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37
Develop Accreditation Standards for Nursing Departments at
Mansoura University Hospital.

Prof. (r. Nea)at *o+a)ed and ,ss. Prof. -ala .a/r
Nursing ,d)inistration (epart)ent& 0acult1 of Nursing& *ansoura 2ni3ersit1& Eg1pt

Abstract
,ccreditation +as gained worldwide attention as an effecti3e 4ualit1 e3aluation and )anage)ent tool.
,ccreditation +as /een defined as a s1ste) of e5ternal peer re3iew for deter)ining co)pliance wit+ a set of
standards. ,ccreditation standards are written to reflect current practice and e5pectations for t+e specific
functions t+e nurses perfor). ,ccreditation s1ste)s pro3ided /etter 4ualit1 results in nursing care6 positi3e
c+anges in leaders+ip& co))it)ent and support& use of data& staff in3ol3e)ent& and 4ualit1 )anage)ent6 i)pact
or effecti3eness of +ealt+ sector accreditation. ,ccreditation +as recentl1 gained great i)portance in Eg1pt& /ut
nursing depart)ents still lac7 accreditation standards and criteria. -ence& t+e present stud1 ai)s to de3elop and
3alidate a set of rele3ant& feasi/le& and relia/le standards t+at needs for accrediting nursing depart)ents at
*ansoura 2ni3ersit1 -ospital. 8+e stud1 su/9ects includes a 9ur1 group includes 12 acade)ic staff fro) 0acult1
of Nursing and 1' nurse )anagers fro) *ansoura 2ni3ersit1 -ospital. ,ll +ead nurses (n:%; wor7s in all
inpatient depart)ents at *ansoura 2ni3ersit1 -ospital were included in t+e stud1. 8+ree tools were used for
data collection& na)el16 a 3alidit1 for)& inter3iew 4uestionnaire s+eet& and an audit for). 8+e stud1 findings
indicated t+at t+e proposed accreditation standards for nursing depart)ents at *ansoura 2ni3ersit1 -ospital are
3alid. , )ost proposed accreditation standard was )et in less t+an a +alf of t+e cases. It is reco))ended t+at t+e
de3eloped accreditation standards could /e used in *ansoura 2ni3ersit1 -ospital.

