Development of Clinical Practice Standards for Nurses Joyce Waterman Taylor, R.N., M.S.N., F.A.A.N.* Kaiser Permanente
Hospital, Fontana, California 92335
Nursing, with leadership from the American Nurses Association (ANA), has a long-standing commitment to the development of standards. The first nursing practice standards were published in 1973. Since that time, both the ANA and specialty nursing organizations have developed standards. However, the proliferation of standards, reflecting a wide divergence of intent, format, and scope, has limited their usefulness. In 1989, the ANA appointed a Task Force (now a Committee) to address this issue. The Committee, working with representatives of the spe-
(JCAHO), and with various governmental agencies (2). Along with physicians, nurses provide the major share of health care services in all settings. Nurses form the largest body of health care providers, with more than 1.6 million registered nurses employed in hospitals, clinics, home care agencies, public health departments, schools, industries, the armed services, and, in fact, wherever health care is delivered, including, these days, the streets and shelters for the home-
cialty nursing organizations, has developed a framework for development of both nursing practice stand-
It has been stated that the decade of the sixties was characterized by government spending for health care without interference with the health care system. The decade of the seventies was an era of increasing regulation of health care services designed to control the costs generated during the sixties (1). Yet we are all too painfully aware that the decade of the eighties saw both increasing health care costs and decreasing satisfaction with the quality, availability, and costs of health care. With the specter of ever-increasing regulation and the determined efforts of regulatory bodies to control spiraling costs, it is imperative that health care providers join what we cannot fight, in order that the
hospitals, where
they
account for
some
HISTORICAL PERSPECTIVE
not accomplished at the exand effectiveness. The American Medical Association has recognized this fact and is paying increased attention to cooperative efforts with its own specialty organizations, with the Joint Commission on Accreditation of Healthcare Organizations
necessary pense of
less. In
the majority of nurses work, 30% of the hospitals operating expenses. With the recognition of a national &dquo;shortage&dquo; of nurses and the resultant salary increases, nurses are becoming an increasingly expensive item in the health care budget. If these added costs are to be justified, nurses must be able to demonstrate that the services they perform are not only ef fectiue but are cost-effective. Can we show that public health nurses, school nurses, and home health nurses keep people out of expensive hospital beds? Can we prove that hospital nurses can lower the length of stay, and through rehabilitative nursing techniques prevent or reduce readmissions and institutionalization in longterm care facilities? It is in this context that the discussion of nursing standards has relevance.
ards and guidelines. Standards and guidelines are defined and differentiated. The relationship of standard and guidelines development to the federal government’s effectiveness initiative is discussed.
cost-cutting is
Since early in the 1960s the ANA has been actively engaged in the development and promulgation of nurs-
quality
ing standards. The earliest standards addressed the organization of nursing services (structure standards) (3). The first standards of nursing practice were published in 1973 by the ANA (4) and focused on the nursing process (process standards). Since that time, many groups and organizations have developed standards of practice, some in collaboration with ANA and some independently (4). Initially, standards of practice, regardless of origin,
* To whom requests for reprints should be addressed at 8265 Alston Avenue, Hesperia, CA 92345. This article is based on a presentation made on behalf of the American Nurses Association Committee on Nursing Standards and Guidelines.
72
Downloaded from ajm.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015
73 tended to follow the format of the original ANA standards with modifications of content believed to be specific to the particular specialty group or patient population (4). In 1982, however, the ANA Council on Psychiatric and Mental Health Nursing followed a new format, including structure, process, and outcome criteria. Two categories of outcome criteria were presented : nurse-centered outcomes and patient-centered outcomes (4). The new format was subsequently used by a number of other councils and specialty groups. Beginning in 1983, with the &dquo;ANA Outcome Standards for Rheumatology Nursing Practice,&dquo; several specialty groups (some in conjunction with ANA) wrote standards that focused on patient outcomes related to specific nursing diagnoses (4). In addition to the professional nursing practice standards, many organizations also developed professional performance standards, which focused on the behaviors expected of the nurse, including such things as
collaboration, continuing education,
peer
review,
and research (4). As the ANA and the various specialty organizations developed and promulgated standards, these and others specific to an institution were increasingly used as criterion measures for quality assurance programs within agencies (5). Furthermore, the ANA and other nursing groups have been heavily involved in the process by which JCAHO accreditation standards are
developed. Anticipating the increased role of the federal government in exploring the effectiveness and financing of health care in the 1990s, the ANA Cabinet on Practice (now known as the Congress on Nursing Practice) appointed a Task Force on Nursing Practice Standards and Guidelines in August 1989. The charge to the task force was, in essence, to explore current health care quality assurance activities and to define the nature and purpose of standards of practice for nursing and their relationship to quality assurance activities, specialization in nursing, credentialing, and information systems (6). The initial report of the Task Force, in the fall of 1989, identified a number of issues and concerns that had arisen as a result of the rapid proliferation and evolution of standards within the profession (6). These included: ~ Lack of consistency in the process by which the profession develops standards ~ Proliferation of standards of nursing practice ~ Wide range in the intent, format, and scope of current standards ~ The number and divergent approaches used in current standards which limit their use by nurses, other health care providers, payers, policy makers, and consumers for use in a variety of activities
such
as
ment
broad based quality assurance, reimburse-
schemes,
etc.
