ACM Interim Council, MEAC & SRAC collated response to the Public consultation on review of the Registered nurse standards for practice

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1 Question Detail ACM Comments 1. Are you a registered nurse? 2. Which of the following best indicates your current role? 3. What is your age? 4. If you work in nursing what is your current area of practice? 5. If employed in nursing which sector do you work in? 6. Standard 1: Thinks critically and analyses nursing practice ACM suggest that the wording for this Standard does not seem quite right Two options below: 1. Thinks critically, analyses and evaluates nursing practice Nurses use a variety of thinking strategies, research and best available evidence in making decisions and providing safe, quality nursing practice within a person-centred framework. Do you have any comments or suggested amendments? 2. Thinks critically to inform nursing practice ACM support the inclusion of personcentred care and movement away from patient-centred care. And further note and agree with the separation of person centred care and cultural safety into different standards as both are important. ACM also notes previous comments made re separation from evaluation that is included in Standard 7. ACM advises that thinking strategies may need further clarification. Suggest addition to Glossary. Note - Thinking strategies has no shared meaning within the profession. However, there appears to be some shared meaning in school education. There is also no shared meaning for the term continuous thinking used in the preamble.

2 7. Standard 1: Criteria The registered nurse: 1.1. Accesses, analyses, and uses research, and the best available evidence for safe quality practice 1.2. Develops practice through reflection on experiences, knowledge, actions, feelings, beliefs; identifying how these shape practice 1.3. Respects peoples culture and experiences as a core part of person-centred and evidencebased practice, which includes recognising the role of family and community that underpin Aboriginal and Torres Strait Islander cultures and health 1.4. Considers legislation and common law policies and guidelines relevant to the context of practice when making decisions 1.5. Appropriately maintains records and accurately and comprehensively documents assessment, planning, decision-making, actions and evaluations in a timely manner 1.6. Contributes to research and quality improvement. The criteria are the means by which the standard can be demonstrated. Do you have any comments or suggested amendments? Consider explanatory definition in the glossary identifying some of the key thinking strategies to which the NMBA attributes the profession e.g. may include but not limited to.mindfulness, evaluative, reflective, emancipatory and / or critical thinking strategies 1.1 suggest including interprets such that the criteria reads: Accesses, analyses, interprets and uses research, and the best available evidence for safe quality practice 1.2 The ACM suggests the inclusion of evidence to this Criteria such that it reads: Develops practice through reflection on experiences, knowledge, evidence, actions, feelings, beliefs; identifying how these shape practice 1.3 ACM support there being a primary focus on Aboriginal and Torres Strait Islander cultures and health to support closing the gap. Australia is, however, a multicultural society with increasing numbers of refugees which is a pattern that will continue long into the future. Therefore, ACM consider that many cultures hold different perspectives to family, community and health. Suggest - adding inclusion of and other cultures in this criterion such that it reads:

3 Respects peoples culture and experiences as a core part of person-centred and evidence-based practice, which includes recognising the role of family and community that underpin Aboriginal and Torres Strait Islander cultures and health and other cultures 1.5 ACM appreciates the importance of documentation but is unsure whether this Standard/criteria is the best place to include this requirement (documentation) as it is also included in ACM suggest that capacity to contribute to research may be context and opportunity dependent consider rewording to include quality improvement and where possible research such that it reads: Contributes to quality improvement and where possible research 8. Standard 2: Engages in therapeutic and professional relationships Nursing practice is based on purposefully engaging in the formation and maintenance of effective therapeutic and professional relationships. This includes collegial generosity in the context of interdisciplinary and professional relationships. Do you have any comments or suggested amendments? ACM questions the difference between a therapeutic and professional relationship. Suggests this needs greater definition - and should be added to the Glossary. ACM suggests that collegial generosity may not be fully understood or easily assessed as it is new nomenclature which doesn t necessarily have the same meaning to all and can therefore be open to interpretation. Suggestions:

4 1 Include brief measurable definition in brackets. 2 Collegial generosity is included in the glossary to promote understanding. Or change the wording to use terms that are more commonly used and understood such as respectful and/or collaborative. ACM also suggests that the importance of intra-disciplinary relationships not be over looked. Therefore suggest the sentence be restructured to read: This includes respect and collaboration in the context of both intra-disciplinary and interdisciplinary and professional relationships. 9. Standard 2: Criteria The registered nurse: 2.1 Establishes, sustains and concludes therapeutic relationships in a way that is respectful and acknowledges the dignity, culture, values and beliefs and rights of a person 2.2 Recognises that people are the experts in the experience of their life 2.3 Communicates respectfully and effectively with people 2.4 Resources and supports people in optimising and making health related decisions 2.1 ACM suggests including the term nonjudgmental here such that the criteria reads: Establishes, sustains and concludes therapeutic relationships in a way that is respectful, non-judgemental and acknowledges the dignity, culture, values and beliefs and rights of a person 2.4 The ACM is concerned that the wording of this criterion will not be easily understood. Suggestion:

5 2.5 Advocates on behalf of people and their rights in a manner that respects the person s autonomy and legal capacity 2.6 Establishes and maintains appropriate professional relationships including delegation, supervision, consultation and referrals to achieve improved health outcomes 2.7 Actively fosters a culture of safety and learning 2.8 Participates in and/ or leads collaborative practice. The criteria are the means by which the standard can be demonstrated. Do you have any comments or suggested amendments? Change to read: Enables and supports people to make the best health related decisions possible in their circumstances where nursing care is planned with the person. 2.7 The ACM suggests replacing fosters with promotes and add quality care such that this Criteria reads: Actively promotes a culture of safety, quality care and learning 10. ACM suggests that this Standard might be better placed first as it pertains to the ability to practice that it is the basis for all ongoing assessment. Standard 3: Maintains fitness to practise and participates in lifelong learning Registered nurses, as regulated health professionals, are responsible and accountable for ensuring they are safe and have the capability for practice. This includes ongoing selfmanagement and responding when there are concerns about other health professionals fitness for practice. Registered nurses are responsible for their professional development and contribute to the development of others. They are also responsible for providing information and education to enable people to make decisions and take action in relation to their health. Do you have any comments or suggested amendments? Title change suggestion: Reword to add own such that it is a refocus to make this one about the individual s maintenance of their own fitness to practice, not that of others. To read as: Maintains own fitness to practise and participates in lifelong learning The ACM questions to inclusion of the wording self-management as this should be evident by the preceding and following sentences. Further the middle sentence means that this Standard lacks clarity as to whether it is about self or others.

6 The ACM suggest that the following sentence This includes ongoing self-management and responding when there are concerns about other health professionals fitness for practice. Be removed as self management is thought to be superfluous, and remaining details are addressed in Safety standard (6.6). The new text would read: 11. Standard 3: Criteria The registered nurse: 3.1. Considers and responds in a timely manner to the health and well being of self and others in relation to fitness for practice 3.2. Provides information to people to enhance their control over health care and facilitate informed consent 3.3. Responds to a person s educational needs to enhance health and wellbeing 3.4. Takes a lifelong learning approach to the continuing development of self and others 3.5. Actively engages with the profession Registered nurses, as regulated health professionals, are responsible and accountable for ensuring they are safe and have the capability for practice. Registered nurses are responsible for their professional development and contribute to the development of others. They are also responsible for providing information and education to enable people to make decisions and take action in relation to their health. General comment: There does not appear to be a clear conceptual thread across the Criteria in this standard. Ordering of criterion may improve clarity for example the word accountable is used in the first sentence of the stem perhaps criterion 3.9 should then be one of the first criterion and so on Need to clarify 3.1 and 3.4 who are others. ACM suggests either a clear division 1. Education of self 2. Education of peers mentoring/teaching/clinical supervision

7 3.6. Completes continuing professional development requirements as specified in the Nursing and Midwifery Board of Australia registration standards 3.7. Identifies and promotes the integral role of nursing and its profession in influencing better health outcomes for people 3.8. Seeks and responds to practice review and feedback 3.9. Accepts accountability for decisions, actions, behaviours and responsibilities inherent in their role, and for the actions of others to whom they have delegated responsibilities. The criteria are the means by which the standard can be demonstrated. Do you have any comments or suggested amendments? 3. Education of clients/patients health promotion, informed consent. OR the removal of references to others throughout this criterion and making it about the registrant s behaviour / delegatory responsibilities only 3.1 suggest more qualifiers of the actions in this criterion as it is thought that responds is very broad and needs additional parameters that reflect legal / regulatory duty of care. Suggest change of wording to add when fitness for practice is perceived as below the expected standard such that the Criteria now reads: Considers and responds in a timely manner to the health and well being of self and others when fitness for practice is perceived as below the expected standard 3.2 Suggested reword to: Acts to enhance peoples control over heath care by provision of information and facilitating informed consent. 3.3, ACM believes this criterion currently refers to patient care and is therefore not related to the RN as per the Standard Statement. 3.4 ACM commented previously on capacity to taking this approach for others and continues to believe it needs a context, which was included in previous draft using formal and informal learning, teaching and clinical supervision/mentoring/coaching.