Introduction
,ccreditation +as gained worldwide attention as an effecti3e 4ualit1 e3aluation and )anage)ent tool.
,ccreditation +as /een defined as a s1ste) of e5ternal peer re3iew for deter)ining co)pliance wit+ a set of
standards. It is a procedure t+at e3aluates t+e institutional resources periodicall1 and confidentiall1& see7ing to
ensure t+e 4ualit1 of care on t+e /asis of pre3iousl1 accepted standards
(1
. ,ccreditation standards are usuall1
regarded as si)ultaneousl1 opti)al and ac+ie3a/le. ,ccreditation pro3ides 3isi/le co))it)ent /1 an
organi<ation to i)pro3e t+e 4ualit1 of care pro3ided to patients and to ensure a safe care en3iron)ent as well as
i)pro3es t+e a/ilities of +ealt+ care personnel
(!
.
8+ere are t+ree purposes of accreditation. 0irst& for 4ualit1 i)pro3e)ent using t+e accreditation process to
/ring a/out c+anges in practice t+at will i)pro3e t+e 4ualit1 of care for patients. Second for infor)ing decision-
)a7ing6 pro3iding data on t+e 4ualit1 of +ealt+ care t+at 3arious sta7e+olders& polic1)a7ers& )anagers&
clinicians and t+e pu/lic can use to guide t+eir decisions. 8+ird& for accounta/ilit1 and regulation6 )a7ing
+ealt+care organi<ations accounta/le to statutor1 or ot+er agencies& suc+ as professional /odies& go3ern)ent&
patient groups societ1 and regulation t+eir /e+a3iors to protect t+e interests of patients and ot+ers sta7e+olders
(1
.
,ccreditation is a rigorous e5ternal e3aluation process t+at co)prises self-assess)ent against a gi3en set of
standards. Standards are defined as written 3alue state)ents fro) t+e rules t+at appl1 to 7e1 processes and t+e
results t+at can /e e5pected w+en t+e processes are perfor)ed according to specifications
("
. ,ccreditation
standards are written to reflect current practice and e5pectations for t+e specific functions t+e nurse perfor)s.
Setting standards in3ol3es *ost standards toda1 are not 4uantitati3e or prescripti3e6 t+e1 re4uire e3idence and
anal1sis of outco)es& outputs& and i)pact. 8+e1 e)p+asi<e t+e i)portance of eac+ organi<ation=s clear state)ent
of )ission& goals& and o/9ecti3es& and its plans to ac+ie3e t+ese o/9ecti3es
(#
.
,ccreditation standards +a3e e3ol3ed to enco)pass an additional +ig+er le3el of standards 7nown as opti)al
ac+ie3a/le. Standards are set at a le3el w+ic+ encourages staff and )anage)ent to aspire to +ig+er le3els of
4ualit1. 8+e accreditation standards usuall1 contain a 3ariet1 of le3els& t+us allowing different accreditation
statuses to /e assigned according to t+e degree of co)pliance wit+ t+e standards. 8+erefore& accreditation
standards need to /e written to reflect and /uild on t+e re4uire)ents of an1 national regulator1 and financing
processes alread1 in place
($
.
,ccreditation standards )a1 ta7e t+e for) of procedures& clinical practice guidelines& treat)ent protocols or
state)ents of e5pected +ealt+care outco)es. Perfor)ance in accordance wit+ standards is t+us t+e cornerstone of
4ualit1 assurance in +ealt+care and t+e end result of a wide range of 4ualit1 assurance acti3ities& including
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accreditation of +ealt+ facilities& e5ternal 4ualit1 e3aluation and perfor)ance i)pro3e)ent
(%
. Nurses wor7
interdependentl1 wit+ ot+er +ealt+ care practitioners6 t+e1 now plan and i)ple)ent client care )ore
independentl1. In e3en nurses are +eld responsi/le and accounta/le for pro3iding client care t+at is safe and
appropriate and reflects currentl1 accepted standards for nursing practice. ,ccreditation s1ste)s pro3ided /etter
4ualit1 results in nursing care6 positi3e c+anges in leaders+ip& co))it)ent and support& use of data& staff
in3ol3e)ent& and 4ualit1 )anage)ent6 i)pact or effecti3eness of +ealt+ sector accreditation
(&
.
In addition& so)e researc+ers indicate t+at t+e accreditation i)pro3es t+eir operations and perfor)ance in
ter)s of effecti3eness and efficienc1. ,ccreditation )a1 /e ad3antageous regarding standardi<ation of
procedures& cost contain)ent or )ar7eting. -owe3er& t+ere are reser3ations t+at accreditation is a suita/le
instru)ent for 4ualit1 i)pro3e)ents t+at are rele3ant to patient satisfaction. -ospitals are accredited for t+eir
co)pliance wit+ standards
('
. ,ccreditation related i)pro3e)ents +a3e affected not 9ust 4ualit1 and ris7
)anage)ent /ut ot+er t1pes of )anage)ent as well
((
. ,ccreditation is constructed around nor)s or standards
related to t+e inputs& processes and outputs wit+ w+ic+ organi<ations )ust co)pl1 in order to recei3e
accreditation. #riginall1& t+e pri)ar1 goal of +ealt+care organi<ation accreditation was to i)pro3e t+e
perfor)ance of +ealt+ s1ste)s t+roug+ t+e standardi<ation of practices and 4ualit1 i)pro3e)ent.
*ost accreditation progra)s focus t+eir accreditation processes around a collection of standards&
perfor)ance )easures& and assess)ent criteria de3eloped internall1 /1 t+e progra). Progra)s t1picall1 de3elop
t+ese standards using an e5pert panel process in3ol3ing professionals and sc+olars wit+ e5perience in t+e
rele3ant field of practice. In )ost cases& accreditation standards reflect structural and process-/ased )easures of
organi<ational perfor)ance deri3ed fro) t+e consensus 9udg)ents of e5pert panelists. ,ccreditation progra)s
rel1 on a relati3el1 large collection of perfor)ance standards and )easures t+at reflect )ultiple do)ains of
organi<ational perfor)ance. >o))on do)ains of perfor)ance include t+e scope of ser3ices offered& ser3ice
4ualit1& consu)er protection and safet1& financial perfor)ance and sta/ilit1& ad)inistrati3e processes& staffing
and training& and custo)er ser3ice
(1)*11
.
,ccreditation +as recentl1 gained great i)portance in Eg1pt. 8+is was especiall1 witnessed in +ealt+care
and )edical and nursing education. ?+ile )an1 efforts were e5erted in accreditation of +ospital in general and
nursing depart)ent specificall1. Nursing depart)ents still lac7 accreditation criteria. 8+erefore& t+is stud1 is an
atte)pt to fill t+is gap t+roug+ de3eloping accreditation standards for nursing depart)ents and )easuring to
w+at e5tent nursing depart)ents are fulfilling t+e accreditation criteria.
+esearc, -uestions.
1. ?+at are t+e standards needed for accrediting nursing depart)ents at *ansoura 2ni3ersit1 -ospital@
2. ?+at are t+e e5tent nursing depart)ents at *ansoura 2ni3ersit1 -ospital to fulfill t+e adopted
accreditation criteria@
Aim of t,e study
8+e ai) of t+e present stud1 is to de3elop and 3alidate a set of rele3ant& feasi/le& and relia/le standards t+at
needed for accrediting nursing depart)ents at *ansoura 2ni3ersit1 -ospital.
Sub/ects and Met,ods
Design.
(escripti3e stud1 design was used in t+e present stud1.
Setting.
8+e stud1 is conducted in *ansoura 2ni3ersit1 -ospital. 8+e stud1 was conducted at *ansoura uni3ersit1
+ospital t+at affiliated to teac+ing uni3ersit1 +ospital. 8+e *ain *ansoura uni3ersit1 +ospital& wit+ total /ed
capacit1 is 1!;' /eds wit+ general and special units.
Sub/ects.
8+e su/9ects of t+e present stud1 include two groups& na)el1 a 9ur1 and nurse leaders group.
0ury group. 8+is group used to confir) 3alidating of t+e de3eloped accreditation standards and criteria.
It consists of 22 )e)/ers& of w+ic+ 12 were fro) acade)ic staff in facult1 of nursing and 1' fro) nursing
ad)inistrators or leaders& and 4ualit1 )anage)ent specialists.
Nurse managers group. 8+is group ser3ed to assess of fulfill)ent of accreditation criteria in t+eir
+ospitals. It includes all directors of nursing and t+eir assistants& nursing super3isors& and +ead nurses in t+e
stud1 +ospitals )a7ing a total of %; su/9ects.
1ools of Data 2ollection
8+ree tools were used for data collection& na)el1A a 3alidit1 for)& inter3iew 4uestionnaire s+eet& and an audit
for).

I. 3alidity form
It was de3eloped /1 t+e researc+ers /ased on standards t+at were de3eloped /1 t+e Joint >o))ission on
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,ccreditation of +ealt+ care organi<ation& standards of Eg1ptian -ospital ,ccreditation Progra)& and standards
fro) >entral Coard ,ccreditation -ealt+ Institution (>C,-I of Saudi ,ra/ia. It consists of 21 standards wit+
!! criteria co3ering t+e followingA

$ision (% criteria 2.*ission (5 criteria
3. Policies and procedures ( 5 criteria %. Nursing care plan ( % criteria
5. (isc+arge plan ( 3 criteria ;. Nursing depart)ent organi<ational structure ( 3 criteria
7. Jo/ description ( 3 criteria !. Nursing assign)ent ( % criteria
B. Nursing director 4ualification D e5perience
( ! criteria
1'. Nursing director deter)ine standard of practice ( 5
criteria
11. Nursing director role D participate in +ospital
co))ittee ( 5 criteria
12. Nursing standard for e3aluating nursing care ( 3 criteria
13. Eualit1 assurance plan ( 7 criteria 1%. #rientation progra) (% criteria
15. >ontinuing training progra) (3 criteria 1;. (ocu)enting annul training (3 criteria
17. Patient rig+ts ( ; criteria 1!. Patient education ( ; criteria
1B. Perfor)ance appraisal (one criteria 2'. #ccupational +a<ards ( 2 criteria
21. Sc+eduling polic1 ( % criteria

