Standard of care

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Care standards are an important element of quality assurance in professional care . On the basis of current nursing scientific findings, they determine comprehensible and verifiable rules for the provision of services in nursing practice. A care standard thus defines the framework in whose corridor individual care takes place and on the basis of which the quality of care can be assessed. Since 1984, the importance of care standards for the quality of care has been defined by the World Health Organization (WHO). By specifying criteria for the evaluation , nursing standards establish a reference to the nursing process .

There are a number of different standards that can be differentiated and classified with regard to their goals, their position in the hierarchy , their originators, their binding force, their distribution and their content. However, the names are not clear and make an assignment difficult. The structure of a nursing standard does not follow any fixed regulation, but there are efforts within nursing science to develop a uniform structure on this issue. The application in practice is often determined by the binding nature and hierarchy, compliance with and application of international and national standards is determined and checked by legal requirements, the implementation of lower-level guidelines can be mandatory as an internal service instruction or formulated and understood as a recommendation by the employer.

Definitions and linguistic problems of the term

The term standard is not clearly defined in nursing scientific terminology and is applied to a number of sometimes very different instruments. In addition, instruments of the same type for quality assurance are not referred to as nursing standards, but have other names such as nursing guidelines or guidelines. In this context, Trede speaks of "Babylonian language confusions" which make it difficult to deal with nursing standards in practice. Most nursing science authors therefore refer to the definition of the WHO, according to which "standards correspond to an achievable and professionally coordinated level of performance and reflect a specified target of nursing quality by which the actual performance is measured." Various national definitions are based on the WHO. For example, a nursing standard is defined by the Swiss professional association as a “generally achievable level of performance that is described by one or more criteria”, while the German Network for Quality Development in Nursing (DNQP) defines it as “a professionally coordinated level of performance that meets the needs of the is adapted to the targeted population ”and describes this as a quality standard. This linguistic disagreement often leads to subsuming descriptions under the term care standard that do not essentially correspond to these definitions.

Objectives

What all standards have in common is that they contain an objective and record this in writing and make it verifiable. At the same time, professionalization and the delimitation of care from other professional groups are sought. Roughly, two objectives can be identified, which can definitely contradict each other: on the one hand, normative standards that serve to standardize the way of working and on the other hand, the knowledge-based solution of problems.

Normative standards refer, among other things, to frequently recurring care measures or more complex care problems and thus serve to facilitate care documentation and care planning . This group includes:

  • Process standards that systematize individual care activities in terms of work organization
  • Implementation standards with a technical and methodical character that describe the care goal and the care measures required to achieve the care goal
  • Standard care plans that relate to a specific clinical picture or a specific nursing diagnosis and, in addition to the typical nursing problems and measures, also contain the goals to be striven for.

Content of care standards

  • The necessary information to be collected prior to providing care: patient-related issues; Care category / level; personal resources of the patient to be considered etc.
  • Postulates of action for specific nursing situations: nursing diagnosis, DRG case group, disease-health, diagnoses , therapy program; Cooperation with other groups etc.
  • Necessary requirements for the nursing staff: qualifications, number, etc.
  • Preparatory steps: information, personal preparation, material, space, person to be cared for, arrangements in the team
  • Essential points for the implementation process: sequence of measures, involvement of the patient, hand movements
  • Theses and follow-up support
  • Possible complications to be prepared for.

According to Bartholomeyczik , standards can also have professional-political or economic goals, which can be described as secondary functions. These include, for example, standards that relate to budgeting, resource allocation or nursing staff planning; Institution-internal standards can, for example, also be formulated with the aim of making the in-house quality level known to the respective target group or to train new staff. The designation of these types of guidelines as standards of care leads to a watering down of the term.

The same applies to the standard care plans mentioned, which can be compared with the guidelines in medicine.

Creator of standards

Nursing standards are drawn up by various authors: In addition to internationally active organizations such as the World Health Organization or the International Council of Nurses (ICN), social and health policy committees, national nursing associations, working groups within nursing, individual providers and institutions for inpatient and outpatient care as well Individuals standards of care formulated.

