Journal of Advanced Nursing, 1978, 3, 413-415
Summary report of a working group on the evaluation of inpatient nursing practioe World Health Organization Regensburg, 18-21 October 1977
Introduction This working group, consisting of nurses and physicians and convened by the W H O Regional Office for Europe in collaboration vAxk the Federal Republic of Germany, was attended by 14 temporary advisers (Austria, Belgium, Finland, France, Federal Republic of Germany, Hungary, Poland, Romania, Switzerland, Turkey, United Kingdom and Yugoslavia) and four members of the Regional Office staff. The objectives of the working group were to (i) discuss the relationship of evaluation to the other elements of the nursing process as these are being studied in the W H O Regional Office for Europe's medium-term programme in nursing/ mid-wifery in Europe, (2) examine current thinking and practice related to the evaluation of inpatient nursing care, (3) identify specific aspects of evaluation requiring special study, and (4) propose activities which would assist in solving major problems in evaluation and which would be suitable for carrying out either as part of the medium-term programme and/or as national experiments. The need for sound evaluative techniques to be developed and used in all areas of health care is obvious. The fact that evaluation of health interventions of any kind is not particularly easy should not excuse health workers from striving to achieve something really useful in this area. In nursing, evaluation presents particular problems since the work of those engaged in discipline is, in many instances, still relatively undefined.
Nurses' work The work of nurses in hospitals is often largely composed of support for other disciplines, particularly medicine, coupled with day-to-day management of the unit to which they are assigned. Interventions by nursing personnel are not therefore seen as something which can be distinguished as a discrete, purposeful activity or series of activities. In such settings, nursing per se has never been differentiated and such nursing as is done if often performed in a ritualistic and rote fashion. 0309-2402/78/0600-0413$O2.oo
©1978 Blackweil Scientific Publications
413
414
World Health Organization
As a result, little or no emphasis has been placed on the need to define objectives and measure outcomes in terms of the patient's progress. Even in situations where nursing is recognized as a discrete disciphne, evaluation ofthe outcome ofnursing interventions is rarely done in a planned and systematic manner. Members ofthe working group therefore agreed that in both the hospital and community setting, evaluation ofnursing interventions was at present inadequate. It was felt that the application ofthe nursing process methodology to the provision of care would be highly effective in solving problems in this area. Great importance was attached to evaluation, not only as the fourth step in the nursing process, but also as an integral part of the total process in all four steps (assessment, planning, implementation, and evaluation) and in documentation. Nursing badly needed to be planned and provided as a purposeful activity. Tasks undertaken by nursing personnel in support of interventions in other disciphnes, such as medicine, should be incorporated into the nursing process and the results of these activities in terms ofnursing should form a measurable element of patient outcomes. The activities unique to nursing should be clearly identified and their results, as these can be seen as changes in patient/chent health, should be documented, studied and improved. Present focus It was agreed that such evaluation as was currently being done was focused mainly on the competence ofthe personnel and on the resources needed to provide nursing care. A positive correlation between the competence ofthe practitioner and patient outcomes was acknowledged. Such a positive correlation must also exist between resources and patient outcomes. It was interesting to note that while considerable effort has been made to study the competence of personnel and adequacy of resources, httle has been done to relate the results of fmdings to outcomes in terms ofthe health ofthe patient/client. All three areas required investigation, but emphasis needed now to be placed on the development of measurable objectives for well-defined nursing interventions and the related development of methods for taking these measurements in an accurate and usable fashion. The results of such evaluation should be used to improve nursing care and correspondingly the health status of the patient/client. The initial steps in the nursing process are concerned with data collection and identification ofthe objectives ofthe intervention in terms of an accepted method of assessment of patient/chent nursing care needs. A number ofthe more common assessment methods now being used were briefly discussed. These included the functional, daily living activities and problem-oriented methods. There was now urgent need to decide the approach to be used for assessment within the experimental centres to be developed under the Regional Office for Europe's mediumterm programme in nursing/midwifery in Europe. In the immediate future, development of assessment tools should therefore be given priority in the programme.
