Title : Nursing Care Audit

 Nursing Care Audit Based on Nursing Process Model and Ensuring Patient Safety among Staff Nurses


The nursing process model involves assessing, diagnosing, planning, implementing and evaluating patient situations. In this study to audit nursing care, using a nursing process model, nursing audit checklist was designed based on nursing process model. The demo-graphic questionnaire contained nurses’ age, gender, work experience, type of employment, education level, and work shift. Nurses’ performance was assessed using the audit check-list during a single work shift. Some indicators were assessed through a review of docu-ments and nursing notes. Sample size was 100. The results showed that the majority of nurses (about 80%) worked in rotational shifts, 70 percent had 5 - 10 years of experience and 90 percent had GNM qualification. The rate of least compliance with nursing process indicators was 12.6, confirming that the majority of nursing care was not carried out based on the nursing process. The mean overall compliance score significantly differed between nurses with a BSc and those with GNM (p=0.04). This difference was also found in the mean compliance scores for three domains, diagnosis (p=0.001), implementation (p=0.02), and evaluation (p=0.01). In addition, the overall mean score did not significantly differ be-tween nurses with permanent and non-permanent employment (t=0.123, p=0.42). The find-ing revealed that the knowledge of nurses on the nursing process is not adequate to be put into practice and high patient nurse ratio affects its application.