8 Suggest rewording to: Takes a lifelong learning approach to the continuing development of self and others, using formal and informal learning, teaching and clinical supervision/mentoring/coaching. 3.8 the ACM recommends the rewording of this criteria to reflect the responsibility of the Nurse for own reflection and practice review. To read: 12. Standard 4: Comprehensively conducts assessments Evaluates own practice supported by performance reviews and feedback. Registered nurses accurately conduct comprehensive and systematic assessments, analyse information and data and communicate outcomes as the basis of practice. Do you have any comments or suggested amendments? 13. Standard 4: Criteria The registered nurse: 4.1. Conducts assessments that are comprehensive, systematic and holistic as well as culturally appropriate 4.2. Uses a range of assessment techniques to collect relevant and accurate information and data to inform practice 4.3. Works with people to determine factors that affect or potentially affect the health and well being of people, families, communities, and/ or populations and determines priorities for action and/ or for referral Would consider adding a criterion that addresses effective and appropriate use of health informatics and health technologies. The ACM has previously suggested inclusion of working in partnership with people which has not at this stage been identified. It is important to note that Nursing care should be planned with the person. The ACM also suggests inclusion of a note identifying that Nurses reflect on own practice and how own beliefs/values can

9 4.4. Establishes the need for nursing action and/ or the need for referral 4.5. Assesses the available resources to address the need and plans accordingly. The criteria are the means by which the standard can be demonstrated. Do you have any comments or suggested amendments? influence how information is gathered and/or informed consent obtained with an understanding of personal biases on sexual orientation, ethnicity, culture, gender, age etc. ACM suggest inclusion around documentation in this Standard as documentation is a requirement/outcome of the assessment process. 4.1 The word conducts is very power-laden and does not suggest a notion of partnership. This may be what nurses want to do but ACM would have thought a sense of engagement and partnership was more useful and in line with practice in a range of settings. Suggested rewording to: Works in partnership with people to undertake assessments that are comprehensive, systematic and holistic as well as culturally appropriate 4.3 Potential wording to read: Recognition of aberrations from normal parameters of health and responding appropriately and in a timely manner. 4.4 Establishes the option of referral consider whether this a conceptual thread that needs to be followed up in planning and evaluation below.

10 14. Standard 5: Develops a plan for nursing practice Registered nurses are responsible for the planning and communication of nursing practice. Agreed plans are developed in partnership. They are based on the registered nurse s comprehensive assessment, use of evidence and judgment that is documented and communicated to all the relevant persons. Do you have any comments or suggested amendments? 1 st sentence is descriptive text for the Standard, suggest reword to: Registered nurses are responsible for the planning of nursing practice and the communication of that plan. 15. Standard 5: Criteria The registered nurse: 5.1. Uses assessment data and best available evidence to develop a plan 5.2. Co-constructs nursing practice plans until priorities, goals, actions, outcomes and timeframes are agreed with the relevant persons 5.3. Documents, evaluates and modifies plans to facilitate the agreed outcomes 5.4. Plans how practice will be evaluated and the time frame of engagement 5.5. Coordinates resources effectively and efficiently for planned actions. The criteria are the means by which the standard can be demonstrated. Do you have any comments or suggested amendments? Providing care needs to be as part of a collaborative team so it is disappointing that the partnership with the patient again seems to be missing. For example developing a plan seems to omit the person receiving nursing care or the patient. Further, collaboration with the medical and other professions could be included in here. Criterion 5.1 & 5.4 If assessment is culturally appropriate suggest planning, implementation and evaluation need also to reflect cultural considerations. Criterion 5.2 The Australian Commission on Safety and Quality in Health Care discuss partnership with consumers (Standard 2). The ACM suggest that in 5.2 wording should therefore better reflect the central role of the person directly receiving care in the coconstruction of the nurse practice plan. This would be in keeping with the person-centred approach reflected throughout the standards. The ACM is also concerned with the term coconstructs and whether it will be easily understood (eg it is not believed to be a commonly used term in practice)