Evaluation of inpatient nursing practice
415
It should be remembered that in health care, as in other services which deal partially with values as seen by individuals and famihes, not all results of nursing interventions will be objectively 'measurable'. Psychosocial and physical needs which do not lend themselves to quantitative measures will have to be kept in mind and subjective evaluation measurements based on patient and/or expert opinion should neither be forgotten nor underrated. Conclusions Participants reached the following conclusions: 1 There appears to be inadequate evaluation of inpatient nursing practice in most situations. 2 Evaluation of nursing practice is not only a concluding activity to be carried out on discharge of a patient/client from the health care system, but is also an integral part of each step of the nursing process. Evaluation of patient outcomes should be made at the completion of each planned intervention and the results should be used to improve all steps in the process. 3 Evaluation is at present considered to be most effective when objectives can be stated as observable and/or measurable patient outcomes. In nursing, however, some objectives and outcomes are not readily quantifiable and methods for evaluating the efficacy of these require to be developed. 4 Health service information systems urgently require a nursing information subsystem incorporating epidemiologically based data. Such data can only be collected by using a nursing frame of reference for accurate documentation ofthe nursing process. 5 There is an urgent need for nomenclature that adequately describes nursing phenomena and has the same meaning throughout the world. All phases of the nursing process, including evaluation, depend on this. 6 The nursing process concept and techniques for all steps in the process need, after suitable testing, to be introduced into nursing practice and into curricula preparing nursing personnel of all levels and types. 7 Efforts need to be made to estabhsh systems which will effectively activate and support nursing personnel during the process of change. 8 Effective methods need to be developed in the immediate future for informing other health professionals, particularly physicians, of changes in nursing. Similar methods need to be developed for informing the pubHc at large. 9 Effective methods need to be developed for a continuous exchange of information, between the Regional Office and relevant persons working with the nursing process in national settings, on the progress both of the medium-term programme in nursing/midwifery in Europe and activities being conducted on a country and bilateral basis.
Summary report of a working group on the evaluation of inpatient nursing practioe World Health Organization Regensburg, 18-21 October 1977
Introduction This working group, consisting of nurses and physicians and convened by the W H O Regional Office for Europe in collaboration vAxk the Federal Republic of Germany, was attended by 14 temporary advisers (Austria, Belgium, Finland, France, Federal Republic of Germany, Hungary, Poland, Romania, Switzerland, Turkey, United Kingdom and Yugoslavia) and four members of the Regional Office staff. The objectives of the working group were to (i) discuss the relationship of evaluation to the other elements of the nursing process as these are being studied in the W H O Regional Office for Europe's medium-term programme in nursing/ mid-wifery in Europe, (2) examine current thinking and practice related to the evaluation of inpatient nursing care, (3) identify specific aspects of evaluation requiring special study, and (4) propose activities which would assist in solving major problems in evaluation and which would be suitable for carrying out either as part of the medium-term programme and/or as national experiments. The need for sound evaluative techniques to be developed and used in all areas of health care is obvious. The fact that evaluation of health interventions of any kind is not particularly easy should not excuse health workers from striving to achieve something really useful in this area. In nursing, evaluation presents particular problems since the work of those engaged in discipline is, in many instances, still relatively undefined.