Quality is a judgement of what constitutes good or bad. Audit is a systematic and critical ex-amination to examine or verify. Nursing audit is the assessment of the quality of nursing care and uses a record as an aid in evaluating the quality of patient care. Nursing Audit is an important com-ponent of medical audit. Nursing documentation con-stitutes an integral part of the nurse’s daily work (Heartfield, 1996). Meticulous nursing documenta-tion is an important part of multi professional pa-tient care. The delivery of good care and the ability to communicate effectively about patient care de-pends on the quality of information available to all health care professionals. One important part of this information is nursing documentation in nursing care plans (Saranto & Kinnunen, 2014).
The nursing process model has been used as a framework for nursing and nursing documentation. The nursing process model involves assessing, diag-nosing, planning, implementing and evaluating pa-tient situations, with the ultimate goal of prevent-ing or resolving problematic situations (Yura & Walsh,1978). Earlier studies have reported that nursing documentation has conformed to the nursing process and the use of the nursing process has been shown to improve legislative compliance and entire nurs-ing documentation (Waneka & Spetz).
Care plans provide direction and path for individualised care of the client. A care plan flows from each patient’s unique list of diagnoses and can be organised by the individual’s specific needs. The care plan is a means of communicating and organising the actions of a constantly changing nurs-ing staff. As the patient’s needs are attended to, the updated plan is passed on to the nursing staff at shift change and during nursing rounds. Care plans help teach documentation. The care plan should specifi-cally outline which observations to make, what nurs-ing actions to carry out, and what instructions the client or family members require. They serve as a guide for assigning staff to care for the client. There may be aspects of the patient’s care that need to be assigned to team members with specific skills (Hooks, 2016). The medical record is used by the insurance companies to determine what they will pay in rela-tion to the hospital care received by the client. If nursing care is not documented precisely in the care
plan, there is no proof the care was provided. Nurs-ing process enables nurses to perform their activi-ties with logical justification. It safeguards the rights of both the patient and the nurse. Nursing process implementation could be highly influenced by differ-ent factors that can lead to poor quality of nursing care, disorganisation of the service, conflicting roles, medication error, poor diseases prognosis, readmis-sion, dissatisfaction with the care provided, and in-creased mortality. These problems are manageable if a nurse can properly implement nursing process.
Review of Literature
Hagos et al (2014) conducted a cross-sectional design employing quantitative and qualitative methods in Mekelle zone hospitals in March 2011. Qualitative data was collected from 14 head nurses of six hospi-tals and quantitative data was collected from 200 nurses selected by simple random sampling tech-nique. SPSS version 16.1 and thematic analysis was used for quantitative and qualitative data respec-tively. Majority i.e. 180 (90%) of the respondents had poor knowledge and 99.5 percent of the respondents have a positive attitude towards the nursing process. All of the respondents said that they did not use the nursing process during provision of care to their pa-tients at the time of the study. Majority (75%) of the respondent said that the nurse to patient ratio was not optimal to apply the nursing process.
Zamanzadeh et al (2015) assessed the databases of Iran medix, SID, Magiran, PUBMED, Google scholar, and Proquest using the main keywords of nursing pro-cess and nursing process. The articles were retrieved in three steps including searching by keywords, re-view of the proceedings based on inclusion criteria, and final retrieval and assessment of available texts. Systematic assessment of the articles showed differ-ent challenges in implementation of the nursing pro-cess. Intangible understanding of the concept of nurs-ing process, different views of the process, lack of knowledge and awareness among nurses were found related to the execution of process, supports of man-aging systems. Problems related to recording the nurs-ing process were the main challenges.
Melin & Linda (2017) reviewed the characteristic of registered nurses’ intuition in clinical settings, in relationships and in the nursing process. Litera-ture searches were conducted in the databases CINAHL, PubMed and PsycINFO, and literature pub-lished 1985 – 2016 that the characteristics of intu-ition in the nurse’s daily clinical activities included application, assertiveness and experiences; in the relationships with patients’ intuition it included unique connections, mental and bodily responses, and personal qualities; and in the nursing process included support and guidance, component and clues in decision-making, and validating decisions.
Intuition is more than simply a ‘gut feeling’, it is a process based on knowledge and care experience and has a place beside research-based evidence. Nurses integrate both analysis and synthesis of in-tuition alongside objective data when making deci-sions. They should rely on their intuition and use this knowledge in clinical practice as a support in decision-making, which increases the quality and safety of patient care.
The objective of this study was to assess the indica-tor score in nursing process techniques of nursing process model among nurses in selected hospitals of Pune to provide pragmatic evidence for educators, clinicians, programme planners, decision makers to design a new one and/or strengthen the existing nursing process to serve as a baseline for future re-searchers.
In this cross-sectional study carried out from April 2015 to October 2016 in four selected hospitals of Pune staff nurses were targeted care provider. First, a nursing audit checklist was designed based on a literature review and expert opinions obtained from in-depth interviews of 8 experts in nursing and ac-creditation. There were 25 items (indicators) in the checklist, covering the following domains: assess-ment (5 items), nursing diagnosis and identifying outcomes (5 items), planning (5 items), implemen-tation (7 items), and evaluation (3 items). Most items were rated on a three-point scale (never = 0, some-times = 50, and always = 100) depending on the level of nurses’ compliance. Mean scores were calculated for each indicator as well as for each domain and for the full checklist. Higher scores indicated better per-formance. External consistency was assessed through the test-retest method with a two-week interval. The value of r was 0.954. Internal consistency was done by using Cronbach’s a-method, the value of a was was 0.889. The results show that the study check-lists were more reliable to use for main study. Inclu-sion criteria were working full-time, having at least 2 years of clinical experience, and willingness to par-ticipate in the study; the sample size was 100.
