A to Z Guideline Manual in Nursing Performance Evaluation Tool (for Practitioners and Students) SN Nanjunde Gowda, Jyothi Nanjunde Gowda
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Introduction to Evaluation ProcessCHAPTER 1

 
Introduction
Education technology refers to the development of various methods of educational technological inventions. These advances come from the interaction of changing concepts with changing techniques leading to new ways of performing educational activities.
Basic of nursing education depending on theory and clinical exposure. The quality of nursing education only gained through theory and clinical experience, nursing educators have the greater responsibilities to develop psychomotor and technical skills with the learner, if the theory and clinical experience systematically planned organized and adhering to the criteria of evaluation, only we can expect nursing care skills are imparted in the learner. The nursing educational institute play a vital role in developing criteria for evaluating performance of learner and teachers.
In order to develop and provide high quality of care, it is necessary to develop appropriate standards of care and appropriate evaluation tools. Setting up of standard is the first step in the evaluation process.
Evaluation process standards describe the behavior of learner at the desired levels of performance. This specifies the desired methods of specific nursing interventions. This involves all the activities concerned with delivering patient care. These standards measures the nursing actions or lack of actions involving patient care
Thus the process standard assist in measuring the degree of skills, with which a technique or procedure was carried out by the learner which includes the levels of learner and client interaction. This includes:
  • Nursing techniques
  • Nursing procedures
  • Nursing activities (in terms of quality of care, appropriateness of care, adequacy of care
  • Learner with appropriate assessment collects data, prioritize the needs, and identify the expected outcome and plan of care.
 
Objectives of Performance Evaluation
  1. Provides reflective feedback on the work of learner and staff for a given period of time.
  2. To acknowledge and encourage appropriate performance.2
  3. To identify and remove ineffective performance and behaviors.
  4. To identify the areas of growth for the staff and as well as the organization.
  5. To ensure quality care and to maintain high standards of care.
  6. Performance of learner and staff is assessed in relation to the behaviorally stated work goals.
  7. Observation of the representative sample of the learner and staff total work activities, should be taken into consideration.
  8. When several areas of performance requires improvement, indicate which area has the highest priority for improvement.
  9. Purpose of the evaluation is to improve the work performance and job satisfaction.
 
Standards of Nursing Documentation
 
Introduction
Creating and maintaining records is an integral part of health care. Complete, accurate, relevant, and timely documentation is crucial for the continuity of patients care.
By maintaining proper standards of documentation, health care providers are honoring the expectation of the nursing profession.
As a nursing educator, learner or as a registered nurse or midwife, you are personally accountable for your practice and in the exercise of your professional accountability.
  1. Act always in such a manner as to promote and safeguard the interests and well being of patients and clients.
  2. Ensure that no addition or omission on your part or within the sphere of responsibility is detrimental to the interests, conditions or safety of patients and clients.
 
Purpose and Value of Documentation
Documentation of care is synonymous with care itself. If it is not documented, it has not been done. A well documented medical record must:
  • Reflect patients care given
  • Demonstrate the expected outcomes of treatment
  • Help to plan and coordinate care contributed by each members of professional team
  • Allow interdisciplinary exchange of information about the patient
  • Provide evidence of the nurses’ legal responsibilities towards the patient
  • Demonstrate adherence to standards, rules, regulations, and laws of nursing and midwifery practice
  • Provide information for analysis of cost benefit and reduction
  • Reflect ethical and professional conduct and responsibility.
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Guidelines for Nursing Documentation
  1. Use only your institutions approved forms. Do not improvise and/or introduce new forms unless approved by your health institution.
  2. All nursing documentation must be written in black or blue ink (including narcotics and blood transfusions).
  3. Place the patient identification (sticker) on every page or record patient's identification on each page (full name, age, sex, hospital number, date of admission, ward, and bed number).
  4. Use standard date at the beginning of each shift (day, month, and year).
  5. Each entry must be authenticated (name, signature and title).
  6. Unfinished documentation should be signed before starting a new page.
  7. Do not leave blank space between entries.
  8. Draw a line ending last sentence.
  9. Do not erase and/or obliterate error. Draw a line through an error, write “Error”, date and initialize.
  10. Document omission as new entry.
  11. Use only standard and institutions approved abbreviations, do not use short handwriting.
  12. Do not alter previously documented patients records.
  13. All nursing documentation must be ligible, relevant, accurate and concise (e.g. clear handwriting).
  14. Do not document using vague or broad statement, e.g. good day, bad food, adequate, slept well and good, satisfactory, etc.
  15. Do not transcribe physician's orders.
  16. Do not document interpreatation, what someone said, heard or smelled unless the information is crucial.
  17. Use appropriate graphic and specialized flow sheet according to department's policy.
  18. Check that you have the correct chart before you begin documenting.
  19. Do not document care unless it has been provided.
  20. Document explanations if care was not provided.
  21. Do not document other nurse’ care for patients.
  22. Do not document care that was provided in previous shifts.
  23. Do not duplicate entries.
  24. The documentation must reflect the nursing process, initial assessment, reassessment, planning, implementation or nursing intervention, and evaluation of care provided. Record changes of patient's condition and complications.
4
 
Performance Evaluation in Nursing
 
Administration of Tool
  1. The clinical assessment of fundamentals of nursing course based on a formal clinical assessment on each nursing procedures.
  2. There are two major areas of student's performance being measured in a continuous assessment. Application of nursing process and professional conduct, each area identifies certain standards which must be met by the students in order to achieve the highest marks for that standard. The standard is the optimum behavior expected from the students. Form is provided to record the score of students’ performance titled continuous assessment tool.
  3. This clinical continuous assessment form is to be provided to the student at the beginning of the clinical experience in which it will be used.
  4. The clinical teacher is to discuss student progress and clinical performance on a continuous basis. Strengths and weakness of the students to be identified and documented on anecdotal notes.
  5. The clinical assessment form is to be completed by the clinical teacher at the end of the clinical experience.
  6. The completed form is to be discussed with the student and an explanation provided for any marks that are not understood by the students.
  7. The students’ signature on the form only indicates that she/he has been presented with the form. If the student disagrees with the marking, the students should write a comment on the form to that effect and may pursue the matter with the division coordinator, if there is one, or with principal.
 
Use of the Tool (Example, Rating Scale)
1. Each standard has a four point rating scale with the following definitions:
Standard met
The student achieved all of the items identified in the standard.
Standard almost met
The student achieved more than half of the items identified in the standard.
Standard far from met
The student achieved less than half of the items identified in the standard.
Standard not met
The student did not achieved the items identified in the standard.
1. Each standard has different points depending on the importance of that standard to the overall assessment.5
2. The score of the clinical assessment form enter the appropriate point in the box provided at the right side of the form against each standard.
3. Students must be informed when they are being graded for the final assessment.
NB: If a student misses any critical element he/she should be reassessed.
If you are using different scale student will be graded as per scale.
 
Guidelines for the Use of Clinical Continuous Assessment Tool
Guidelines are provided for the clinical teacher in order to increase the objectivity of the clinical continuous assessment and to maintain the standard among the entire nursing institute. Assessment should be based on knowledge and skills of the course objectives.
 