Nurses' work The work of nurses in hospitals is often largely composed of support for other disciplines, particularly medicine, coupled with day-to-day management of the unit to which they are assigned. Interventions by nursing personnel are not therefore seen as something which can be distinguished as a discrete, purposeful activity or series of activities. In such settings, nursing per se has never been differentiated and such nursing as is done if often performed in a ritualistic and rote fashion. 0309-2402/78/0600-0413$O2.oo
©1978 Blackweil Scientific Publications
413
414
World Health Organization
As a result, little or no emphasis has been placed on the need to define objectives and measure outcomes in terms of the patient's progress. Even in situations where nursing is recognized as a discrete disciphne, evaluation ofthe outcome ofnursing interventions is rarely done in a planned and systematic manner. Members ofthe working group therefore agreed that in both the hospital and community setting, evaluation ofnursing interventions was at present inadequate. It was felt that the application ofthe nursing process methodology to the provision of care would be highly effective in solving problems in this area. Great importance was attached to evaluation, not only as the fourth step in the nursing process, but also as an integral part of the total process in all four steps (assessment, planning, implementation, and evaluation) and in documentation. Nursing badly needed to be planned and provided as a purposeful activity. Tasks undertaken by nursing personnel in support of interventions in other disciphnes, such as medicine, should be incorporated into the nursing process and the results of these activities in terms ofnursing should form a measurable element of patient outcomes. The activities unique to nursing should be clearly identified and their results, as these can be seen as changes in patient/chent health, should be documented, studied and improved. Present focus It was agreed that such evaluation as was currently being done was focused mainly on the competence ofthe personnel and on the resources needed to provide nursing care. A positive correlation between the competence ofthe practitioner and patient outcomes was acknowledged. Such a positive correlation must also exist between resources and patient outcomes. It was interesting to note that while considerable effort has been made to study the competence of personnel and adequacy of resources, httle has been done to relate the results of fmdings to outcomes in terms ofthe health ofthe patient/client. All three areas required investigation, but emphasis needed now to be placed on the development of measurable objectives for well-defined nursing interventions and the related development of methods for taking these measurements in an accurate and usable fashion. The results of such evaluation should be used to improve nursing care and correspondingly the health status of the patient/client. The initial steps in the nursing process are concerned with data collection and identification ofthe objectives ofthe intervention in terms of an accepted method of assessment of patient/chent nursing care needs. A number ofthe more common assessment methods now being used were briefly discussed. These included the functional, daily living activities and problem-oriented methods. There was now urgent need to decide the approach to be used for assessment within the experimental centres to be developed under the Regional Office for Europe's mediumterm programme in nursing/midwifery in Europe. In the immediate future, development of assessment tools should therefore be given priority in the programme.
Evaluation of inpatient nursing practice
415
It should be remembered that in health care, as in other services which deal partially with values as seen by individuals and famihes, not all results of nursing interventions will be objectively 'measurable'. Psychosocial and physical needs which do not lend themselves to quantitative measures will have to be kept in mind and subjective evaluation measurements based on patient and/or expert opinion should neither be forgotten nor underrated. Conclusions Participants reached the following conclusions: 1 There appears to be inadequate evaluation of inpatient nursing practice in most situations. 2 Evaluation of nursing practice is not only a concluding activity to be carried out on discharge of a patient/client from the health care system, but is also an integral part of each step of the nursing process. Evaluation of patient outcomes should be made at the completion of each planned intervention and the results should be used to improve all steps in the process. 3 Evaluation is at present considered to be most effective when objectives can be stated as observable and/or measurable patient outcomes. In nursing, however, some objectives and outcomes are not readily quantifiable and methods for evaluating the efficacy of these require to be developed. 4 Health service information systems urgently require a nursing information subsystem incorporating epidemiologically based data. Such data can only be collected by using a nursing frame of reference for accurate documentation ofthe nursing process. 5 There is an urgent need for nomenclature that adequately describes nursing phenomena and has the same meaning throughout the world. All phases of the nursing process, including evaluation, depend on this. 6 The nursing process concept and techniques for all steps in the process need, after suitable testing, to be introduced into nursing practice and into curricula preparing nursing personnel of all levels and types. 7 Efforts need to be made to estabhsh systems which will effectively activate and support nursing personnel during the process of change. 8 Effective methods need to be developed in the immediate future for informing other health professionals, particularly physicians, of changes in nursing. Similar methods need to be developed for informing the pubHc at large. 9 Effective methods need to be developed for a continuous exchange of information, between the Regional Office and relevant persons working with the nursing process in national settings, on the progress both of the medium-term programme in nursing/midwifery in Europe and activities being conducted on a country and bilateral basis.