with these concerns in mind that, from the outset, the Task Force recognized the need to involve a broad spectrum of nurses in the process of carrying out their charge. As part of the very first Task Force meeting in August 1989, leaders from ANA practice councils and from nursing specialty organizations were invited to participate. Some 30 groups responded It
was
and sent
meeting
representatives to a one-day provide input into the work of the Task
one or more
to
Force. The first draft of the Task Force report was sent out for field review to ANA constituents and specialty organizations. The generally positive response was evidence of wide support for the need to develop a common and unified approach to the development of nursing practice standards. However, even as the responses were coming in, changes in the external environment resulted in a reassessment of the initial recommendations (6). ANA had been approached by the new federal Agency for Health Care Policy and Research (AHCPR) and had convened a conference of key nursing leaders to further define nursing’s role in the development of public policy in regard to the effectiveness and costs of health care. A panel of nursing leaders convened to provide input into AHCPR’s guideline development and the effectiveness initiative. Based on recommendations from these groups and additional joint meetings with the councils and specialty groups, the report of the Task Force has been revised several times, most recently in November 1990. That report has been officially approved by the Congress on Practice and the ANA Board of Directors and is currently being forwarded to the various specialty organizations for their consideration. In August 1990, the Task Force was made a standing committee of the Congress on Nursing Practice, charged with the responsibility for implementing its own recommendations.
RECOMMENDATIONS OF THE TASK FORCE The final report (6) of the Task Force (hereafter to be called the Committee) recommended the on-going development and promulgation of both standards and guidelines for nursing practice, and it proposed a framework for the coordination of activities between the ANA, the ANA Councils, and the various specialty organizations (the unified voice of nursing). Standards and guidelines differ primarily in their scope and intent.
Downloaded from ajm.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015
74 Standards
Framework for Standards and Guideline
Development The scope of standards is broader than that of
guidelines and applies to the care of all patients/ clients wherever they are served. Standards of Nursing Practice (Table 1) have two components: (1) standards of
care
focused
on
the
nursing process and (b) standards of professional performance which focus on the professional behaviors of the
nurse.
Guidelines
unlike standards, are develclinical conditions or problems. Universal Guidelines address those nursing diagnoses common to all (or most) of nursing such as pain, skin integrity, etc. Specialty Guidelines address specific clusters of phenomena unique to the practice of that specialty or diagnoses treated differently by that specialty.
Guidelines (Table 2), oped around particular
Table 1
Standards of Care
The Committee envisions that the development of nursing practice standards and guidelines will continue to be a joint endeavor of ANA (through the permanent Committee on Nursing Practice Standards and Guidelines), the ANA Councils on Practice, and the specialty organizations. The Committee will be responsible for developing standards with criteria to measure achievement. Councils and specialty organizations would have responsibility for modifying the criteria to apply to their specific areas of practice. Similarly, the Committee will be responsible for developing the format and process for guidelines and for overseeing and coordinating the development of universal guidelines. Councils and specialty nursing groups would then develop specialty guidelines, using a standardized format and process.
ANA will create and maintain a repository or bank containing all of the standards and guidelines. Specialty practice criteria and guidelines will feed into the universal criteria and guidelines so that overlap and duplication can be avoided. The bank will be accessible to nurses, other health care providers, governmental agencies, third-party payers, and others who may need the information. Thus, the standards and guidelines may serve as the basis for: .
Quality
assurance
systems
’ Data base systems .
. .
Regulatory systems Health care reimbursement/financing systems Planning, organizing, and evaluating nursing service delivery systems/organizational structures
Certification activities · Job descriptions, performance appraisals; institutions/agencies specific policies and procedures . Educational offerings ANA is also cooperating with federal government initiatives designed to improve the cost effectiveness of medical care. The new Agency for Health Policy and Research (AHCPR), through the Medical Treatment Effectiveness Program (MEDTEP) is responsible for (a) developing and updating practice guidelines used to manage clinical conditions and (b) data base development, effectiveness and outcomes research, and dissemination of findings. The Nursing Advisory Panel (mentioned previously) assures nursing input into these activities. The first sets of guidelines selected for development contain several that are primarily responsive to nursing interventions (7): cataracts, benign prostatic hy.