Data was collected using a demographic question-naire and the audit checklist. The demographic ques-tionnaire contains nurses’ age, gender, work expe-rience, type of employment, education level, and work shift. Checklist was used by observations, interviews, and document evaluation methods to audit nursing care. Using a random number table, the required number of nurses was randomly selected from the list of nurses from PCMC Hospital. To determine the rate of compliance with indicators, all of the nursing activities were observed during a single work shift and nursing documents were evaluated. In some cases, interviews were conducted with nurses as explained in detail in the audit guide.
Table: 2 Indicator Score for Dignosis and outcome detemination in the Nursing Process Technique.
Nurses’ performance was assessed using the au-dit checklist during a single work shift. Some indi-cators needed to be assessed through a review of docu-ments and nursing notes (e.g. recording and report-ing). Some indicators had to be assessed through ob-servation (e.g., collaborating with the client/family in decision making for clinical practice). A few indi-cators were assessed through interviews of patients and their families (e.g. education about the home care plan). This study was approved by Medical su-perintendent of PCMC Hospital.
Majority of nurses (about 80%) worked in rotational shifts. About 70 percent had 5 - 10 years of experience; 30 percent were non-permanently employed, about 90 percent had GNM qualification and 5 percent of them had ANM qualification and another 5 percent 
were BSc Nursing. The rate of least compliance with nursing process indicators was 12.6, confirming that the majority of nursing care was not carried out based on the nursing process.
The mean overall compliance scores significantly differed between nurses  with a BSc and those with an GNM (p=0.04). This difference was also found in the mean compliance scores for three domains: diagnosis (p=0.001), implementation (p=0.02), and evaluation (p=0.01) In addition, the overall mean score did not significantly differ between nurses with permanent and non-permanent employment (t=0.123, p=0.42).
Table 1 shows that only 20 percent of staff nurses perform comprehensive nursing assessment of the patient dur-ing the first 24 hours of admission and 50 percent of nurses do not perform assessment in 24 hrs of admission. Only 16 percent of nurses record and report the findings of assessment whereas 54 per-cent of them do not report and record.
As shown in Table 2, 21 percent of nurses have practice of extracting a nursing diagnosis from the data by using critical thinking and reasoning skills and 50 percent of staff nurses do not extract the nurs-ing diagnosis. Table 3 indicates that 19 percent staff nurses had documented the care plan; 48 percent of nurses provided care to the patients according to his health condition; 2 percent had practice of designing a discharge care plan to meet the need for follow-up after discharge and 50 percent of them did not prac-tice it. 20 percent of nurses documented the care plan in a reliable, understandable way that is acces-sible to all members of the healthcare team and 72 percent of them do not plan.
It was found that 20 percent of staff nurses imple-ment interventions based on the care plan, 19 per-cent the implement planning as per the policies, 16 percent of them approached experts in case of doubts (Table 4). Only 13 percent of staff nurses record patient reaction to the actions taken, 8 per-cent evaluate the interventions based on relevant outcomes and 10 percent of them participate with families and health care providers (Table 5).
In the present study, an audit tool was developed and used to evaluate nurs-ing activities in accordance with nurs-ing process indicators. Mykkanen et al (2012) also audited nurse performance but mostly used nursing documentation as the only data source. In the present study, nurses obtained a relatively less score for compliance with the nursing process indicators, almost in all the do-mains of assessment, diagnosis, plan-ning, implementation and evaluation. Rivas et al (2012) who investigated the implementation of the nursing process in primary healthcare reported that using the nursing process can improve the quality of care and people’s health. Ledesma-Delgado et al (2009) studied nursing process presented as routine care actions: Building its meaning in clinical nurses’ perspective, nurses at-tributed to the nursing process in their daily care practice, which was unveiled as routine care actions, performed dif-ferently from what they had learned in school. Lee (2005) studied the use of factors affecting nursing diagnoses in charting standardised care plans, us-ing educational programmes for en-hancing nurses’ ability to use nursing diagnoses and exploring the process of diagnostic reasoning to improve the quality of patient documentation, its relevance to clinical practice and the trend in health care is to focus on chart audit to reveal indicators of quality of care.
In Nursing service, planned health teaching programmes need to be con-ducted to enhance the knowledge and skills of staff nurses on nursing process model. Nursing schools and colleges should enlighten the students and staff nurses with adequate knowledge on nursing process model.
A similar study can be replicated with larger sample to generalise the findings. Also, a study can be conducted to assess the barriers to maintain the nursing process model by staff nurses working in Government hospitals.

Majority of the study participants (90%) were poorly knowledgeable, not applying the nursing process model in their regular patient care. Participants reported that factors such as shortage of resources, lack of knowledge, high patient nurse ratio/work load, and lack of training and motivating factors such as salary affected the appli-cation of the nursing process. It is possible to recom-mend the hospitals as well as the nurses to seek means to upgrade the knowledge of their nurses on the nurs-ing process and its implementation to improve their knowledge on the nursing process application respec-tively. The government must reemphasise on the pro-vision of adequate resources such as materials, nurs-ing human power, and adequate salary for the profes-sionals so that the nursing process may be applied.
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Author: A. Seeta Devi


The author is Asst. Professor, Symbiosis College of Nursing, Symbiosis International University, Pune