Table 3 Final agreed metrics (n = 9) and indicators (n = 71) with Delphi round 4 consensus percentages
METRIC | INDICATOR | FINAL DELPHI ROUND 4 CONSENSUS PERCENTAGE |
|---|---|---|
ASSESSMENT | 1 Presenting Complaints/Reasons for admission/attendance is recorded and the admission date and times are recorded | 98.66% |
2 The service user's name/date of birth and Healthcare Record Number are on each page/screen | 95.30% | |
3 Initial assessment includes contact details for family member/carer | 98.66% | |
4 There is a documented reason if the service user refuses to give next of family member/carer details | 81.21% | |
5 There is documented evidence of discharge planning is recorded from admission | 82.55% | |
6 There is documented evidence of service user consent for family member/carer involvement in care and communication | 90.60% | |
7 The service user is involved in all aspects of his/her assessments e.g. falls, risks, neglect etc. as per local policy | 92.62% | |
8 It is documented that the mental health service, with the service user's informed consent has involved other named service providers in their assessment if required | 98.66% | |
CARE PLAN | 1 All entries are in chronological order | 94.63% |
2 Nursing interventions are individualised and include nurse's title, name, signature, the date and time | 91.28% | |
3 All records are legible, in permanent black ink | 95.97% | |
4 Student entries are countersigned by the supervising nurse | 92.62% | |
5 There is documented evidence that the service user is involved in a co- production of their nursing care plan | 93.96% | |
6 Any alterations in nursing documentation are as per Nursing and Midwifery Board of Ireland (NMBI) Guidelines | 88.59% | |
7 There is documented evidence that the nursing care plan has been reviewed on a regular basis, as defined by the individual clinical area | 83.89% | |
8 Any abbreviations/grading systems used are from a national or locally approved list/system | 77.18% | |
MANAGEMENT OF RISK | 1 All entries are in chronological order | 97.32% |
2 Nursing interventions are individualised and include nurse's title, name, signature, the date and time | 97.99% | |
3 All records are legible, in permanent black ink | 97.99% | |
MANAGEMENT OF VIOLENCE AND AGGRESSION | 1 There is documented evidence that all incidents of violence and aggression are recorded | 98.66% |
2 There is documented evidence that timely and appropriate post- incident debriefing has occurred for service users | 89.26% | |
3 There is documented evidence in the nursing care-plan of nursing responses/interventions to violent and aggressive incidents and risk | 91.28% | |
PHYSICAL HEALTH AND WELLBEING | 1 There is documented evidence that that medical history is recorded in the service user’s notes | 93.92% |
2 The allergy status is clearly identifiable on relevant nursing documentation | 97.30% | |
3 There is documented evidence of an ongoing physical health assessment from admission/referral | 89.26% | |
4 There is documentary evidence that identified | 83.22% | |
SERVICE USER EXPERIENCE | 1 Were you given information about this service? | 94.48% |
2 Were you introduced to the nurse or nurses responsible for your care? | 84.83% | |
3 Do you know the names of your nursing team? | 78.62% | |
4 Have you received information from your responsible nurse on how to manage symptoms of your illness? | 97.24% | |
5 Has your medication and any potential benefits/side effects been explained to you by your responsible nurse? | 94.48% | |
6 Have you got the relevant information on who to contact in times of a crisis? | 97.24% | |
7 Were you involved in developing your nursing care plan? | 94.48% | |
8 Were you offered a copy of your care plan? | 82.07% | |
9 Have you been offered the opportunity to have your family/carer involved in your care? | 93.10% | |
10 Are you offered 1:1 nursing time as indicated in your care plan? | 85.52% | |
11 Has information been offered on organised activities/groups in your area? | 91.72% | |
12 Do the activities/groups offered support you in your recovery process? | 89.66% | |
13 Is there the opportunity for access to outside space? | 91.03% | |
14 Can you access fresh drinking water? | 89.66% | |
RECOVERY BASED CARE | 1 The service user has been informed of / offered peer support to aid in their recovery | 77.93% |
2 The nurse has documented evidence that the service user has access to a recovery-based programme | 88.28% | |
3 There is documented evidence that the service user is involved in all aspects of his/her recovery planning including discharge planning | 96.64% | |
4 There is documented evidence in the nursing care plan that the nurse has provided information about voluntary services that may help service users in their recovery process | 69.13% | |
NURSING COMMUNICATION | 1 There is evidence in the clinical notes that a nurse has communication with the service user as per care plan | 93.79% |
2 The nurse has offered the service user has received information regarding their rights | 93.79% | |
3 There is documented evidence in the nursing care plan that the nurse has offered the service user information on advocacy services and how to access them | 83.45% | |
4 There is documented evidence to support the coordination of nursing care on transfer or discharge | 95.17% | |
5 There is documented evidence that the service user's communication style and preferences are recorded in the nursing notes | 77.85% | |
MEDICATION MANAGEMENT | 1 There is documented evidence in the nursing notes that medication side effects are assessed by the nurse | 94.48% |
2 A registered nurse is in possession of the keys for Medicinal Product Storage | 95.10% | |
3 All Medicinal products are stored in a locked cupboard or locked room | 95.10% | |
4 All medication trolleys are locked and secured as per local organisational policy and open shelves on the medication trolley are free of medicinal products when not in use | 98.60% | |
5 A current Drug Formulary is available on all Medication Trolleys | 98.60% | |
6 Misuse Drug Act (MDA) drugs are checked & signed at each changeover of shifts by nursing staff. ( member of day staff & night staff) | 92.31% | |
7 Two signatures are entered in the MDA Drug Register for each administration of an MDA drug | 94.41% | |
8 The MDA Drug cupboard is locked and keys for MDA cupboard are held by designated nurse | 97.90% | |
9 MDA drug keys are kept separate from other medication keys | 95.10% | |
10 The individual’s prescription documentation provides details of individual’s legible name and health care record number | 95.10% | |
11 The Individuals’ identification band has correct and legible name and healthcare record number and/or photo ID if in use | 98.60% | |
12 The allergy status is clearly identifiable on the front page of the prescription chart | 98.60% | |
13 Prescribed Medication not administered have an omission code entered | 92.31% | |
14 The generic name is used for each drug prescribed | 94.41% | |
15 The date of commencement of the most recent prescription is recorded | 97.20% | |
16 The Prescription is written in block letters | 90.91% | |
17 The correct legible dose of the drug is recorded with the correct use of abbreviations | 98.60% | |
18 The route and/or site of Administration is recorded | 91.61% | |
19 The frequency of administration is recorded & correct timings indicated | 98.60% | |
20 The minimum dose interval and/or 24 h maximum dose is specified for all “as required” or PRN drugs | 98.60% | |
21 The prescription has a legible prescriber’s signature (in ink) | 90.21% | |
22 Discontinued drugs are crossed off, dated and signed by a person with prescriber authority | 97.20% |