Table 2 Practice Guidelines
Downloaded from ajm.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015
75
pertrophy, incontinence, pain, skin integrity, depression, and AIDS. ANA has recommended expert nurses to serve on each of these panels, and nurses have been appointed to co-chair the panels on incontinence, pain, and skin integrity. LOOKING AHEAD As we move into the decade of the nineties, nursing is positioning itself to be able to identify the elements of health care that are particularly sensitive to nursing interventions and to participate in the multidisciplinary efforts to reduce the burgeoning health care costs, while protecting the public’s right to quality care. Thus, nursing in the years ahead will be involved in health care policy development and funding for health
directed nursing research to relate nursing pracpatient outcomes, development of a nursing data base and a uniform classification system, and standard and guideline development. care,
see continued pressure to lower costs and to face the prospect of increasing governmental regulation. As health care providers, we must continue to provide quality services to our patients even as we provide leadership in the development of standards and guidelines that will facilitate the evaluation of more costeffective treatment modalities.
to
References
1. American Nurses Association. A Social 2.
3. 4.
tice to
CONCLUSION It is indeed a challenging time to be a health care provider. In the decade of the nineties, we must expect
5. 6.
Policy statement. ANA, 1980, pp. 5-6. Kelly T, Swartwout JE. Development of practice parameters by physician organizations. Qual Rev Bull 1990;16:54-57. American Nurses Association. Standards for Organized Nursing Services. ANA, 1965. McGuffin B, Mariani M. Clinical nursing standards: Towards a synthesis. J Nurs Qual Assur 1990;4(3):35-45. Green E, Katz J. Innovations and excellence. J Nurs Qual Assur 1990;4(4):75-85. American Nurses Association. Task Force on Nursing Practice Standards and Guidelines: Working Paper. November 1990. Unpublished.
7. O’Connor K. Effectiveness and outcomes of health care services: Implications for nursing. Final Report Project funded by Agency for Health Care Policy and Research (AHCPR) Grant Number 1 R13 HS 06662-02. 1990. Unpublished.
Downloaded from ajm.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015
Hospital, Fontana, California 92335
Nursing, with leadership from the American Nurses Association (ANA), has a long-standing commitment to the development of standards. The first nursing practice standards were published in 1973. Since that time, both the ANA and specialty nursing organizations have developed standards. However, the proliferation of standards, reflecting a wide divergence of intent, format, and scope, has limited their usefulness. In 1989, the ANA appointed a Task Force (now a Committee) to address this issue. The Committee, working with representatives of the spe-
(JCAHO), and with various governmental agencies (2). Along with physicians, nurses provide the major share of health care services in all settings. Nurses form the largest body of health care providers, with more than 1.6 million registered nurses employed in hospitals, clinics, home care agencies, public health departments, schools, industries, the armed services, and, in fact, wherever health care is delivered, including, these days, the streets and shelters for the home-
cialty nursing organizations, has developed a framework for development of both nursing practice stand-
It has been stated that the decade of the sixties was characterized by government spending for health care without interference with the health care system. The decade of the seventies was an era of increasing regulation of health care services designed to control the costs generated during the sixties (1). Yet we are all too painfully aware that the decade of the eighties saw both increasing health care costs and decreasing satisfaction with the quality, availability, and costs of health care. With the specter of ever-increasing regulation and the determined efforts of regulatory bodies to control spiraling costs, it is imperative that health care providers join what we cannot fight, in order that the
hospitals, where
they
account for
some
HISTORICAL PERSPECTIVE
not accomplished at the exand effectiveness. The American Medical Association has recognized this fact and is paying increased attention to cooperative efforts with its own specialty organizations, with the Joint Commission on Accreditation of Healthcare Organizations
necessary pense of
less. In
the majority of nurses work, 30% of the hospitals operating expenses. With the recognition of a national &dquo;shortage&dquo; of nurses and the resultant salary increases, nurses are becoming an increasingly expensive item in the health care budget. If these added costs are to be justified, nurses must be able to demonstrate that the services they perform are not only ef fectiue but are cost-effective. Can we show that public health nurses, school nurses, and home health nurses keep people out of expensive hospital beds? Can we prove that hospital nurses can lower the length of stay, and through rehabilitative nursing techniques prevent or reduce readmissions and institutionalization in longterm care facilities? It is in this context that the discussion of nursing standards has relevance.