0or eac+ of t+e !! criteria& t+e 9ur1 )e)/er +as to respond on t+e face 3alidit1 ( does it loo7 li7e a standard
criterion& and its content 3alidit1 ( is it ac+ie3a/le& o/ser3a/le& )easura/le& desira/le& written in professional
conte5t& rele3ant to nursing field& and its language is understanda/le. 0or eac+ criteria& a score was calculated
for 3alidit1 /ased on su))ing up t+e nu)/er of agree)ents upon t+e se3en content 3alidit1 indicators. 8+e su/-
ite)s wit+ ;'F agree)ent or +ig+er was considered agree upon and 3alid Saad(
1!
.
II. Intervie4 -uestionnaire S,eet
8+is 4uestionnaire s+eet was de3eloped to assess nursing depart)ent fulfilling wit+ accreditation standards
as percei3ed /1 nurse )anagers. It includes as t+e sa)e 3alidit1 for) standards w+ic+ consists of 21 standards
wit+ !! criteria. Eac+ criteria was to /e )ar7ed as )et& partiall1 )et& or not )et.
III. Audit 5orm.
8+is for) was de3eloped to assess nursing depart)ent fulfilling wit+ accreditation criteria /1 t+e researc+er.
8+is tool was de3eloped /ased on t+e 3alidated accreditation standards. It consists of 21 standards wit+ !!
criteria. Eac+ criteria was to /e )ar7ed as )et& partiall1 )et& or not )et. 0or eac+ of t+e 21 standards& t+e
nu)/er of su/-ite)s )ar7ed G)etG were counted and t+eir percentage was calculated /1 di3iding t+eir total /1
t+e total nu)/er of criteria of t+e standard. 8+is was also done for t+e G partiall1 )etG ite)s.
Met,ods of Data 2ollection
,ppro3al was o/tained fro) t+e director of *ansoura 2ni3ersit1 -ospital as well as t+e director of nursing
ser3ice ad)inistration in eac+ +ospital. (ata collection for)s were de3eloped /ased on national and international
standards of accreditation. 8+e de3eloped accreditation standards and criteria was tested for its face and content
3alidit1 /1 9ur1 group )e)/ers. Hesearc+ers )et e3er1 nursing )anagers in t+e sa)ple to e5plain t+e purpose of
t+e stud1& and as7 for 3er/al consent to participate. 8+e 4uestionnaire s+eet was +andled to e3er1one& it too7
a/out 3' )inutes for fill it. (ata collection infor)ation for t+e audit for) tool were fro)A patientsI record6
o/ser3ation of t+e patients6 inter3iew conducted wit+ t+e patients6 inter3iew conducted wit+ t+e nurse6
o/ser3ation of t+e nurse6 o/ser3ation of t+e patientIs en3iron)ent6 o/ser3erIs inference6 and inter3iew
conducted wit+ t+e )ain caregi3er. 8otal ti)e ta7en for data collection was fi3e )ont+s& starting Jul1 2'1'.
Statistical analysis
(ata anal1<ed and su))ari<ed using percentages for categorical 3aria/les and )ean and standard de3iation
for nu)erical 3aria/les. (ata were presented using descripti3e statistics in t+e for) of fre4uencies and
percentages for 4ualitati3e 3aria/les and )ean and standard de3iation for 4uantitati3e 3aria/les. >o)parison of
)eans was done using t-test for independent sa)ples 0or co)parati3e purpose& score are presented as a/solute
3alues and as percentages fro) t+e )a5i)u) score of eac+ topic. 8+is )a5i)u) score depends on t+e nu)/er
of ite)s of eac+ topic 8+e t+res+old of statistical significance was p-3alue J'.'5.

+esults
1able 1 descri/es de)ograp+ic c+aracteristics of t+e 9ur1 group. It was re3ealed t+at 31.!2F ranged age fro) 31
to 35 1ears old and 5%.5F of t+e) were acade)ic staff. *ore t+an a +alf of 9ur1 group was 5%.5F wor7s as a
lecturer followed /1 27.3F wor7s as a +ead nurses and %5.%;F of t+e sa)ple +ad a wor7ing e5perience ranged
fro) 15 to 2' 1ears.
1able ! s+ows 9ur1 group agree)ent and 3alidation proposed of nursing depart)ents= accreditation standard.
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8+e face 3alidit1 of all accreditation standards was 7'.51F. ,nd& face 3alidit1 of standards ranged /etween
!'.B;F and ;;.3BF. ,ll t+e proposed accreditation standards were agreed upon /1 )ore t+an a +alf of t+e 9ur1
group )e)/ers. 8+e +ig+est agree)ent upon inclusion of /eing disse)ination of nursing depart)ent 3ision
!'.B; followed /1 7%.31 and 73.1' for nursing depart)ents policies and procedures and disc+arge plan
respecti3el1.
1able " s+ows no statisticall1 significant difference /etween acade)ic staff and nurse )anagers= groups
agree)ent for proposed accreditation standards (pJ'.'5. 8+e o3erall acade)ic staff agree)ent upon proposed
accreditation standard was ;B.5!F of )a5i)u) score and 71.;2F of )a5i)u) score for nurse )anagers. 8+e
+ig+est )a5i)u) score was !'.%1F as percei3ed /1 acade)ic staff for disse)ination of nursing depart)ent
)ission and !3.12F for disse)ination of nursing depart)ent 3ision as percei3ed /1 nurse )anagers.
1able # illustrates nu)/er and percent of fulfilling proposed accreditation standard in t+e assess)ent stud1 units
/1 t+e researc+er. 8+is ta/le s+ows )ost of t+e standards were eit+er not )et and partiall1 )et. 8+e percentages
of full1 )et standards ranged /etween%5.;5F and ;.52F. *oreo3er& so)e standards was o/ser3ed to /e not )et
as nursing depart)ent 3ision& disc+arge plan& nursing organi<ational structure& 9o/ description& perfor)ance
appraisal& and annual education on occupational +a<ards. ,/out +alf of standards to /e partiall1 )et reported for
4ualit1 assurance plan and patient education. ,nd ;.52 F of stud1 settings not )et patient rig+ts standard. ,s
well as& +alf of stud1 settings not )et nursing care plan and nursing director and )anagers s+ould de3elop and
i)ple)ent standards for e3aluating nursing care standard.
1able $ de)onstrates co)parison /etween assessing t+e e5tent of fulfilling proposed accreditation standards as
percei3ed /1 nurse )anagers wit+ t+ose o/ser3ed. In t+is ta/le t+ere was a statisticall1 significant differences
/etween proposed accreditation standards as percei3ed /1 nurse )anagers wit+ t+ose o/ser3ed pJ'.'5. 8+e
o3erall assessed )et standards were 33.!;F& w+ile 3B.11F was )et as percei3ed /1 nurse )anagers. in t+e
ta/le t+e +ig+est )a5i)u) score was 55.%3F for nursing assign)ent& followed /1 52.17F and 51.%%F for
patient education and rig+ts as percei3ed /1 nurse )anagers respecti3el1. ,s for assess)ent /1 t+e researc+er&
)ost proposed accreditation standards were )et in less t+an a +alf of t+e cases.

