A nursing audit is the process of collecting and analyzing data to evaluate the

effectiveness of nursing interventions.

A nursing audit can focus on implementation of the nursing process, client outcomes,
or both in order to evaluate the quality of care provided. Nursing audits examine data related
to:
Safety measures
Treatment interventions and client responses to the interventions
Preestablished outcomes used as basis for interventions
Discharge planning
Client teaching
Adequacy of staffing patterns
Audits are based on components such as institutional policies; federal, state, and local
regulations; accreditation standards; and professional standards (see Figure 10-3). Audits
assist in identifying strengths and weaknesses that, in turn, provide direction for areas
needing revision. Corrective action plans are developed in accordance with the audit results.

Peer Evaluation
Another method of evaluating quality of care is peer evaluation (also referred to as
peer review), the process by which professionals provide to their peers critical performance
appraisal and feedback that are geared toward corrective action. According to the ANA
(1988): Peer review in nursing is the process by which practicing Registered Nurses
systematically assess, monitor, and make judgments about the quality of nursing care
provided by peers, as measured against professional standards of practice. (p. 3)

In 1984, Lucille Joel postulated that peer review is the basis of nursings autonomy
and self-governance (Joel, 1984). This perspective is still very relevant in todays health care
climate. By evaluating itself, nursing is demonstrating an essential criterion by which
professions are recognized. Peer evaluation promotes both professional and individual
accountability.
The quality of nursing care is strongly evident to coworkers and nurses who are
expected to assess the work of their peers. Peer review is an essential mechanism for
evaluating the judgment and performance of clinical providers (Wakefield, Helms, & Helms,
1995, p. 11).
Such judgment may result in one of the following outcomes:
Destructive: Complaints and attacks that undermine morale and cohesiveness

 Constructive: Positive feedback that improves the quality of care

Peer evaluation can be destructive if the parties involved begin to personalize the
process, misunderstand the purpose, or deliver feedback in an unfeeling and nonobjective
manner. Peer evaluation can be threatening when guidelines have not been established for the
process and when the assessment focuses on emotions and personalities instead of on
behaviors. Conversely, peer evaluation is constructive when the focus remains on quality
improvement and encourages the continued growth and learning of all the parties involved.
The accompanying display provides principles that promote the use of objective, nonbiased
peer evaluation.

EVALUATION AND ACCOUNTABILITY

Accountability means assuming responsibility for ones actions. Evaluation enhances
nursing accountability by providing a mechanism for assisting the nurse to define, explain,
and measure the results of nursing actions.
Accountability is increased by ongoing evaluation; nurses are continually checking
their own progress against predetermined standards.
Accountability is an integral part of professional nursing practice and is an important
method through which commitment to quality client care can be demonstrated.
Nurses are accountable for designing effective care plans, implementing appropriate
nursing actions, and judging the effectiveness of their nursing interventions (Kenney, 1995,
p. 195). In other words, nurses are accountable, for their judgments, decisions, and actions,
to:
Clients, families, and significant others
Colleagues
Employers
The general public (society)

 The nursing profession

Themselves
Nurses demonstrate their commitment in a variety of ways, including:
Maintaining expertise in skills
Participating in continuing education programs
Achieving and maintaining certification
Participating in peer evaluation

MULTIDISCIPLINARY COLLABORATION IN EVALUATION

Evaluating the quality of care provided is a responsibility shared among members of
the health care team. In addition to those directly involved (the health care providers, clients,
and families), others interested in the outcomes of evaluation include the community and
third-party payers (both public and private reimbursement organizations).
An ongoing monitoring process is implemented to evaluate quality of care. Ideally,
every discipline monitors its own quality efforts. No single discipline is responsible for allinclusive evaluation of client care. However, in most health care agencies, nurses are actively
involved in monitoring evaluation activities. Many agencies have nurses on staff who
function either as quality management coordinators, utilization review evaluators, or both.
When health care providers from all the relevant disciplines are involved in
evaluation, the result is decreased fragmentation of care. The team approach mandates active
involvement of all care providers in the evaluation of quality care. Multidisciplinary

evaluation helps promote a continuum of care for the client, from the preadmission phase to
discharge planning and follow-up care.