11 Suggested reword to: Engages with people to construct and agree nursing practice plans until priorities, goals, actions, outcomes and timeframes are agreed. If a re-wording is not agreed, then for coconstructs to be defined in the glossary 5.5 rewording suggestion: 16. Standard 6: Provides safe, appropriate and responsive quality nursing practice Registered nurses delegate and implement person-centred, quality, and ethical goal directed actions. These are based on comprehensive and systematic assessment, and the best available evidence to achieve planned outcomes. Do you have any comments or suggested amendments? Coordinates available resources and engages in ongoing monitoring and evaluation for effective and efficient planned actions. Definition statement - suggest rewording so that implement is the first word followed by and, where necessary, delegates personcentred such that the sentence now reads Registered nurses implement and where necessary delegate person-centred, quality, and ethical goal directed actions. 17. Standard 6: Criteria The registered nurse: 6.1. Provides comprehensive safe, quality nursing practice to achieve agreed goals and outcomes 6.2. Practises within their scope of practice 6.3. Appropriately delegates aspects of practice to enrolled nurses according to the enrolled nurse s scope of practice and/ or others according to their clinical or non-clinical roles General note - more RNs are working in teams with midwives and nurse practitioners. Therefore suggest expanding the focus to include aspects of Registered nurse practice applicable to when they accept a delegation - in a similar vein to criterion 6.4. E.g. Accepts delegations appropriately, seeks timely direction, teaching or supervision as needed and undertakes effective reporting to ensure delegated practice is provided safely and correctly. General suggestion:

12 6.4. Provides effective timely direction and supervision to ensure that delegated practice is provided safely and correctly Include a criteria related to accountability and responsibility of own actions Practises in accordance with relevant nursing and health guidelines, standards, regulations and legislation 6.6. Reports and raises concerns where own or others practice may be below expected standards, errors have occurred and there is potential for harm. The criteria are the means by which the standard can be demonstrated. Do you have any comments or suggested amendments? 6.4 Suggest reword form provided to undertaken : ensure that delegated practice is undertaken safely and correctly 6.6 The ACM questions whether this criteria needs to be more clearly directive as there Is a risk for interpretation otherwise. Suggest adding to this criteria to read: Reports and raises concerns where own or others practice may be below expected standards, omissions and/or errors have occurred and there is potential for harm, using the appropriate formal channels available in the care environment. 18. Standard 7: Evaluates outcomes to inform nursing practice Registered nurses take responsibility for the evaluation of practice based on agreed outcomes, to plan, and revise practice accordingly. Do you have any comments or suggested amendments? 19. Standard 7: Criteria The registered nurse: 7.1. Evaluates and monitors progress towards expected goals and outcomes with people based on agreed priorities In 7.1, whose goals and outcomes are being considered? It is not clear if it is the patient or the nurse. Suggest addition of words for further clarification:

13 7.2. Revises practice plan as needed and determines further priorities and goals with people as indicated. The criteria are the means by which the standard can be demonstrated. Do you have any comments or suggested amendments? Evaluates and monitors progress towards expected goals and outcomes with people in their care based on agreed priorities. Criterion 7.2 and 5.3 appear to have some overlap consider amalgamation or rewording to make each more distinct. Suggestion for added criteria: Works in an effective partnership with people in planning care outcomes. 20. Glossary The next set of questions relate to the Glossary that forms part of the Registered nurse standards for practice. Please comment on each definition and the suitability and inclusion of each key term. These definitions relate to the use of these terms in these Registered nurse standards for practice. Where such definitions are available with further detail in other Nursing and Midwifery Board of Australia documents, the source is provided. Add thinking strategies from Standard 1 Add continuous thinking from the preamble (see Standard 1 for more notes on this). Add collegial generosity from Standard 2 (if not using the alternative suggested words) Add definition of therapeutic and professional relationships from Standard 2. Add co-constructs from Standard Accountability means that nurses answer to the people in their care, the nursing regulatory authority, their employers and the public. Nurses are accountable for their decisions, actions, behaviours and the responsibilities that are inherent in their nursing roles. Accountability cannot be delegated. The registered nurse who delegates activities to another person is accountable for their decision to delegate, for monitoring the level of performance of the other person, and for evaluating the outcomes of what has been delegated (See Nursing and Midwifery Board of Australia, 2007, p. 16 for more detail).