Guidelines (Nursing Process Approach)
  1. Assessment and Diagnosis
    1. Collects data about patients needs
      1. Provides privacy, selects suitable time and place
      2. Collects relevant data such as personal family, medical history
      3. Identifies the deviations from health and illness and from normal to abnormal.
    2. Identifies basic needs of the patients
      1. Lists the basic needs, oxygen, nutrition, hygiene, elimination, comfort, rest, sleep, love and safety.
      2. Makes relevant observations, vital signs, and deviation from the physical examination.
      3. Identifies the actual problems—lack of oxygen, lack of comfort and rest, sleeplessness.
      4. Recognizes the potential problems such as injuries, chemical, mechanical and thermal problems.
    3. Categorizes the patients’ needs/problems
      1. Categorizes the basic needs according to Maslow's hierarchy
      2. Categorizes the actual and potential problems
      3. Identifies the significance of the data collected.
    4. Formulates nursing diagnosis
      1. Organizes the data and utilizes teachers assistance in analyzing the data
      2. Identifies the significance of the data
      3. Makes nursing diagnosis at the basic level on the basis of data.6
  2. Planning
    1. Prioritizes the patients’ needs
      1. Establishes priority of needs on the basis of assessment made, resources available and urgency
      2. Identifies the clients values and beliefs and priorities
      3. Identifies the importance of providing care as per the priority of needs
      4. Organizes the nursing care plans by priority.
    2. States the outcome criteria
      1. Derives the outcome criteria relating to the goals
      2. Describes the outcome criteria specific, observable and measurable responses of the patients
      3. Recognizes the importance of outcome criteria for evaluating care.
    3. Plans nursing action for each needs of the patients
      1. Makes appropriate nursing care plans using the immediate and long-term nursing objectives
      2. Organizes nursing care plans using the investigations and medical orders
      3. Seek guidance from senior nursing staff when needed
      4. Identifies patients social background
      5. Recognizes the individuals needs and problems
      6. Considers the patients values/beliefs in planning care.
    4. Plans rationale for nursing action
      1. Nursing actions are safe and appropriate for the individual's age, health and so on
      2. Recognizes it is achievable with the resources
      3. Congruent with clients values and beliefs
      4. Follows basic scientific principles in planning care.
    5. Formulates the needed patient health instructions
      1. Identifies the felt needs and potential problems of the patient.
      2. Involves the patient, family members in planning care
      3. Utilizes appropriate time for teaching
      4. Seeks guidance to organize the learning materials and uses suitable materials
      5. Flexes teaching plan according to the situation.
  3. Implementation
    1. Implements nursing care competently, safely and accurately within a given time
      1. Makes appropriate attempts in solving the problems
      2. Carries out nursing intervention appropriately according to priority7
      3. Encourages patients to utilize own capacities
      4. Possesses manual dexterity
      5. Works quietly without apparent strain
      6. Has self confidence
      7. Follows the technique of procedures correctly
      8. Demonstrates skill in carrying out basic procedures.
    2. Maintains comfortable environment for patient
      1. Reduces environment distractions such as bright light, loud noise and staff conversations
      2. Places the patient with a compatible room mate/next bed mate
      3. Provides a comfortable bed, bed linen is smooth, clean, dry and provides warmth
      4. Personal hygiene needs are met
      5. Shows a concerned and caring attitude
      6. Provides privacy.
    3. Applies scientific principles
      1. Recalls the underlying scientific principles
      2. Explains the therapeutic effect
      3. Takes precautions wherever necessary
      4. Makes adaptation while following scientific principles
      5. Integrates the scientific principles in giving patient care.
    4. Maintains safe environment
      1. Provides the unit that is safe, e.g. bed in low position
      2. Places the call bell within easy reach
      3. Instructs the patient how to obtain assistance
      4. Ensures safety while caring for patient, e.g. shifting or ambulating
      5. Observes precautions to provide safety.
    5. Records and reports patients information accurately
      1. Gives complete reports
      2. Uses appropriate language
      3. Report continuity of care
      4. Decides on specific information to be communicated
      5. Knows to whom the information is to be communicated
      6. Determines the change in patient condition
      7. Records what he/she observes
      8. Follows hospital policy regarding records such as signature, date, time and ink.
    6. Gives health instructions to patients and family
      1. Reinforce the promotive and preventive aspects of care
      2. Provides and inform about appropriate equipment and resources
      3. Encourages active involvement of patient and family
      4. Considers the factors such as education, age, sex needs and suitable time for the appropriate health teaching.8
  4. Evaluation
    1. Identifies outcome criteria used to evaluate the patients response to nursing Care
      1. Identifies data related to outcome criteria
      2. Identifies the response of patients to nursing interventions
      3. Recognizes the specific and observable outcome criteria.
    2. Collects data related to identified criteria
      1. Data is collected related to physical need
      2. Determines the utilizations of resources
      3. Data related to health teaching given is collected.
    3. Re-examines the patients care plan
      1. Evaluate the care plan in the light of care given
      2. Observe whether the health teaching plan is implemented
      3. Determines whether the problem has been solved
      4. Determines whether the goals have been achieved.
    4. Modifies the care plan
      1. Modifies the plan for nursing action based on patient progress
      2. Modifies procedures according to patients response
      3. Communicates the modified plan to the team members verbally
      4. Documents the modified plan
      5. Recognizes the facilities available to improve the planning.
  5. Sense of Responsibility
    1. Readily accepts responsibility for own behavior, respects rules and regulations
      1. Assumes responsibility and does the work
      2. Does not need more supervision than the she/he should at his/her level
      3. Is honest, consistent, accountable.
  6. Initiative for Self-learning
    1. Eager to learn and seeks new learning experiences
      1. Eager to learn and seeks new learning experiences
      2. Reports illness on time and keeps fit and alert
      3. Strives for quality improvement
      4. Creative, innovative and imaginative
      5. Able to handle situations intellectually
      6. Initiates positive development
      7. Demonstrates leadership abilities.
  7. Interpersonal Skills
    1. Establishes and maintains outstanding working relationships
      1. Courteous and considerate towards others
      2. Recognizes individual differences
      3. Accepts the differences and uniqeness of each individual9
      4. Cooperative in assertive manner with co-workers, doctors and other health care team
      5. Identifies and accepts the beliefs and practice of others including patients family and community
      6. Receptive to suggestions and critisms and attempt to improve
      7. Listens to patients, co-workers and seniors
      8. Seeks help in difficult situations
      9. Expresses herself/himself clearly (verbal and nonverbal).
  8. Professional Conduct
    1. Uniform
      1. Always well groomed and neat, conscious about professional appearance
        1. Wears clean uniform according to the uniform regulations
        2. Keeps nails and hands clean
        3. Appears professional in activities and attitudes.
  9. Punctuality
    1. Exceptionally punctual for clinical and has never been late, completes all given learning assignments on time
      1. Exceptionally punctual for clinical and has never been late
      2. Completes all given learning assignments on time
      3. Reports any problems related to patient care on time.
 