1able ( 1 . Demograp,ic 2,aracteristics of t,e /ury group ( n6!!.
Demograp,ic 2,aracteristics 0ury group
No. 7
Age
J 25
25-
3'-
K35

% 1!.1!
5 22.73
7 31.!2
; 27.27
,cade)ic staff
Nurse )anager
12 5%.5
1' %5.5
0ob 8osition
Professor
,ssistant professor
Lecturer
(irector
,ssistant director
Super3isor
-ead nurse

2 B.1
2 B.1
! 3;.%
1 %.5
1 %.5
2 B.1
; 27.3
9ears of e:perience
J 15
15-
K2'

% 1!.1!
1' %5.%;
! 3;.3;

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1able (!. 0ury group agreement and validation proposed of nursing departments accreditation standard
( n6!!.
Accreditation standards Mean rating score 5ace
validity
$ision 12.B5 !'.B;
*ission 1; !'
Policies and procedures 1%.!; 7%.31
Nursing care plan 11.%' 71.3'
(isc+arge plan !.77 73.1'
Nursing organi<ational structure& !.27 ;!.B3
Jo/ description& ! ;;.;;
Nursing assign)ent 1'.B' ;!.1!
Nursing director s+ould /e licensed and 4ualified 1!.5B ;;.3B
Nursing director s+ould /e responsi/le for deter)ining D i)ple)enting
nursing standards
13.72 ;!.;3
Nursing director s+ould attend D participate in +ospital co))ittees 1%.'% 7'.22
Nursing director and nursing )anagers s+ould de3elop and i)ple)ent
standards for e3aluating nursing care
1'.72 ;7.'%
Eualit1 assurance plan is consistent wit+ t+e o3erall +ospital 4ualit1
)anage)ent plan
17.1! 71.5B
#rientation progra) 11.'B ;B.31
Staff de3elop)ent training progra) in all nursing practice areas !.13; ;7.!'
Continue table 2.
Accreditation standards Mean rating score 5ace validity
(ocu)ented annual training re3iew for all nursing staff !.31 ;B.31
Patient rig+ts 17.%' 72.53
Patient education 1;.5' ;!.75
Perfor)ance appraisal& 2.77 ;B.31
,nnual education on occupational +a<ards 2.72 ;!.1!
Sc+eduling polic1 1'.B' ;!.1!
Content validity index = 70.51
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1able (". 2omparison bet4een academic staff and nurse managers; agreement of proposed nursing
departments; accreditation standard.
Accreditation standards 0ury group t