14 22. Criteria mean the actions and behaviours of the registered nurse that are necessary to demonstrate these Standards for practice. 23. Delegation is the relationship that exists when a registered nurse delegates aspects of their nursing practice to another person such as a registered or enrolled nurse, a student nurse or a person who is not a nurse. Delegations are made to meet peoples needs and to enable access to health care services, that is, the right person is available at the right time to provide the right service. The registered nurse who is delegating retains accountability for the decision to delegate and for monitoring outcomes. Both parties share the decision-making, capability, and risk assessment processes of delegation. In some instances delegation may be preceded by teaching and competence assessment. See row 17 above and expand to include 24. Enrolled nurse is a person who has completed the prescribed education preparation, demonstrates competence to practise and is registered under the National Law as an enrolled nurse in Australia. Enrolled nurses provide nursing care under the supervision of a registered nurse. 25. Evidence-Based Practice is accessing the best available evidence, which includes the most current, valid and available research findings as the basis for practice decisions. 26. Person or people is used in these Standards to refer to those individuals who have entered into a therapeutic or professional relationship with a registered nurse. The words person or people include all the patients, clients, consumers, families, carers, groups and/ or communities that are within the registered nurse scope and context of practice. This includes those cultures where family and community are a fundamental part of a person s identity. The registered nurse has professional relationships with colleagues and people in health care related teams. Do other health care professionals enter into a professional relationship with the RN a distinction that may not be clear in some of the criterion in Standard 3.

15 27. Person-centred practice is collaborative and respectful partnerships built on mutual trust and understanding. Each person is treated as an individual with the aim of respecting people s rights and preferences while protecting their dignity. Person-centred practice is also recognising the role of family and community that particularly underpin Aboriginal and Torres Strait Islander cultures and health. Add other cultures as above. 28. Registered nurse is a person who has completed the prescribed education preparation, demonstrates competence to practise and is registered under the National Law as a Registered nurse in Australia. 29. Scope of practice is that in which nurses are educated, competent to perform and permitted by law. The actual scope of practice is influenced by the contexts in which the nurse practises, the health needs of people, the level of competence and confidence of the nurse and the policy requirements of the service provider. 30. Standards for practice in this document are the expectations of registered nurse practice. They replace the previous National competency standards for the registered nurse while still informing the education standards for registered nurses and the regulation of nurses and determination of nurses fitness for practice. The Standards also guide consumers, employers and other stakeholders on what to reasonably expect from a registered nurse. 31. Supervision incorporates direction and guidance. It is a formal process of professional support and learning which allows a nurse or nursing student to develop knowledge and competence, assume responsibility for their own practice and enhance public protection and safety.

16 Supervision may take the form of clinical supervision which is a reflective practice engaged within the practice context with another professional. Supervision of practice may be direct or indirect according to the context under which the practice is being supervised. Direct supervision is when the supervisor takes principal responsibility for the nursing care provided (e.g. assessment and/or treatment of persons). The supervisor is physically present during practice (which may include providing care), and observes the person being supervised. Indirect supervision is when the supervisor is available for contact as well as to observe and discuss the nursing practice of the person being supervised. (See NMBA Supervision Guidelines for Nursing and Midwifery Oct 2013 for more detail). 32. Therapeutic relationships are where the nurse is sensitive to a person s situation and purposefully engages with them using knowledge and skills in respect, compassion and kindness to consider and where possible accommodate the person s rights and dignity. This includes collegial generosity in the context of professional relationships with mutual trust and collaboration the practice norms. 33. Please add any additional comments you have on the draft Registered nurse standards for practice. Overall, the ACM believes standards are too nebulous and do not provide the guidance that is required by nurses and organisations around nursing practice. To be effective, the standards need to emphasis the key elements that make up nursing practice such as person-centre care, collaboration and critical thinking. Reference to the midwife has been removed throughout, which is appropriate. The standards seem to be lacking an overarching framework or philosophy. ACM would have expected to see some sort of framework that the standards link with.

17 It is felt the scope was so broad that it was hard to see the nurse and the nursing in the standards. This may because it is trying to accommodate everyone including those in direct nonclinical relationship with clients, working in management administration, education, research, advisory, regulatory or policy development and other roles that impact on safe, effective delivery of services in the profession and/ or use of the nurse s professional skills. Being so broad always runs the risk that it says little about what actual safe and effective care looks like. There is very little global context or engagement in the documents. Whilst ACM know these Standards are for Australia, we live in a global context and global issues in health will affect Australian nurses. Team work and interdisciplinary learning and collaboration seem not to be strong in the document. Given the national and global context of health care this was surprising. Does the International Council of Nurses have relevant standards or frameworks that would be useful to include?

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