Implementation of a National Nursing Standards Program Joni Congleton Ziegler, MSN, RN, CCRN Nancy K. VanEtten, MN, RN, CS At an annual nursing management conference of a multisystem hospital managementfirm,nursing executives expressed a need for developing nursing care standards. Because many of the hospitals were small or rural, they lacked some of the resources needed to develop such a program individually. Pooling resources so that all could benefit was an innovative and sensible approach. The authors describe the project that resulted in the development of a nation-wide standards program involving nearly 50 hospitals. Standards for nursing practice were first developed by the American Nurses Association in the 1970s in response to the need for the nursing profession to regulate itself.1 Subsequent standards of care were developed by specialty organizations, such as the American Association of Critical Care Nurses, the American Heart Association and NAACOG (The Organization for Obstetric, Gynecologic, and Neonatal Nurses). Standards of care define the level of care that a patient can expect to receive in a given situation or on a given nursing unit.2 These standards are the foundation of quality improvement programs.3 Allocation of resources, role-modeling of standards implementation, acceptance and support by administration, integration into quality improvement (QI), and maintaining an appropriate and up-to-date standards program are ways that institutions can foster staff recognition that standards are essential to patient care. The level of staff involvement in the development of standards is a predictor of the level of implementation of standards.4 The integration of standards of care into unit-based QI programs in The authors ate coowners of Q-Aide Systems, Inc., of Rye, Colorado, a management consulting firm specializing in standards development. This project was made possible through the vision and determination of Barbara Scott, MS, RN.

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the 1980s has facilitated the involvement of nursing staff in monitoring and evaluating patient care. Compliance with these activities is much more likely if it is based on standards that staff have developed and believe are representative of the care patients ought to receive. How does an organization prove that it is delivering safe, effective, and appropriate care?3 The answer is simpler than one might imagine. When written meaningful standards are established, implemented, and updated, quality is present. In other words, quality occurs when the organization can assure that things are happening the way it intends for them to happen. Without written standards, however, there can be no determination of quality because standards are the "yardstick" by which quality is measured.

The Needfor Nursing Standards The directors of an investor-owned, multisystem hospital management firm were convinced by the corporate nurse consultant and the client hospital nurse executives to provide the resources for a corporate-wide standards and quality improvement program. Before approval of the program, the nurse executives educated the corporate directors and their individual hospital administrators on nursing, nursing standards, and the need for standards development. The corporate executives soon realized the long-term benefits of assisting their clients to provide quality care through staff nurse involvement in a standards development program. Nursing executives today have become true management specialists. As specialists, they have the responsibility for developing and advancing nursing management and staffing systems to optimize the use of personnel while dealing with a growing shortage of professional nurses. At an annual corporate nursing conference, nursing execuJONA • Vol. 22, No. 11 • November 1992

tives expressed a tremendous amount of interest in the development of nursing care standards among the firm's hospitals. Because many of the hospitals were small or rural, they lacked some of the resources needed to develop such a program individually. Pooling resources so that all could benefit was an innovative and sensible approach.

The introUiiction of anew and comprehensive program for nursing standards required change at all levels of the organization, from the corporate principles to the nursing staff at individual hospitals. Through the efforts of the nurse executives, the corporate nurse, and outside consultants specializing in nursing standards, the firm's executives became convinced that there was a solidified need to redefine nursing work to effectively address quality patient care issues. They also realized the effect that a national, corporate standards program would have on productivity, recruitment, retention, and work relationships. The development of nursing standards was considered to be an operational imperative, and with that in mind, corporate executives embarked on a project that would result in the establishment of a multifaceted support system for all of their client hospitals. Forty-seven hospitals participated in the project representing a majority of the firm's client hospitals. Participation was voluntary. Project participants developed and implemented 70 standards of care. The project involved a tremendous amount of data collection, analysis, education, and coordination. Presented in this article are the methods and data and the results and organization of a multihospital, national standards project.

Project Evolution Before we could plan the project from beginning to end, we needed to have certain information that was not available in the nursing literature at the time. We asked ourselves: 1) What information is necessary to develop a nursing standards project for multiple hospitals nationwide? 2) What, if any, are the commonalities among the group of hospiJONA • Vol. 22, No. 11 • November 1992

tals that would enable the success of such a project? 3) How should the project be developed, structured, and implemented so that each participating hospital benefits equally? Theoretical Framework The primary theoretical framework we used during the project was change theory. The introduction of a new and comprehensive program for nursing standards required change at all levels of the organization, from the corporate principles to the nursing staff at individual hospitals. Lancaster and Lancaster describe this type of change as deliberate and conscious with a defined purpose of adjusting a system to meet a certain demand.5 Planned change consists of the identification of mutually defined areas in which change is needed, implementation of the change process, and evaluation of the change.6 These theories were integrated into the project organization so that the participants received a product and a process for implementation. The standards workshop was followed by a workshop on quality improvement thus, providing the participants with the means to evaluate the change process. In addition to planning the change, certain strategies had to be used to assure that the project did not become the work of a few and that the ' original objectives were achieved. Using Nadler's systems theory, we defined a period of assessment in which the need for change is established to motivate participation in the change process.7 During the workshop, participants were educated on ANA standards and the nursing standards from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). We used strategies, such as audience participation and sharing of experiences to create a desire to change the status quo and promote a feeling of cooperation and mutually common barriers. According to Nadler, the success of the transition phase is dependent on the participants' ability to view the future.7 As project leaders, we used our own experiences to paint a picture of a nursing department in which current standards were developed, implemented, and evaluated by staff nurses. Our descriptions were accompanied by anecdotes for success and strategies we had used unsuccessfully. In addition to applying the theories of change and the change process to the project, the participants were also educated on these theories. By sharing with them what could be expected when 41

Implementation of a national nursing standards program.

At an annual nursing management conference of a multisystem hospital management firm, nursing executives expressed a need for developing nursing care ...
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