Aim

The aim of this assessment is for you to demonstrate an applied understanding of clinical governance in your workplace.

Instructions

In this assessment, you are required to develop an audit plan on one nursing practice in your clinical workplace. Your audit will demonstrate your understanding of clinical governance theories, requirements, and how they are enacted in your workplace. To complete this assessment, you are asked to:

• Collaborate with your unit nursing leaders, i.e., Nurse Unit Manager, Clinical Nurse Consultant, Nurse Educator, Service/Clinic to identify one nursing practice to audit using the principles of clinical governance,
• Link your nursing audit to one relevant National Safety and Quality Health Service Standard (NSQHSS) or one Aged Care Quality Standards (for students working in aged care settings), and
• Outline the steps you will implement to undertake your chosen clinical audit in your workplace.

This assessment task will be the basis for Assessment Two, where you will undertake and report the results of this audit. Assessment One is therefore the plan for the audit you have chosen to undertake, and Assessment Two presents the results of the audit.

Prepare your assessment using the following four (4) steps:

1. Provide an overview of clinical governance in healthcare organisations

Your overview will be informed by current literature to describe and explain what clinical governance is, including how clinical governance impacts clinical risk and influences safety and quality in nursing practice. Then apply this information to how your healthcare organisation addresses clinical governance, including risk identification and nurse-initiated audits.

2. Choose one nursing practice for your audit

a. State the nursing practice you will audit.

b. Discuss your nursing audit to be undertaken in your clinical workplace with your nursing leaders, i.e., Nurse Unit Manager, Clinical Nurse Consultant, Nurse Educator, Nursing Service/Clinical Manager. Identify in your assignment who the nurse leaders you collaborated with to decide on the audit you will undertake.

c. Discuss the background to your audit; i.e., why is your audit important in your workplace for patient safety and clinical governance. To do this, you will need to research current literature and your local health service policies and procedures. This background should include the clinical risks associated with the identified nursing practice you will audit.

3. