1

Definition: Standard is an
established rule as basis of
comparison in measuring or
finding
capacity, quality context and
value of objects in the same
category. Standard is a broad
statement
of quality. It is a definite level
of excellence as adequately
required, aimed at or possible.
Standard is a predetermined
baseline condition as level of
excellence that comprises a
model to
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be followed and practiced. It is

used as a measurement tool.
Professional Standards of
Nursing Practice:
Professional standards of
nursing practice as established
by professional nursing
organization
exist to guide the nurse in
providing case.
“A standard in a model of
established practice which has
general recognition and
acceptance
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among registered professional

nurses and is commonly
accepted as correct standards of
practice
are agreed on levels of
competence as determined
by the ANA and specially
nursing
organizations” [ANA – 1996].
“Standards are defined as
authoritative statements that
describe a common level
of care as
performance by which the
quality of practice can be
 4

determined or measured.
Standard help
define professional practice
(Hubes – 1996).
Importance of standards in
Nursing :
 It is an authoritative
statement by which the
quality of nursing practice,
service and
education can be judged.
 In nursing practice,
standards are established
criteria for the practice of
nursing.
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 It is a guideline and a
guideline far is a
recommended path to safe
conduct an aid to
professional performance.
 It provides a baseline for
evaluating quality of nursing
care, increase effectiveness of
care
and improve efficiency
Definition: Standard is an
established rule as basis of
comparison in measuring or
finding
 6

capacity, quality context and

value of objects in the same
category. Standard is a broad
statement
of quality. It is a definite level
of excellence as adequately
required, aimed at or possible.
Standard is a predetermined
baseline condition as level of
excellence that comprises a
model to
be followed and practiced. It is
used as a measurement tool.
Professional Standards of
Nursing Practice:
 7

Professional standards of
nursing practice as established
by professional nursing
organization
exist to guide the nurse in
providing case.
“A standard in a model of
established practice which has
general recognition and
acceptance
among registered professional
nurses and is commonly
accepted as correct standards of
practice
 8

are agreed on levels of

competence as determined
by the ANA and specially
nursing
organizations” [ANA – 1996].
“Standards are defined as
authoritative statements that
describe a common level
of care as
performance by which the
quality of practice can be
determined or measured.
Standard help
define professional practice
(Hubes – 1996).
 9

Importance of standards in
Nursing :
 It is an authoritative
statement by which the
quality of nursing practice,
service and
education can be judged.
 In nursing practice,
standards are established
criteria for the practice of
nursing.
 It is a guideline and a
guideline far is a
recommended path to safe
conduct an aid to
 10

professional performance.
 It provides a baseline for
evaluating quality of nursing
care, increase effectiveness of
care
and improve efficiency
STANDARDS OF MIDWIFERY PRACTICE
INTRODUCTION

Standard is an established rule as basis of comparison in measuring or finding

capacity, quality context and value of objects in the same category. Standard is a
broad statement of quality. It is a definite level of excellence as adequately
required, aimed at or possible.

Standard is a predetermined baseline condition as level of excellence that

comprises a model to be followed and practiced. It is used as a measurement tool

All standards of practice provide a guide to the knowledge, skills, judgment &
attitudes that are needed to practice safely.

DEFINITIONS

They reflect a desired and achievable level of performance against which actual
performance can be compared. Their main purpose is to promote, guide and direct
professional nursing practice. (Registered Nurses Association of BC (2003) & the
College of Nurses of Ontario (2002)

“A nursing care standard is "a descriptive statement of desired quality against

which to evaluate nursing care given to a patient".
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-Gillies(1989)
“A standard in a model of established practice which has general recognition and
acceptance among registered professional nurses and is commonly accepted as
correct standards of practice are agreed on levels of competence as determined by
the ANA and specially nursing organizations” - [ANA – 1996].

“Standards are defined as authoritative statements that describe a common level of

care as performance by which the quality of practice can be determined or
measured. Standard help define professional practice - (Hubes – 1996).

IMPORTANCE OF STANDARDS IN NURSING

 It is an authoritative statement by which the quality of nursing practice,

service and education can be judged.
 In nursing practice, standards are established criteria for the practice of
nursing.
 It is a guideline and a guideline far is a recommended path to safe conduct
an aid to professional performance.
 It provides a baseline for evaluating quality of nursing care, increase
effectiveness of care and improve efficiency.
 Standard, help supervisors to guide nursing staff to improve performances

 Standards may help to clarify nurses’ area of accountability

 Standards may help nursing to clearly define different levels of care
 Standard is a device for quality assurance as Quality control.

PURPOSE OF STANDARDS
The purposes of publishing, circulating and enforcing nursing care standards are to

 Improve the quality of nursing

 Decrease the cost of nursing
 Determine the nursing negligence
 To give direction and provide guidelines for performance of nursing care.
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 To provide a baseline for evaluating quality of nursing care, ranging from

excellent care to unsafe care.
 To help to improve quality of nursing care, increase effectiveness of care
and improve efficiency. (Quality assurance)
 To improve documentation of nursing care provided that is maintain record
of care.

 Help to determine the degree to which standards of nursing care should be

maintained and take necessary action time.
 To help supervisors to guide nursing staff to improve performance.

 To help to improve the decision making and devise alternative system for
delivering nursing care.

 It may help justify demands for resources association or improvement.

 To help to clarify nurses area of accountability.

 To help nursing to define clearly different levels of care.

 Help to decrease the costs of nursing care of eliminating nonessential
nursing tasks.

 Be used as a framework or basis for determining nursing negligence.

 Motivate nurses to achieve excellence.

CHARACTERISTICS OF STANDARDS

1. Statement must be broad enough to apply a wide variety of settings.

2. Must be realistic, acceptable and attainable.

3. Nursing care must be developed by members of the nursing profession.

4. Must be understandable and stated in unambiguous term.

5. Must be based on current knowledge and scientific practice.

6. Must be reviewed and revised periodically.

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7. Must be directed towards an optimal standard.

SOURCES OF NURSING CARE STANDARD:

The standard can be established, developed, reviewed as enforced by variety of

sources as follows-

 Professional organizations like TNAI

 Licensing bodies IC, MCI, & DCI etc
 Departments of the institution
 Patient care unit
 Government unit at national, state and local government unit
 Individual personal standard

USES AND ADVANTAGES OF STANDARD

 They establish norms and allow community members and individuals to

know what level of service to expect demand. Because they are written
down they can be made public.

 They demonstrate quality provision and act as a bench mark to monitor

quality performance.

 They focus on the core and critical tasks that must be performed in the actual
situation and can be tailored to meet specific and local situation.
 They improve efficiency and lead to better utilization of resources.

 They improve staff utilization and staff motivation 6. They can be used to
access the practical aspects of both basic and post basic education and
training.

APPROACHES

A frame work for implementing the standards considers three possible approaches:

1. Centralized/National approach

2. Decentralized/ Local approach

3. Combined approach
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1. Centralized/National approach
It relies on the centre taking a lead, making all the decisions and initiating all the
activities. For this approach to be effective there should be an effective management
system. This approach has not been successful because it relies on decisions made at
levels away from where the activities will eventually take place. Sometimes local level
difficulties arise which cannot be foreseen at the national level, at the time when the
plan is being developed.

2. Decentralized/ Local approach

This approach is when the centre takes the lead in making the policy decision to
use midwifery standards. As a major component of quality assurance. However the
planning of activities and adaptations of the midwifery standards are left to the
local districts.

Disadvantages:
Lack of expertise in the local level.

It does not ensure the use of national norms and consistency, as each site may
make their own adaptations and decisions

3. Combined approach:

The centre at the National level remains responsible for the overall implementation
of the midwifery standards, but uses local demonstration sites to try them out, to
learn lessons on how they can be implemented elsewhere, and what adaptations are
required to make them specific to the country situation The centre must therefore
work closely and take action with the local demonstration sites at all stages, right
from the initial decision making and planning stages to the evaluation stage.

Advantages:

 The approach is flexible. It allows for local differences, while at the same
time ensuring consistency and uniformity in the midwifery standards

 The approach is good for developing expertise within and across the
country, as each district is involved with all parts of the implementation
process

 The approach lends itself to long term sustainability.

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THE STANDARDS DEVELOPMENT CYCLE.

Step 1.Define and agree. In this step, the goal is to define and agree on several
areas and issues that will define the standards.
Clarify the consensus process, both for topic selection and approval.
Clarify the approval process for the standards.

Step 2. Select who should be involved. Identify, at the outset of the process, all
stakeholders, that is, those individuals or groups with a vested interest in the
successful development of the standards.

Step 3. Gather information. In this step, the working group information about the
topic under review and other resources that can help define the key elements that
should be included in the standards. A flowchart may be developed to better
understand the points in the current process requiring the development of
standards.

Step 4. Draft standards. There are several components to drafting standards:

Decide the structure and format of the standards, depending on their purpose. After
the format is decided, the working group drafts the standards.
Develop indicators to measure performance according to the standards.
Prior to field testing, the graft standards should be evaluated internally.

Step 5. Test the standards. Once indicators are developed, the working group
must decide, whether a field test is needed.

Step 6. Communicate the standards. Although the standards -setting process

might be completed with the approval of the standards, the impact of well-
developed standards depends on health care providers using the standards.
Standards communication and implementation strategies are critical to achieving
healthcare provider performance according to the standards.

LEGAL SIGNIFICANCE OF STANDARDS

 Standards of care are guidelines by which nurses should practice.

 Malpractice suit against nurses are based on the charge that the patient was
injured as a consequences of the nurses failure to meet the appropriate
standards of care.

II. IMPLEMENTATION OF STANDARDS

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Each employees of the institution should follow the standards developed by the
organization.

III.MONITOR COMPLIANCE ON STRUCTURE STANDARDS AND

PROCESS STANDARDS

Compliance monitoring is done by survey and auditing.

STANDARDS FOR NURSING PRACTICE:

The standards for nursing practice are interrelated and all equally important.
Standard 1: Accountability. The registered nurse is accountable to the public for
competent, safe and ethical nursing practice.

Standard 2 Continuing competences- the registered nurse attains and maintains

competencies relevant to own scope of nursing practice.

Standard 3: Application of knowledge, skills and judgment the registered nurse

demonstrates competencies relevant to own scope of nursing practice.

Standard 4: Professional relationships an advocacy the registered nurse

establishes professional therapeutic relationships with clients and advocates for
clients in their relationships with the health system.

Standard 5: Professional leadership- the registered nurse demonstrates

professional leadership in the delivery of quality nursing and health care services
to the public.

Standard 6: Self regulation- the registered nurse assumes personal accountability

to practice nursing competently and ethically.

THE IMPORTANCE OF STANDARDS FOR QUALITY MATERNITY

AND MIDWIFERY CARE
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A standard serves to establish norms and states what level of performance is

required to obtain a specific desired outcome. In doing so, it provides protection to
the public by having criteria against which products and the performance of
practitioners can be assessed.

Standard statements are usually expressed in behavioral and measurable terms.

They will say precisely what the workers will do and how they will carry out the
task. Eg: correctly, accurately, and gently. It is also important that standards are
realistic, desirable and achievable.

Standards of practice can help identify the actual competencies required by a

midwifery trained personnel in routine normal practice. Such standards can be used
as the basis for assessing current practice, organizing refresher and updating
programmes, as well as developing future curricula.

FORMAT OF MIDWIFERY STANDARD

Each standard includes seven major components i.e. the code, title, aim, standard
statement, outcome. Prerequisites, process, and audit.
Each standard has a title and code for easy reference. The aim indicates the
intended objectives of the standard.
The standard statement describes precisely what the midwifery trained personnel
will do and to what level of competence. The expected outcomes are stated in
measurable terms although some of the outcomes are long term outcomes such as
increased utilization of midwifery trained personnel The pre requisites include
those elements that are required to allow the health worker to perform the standard.
Eg: training, resources, knowledge, equipment, drugs and system.

Process: the critical task to be followed for meeting the standard have been
specified as process

The audit is an integral part of the standard. It includes a checklist and action plan.
The check list can be used to test or audit the standard. The action plan is the
critical part of the audit. It is intended to identify the areas which need
strengthening or correcting and to assist the supervisors, managers in their routine
supervisory visits. Without action following the audit, standards will be difficult to
maintain and impossible to improve.

Pre requisites:
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The essential elements that must be in place to enable the midwifery trained
personnel to carry out the standard effectively. A review or revision of the
supportive regulations and policies may be necessary to allow the midwifery
trained personnel to perform the standard correctly. Other elements/ structures,
which must be in place to ensure success, include:

 Supportive guidelines, policies or legislation

 Training needs

 Essential equipment; and

 Systems and other essential structures that must be in place.

PROCESS

The critical task that must be undertaken to achieve the desired outcomes.

a. Check list:

A list of items to assess whether essential pre requisites, knowledge, skills and/or
equipment are in place as well as critical tasks is performed correctly.

b. Action plan:

A series of questions to identify the deficiencies in the pre requisites and process
components of standard as well as action needed to rectify the deficiencies or to
strengthen the standard including target dates for completion of each action and
responsible person to implement the action.