p
,cade)ic staff
(n:12
Nurse )anagers
(n:1'
*eanMMN S( *eanMM N S(
$ision 7B.1;;N11.'B5 !3.125N7.!22 .B% .35
*ission !'.%1;NB.15B 7B.5''N11.1;7 .21 .!3
Policies and procedures 73.75'N1'.%71 75.'''N1'.''' .2! .77
Nursing care plan 7'.312N13.'!B 72.5''N!.B3; .%; .;%
(isc+arge plan& 72.B1;N1;.713 73.333N1%.5B3 .'; .B5
Nursing organi<ational structure& ;!.75'N11.3'; ;B.1;;N1B.;;1 .'5 .B5
Jo/ description& ;;.;;;N13.2B5 ;;.;;;N17.5;! .'' 1.''
Nursing assign)ent ;!.75'N13.'55 ;7.5''N1%.373 .21 .!3
Nursing director s+ould /e licensed D 4ualified ;;.;;;N1'.5!7 ;;.'71N7.B%1 .1% .!!
Nursing director s+ould /e responsi/le for deter)ining D
i)ple)enting nursing standards
;7.'!3N15.%%1 7'.5''N1B.';! .%5 .;5
Nursing director s+ould attend in +ospital co))ittees ;!.75'N1'.!B7 72.'''NB.1!B .7% .%;
Nursing director D nursing )anagers s+ould de3elop
Di)ple)ent standards for e3aluating nursing care
;;.;;;N13.;75 ;7.5''N12.77% .1% .!!
Eualit1 assurance plan is consistent wit+ t+e o3erall
+ospital 4ualit1 )anage)ent plan
71.!75N1;.2B5 71.25'N;.;%; .11 .B1
#rientation progra) ;7.7'!N13.2!' 71.25'NB.%'B .73 .%7
Staff de3elop)ent training in all nursing practice areas ;1.!'5N13.B7' 75.'''N11.111 2.%1 .'2M
(ocu)ented annual training for all nursing staff ;5.277N11.;B5 7%.1;;N13.2B2 1.;% .11
Patient rig+ts 73.;11N;.B57 71.25'N11.52! .5B .5;
Patient education ;!.'55N1%.25' ;B.5!3N7.3;2 .32 .75
Perfor)ance appraisal& ;;.;;;N2!.!;7 72.5''N1!.%%; .55 .5!
,nnual education on occupational +a<ards ;!.75'N1!.!%% ;7.5''N2'.5!1 .1% .!!
Sc+eduling polic1 ;7.7'!N17.'2B ;!.75'NB.771 .17 .!;
1otal %(.$'<$.'' &1.%!<#.)1 ).(" ."$
*Significant p<0.05 **Mean pecentage fo! !axi!u! scoe
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%3
1able (#. Number and percent of fulfilling proposed accreditation standard in t,e assessment study units
by t,e researc,er (n6#%
Standards
Source of information
Not met
No F
8artially met
No. F
5ully Met
No. F
$ision (5&; 3; !7.2; 1' 21.7% '.' '.''
*ission (5&; 22 %7.!3 2' %3.%! % !.;B
Policies and procedures (5&; 22 %7.!3 15 32.;1 B 1B.5;
Nursing care plan (2&3 23 5' 17 3;.B; ; 13.'%
(isc+arge plan (2&; 33 71.7% 13 2!.2; '.' '.''
Nursing organi<ational structure (2&; 35 7;.'B 11 23.B1 '.' '.''
Jo/ description (2&; %1 !B.13 5 1'.!7 '.' '.''
Nursing assign)ent (2&3&% 1% 3'.%% 2B ;3.'% 3 ;.52
Nursing director s+ould /e licensed and 4ualified (2&; ; 13.'% 22 %7.!3 1! 3B.13
Nursing director s+ould /e responsi/le for deter)ining D
i)ple)enting nursing standards (2&;
2' %3.%! 17 3;.B; B 1B.5;
Nursing director s+ould attend and participate in +ospital
co))ittees (2&;
1' 21.7% 31 ;7.3B 5 1'.!7
Nursing director D nursing )anagers s+ould de3elop D
i)ple)ent standards for e3aluating nursing care (2&%&;
23 5' 1% 3'.%% B 1B.5;
Eualit1 assurance plan is consistent wit+ t+e o3erall
+ospital 4ualit1 )anage)ent (2&;
13 2!.2; 25 5%.35 ! 17.3B
#rientation progra) (2&; 2% 52.17 1! 3B.13 % !.7'
Staff de3elop)ent training progra) in all nursing practice
areas (2&%&;
32 ;B.57 1% 3'.%3 '.' '.''
(ocu)ented annual training for all nursing staff (2&; 3% 73.B1 11 23.B1 1 2.17
Patient rig+ts

(1&% 3 ;.52 22 %7.!3 21 %5.;5
Patient education (1&3&; 5 1'.!7 23 5' 1! 3B.13
Perfor)ance appraisal (2&5&; %; 1'' '.' '.' '.' '.''
,nnual education on occupational +a<ards (2&; 3; 7!.2; 1' 21.7% '.' '.''
Sc+eduling polic1 (2&; 22 %7.!3 21 %5.;5 3 ;.52
"o=Souce of info!ation 1# $ntevie%
patients 2# $ntevie% nuses &#'bseve nuses (#
'bseve patient)s envion!ent 5# 'bseve infeence *# $ntevie% %it+ cae give
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1able ($. 2omparison bet4een assessing t,e e:tent of fulfilling proposed accreditation standards as
perceived by nurse managers 4it, t,ose observed.
accreditation standards Nurse managers
perceptions
Assessment by
researc,er
t p
Mean==<SD Mean==<SD
$ision 2;.'!7N1;.!37 17.3B1N1;.557 2.%B .'1M
*ission 33.B13N22.'5! 2;.521N1!.BBB 1.72 .'!
Policies and procedures 33.B13N22.752 2B.5;5N21.3B1 .B% .3%
Nursing care plan 3%.7!2N2!.%B3 31.7B3N2;.1!1 .52 .;'
(isc+arge plan 27.173N2;.1%2 2%.275N23.75% .55 .57
Nursing organi<ational structure 2B.3%7N25.3!2 21.'1%N21.2'! 1.7' .'B
Jo/ description 27.!B!N1!.B3B 21.37;N15.5!' 1.!' .'7
Nursing assign)ent 55.%3%N21.352 %2.3B1N1!.3%! 3.1% .''2M
Nursing director s+ould /e licensed D 4ualified %2.!57N1;.!35 37.!!!N17.BBB 1.3; .17
Nursing director s+ould /e responsi/le for deter)ining
D i)ple)enting nursing standards
3!.%7!N21.5BB 35.%3%N21.B!' .;7 .5'
Nursing director s+ould attend and participate in
+ospital co))ittees
%'.%3%N12.B!! 37.!2;N1%.5B2 .B' .3;
Nursing director and nursing )anagers s+ould de3elop
and i)ple)ent standards for e3aluating nursing care
%1.3'%N25.!'2 37.5''N2;.7%% .;B .%!
Eualit1 assurance plan is consistent wit+ t+e o3erall
+ospital 4ualit1 )anage)ent plan
33.333N17.B1; 3'.'72N17.3%5 .!! .37
#rientation progra) %1.57;N22.;77 35.!;BN22.B1% 1.2' .23
Staff de3elop)ent training progra) in all nursing
practice areas
3B.!55N1B.'7; 33.;B5N22.'7B 1.%3 .15
(ocu)ented annual training re3iew for nursing staff 35.!;BN21.B33 32.B71N23.%3; .;1 .5%
Patient rig+ts 51.%%BN1B.;;5 %;.73BN21.%7B 1.'B .27
Patient education 52.173N1!.!75 %7.;%%N21.5;% 1.'7 .2!
Perfor)ance appraisal %5.;52N%'.5!7 %1.3'%N3B.!;; .51 .;'
,nnual education on occupational +a<ards 5'.'''N%'.!2% %%.5;5N%1.13% .;3 .52
Sc+eduling polic1 3B.B%5N2'.;!; 35.32;N2'.B;7 1.'; .2B
1otal "(.11'<'.'$& "".'%$<1).1)! !.%$ .)1=
*Significant p<0.05 **Mean pecentage fo! !axi!u! scoe

Discussion
8+e use of accreditation s1ste)s to i)pro3e +ealt+care 4ualit1 and patient safet1 +as /een widespread across
)an1 countries& w+ere accreditation is a process w+ere/1 an organi<ation is assessed on a set of pre-deter)ined
standards. It intends to pro)ote 4ualit1 i)pro3e)ent t+roug+ di3erse approac+es w+ic+ are eit+er )andated /1
t+e go3ern)ent& 3oluntar1 or initiated /1 independent agencies
(1"
. In t+e present stud1& 3alidation of t+e
de3eloped accreditation standards was done t+roug+ a 9ur1 group to 9udge a/out practica/ilit1 and applica/ilit1
of t+e standards. 8+e 9ur1 group appro3ed face and content 3alidit1 of t+e de3eloped standard. 8+e results of t+e
present stud1 re3ealed t+at t+ere no statistical significance difference /etween agree)ent of acade)ic staff group
and nurse leaders group regarding proposed standards for nursing depart)ents at *ansoura 2ni3ersit1 -ospital.
,lso& findings of t+e present stud1 re3ealed t+at t+ere a significant difference /etween nurse leaders perception
of fulfilling accreditation standards in t+e stud1 nursing depart)ents wit+ t+ose assessed /1 auditing for).
,ccording to findings of t+e present stud1 )a9orit1 of t+e 9ur1 group )e)/ers agreed t+at t+e nursing
depart)ent s+ould +a3e a 3ision and )ission t+at )ust /e written& and /e consistent wit+ t+e +ospitals= )ission.
8+eir agree)ent was represented a +ig+er percentage of face 3alidit1. 8+is could /e contri/uted to t+e wording
of t+e standard and language is clear and findings point to t+e i)portance t+at t+ese standard )ust included in
t+e accreditation. 8+is result is agreed wit+ Hall
(1#
w+o reco))ended t+at 3ision and )ission s+ould /e written
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in si)ple )anners& and /e set for at least t+ree 1ears. In t+is respect Simpson
(1$
reco))ended 3ision state)ent
s+ould re4uire all organi<ation )e)/ers to stretc+ t+eir e5pectations aspirations and perfor)ance. ,s well as
Hader
(1)
suggested t+at a )ission state)ent needs to /e a )anagerial and staff co))it)ent t+at=s de3eloped /1
an organi<ation=s leaders following an e5+austi3e dialogue /etween all le3els of t+e organi<ation.
,s regard to assess)ent t+e e5tent of fulfilling 3ision and )ission standards in t+e stud1 nursing depart)ents
at *ansoura 2ni3ersit1 -ospital& it re3ealed t+at t+is standard did not )et. 8+is )a1 /e contri/uted to 3ision and
)ission standards were not written and not disse)inated and not engaged in +ospitals s1ste). #n t+e sa)e 3iew&
>ut,ans ? 0ensen!))$
(1%
pro3ed t+e i)portance of a clear 3ision and )ission of t+e nursing ser3ice
depart)ent w+ic+ )ust /e written wit+ organi<ational 3alues and culture to )eet t+e co))unit1 needs. 8+is is
supported /1 S,irey
(1&
as well as Ingersoll et al.*
(1'
t+at an organi<ation=s )ission& 3ision& and 3alues state)ents
are guiding force /e+ind t+e +ealt+ care institution=s ad)inistrati3e strategic planning are e3ident in nurses= dail1
wor7 life.
Policies and procedures are two functional standards of a +ealt+ care organi<ation t+at are deri3ed fro) t+e
)ission state)ents. 8+e results of t+e present stud1 assured t+at t+e )a9orit1 of t+e 9ur1 group )e)/ers agreed
upon its content and face 3alidit1. In addition to assessing t+e e5tent of fulfilling policies and procedures
standards in t+e stud1 nursing depart)ents& it re3ealed t+at t+e )inorit1 +ad )et related standard. 8+is is t+e
sa)e 3iew of t+e Mays
(1(
w+o pro3ed t+e i)portance of standard of policies and procedures in guiding nursing
care. -owe3er& t+e researc+ +ig+lig+ted t+at t+ese policies and procedures standards s+ould /e designed
according to co))unit1 needs.
In relation to nursing care plan& disc+arge plan& and nursing assign)ent standard t+e findings of t+e present
stud1 re3ealed t+at t+ere was no statistical significance difference a)ong agree)ent of acade)ic staff group& and
nurse )anager& w+o) all agreed t+at t+e nursing depart)ent s+ould +a3e nursing care plan& disc+arge plan& and
nursing assign)ent plan standards. 8+is is standard wit+ Mays ? @,ite
(1(*!)
w+o clarified t+at designed
accreditation criteria for) regarding nursing care plan and disc+arge plan were 3ital criteria for accreditation and
s+ould /e 3alid in t+eir content. 0or assessing t+e e5tent of fulfilling nursing care plan& disc+arge plan& and
nursing assign)ent plan standards in t+e stud1 nursing depart)ents re3ealed t+e few +ad )et for nursing care
and nursing assign)ent plan& w+ile t+e disc+arge plan was not )et. ,ccording to Aarrett et al.
(!1
nursing care
plan as an inter)ediate stage of t+e nursing process in resol3ing nursing pro/le)s identified /1 assess)ent and