Modifying the Plan of Care

If the evaluation data indicate a lack of progress toward goal achievement, the plan of
care is modified. These revisions are developed through the following process: reassessment
of the client; formulation of more appropriate nursing diagnoses; development of new or
revised goals and expected outcomes; and implementation of different nursing actions or
repetition of specific actions to maximize their effectiveness (for instance, client teaching).
See the Nursing Checklist for guidelines for evaluating effective application of the nursing
process to client care.
Evaluation is performed by every nurse, regardless of the practice setting. For
example, the home health nurse evaluates the care provided regularly throughout the clients
relationship with the agency. Evaluation of the home care client is carried out in order to

determine whether the care was delivered in an effective and efficient manner, to modify the
plan of care as needed, and to decide when the client is ready for discontinuation of home
care services. The accompanying display provides an example of evaluation performed by the
home health care nurse.

Critical Thinking and Evaluation

Evaluation is a critical thinking activity. It is a deliberate mechanism used to analyze
and make judgments.
Nurses need to remain objective when evaluating client care in order to modify care
based on reason rather than emotion. One critical thinking strategy, juxtaposing, is described
as putting the present state condition next to the outcome state in a side-by-side contrast
(Pesut & Herman, 1999, p. 93). Nurses use juxtaposing throughout evaluative activities by
comparing client responses to expected behaviors. They make conclusions about whether
expected outcomes have been met.
In order to make such conclusions, assessment data is needed to determine client
progress toward achievement of objectives. Evaluation involves analysis and is much more
complex than merely answering questions

1. Evaluation
2. INTRODUCTION. Evaluation, the final step of the nursing process, is crucial to
determine whether, after application of the nursing process, the clients condition or
well-being improves. The nurse applies all that is known about a client and the clients
condition, as well as experience with previous clients, to evaluate whether nursing
care was effective. The nurse conducts evaluation measures to determine if expected
outcomes are met, not the nursing interventions.

3. The expected outcomes are the standardsagainst which the nurse judges if goals
havebeen met and thus if care is successful.Providing health care in atimely,
competent, and cost-effectivemanner is complex and challenging. Theevaluation
process will determine theeffectiveness of care, make necessarymodifications, and to
continuously ensurefavorable client outcomes.

4. DEFINITIONEvaluation is defined as the judgment of the effectiveness of nursing

care to meet client goals; in this phase nurse compare the client behavioral responses
with predetermined client goals and outcome criteria. {CRAVEN 1996}

5. Nursing Diagnosis : Impaired skin integrity related to physicalmobilityExpected

Outcomes : The patient will be able to get recovery of pressuresore.Planning
Rationale Evaluation Wound healingPressure sore dressing, Cleansing the was
observed area will prevent (tissues were further infection red, healthy)Back care It
will promote blood circulationChange the position frequently It will put little
pressure on the sore siteEncourage the patient to ambulateTake protein rich diet
Protein helps in repair of tissues

6. PURPOSES1. Determine clients behavioral response to nursing interventions.2.

Compare the clients response with predetermined outcome criteria.3. Appraise the
extent to which clients goals were attained.

7. 4. Assess the collaboration of client and health care team members.5. Identify the
errors in the plan of care.6. Monitor the quality of nursing care.

8. ACTIVITIES IN EVALUATION PHASE Identifying criteria and standards

Collecting evaluating data Interpreting & summarizing findings

9. Documenting findings Care plan revision

10. Identifying criteria and standard Nurses evaluate the nursing care by
knowingwhat to look for. A clients goals & expectedoutcome give the objective
criteria needed aclients response to care.

