policies and promoting the betterment of health care by being a
member of the committee within the organization and also interacting with other
organizations to bring out positive changes. Proper job description and job satisfaction will
make the work of a nurse easier and for other health care professionals to know what to
expect from the nurse.
 Role in Planning: Perhaps this is the most significant role for the future for which
nurse must be prepared in her responsibility in the planning forum of healthcare
47
 delivery. Much nursing in the past had been of clinical services. Now the nurse
manager is well-prepared to assume leadership and take responsibility for making key
decisions in groups.
 Transitions of illness to health: In the past, nurses have been exposed to patients when
illness has occurred already. A major responsibility of the nursing in the future will be
to focus on preventing illness, maintaining health and changing those life conditions
that have contributed to illness. But the significant change in the delivery system is
the slow social transformation away from focusing on illness towards focusing on
health or wellness. Nurse can play a major role in providing services that maintains
health. Participating in that transitions will be an important part of the leadership role
of nursing in the future.

 Nursing research-
Nursing research with its small beginning now has moved a long way in which nursing
research is being done as a small project in the BSc nursing and a lot of individualized
research activity is being carried out at the master level. Institutional researcher and
collaborative research have also been started on a small scale but the findings of the research
has to be disseminated and put into practice with the permission of the organization.

CHALLENGES FOR FUTURE:-

 Placement in terms of education or experience both to be given their due importance.
 Overcoming the concept of “A Nurse is a nurse is a.....” – identifying resources and
approximately demonstrating competencies.
 Uniformity of entrance into education and service to overcome discrepancies.
 Placement, position and promotion based on the capacity, education and skills and
efficiency.
 Research dissemination and application with due importance to the findings rather than
to the methodology.
 Joint research, sponsorship, institutional research with co-operational among the
members.
 Increase in Indian authors and publications of nursing literature to be
encouraged.

48
 There are numerous challenges facing nursing from both within and outside and as a
member of this group. It becomes nurses’ duty to take up the relay in launching nursing
further ahead with the right fuel of efficiency, co-operation, evidence based practice in
order to meet the changing needs of the society, health care, private and public players,
economy and the government.

NURSING’S CHANGING HEALTH CARE ROLE:-

As nursing’s transition from an illness-care orientation to health promotion and health
maintenance increases, and as future health needs begin to surface, new
perceptives are need.

 A changing health care role requires that nursing meet its societal responsibilities by
orienting nurses to their evolving health care role.
 As identified in the definition of nursing addressed in the ANA’S societal policy
statement of human resources to actual or potential health problems.
 Once nurse accept this social mission, they should be able to articulate what
contributions nursing makes to the health care of individuals, regardless of their health
state.
 To assume responsibility for assessing the health status of people within society will
require a greater nursing knowledge and more skilful nursing practice than previously
processed by practicing nurse.
 The challenge to nurses will be to translate nursing’s specific knowledge base in to
innovative ways to provide nursing care in promoting and maintaining health.
 Specialization in nursing will undergo many changes, as new speciality areas are
developed from nursing diagnostic classifications, such as anxiety, pain,
oncological, burn chronicity, cardiovascular and respiratory categories.
 The increases of chronic illness and an aging population will lead to greater involvement
of future professional nurses in long-term care of the elderly in various stages of health.
 Nurses will care for clients in their homes, ambulatory health clinics, nursing homes,
hospitals, day care, wellness centers and other extended care facilities.

IMPACT OF NURSING RESEARCH ON FUTURE NURSING PRACTICE:-

49
Nursing research is essential to produce a specific theoretical knowledge base that
professional nurses can use to provide quality nursing care for individuals with critical or
chronic illness or for people seeking health promotion and health maintenance services.
Over the next two decades, nursing research will increase their efforts to apply research will
increase their efforts to apply research findings to nursing practice .As nurse
researchers and nurse clinicians interact and collaborate with one another, research findings
will be utilized and nursing practice will be greatly improved.

IMPACT OF SOCIAL TRENDS ON NURSING:-

Social trend shave improved greatly in the recent years. This has been the most influential
system which has been growing in the recent years. According to the upgradation of the
society the nursing profession has been changing in the past few years. Changes in the
society, culture, traditions and technology advancements have become more and more
triggering factors in the improvement of the nursing profession.