ards and guidelines. Standards and guidelines are defined and differentiated. The relationship of standard and guidelines development to the federal government’s effectiveness initiative is discussed.
cost-cutting is
Since early in the 1960s the ANA has been actively engaged in the development and promulgation of nurs-
quality
ing standards. The earliest standards addressed the organization of nursing services (structure standards) (3). The first standards of nursing practice were published in 1973 by the ANA (4) and focused on the nursing process (process standards). Since that time, many groups and organizations have developed standards of practice, some in collaboration with ANA and some independently (4). Initially, standards of practice, regardless of origin,
* To whom requests for reprints should be addressed at 8265 Alston Avenue, Hesperia, CA 92345. This article is based on a presentation made on behalf of the American Nurses Association Committee on Nursing Standards and Guidelines.
72
Downloaded from ajm.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015
73 tended to follow the format of the original ANA standards with modifications of content believed to be specific to the particular specialty group or patient population (4). In 1982, however, the ANA Council on Psychiatric and Mental Health Nursing followed a new format, including structure, process, and outcome criteria. Two categories of outcome criteria were presented : nurse-centered outcomes and patient-centered outcomes (4). The new format was subsequently used by a number of other councils and specialty groups. Beginning in 1983, with the &dquo;ANA Outcome Standards for Rheumatology Nursing Practice,&dquo; several specialty groups (some in conjunction with ANA) wrote standards that focused on patient outcomes related to specific nursing diagnoses (4). In addition to the professional nursing practice standards, many organizations also developed professional performance standards, which focused on the behaviors expected of the nurse, including such things as
collaboration, continuing education,
peer
review,
and research (4). As the ANA and the various specialty organizations developed and promulgated standards, these and others specific to an institution were increasingly used as criterion measures for quality assurance programs within agencies (5). Furthermore, the ANA and other nursing groups have been heavily involved in the process by which JCAHO accreditation standards are
developed. Anticipating the increased role of the federal government in exploring the effectiveness and financing of health care in the 1990s, the ANA Cabinet on Practice (now known as the Congress on Nursing Practice) appointed a Task Force on Nursing Practice Standards and Guidelines in August 1989. The charge to the task force was, in essence, to explore current health care quality assurance activities and to define the nature and purpose of standards of practice for nursing and their relationship to quality assurance activities, specialization in nursing, credentialing, and information systems (6). The initial report of the Task Force, in the fall of 1989, identified a number of issues and concerns that had arisen as a result of the rapid proliferation and evolution of standards within the profession (6). These included: ~ Lack of consistency in the process by which the profession develops standards ~ Proliferation of standards of nursing practice ~ Wide range in the intent, format, and scope of current standards ~ The number and divergent approaches used in current standards which limit their use by nurses, other health care providers, payers, policy makers, and consumers for use in a variety of activities
such
as
ment
broad based quality assurance, reimburse-
schemes,
etc.
with these concerns in mind that, from the outset, the Task Force recognized the need to involve a broad spectrum of nurses in the process of carrying out their charge. As part of the very first Task Force meeting in August 1989, leaders from ANA practice councils and from nursing specialty organizations were invited to participate. Some 30 groups responded It
was
and sent
meeting
representatives to a one-day provide input into the work of the Task
one or more
to
Force. The first draft of the Task Force report was sent out for field review to ANA constituents and specialty organizations. The generally positive response was evidence of wide support for the need to develop a common and unified approach to the development of nursing practice standards. However, even as the responses were coming in, changes in the external environment resulted in a reassessment of the initial recommendations (6). ANA had been approached by the new federal Agency for Health Care Policy and Research (AHCPR) and had convened a conference of key nursing leaders to further define nursing’s role in the development of public policy in regard to the effectiveness and costs of health care. A panel of nursing leaders convened to provide input into AHCPR’s guideline development and the effectiveness initiative. Based on recommendations from these groups and additional joint meetings with the councils and specialty groups, the report of the Task Force has been revised several times, most recently in November 1990. That report has been officially approved by the Congress on Practice and the ANA Board of Directors and is currently being forwarded to the various specialty organizations for their consideration. In August 1990, the Task Force was made a standing committee of the Congress on Nursing Practice, charged with the responsibility for implementing its own recommendations.
RECOMMENDATIONS OF THE TASK FORCE The final report (6) of the Task Force (hereafter to be called the Committee) recommended the on-going development and promulgation of both standards and guidelines for nursing practice, and it proposed a framework for the coordination of activities between the ANA, the ANA Councils, and the various specialty organizations (the unified voice of nursing). Standards and guidelines differ primarily in their scope and intent.