Scope, binding force and hierarchy

  • Universal standards: Universal, international or macro standards are standards issued by international organizations such as the WHO or the ICN. They refer to transnational and fundamental ethical norms or the professional value system.
  • Guideline standards: The national standards, also known as guidelines or macro standards, which can become valid as legal texts for all members of the care sector, have a smaller scope, an example of this are the common principles and standards for quality and quality assurance including the procedure for carrying out quality tests Section 80 of SGB ​​XI These guidelines are binding for all those employed in the professional care of a country and are legally enforceable.
  • Expert standards : The expert standards issued by the German Network for Quality Development in Nursing (DNQP), a nationwide association of nursing experts, are of major importance for national nursing. They are based on nursing science, the methodology is based on the development of medical guidelines , which are developed on the basis of an overview of the scientific state of knowledge, verifiable therapeutic success and expert consensus. Analogous to the establishment of medical guidelines via evidence-based medicine , evidence-based nursing is used in nursing . In German case law , the expert standards are viewed as a representation of the recognized and current status of nursing research. They are regarded as an anticipated expert report for the standard of care due to care. As a result, non-compliance with expert standards is assessed by case law as a breach of duty of care and thus negligence , without the standards being anchored in law. Establishing the standard leads to a reversal of the burden of proof : a nurse who has acted differently from the standard must justify himself and prove that his or her actions were not negligent.
  • Local standards : The standards with a local scope, also known as meso, micro or action standards, generally describe individual care measures and relate to the process and implementation of individual care interventions. They often arise within the care facilities or sponsorships and are only valid there as service instructions . Standards with which nursing mission statements or quality measures are described can, for example, be issued by nursing management as recommendations for action or as part of the employment contract, the basis for working in a facility.
    • General standards of action : A further differentiation of local standards can relate to the patient-related range; general standards relate to the implementation of certain measures in a patient group.
    • Special standards of action : They determine the implementation and quality of the nursing intervention for a specific care recipient and thus correspond to the individually created care plan .
Table overview
Instruments Other names aims Content scope
Universal standard
  • International standard
  • Macro standard
  • Ensuring an overarching level of professional care
  • Social, ethical and professional norms
  • Values ​​of the entire professional group
  • Definitions of the duties and responsibilities of professional care
  • Definition of a certain quality level of care
 Valid for every nurse for every nursing care of every person in need of care regardless of their illness (international)
Policy standard
  • National standard
  • Guideline
  • Macro standard
  • Ensuring the implementation of normative requirements and corresponding laws
  • Definition of the desired national quality level
  • Definitions and assignment of certain tasks and responsibilities
  • Definition of a certain level or goal of care quality for a state
 Every nurse within the scope of the law (national)
Expert standard
  • Quality standard
  • Definition of the national quality level
  • Standardization of nursing activities
  • Enabling the practical evaluation
  • Description of the quality standards to be observed on the process, structure and result level
 Any caregiver within national territory and care recipients with a specific care problem associated with the standard
General standard of action
  • Mesostandard
  • Micro standard
  • Standard care plan
  • introduction of new employees
  • Simplification of the care documentation
  • Standardization of the implementation of nursing measures
  • Description of typical care measures in the case of special care problems or clinical diagnoses
 All caregivers within an institution and care recipients with a specific care problem or diagnosis assigned to the standard
Special standard of action
  • Micro standard
  • Action instruction
  • Care plan
  • Orientation aids for practice
  • Standardization of the implementation of individual maintenance measures
  • Procedure and implementation of individual nursing interventions
  • Description of individual organizational processes

All employees of a facility entrusted with carrying out the process described

Contribution of expert standards

An expert standard is an instrument for quality development in nursing that is developed and checked using scientific methods in the sense of evidence-based nursing . It shows how professional care should be carried out in health care and elderly care facilities , and provides the reasons and explanations for this.

In Germany, the German Network for Quality Development in Nursing (DNQP) has been developing national expert standards since 1999 . It is developed in five steps: expert working group, literature analysis, consensus conference, implementation in the practical fields, updating.