TECHNOLOGICAL ADVANCEMENT TECHNOLOGY CHANGED THE

NURSING:-
Technology has facilitated change and improvements in health care at a more rapid pace than
ever before with each passing year, the pace of that change and accumulation of knowledge
increase exponentially. Nurse now tends to be specialists rather than generalists because the
equipment they use is so specialized. In addition, computers have helped tremendously
because they have taken away the need for nurses to remember so much information. They
also allow nurses to check information against orders, which makes providing health care
safer advanced monitoring tools have improved efficiency. Technology can make it more
challenging to make sure the art of nursing in not over-shadowed by science. If we merely
take care of the physical person and miss the target in the spirit of the person we fail as a
profession.
 Telemedicine:- The concept of telemedicine was introduced more than 30 yrs ago through
the use of telephone and slow-scan games. The term telemedicine in short refers to the
utilization of telecommunication technology for medical diagnosis, treatment and patient
care. Telemedicine is a rapidly developing application of clinical medicine where medical
information is transferred via telephone, the internet or other networks for the purpose of
consulting and sometimes remote medical procedures or examinations. Telemedicine
enables a physician or specialist at on one site to deliver health care, diagnose patients,

50
 give intra-operative assistance, provide therapy or consult with another physician or
paramedical personnel at a remote site. Telemedicine system consists of customized
medical software integrated with computer hardware, along with medical diagnostic
instruments. The great impact of telemedicine may be in fulfilling its promise to improve
the quality, increase the efficiency and expand the access of the health care delivery
system to the rural population and developing countries.
 Telehealth Nursing: Telehealth Nursing is generally not a separate nursing role. Few
nurses use telehealth exclusively in their practices. Nurses have always used the telephone
to communicate with physicians, patients and other health care providers. Today's
technologies have evolved far beyond the telephone to include computers, interactive
audio and video linkages, teleconferencing.
Telehealth is defined as "the removal of time and distance barriers for the
delivery of health care services and related health care activities through
telecommunication technology". The goals of healthy people 2010 include eliminating
health disparities among population & improving quality of life and life expectancy. Many
health disparities occur because of barriers such as geographic location e.g. rural
population’s experiences greater health disparities, age that creates health disparities
because of limited health care access, home bound status & transportation issues. The use
of telehealth expands access to health care for underserved populations and individuals in
both urban and rural areas. It also serves to reduce the sense of professional isolation
experienced by those who work in such areas and may assist in attracting and retaining
health care professionals in remote areas.
 Impact of Telehealth on Patient outcomes: Telehealth use in home health care opens
the door for direct communication between the patient and the provider by integrating
information and technology to facilitate health care delivery. Telehealth essentially
removes time and distance barriers via videophones, video camera and sensory
monitoring devices. The telehealth contributes to positive outcomes in terms of self
management and compliance.
 Robot Nursing: Human nurses can have peace of mind. Their jobs are secure but little
helper has come to rescue to do most of the boring nursing tasks for them.
Robot-Nurse helps nurses in hospitals. Her body is developed by Samsung and her brain
by Robot-Hosting.com. The nursing school and the psychology departments of the
University of Auckland are creating her nurse knowledge base. She has face recognition
(Camera), voice recognition (Microphone), arms and hands. She talks (Speaker) with the
51
 Patients, Doctors and Nurses in 8 human languages. Another responsibility is talking
with those patients who do not have any visitor to keep their company, carry the
conversation to make them happy. Therefore they will not feel lonely.

FUTURISTIC CYBER NURSING

When you arrive at work, your I.D. tag is automatically detected and you are clocked in
as you walk through the door.
• The patient is being monitored by automatic vital signs.
• You do your assessment verbally into your hand held device that converts it to readable
notes on the computers' main system.
• At patient’s bed side, you can get chemistry, hematology with a small hand held device
that requires no blood drawn. You just place the sensor on the patient’s skin and you
have auto results.
• You verbalize your order into the hand held which goes directly to pharmacy which
fills the orders automatically directly to patient's room.
• Most diagnosis will have a system for auto care plans upon patient admission.
• Patients have a bedside computer to access educational tools and progress of their
recovery or stay.
• Nurses getting laptops and using intranet to do their jobs. This is a way to spend more
time with patients and less time for doing paperwork.

EFFECTS OF COMPUTERIZED TECHONOLOGY ON NURSING’S FUTURE:-

 Computer terminals located in nursing units in hospitals are revolutionizing nursing
functions and reducing the time needed to order medications and supplies from
pharmacy, to transcribe and implement medical regimens, and as mentioned previously,
to develop and use computerized care plans.
 Computer located in patient units in hospitals are providing easy access for caregivers in
decision-making and in acquiring more effective communication.
 Computer networking for nurse administrators can save time, with interoffice
memoranda computerized and transmitted to other officers with in hospitals or university
campuses and transmitted to other offices, thus providing the capability for
receiving feedback in far less time than in previous systems.

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 EDUCATION OF FUTURE PRACTITIONERS FOR A CHANGING
HEALTH CARE SYSTEM:-
 Nurse educators responsible for preparing tomorrow’s nurses for professional nursing
practice must prepare them for a future that can only be vaguely envisioned in this present
decade.
 Professional nurses are assuming more complex responsibilities for health care than ever
before.
 The burden on nurse educators to predict health care needs and to prepare nurses for a
world of nursing vastly different from that of the present period challenges them to be risk
takers and leaders if they are to move nursing forward with vision and confidence.