Downloaded from ajm.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015
74 Standards
Framework for Standards and Guideline
Development The scope of standards is broader than that of
guidelines and applies to the care of all patients/ clients wherever they are served. Standards of Nursing Practice (Table 1) have two components: (1) standards of
care
focused
on
the
nursing process and (b) standards of professional performance which focus on the professional behaviors of the
nurse.
Guidelines
unlike standards, are develclinical conditions or problems. Universal Guidelines address those nursing diagnoses common to all (or most) of nursing such as pain, skin integrity, etc. Specialty Guidelines address specific clusters of phenomena unique to the practice of that specialty or diagnoses treated differently by that specialty.
Guidelines (Table 2), oped around particular
Table 1
Standards of Care
The Committee envisions that the development of nursing practice standards and guidelines will continue to be a joint endeavor of ANA (through the permanent Committee on Nursing Practice Standards and Guidelines), the ANA Councils on Practice, and the specialty organizations. The Committee will be responsible for developing standards with criteria to measure achievement. Councils and specialty organizations would have responsibility for modifying the criteria to apply to their specific areas of practice. Similarly, the Committee will be responsible for developing the format and process for guidelines and for overseeing and coordinating the development of universal guidelines. Councils and specialty nursing groups would then develop specialty guidelines, using a standardized format and process.
ANA will create and maintain a repository or bank containing all of the standards and guidelines. Specialty practice criteria and guidelines will feed into the universal criteria and guidelines so that overlap and duplication can be avoided. The bank will be accessible to nurses, other health care providers, governmental agencies, third-party payers, and others who may need the information. Thus, the standards and guidelines may serve as the basis for: .
Quality
assurance
systems
’ Data base systems .
. .
Regulatory systems Health care reimbursement/financing systems Planning, organizing, and evaluating nursing service delivery systems/organizational structures
Certification activities · Job descriptions, performance appraisals; institutions/agencies specific policies and procedures . Educational offerings ANA is also cooperating with federal government initiatives designed to improve the cost effectiveness of medical care. The new Agency for Health Policy and Research (AHCPR), through the Medical Treatment Effectiveness Program (MEDTEP) is responsible for (a) developing and updating practice guidelines used to manage clinical conditions and (b) data base development, effectiveness and outcomes research, and dissemination of findings. The Nursing Advisory Panel (mentioned previously) assures nursing input into these activities. The first sets of guidelines selected for development contain several that are primarily responsive to nursing interventions (7): cataracts, benign prostatic hy.
Table 2 Practice Guidelines
Downloaded from ajm.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015
75
pertrophy, incontinence, pain, skin integrity, depression, and AIDS. ANA has recommended expert nurses to serve on each of these panels, and nurses have been appointed to co-chair the panels on incontinence, pain, and skin integrity. LOOKING AHEAD As we move into the decade of the nineties, nursing is positioning itself to be able to identify the elements of health care that are particularly sensitive to nursing interventions and to participate in the multidisciplinary efforts to reduce the burgeoning health care costs, while protecting the public’s right to quality care. Thus, nursing in the years ahead will be involved in health care policy development and funding for health
directed nursing research to relate nursing pracpatient outcomes, development of a nursing data base and a uniform classification system, and standard and guideline development. care,
see continued pressure to lower costs and to face the prospect of increasing governmental regulation. As health care providers, we must continue to provide quality services to our patients even as we provide leadership in the development of standards and guidelines that will facilitate the evaluation of more costeffective treatment modalities.
to
References
1. American Nurses Association. A Social 2.
3. 4.
tice to
CONCLUSION It is indeed a challenging time to be a health care provider. In the decade of the nineties, we must expect
5. 6.
Policy statement. ANA, 1980, pp. 5-6. Kelly T, Swartwout JE. Development of practice parameters by physician organizations. Qual Rev Bull 1990;16:54-57. American Nurses Association. Standards for Organized Nursing Services. ANA, 1965. McGuffin B, Mariani M. Clinical nursing standards: Towards a synthesis. J Nurs Qual Assur 1990;4(3):35-45. Green E, Katz J. Innovations and excellence. J Nurs Qual Assur 1990;4(4):75-85. American Nurses Association. Task Force on Nursing Practice Standards and Guidelines: Working Paper. November 1990. Unpublished.
7. O’Connor K. Effectiveness and outcomes of health care services: Implications for nursing. Final Report Project funded by Agency for Health Care Policy and Research (AHCPR) Grant Number 1 R13 HS 06662-02. 1990. Unpublished.
Downloaded from ajm.sagepub.com at SIMON FRASER LIBRARY on June 14, 2015