The Clinical Effectiveness
 
What is Clinical Effectiveness and Why it is Important?
Clinical effectiveness is about doing the right things in the right way and at the right time for the right patient. There are several key activities needed to support clinically effective practice
  • Selecting a particular aspect of practice to question or examine
  • Finding out from the literature and critically apprising this information
  • Implementing and/or learning to provide best in clinical practice
  • Confirming that providing best practice on day-to-day basis
  • Changing practice to make improvements if necessary.
 
Achieving Clinical Effectiveness
Overall, the three functions involved in achieving clinical effectiveness are ensuring that people know what clinically effective practice is . Applying knowledge about clinically effective practice in day to day patient care and making sure that changes in practice are working to benefit patient.10
Clinical Effectiveness MUDEL
Inform
Ensure that nurse patients and managers know the best available evidence of clinical and cost effectiveness
Monitor: Confirm that changes take place locally and result in real improvements in the quality of health care.
Change: Use the information on clinical and cost effectiveness to review, and where necessary, change routine clinical and managerial practice.
 
Critical Thinking
Think of one area of practice you carry out regularly for patients and consider the following critical thinking:
  • Are you certain that you are practicing in a way which is clinically effective for patients that is, the right way to achieve the right result
  • Do you know if any research studies have been done to examine different ways of practicing and determine which is best if the research is valid?
  • Are there any clinical guidelines available which describe good practice based on research findings and/or expert opinion
  • Have you and your colleague discussed and agreed on good practice
  • Have you shared your experiences in implementing good practice with colleagues?
 
Improving Clinical Practice
In recent years, many research studies have confirmed that patients with apparently the same clinical condition are not being treated in the same way across the practioner or places. There is no doubt that this variation in clinical practice exists. Most of this published studies concern medical care. However, it is probable that researchers would find the same levels of variation among the nursing specialties, therapists or any other group of health professionals.
 
Clinical effectiveness for nurses
Function
Key activities
Inform nurse manager and patient about the available evidence on clinical
Searching the literature and other sources for what makes up good practice
  • Critically appraising the literature
  • Seeing if staff are providing what is determined to be good practice on day to day basis
  • Supporting or carrying out research studies
Change practice where appropriate
Leading or helping to design and implement changes in practice which will result in more clinically effective care.
Monitor practice for change and real improvements in quality and clinical effectiveness
Designing and carrying out clinical audits to see if staffs are providing what is determined to be good practice on a day to day basis
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  • Do you think that you and all your colleagues carry out the area of practice in the same way for the same patient or do you think there might be some variation in the way you and your colleagues practice
  • Could you justify any variation based on sound evidence of what is good practice
  • Could you reasonably explain the variation or the resulting variation in the cost of care to members of the public?
  • Could you and your colleagues work together to understand your current practice patterns and try to improve them
  • Can you and your colleagues check out the sources available to support nurses in improving their practice.