guides t+e ongoing pro3ision of nursing care and assists in t+e e3aluation of t+at care is full1 )et standard in +is
researc+.
0or disc+arge plan standard& t+e present stud1 findings indicated it was not )et. 8+is )a1 /e due to concept of
disc+arge plan is new concept in stud1 setting and disc+arge plan is not a co))on practice in Eg1pt +ospitals
and is not part of t+e nursing s1ste) despite of t+eir i)portance. 8+is is supported /1 McMurray et al.;s
researc+
(!!
to in3estigate general surgical patientsI perspecti3es of t+e ade4uac1 and appropriateness of t+eir
disc+arge planning. 8+e1 concluded t+e need for a )ore indi3iduali<ed approac+ to disc+arge planning standers&
ta7ing into account t+e patientIs age& gender& surgical procedure and fa)il1 and co))unit1 support for
i))ediate and longer-ter) nursing follow-up.
8+e results of t+e present stud1 at *ansoura 2ni3ersit1 -ospital re3ealed t+at t+e )a9orit1 +ad partiall1 )et
nursing care assign)ent standard in. 8+is )a1 /e due to +ead nurses in t+e stud1 nursing depart)ents +a3e a
+istor1 of selecting )et+ods of organi<ing patient care /ased upon t+e )ost current popular )ode (case )et+od
of patient assign)ent rat+er t+an o/9ecti3el1 deter)ining t+e /est )et+od for a particular patient needs. In t+e
sa)e line& B;+ourCe
(!"
proposed a nursing care assign)ent=s conceptual fra)ewor7 t+at incorporates nurse
practice& tea) practice& and organi<ational practice in order to deter)ine t+e patient care standard w+ic+ are
needed for en+ancing t+e professional practice of all disciplines& clarif1 accounta/ilit1 for outco)es& and focus
decision )a7ing at t+e point of ser3ice.
8+e )a9orit1 of 9ur1 group agreed t+at face and content 3alidit1 of t+e designed accreditation standard in
*ansoura 2ni3ersit1 -ospital regarding nursing organi<ational structure& and 9o/ description is 3alid. 8+e
assess)ent of t+e e5tent fulfilling of criteria related to nursing organi<ational structure& and 9o/ description
re3ealed t+e )a9orit1 +ad not )et. 8+is result supported /1 Dill
(!#
w+o descri/ed in si)ilar stud1 for 9o/
description t+at organi<ational structure standard s+ould /e clear and written in an organi<ational c+art w+ic+
includes clear lines of aut+orit1 and responsi/ilit1 and co))unication c+annel to +elp t+e nursing staff to
understand t+e wor7 policies.
Jo/ description is t+e proper wa1 to acco)plis+ t+ese c+anges /ecause it is a written state)ent of duties&
responsi/ilities and wor7ing condition of a particular 9o/ $vancevic+
(!$
. In Eg1pt& a/sence of 9o/ description of
t+e +ead nurses +as negati3e i)pact on /ot+ nursing personnel and +ealt+ organi<ations. ,s regard nursing
personnel t+e )ost fre4uent co)plaint is uncertaint1 of w+at specific wor7 is re4uired. 8+is would feel nurses
insecure due to )isunderstanding and conflict )a1 /e de3eloped. ,s regard +ealt+ organi<ation& a/sence of 9o/
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description would affect on 4ualit1 of ser3ices pro3ided and goal acco)plis+ed ,e!ina et al.-
(!%
.
,s regard to nursing director role& t+e present stud1 re3ealed t+at a )a9orit1 of 9ur1 group )e)/ers agreed
upon t+e content and face 3alidit1 of t+e standards regarding nursing director s+ould /e licensed and 4ualified /1
educational and )anagerial e5periences& responsi/le for deter)ining and i)ple)entation nursing standards of
practice& and s+ould attend and participate in +ospital co))ittees. ,ssess)ent t+e e5tent of fulfilling nursing
director s+ould /e licensed and 4ualified for accreditation standard=s findings of t+e present stud1 re3ealed t+at
t+e )a9orit1 accreditation standard re3ealed t+e )a9orit1 +ad partiall1 )et and t+e )inorit1 +ad )et of nursing
director s+ould /e responsi/le for deter)ining and i)ple)enting nursing standards and s+ould uses for
e3aluating nursing care. 8+is is t+e sa)e 3iew of 0ama
(!&
w+o )entioned t+at t+e standards of practice and t+eir
i)ple)entation content s+ould /e 3alid and include at least a docu)ented nursing assess)ent& a docu)ented
nursing diagnosis& a docu)ented nursing care plan& as well as docu)ented nursing treat)ent and its effect. In
addition& Doldstein
(!'
stressed t+at nursing director and +er )anage)ent tea)= 9o/ role is attending and
participating in +ospital co))ittees and s+ould /e acti3e in all t+e procedures and updates of t+ese co))ittees.
,s regard to nursing director 4ualifications and e5perience in leaders+ip and )anage)ent& t+e present stud1
re3ealed t+at t+e )a9orit1 +ad partiall1 )et t+is standard. 8+is is t+e sa)e 3iew of Dreenfield ? Arait,4aite
(!(