The following expert standards have appeared so far:

The methodology is based on the development of medical guidelines , which are developed on the basis of an overview of the state of scientific knowledge, verifiable therapeutic success and expert consensus within the framework of evidence-based medicine .

The National Expert Standards should lead to a unification of the applied standards. The use of scientific resources is an expression of the further professionalization of the nursing professions.

It is criticized that an academic debate about expert standards cannot solve the problem of how the nursing staff in the individual facilities should find a consensus for their concrete actions.

Criticism of care standards

  • too formalized approach to an interactive care situation
  • include self-evident topics that are part of the basic training of a nurse
  • Unclear definition of the level of care (no technical expression)
  • Missing current nursing knowledge - often updating of traditional knowledge or outdated textbook opinions without current review
  • missing references
  • Standards treat all residents / patients equally, unless well-trained staff address the personal concerns of the resident / patient

Whether or not these points apply in each case depends very much on the approach of the carer to their task. Inadequate staffing and insufficient qualifications can also lead to the “blind” application of a standard that contains a precise list of the ideal course of action as it should be carried out by a nurse.

literature

Web links

Individual evidence

  1. ↑ Ines Trede: From Babylonian language confusion. A literature review on the goals and characteristics of standards of care. Care, Volume 10, 1997, Issue 5, pp. 262-272.
  2. ↑ Nursing standards: toward better care: guidelines for standards of nursing practice . World Health Organization, Regional Office for Europe, 1984. The Role of the Advisor in Quality Assurance in Nursing Practice. World Health Organization, 1987, The Hague
  3. ↑ Quality standards for the exercise of health and nursing care (nursing standards). Swiss Professional Association for Nurses and Nurses, SSK-ASI, Bern 1990
  4. ^ Doris Schiemann: Basics of quality assurance in nursing. In: German nursing journal . 43/1990, 526-529
  5. ↑ Claus Bölicke: Standards in Nursing: Develop - Introduce - Check . Elsevier, Urban & Fischer, 2006, ISBN 3-437-27360-4 , pp. 1-3.
  6. ↑ a b Sabine Bartholomeyczik : Sense and nonsense of care standards. ( Memento from July 21, 2003 in the Internet Archive ) In: Heilberufe. 5/2002, pp. 12-16.
  7. ↑ Claus Bölicke (Ed.): Standards in care: Develop - introduce - check. Elsevier, Urban & Fischer, 2006, ISBN 3-437-27360-4 , pp. 1-3.
  8. ↑ Gabriele Vitt: Care quality is measurable. Schlütersche, 2002, ISBN 3-87706-684-4 , p. 28.
  9. ↑ M. Helgard Brunen: Outpatient care: basics - care instructions, care advice, care process, communicative methods - holistic, integrative care. Volume 1, Schlütersche, 2001, ISBN 3-87706-571-6 , p. 191.
  10. ↑ Framework agreements and recommendations: Framework agreements, guidelines and federal recommendations on nursing care and care support points . National Association of Health Insurance Funds; List of available guidelines in PDF format.
  11. ↑ Simone Schmidt: Expert standards in care: practical and efficient. Springer, 2009, ISBN 978-3-642-01322-5 , pp. 4-5.
  12. ↑ Gabriele Vitt: Care quality is measurable. Schlütersche, 2002, ISBN 3-87706-684-4 , pp. 28-32.
  13. ↑ Expert standard : Pressure ulcer prophylaxis at www.dnqp.de (link checked February 27, 2019)
  14. ↑ Expert Standard : Pain Management in Nursing for Acute Pain on www.dnqp.de (link checked February 27, 2019)
  15. ↑ Expert Standard : Pain Management in Nursing for Chronic Pain at www.dnqp.de (link checked February 27, 2019)
  16. ↑ Expert standard : Nutritional management to secure and promote oral nutrition in nursing at www.dnqp.de (link checked February 27, 2019)
  17. ↑ Expert standard : Care of people with chronic wounds at www.dnqp.de (link checked February 27, 2019)