Table 3 Final set of Intellectual Disability Nursing Process Metrics and Indicators

1. Nursing Documentation

Nursing written records are legible, in permanent ink and signed

Documented alterations/corrections are as per NMBI Guidance

Personal information is stored securely with access only to relevant persons in order to protect the privacy and confidentially of the individual’s details

Documented entries are dated and timed (24 h clock)

Documented entries are in chronological order

Documented abbreviations/grading systems are from a national or local approved list/system

All student nurse documented entries are countersigned by the supervising nurse

2. Medicines Management

All medicinal products are stored in a locked cupboard/trolleys/or room

Misuse of Drugs Act (MDA) are checked & signed at each shift changeover by registered nursing staff (member of day & night staff)

Two signatures are entered in the MDA Drug Register for each administration of an MDA.

The MDA cupboard is locked and keys are held by the designated nurse

MDA drug keys are kept separate from other medication keys

The person’s prescription documentation provides details of person’s legible name, unique identifier and photo ID

The Allergy Status is clearly identifiable on the front page of the prescription chart

Prescribed medicines not administered have an omission code entered and appropriate action taken

The prescription start date is recorded

The correct legible dose of drug is recorded with correct use of abbreviations

The route and/or site of administration is recorded

The frequency of medicines administration is as prescribed

The minimum dose interval and/or 24 h maximum dose is specified for all PRN medicines

The prescription has the prescriber’s signature (in ink) and Medical Council Number/Nursing and Midwifery Board of Ireland personal identification number

Discontinued medicines are crossed off, dated and signed by person with prescriptive authority

All medicines are reviewed in accordance with medication protocols

A current Drug Formulary is available at the point of administration

The generic name is used for each medicine unless the prescriber indicates a branded medicine and states “do not substitute”

There is a support plan for self-administration of medication

Self-administration of medicines is monitored for compliance and safety

3. Environment

Policies, Procedures, Protocols and Guidelines (PPPGs) are current and signed by each registered nurse

There is evidence of an action plan based upon the most recent regulatory inspection

Environmental and infection control audits have been conducted and relevant action plans are in place

4. Safeguarding

Safeguarding policies are reviewed and up to date

Information is provided to the person regarding their rights (support to exercise their rights, advocacy, safeguarding/protection) in accessible formats

Where there is evidence of a safeguarding concern there is documentation of registered nurses compliance with the safe guarding policy

A personalised risk assessment has been carried out in consultation with the person and relevant persons (family, advocates and the multidisciplinary team) and evident in the nursing care plans

A plan is in place on the person’s personal property, finances and possessions

When assisting the person in the management of their finances, there is evidence that clear records are maintained, reconciled and subject to audit

5. Person centred communication

A communication assessment has been conducted and a plan is documented

The person’s choice is obtained, respected and documented

Communication strategies are identified in the persons care plan

The person’s communication level and style are documented

Non-verbal and atypical communication behavioural patterns are documented

There is documented evidence of a multidisciplinary team approach

Information provided is in an accessible format for the individual

Where non-engagement occurs, this is noted in the persons care plan

6. Physical health assessments

A comprehensive health assessment has been conducted

Known associated health risk factors are identified within the care plan

A recognised assessment tool for persons with an intellectual disability has been used or appropriate tool adapted for specific areas e.g. pain, oral care, nutrition, hydration

The person has been supported to engage in health screening

The health care plan demonstrates a systematic approach to nursing care, management and interventions

Physical health checks are conducted at least annually

An individualised health passport has been developed in conjunction with the person

7. Mental health assessment

A nursing mental health assessment has been conducted and documented

A diagnosis of mental health illness is documented

The individuals care plan demonstrates the nursing care, management and interventions to support the person’s mental health and well-being

8. Risk assessment and management

There is evidence of positive proactive risk assessment and an action plan for identified risks within the persons care plan

Appropriate referral and resulting consultations have occurred to address identified risks and are documented

Incidents are documented within the care plan and escalated/reported as appropriate

A risk re-assessment is conducted and documented

9. Nursing care plan

The personal plan is based on a model of care (Nursing Care Plan is based on an identified model of care)

An assessment of need has been conducted and documented

An individualised plan of care has been developed

All documented nursing interventions are dated, timed and signed

The care plan reflects the persons’ current health needs

There is evidence of regular review of the care plan, dated, timed and signed

10. Person centred planning

A personal plan/assessment of all aspects of the person’s life has been conducted

Actions/interventions are devised to support the person within their personal plan

There is evidence of the person’s involvement in their Personal Plan

The person’s level of need and preferences regarding the provision of intimate personal support are identified

Self-advocacy/choices are recorded, respected and documented

A transition plan exists across each life course stage

11. Positive behaviour support

An assessment of distress has been conducted

A personal behavioural plan exists

Proactive and reactive behavioural strategies are identified and evident

There is evidence that positive behavioural support strategies are reviewed by the multidisciplinary team

12. End of life/palliative care

An end of life care plan is evident and documented

The person has been supported to make end of life decisions and this process is evident within the personal care plan

An ongoing assessment of changing health needs is evident and document

A collaborative approach is in evident across services

There is evidence of ongoing information sharing with the individual regarding their end of life