WHAT LIES AHEAD IN THE FUTURE:-

In the coming future, there will be changes in the nursing scenarios as well as the technologies
used in the nursing. We can expect to use more of the technologies that are made available
recently and this will later on uplift the profession and also the society in the future.

Evidence Based Practice in Quality Improvement:

Topic- Nurses’ Practices and Lead Selection

in Monitoring for Myocardial Ischemia
An Evidence-Based Quality Improvement Project
Authors- Blakeman, John R. BSN, RN; Sarsfield, Katherine BSN, RN; Booker, Kathy J.
PhD, RN, CNE
Dimensions of Critical Care Nursing: July/August 2015 - Volume 34 - Issue 4 - p 189-195
doi: 10.1097/DCC.0000000000000118

Abstract

Background: 
The 5-lead electrocardiogram (ECG) provides key information, including clues that a patient
may be experiencing myocardial ischemia, usually demonstrated in the ST segment. Studies
have shown that nursing knowledge regarding ischemia monitoring is suboptimal, even
though national guidelines for ECG monitoring were published in 2004 by the American
Heart Association and endorsed by the American Association of Critical Care Nurses.

53
Purpose: 
The aims of this study were to identify best practice regarding 5-lead
ECG myocardial ischemia monitoring, assess current unit-level practice at 1 institution, and
to educate nurses on proper monitoring using a nurse-led, evidence-based intervention.
Methods: 
The authors created an educational PowerPoint designed to educate nurses on proper lead
selection to monitor the ST segment for patients admitted with known or
suspected myocardial ischemia and developed a 3-part online survey to assess current unit
practice and to assess knowledge before and after intervention.
Results: 
A total of 18 registered nurses (RNs) completed the survey. Results indicated that RNs lacked
knowledge regarding continuous ECG monitoring for ischemia and had room for
improvement in their everyday practice habits. The knowledge preintervention test mean
score (out of 9) was 3.11 (SD, 1.68), and the postintervention test mean score was 6.94 (SD,
1.55), which was significant (P = .000). The intervention also significantly improved
the monitoring comfort level of RNs, with a preintervention comfort level of 2.53 (SD, 1.07)
and a postintervention level of 3.41 (SD, 1.00) (P = .007). The process allowed the authors to
reflect on the key steps of implementing evidence-based projects in nursing units.
Conclusions: 
Continuous, 5-lead ECG monitoring is an active process that requires clinical decision
making by the nurse and is not a passive activity. Registered nurses in this sample
demonstrated a lack of knowledge regarding ECG monitoring for ischemia that was improved
with an online educational intervention and reported intentional daily practice pattern
changes postintervention testing. A unit-level intervention driven by nurses may be
successful at improving fellow RNs’ knowledge and evidence-based practice.

RELATED RESEARCH ARTICLE

Title:- Quality assurance A key to success in nursing: an overview
Author:- Suganya Panneerselvam
Abstract
Quality assurance is now a major consideration for providers of goods and services in the
society especially in service industries of higher education and the health services. Nursing, a
human-caring profession, is a complex, complicated and coordinated process of interpersonal
interactions, individual-system relationships and group, cultural, political and social
community connections that must ensure quality assurance in the training of those who are
the providers of goods and services to their service recipients. Nursing education contain a
variety of disciplines from the formal, academic to the impromptu learning and teaching. The
maintenance of quality in higher education and nursing education is a corporate responsibility
involving both academic and support staff. This paper looked at quality assurance in nursing
education and how this important process can be evaluated in a three-dimensional focuses
viz: structure evaluation, process evaluation and outcome evaluation. The research seeks to
show how quality assurance can provide a holistic health-care service in this technologically
advanced age of the 21st century.

54
 CONCLUSION

As health promotion and wellness become a national priority, nursing has begun
to confidently enunciate its specific focus and mission. Perspectives on future health care

55
delivery indicate that nursing’s traditional role in hospital nursing will be substantially
altered. Now that the public is beginning to seek alternative, non-institutional
settings for health care, the potential for nursing, particularly in community health centres,
nursing homes and home health care, far exceeds what was envisioned ten or fifteen years
ago.

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 BIBLIOGRAPHY

1. Basavanthappa BT; Nursing Administration; Jaypee Brothers Medical Publishers (P)

Ltd; New Delhi; Second Edition; Pages-714-732.
2. Brar Navdeep Kaur, Rawat HC; Textbook of Advanced Nursing Practice; Jaypee The
Health Sciences Publisher; New Delhi; Pages 76-91, 97-104.
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