w+o e)p+asi<ed t+at nurse director was t+e )ost i)portant entit1 in ac+ie3ing a successful accreditation.
Hesults of t+e present stud1 is supported /1 Sc,mitt ? >andy
(")
w+o asserted t+at nursing director s+ould
de3elop and i)ple)ent standards for e3aluating nursing care& w+ic+ s+ould include a written e3aluation of t+e
perfor)ance of nursing personnel. 8+e findings of t+e present stud1 re3ealed t+at t+e 9ur1 group )e)/ers agreed
upon content and face 3alidit1 related to t+e 4ualit1 assurance plan& orientation progra) plan and staff
de3elop)ent continuing training progra)s in all nursing practice as a standard at *ansoura 2ni3ersit1 -ospital.
,ssess)ent t+e e5tent of fulfilling 4ualit1 assurance plan& orientation progra) plan and staff de3elop)ent
continuing training progra)s in all nursing practice accreditation standard re3ealed t+at t+e )inorit1 +ad )et t+e
accreditation standard. 8+is is supported /1 SIB
("1
w+o reported t+at t+e 4ualit1 assurance plan s+ould /e 3alid
and written wit+ t+e o3erall +ospital 4ualit1 )anage)ent plan.
,ssess)ent t+e e5tent of fulfilling nursing training accreditation standard& findings of t+e present stud1
re3ealed it was not )et. ?+ile& 8otter
("!
w+o e)p+asi<ed t+e i)portance of continuing nursing staff
de3elop)ent and training w+ic+ /ased on nursing standard. ,ccording to SambrooC
(""
w+o )entioned t+at in
order to )eet clients= +ig+ e5pectations& t+e1 )ust /e co)petent to pro3ide t+e +ig+est 4ualit1 of care and t+is
can /e ac+ie3ed t+roug+ training and continuing education. In relation to training and nursing education of t+e
designed accreditation standard agreed t+at t+ere s+ould /e planned docu)ented orientation progra) for newl1
e)plo1ed nursing staff )e)/ers. 8+is agreed wit+ 0ama
(!&
w+o reported t+at planned docu)ented orientation
progra)s s+ould pro3ided for newl1 e)plo1ed. 8+ese )ust include orientation a/out +ospital s1ste)& policies
and procedures& nursing 4ualit1 assurance plan.
,s regard for patients= rig+ts and education of t+e designed accreditation standard& it was found t+at 9ur1
group )e)/ers agreed upon content and face 3alidit1 of /ot+ pre3ious ite)s as 3alid standard at *ansoura
2ni3ersit1 -ospital. ,ssess)ent t+e e5tent of fulfilling patients= rig+ts and education criteria in t+e stud1 setting
re3ealed t+e )a9orit1 +ad partiall1 )et. 8+is is inconsistence wit+ Dill
(!#
w+o )entioned t+at nursing staff
s+ould co)pl1 to and appl1 rules of patients rig+ts and nursing et+ics s+ould consistence wit+ laws. Nurse
leaderO)anagers often find t+e)sel3es in t+e role of ad3ocate for t+eir patients& su/ordinates& and t+e profession.
Aenner
("#
concurs t+at /eing a good practitioner )eans )ore t+an 9ust e5a)ining patient rig+ts6 it re4uires
/eing )o3ed /1 t+e patient=s plig+t and responding to t+e patient as a person.
,s well as 9ur1 group )e)/ers agreed upon content and face 3alidit1 of perfor)ance appraisal& annual
education on occupational +a<ards and sc+eduling polic1 as 3alid standard at *ansoura 2ni3ersit1 -ospital.
Effecti3e appraisals are /elie3ed to )oti3ate nurses to i)pro3e t+eir practice pro3ide 9o/ satisfaction& and
i)pro3e staff )orale. ,ssess)ent t+e e5tent of fulfilling perfor)ance appraisal criteria in t+e stud1 setting
re3ealed t+e )a9orit1 +ad not )et. ,ccording to MarEuis ? Huston
("$
w+o pro3ed t+at )anagerial controlling
t+roug+ 9o/ perfor)ance en+ance nurses& carr1 out duties of t+eir assigned 9o/s.
In t+e present stud1 t+e 9ur1 group )e)/ers agreed upon content and face 3alidit1 related to annual education
on occupational +a<ards as a 3alid standard at *ansoura 2ni3ersit1 -ospital. ,ssess)ent t+e e5tent of fulfilling
annual education on occupational +a<ards criteria in t+e stud1 setting re3ealed t+e )a9orit1 +ad not )et. 8+e
result is supported /1 MarEuis ? Huston
("$
w+o e)p+asi<ed t+e responsi/ilities of t+e +ospital towards t+eir
nurses fall wit+in t+ree areasA pro3iding a safe wor7place for nurses& infor)ing and training nurses a/out +ealt+
and safet1 issues. -owe3er& )an1 +ospitals go /e1ond t+ese )ini)al re4uire)ents wit+ )ore proacti3e
approac+ to safet1 and +ealt+
("%
.
8+e profession of nursing is ine5trica/l1 lin7ed to t+e practice of s+ift wor7& wit+ inpatient care necessitating
2%-+our wor7 sc+edules. In t+e present stud1 t+e 9ur1 group )e)/ers agreed upon content and face 3alidit1
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%7
related to sc+eduling polic1. ,ssess)ent t+e e5tent of fulfilling sc+eduling polic1 criteria in t+e stud1 setting
re3ealed t+e )inorit1 +ad full1 )et. Staffing and sc+eduling are co)ple5& )ultifaceted responsi/ilities t+at are
central to nursing efforts to effecti3el1 integrate organi<ations and s1ste)s. Nursing care is a )a9or co)ponent
of +ealt+ care. 8+e )a9or goal of staffing and sc+eduling s1ste)s is to identif1 t+e need for and pro3ide t+e
nu)/er and t1pe of nursing personnel re4uired to deli3er care. 8+e nurse leader and )anager will find staffing
and sc+eduling to /e critical& core function
("
.
2onclusion and +ecommendations
8+e present stud1 re3ealed t+at de3eloped accreditation standards were considered t+e essential part of t+e
accreditation s1ste). 8+e proposed accreditation standard (content and face were 3alidated and appro3ed /1 t+e
agree)ent of a group of 9ur1. Less t+an +alf of t+e studied nursing depart)ents re3ealed t+at t+e1 )et t+e
proposed accreditation standards. ,lso& t+ere was a significant difference /etween proposed accreditation
standards as percei3ed /1 nurse )anagers wit+ t+ose o/ser3ed.
Cased on t+e findings stud1& t+e following reco))endations were detectedA
1. Nursing personnel s+ould /e aware and use t+e 3alidated de3eloped accreditation standards t+roug+ staff
de3elop)ent sessions at *ansoura 2ni3ersit1 -ospital.
2. , legal fra)ewor7 is needed to /e de3eloped to support t+e correct application of standards of accreditation in
+ospitals.
3. , s1ste) for recognition and co)pensation of nursing personnel wor7ing in t+e +ealt+ care settings fulfilling
t+e accreditation criteria needs to /e esta/lis+ed to pro)ote and reinforce t+e accreditation process.
%. $ision& )ission& policies and nursing procedures s+ould /e esta/lis+ed& re3ised periodicall1& and to /e 7nown
to all wor7ing personnel.
5. 0urt+er researc+es are proposed to assess t+e i)pact of serial application of t+e de3eloped accreditation
standards and criteria on nurses= 7nowledge and practice.

+eferences
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t+e Eastern *editerranean >airo& 2''3&pp.1-2&22-23&31.
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,ccreditation of -ealt+care #rgani<ations& 1BBB& 2S,&p.1.
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,)erica&2'';&p!2B& !%;
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+ttpAOOwww./io)edcentral.co)O1%72-;B;3O1'O12'. ,ccessed on Septe)/er& 2'1'.
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*anage)ent&2'';&37(7&;. 121-12!
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C*> -ealt+ Ser3ices Hesearc+ 2''B& BA1B5&1-B.8+is article is a3aila/le fro)A
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