EXAMPLE FOR ANTENATAL CARE STANDARD

Abdominal palpation

Aim:

To estimate gestational age, monitor fetal growth and accurately identify lie,
presentation and position of the fetus.

Pregnant women attend ANC

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 Midwifery-trained personnel have been trained in the correct procedure for

conducting abdominal palpation
 Essential equipment such as tailor's measure tape and fetal stethoscope is
available and in good working condition.
 A culturally appropriate place is available which allows privacy to conduct
the abdominal palpation.

 Pregnancy records are in use.

 A fully operational referral system is in place for the pregnant woman
identified as at risk or who develops complication to receive appropriate care
and treatment.

Process

Midwifery trained personnel must

1. Carry out abdominal palpation at every antenatal visit

2. Ask the pregnant women prior to the palpation how she feels, if the baby is
moving and when her last menstrual cycle occur or the date she felt the baby first
moved.

3. Ensure the place for conducting palpation provides the pregnant woman with
privacy

4. Prior to an abdominal palpation ask the pregnant woman to empty her bladder.

5. Lay the pregnant woman on her back with upper part of her body supported with
cushions. Never lie a pregnant woman flat on her back as the heavy uterus may
compress the main blood vessels returning to the heart and cause fainting (supine
hypotension).

6. Inspect the abdomen for scar, previous stretch mark. Signs of over distension/
other signs of multiple pregnancy such as fetal parts felt to fetal heads palpated,
excessive or reduced amount of amniotic fluid. Record findings and refer for
institutional deliveries. If the woman had a previous caesarean section or there are
signs of excessive or reduced amniotic fluid or multiple pregnancy.
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7. Estimate gestational age and assess the fetal growth. After 24 weeks of
pregnancy the most effective way to estimate gestational age is to use a tailor's tape
measure.

8. Using the measuring tape, measure from the upper border of the symphysis
pubis to the top of the funds. Record the measurement in centimeters. If
measurement is different from calculated weeks by more than 3 c.m. or there is no
growth or poor growth from the last examination, refer for further investigation.

9. Gently palpate the abdomen to assess the lie of the fetus

10. Using two hands palpate the abdomen and pelvic area to identify the presenting
part

11. After 37 weeks especially in primi gravida assess the fetal head is engaged. If
not, ask the pregnant women to sit/ stand up and see if the head can be made to fit
in to the pelvis. If the head will not going to the pelvis refer to the first referral
unit/ hospital.

12. Identify where the fetal back is and listen to the fetal heart sound

13. Discuss all findings with the pregnant woman, her husband/ accompanying
family members

Conclusion:

The standards are stated in action verbs that are in observable and measurable
terms. Eg : “the patient demonstrates. The focus is on what was planned, what was
done and what was communicated as recorded. In process standard there is an
element of professional judgment ie determining the quality as the degree of skill.
It includes nursing care technique, procedures, regimens, and processes. An
outcome standard measures changes in the patient health status. This change may
be due to nursing care, medical care or as a result of variety of services offered to
the patient. Outcome standards reflect the effectiveness and results rather than the
process of giving care.

JOURNAL STUDY
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Developing the scope and standards of specialty nursing practice can be a daunting
task for the nurse experts leading the work. The purpose of this article is to
demystify that process, whether to create new or revise existing specialty nursing
scope and standards of practice. We discuss best practices incorporated in the
developmental process for several recently published scope and standards of
specialty nursing practice. These best practices are applicable to nursing specialty
organizations publishing with ANA, as well as those that are not. This article
addresses each of the following best practices in detail: utilizing structures and
processes to initiate the process; Identifying a lead writer for the process;
Convening experts with specific roles and functions; Ensuring incorporation of
foundational documents; Establishing a realistic timeline; Addressing strategies to
overcome barriers; Promoting facilitators for success; Responding to reviewer
feedback, and disseminating the Scope and Standards.

A scholarly journal of American nurses association

REFERENCES

1. Midwifery and obstetrical nursing, as per INC syllabus ,third edition ,

Nima Baskar,page no.724-736,emess medical publishers

2. A text book of midwifery and gynecological nursing.

Neelam kumari, shivani Sharma, Dr.preethi gupta.page no.98-100 s.vikas
and company medical publishers P.V.books
3. http://www.slideshare .net
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