11. Collecting Evaluative Data Evaluating a clients response to nursingcare requires

the use of evaluativemeasures, which are simply assessment, skill &techniques, (Eg.
Auscultation of lungsounds, observation of clients skillperformance, discussion of
the clientsfeeling, and inspection of the skin.) Infact, evaluative measures are
thesame as assessment measures, but nurses performthem at the time of care when
theymake, decission about the clients status andprogress.

12. Interpreting & Summarizing Findings Using evidence, nurses make

judgementabout a client condition. To develop clinicaljudgement, match the result of
evaluative measureswith expected outcomes to determine if a clientsstatus is
improving or not. 1. Examine the goal statement to identify the exact desired client
behavior or response. 2. Assess the client for the presence of that behavior or
response.

13. 3. Compare the established outcome criteria with the behavior or response.4.
Judge the degree of agreement between outcome criteria and the behavior or
response.5. If there is no agreement (or only partial agreement ) between the outcome
criteria and the behavior or response, what is/are the barriers? Why did they not
agree?.

14. Documenting Findings: Documentation and reporting are an importantpart of

evaluation. Written nursing processnotes, assessment flow sheets and information
sharedbetween nurses during changes of shift reportscommunicate a clients progress
toward meetingexpected outcomes and goals for the nursing plan ofcare.

15. Care Plan Revision: Evaluate expected outcomes anddetermine if the goals of
care have been met Then decide the need to adjust the planof care. If goal met
successfully, discontinuethat portion of the care plan.

16. COMPONENTS OF EVALUATION1. Collecting the data related to the desired

outcomes2. Comparing the data with outcomes3. Relating nursing activities to
outcomes4. Drawing conclusion about problem status5. Continuing, modifying, or
terminating the nursing care plan

17. Collecting the data: The nurse collects the data so thatconclusion can be drawn
about whether goalshave been met. It is usually necessary to collectboth subjective &
objective data. Data must berecorded concisely and accurately to facilitate thenext
part of the evaluating process.

18. Comparing the data with outcomes: If the first part of the evaluationprocess has
been carried out effectively , it isrelatively simple to determine whether a
desiredoutcome has been met. Both the nurse and clientplay an active role in
comparing the clientsactual responses with the desired outcomes.

19. Relating nursing activities to outcomes The third aspect of theevaluating process
is determined whether thenursing activities had any relation to theoutcome.

20. Drawing conclusion about problem status: The nurse uses the judgement
aboutgoal achievement to determine whether thecare plan was effective in resolving,
reducingor preventing client problems. When goalshave been met the nurse can draw
one thefollowing conclusions about the status of theclients problem.

21. The actual problem stated in the nursing diagnosis has been resolved , or the
potential problem is beingprevented and the risk factors no longer exist. Inthese
instances , the nurse documents that the goalshave been met and discontinues the care
for theproblem. The potential problem is being prevented, but therisk factors still
present. In this case , the nurse keepsthe problem on the care plan. The actual
problem still exists even though somegoals are being met. In this case the
nursinginterventions must be continued.

22. Continuing , modifying , or terminatingthe nursing care plan: After drawing

conclusion about thestatus of the clients problems , the nursemodifies the care plan as
indicated. Whetheror not goals were met, a number of decisionneed to be made
aboutcontinuing, modifying or terminatingnursing care for each problem.

23. Before making individualmodification, the nurse must first determinewhy the plan
as a whole was not completelyeffective. This require a review of the entireplan.

24. NURSING PLANNING DIAGNOSIS IMPLEMEASSESSMENT NTATION

EVALUATION RE- EVALUATION

25. FACTORS AFFECTING GOALATTAINMENT Family Members Health Team

Factors Affecting NurseMembers Goal Attainment

26. EVALUATION SKILL REQUIRED FORNURSES1. Nurse must know the

hospital policies, procedure and protocols of interventions and recording.2. Nurse
must have up to date knowledge and information of many subject.

27. 3. Nurse must have intellectual and technical skill to monitor the effectiveness of
nursing interventions.4. Nurse must have knowledge and skill of collecting subjective
data and objective data.

28. THANK YOU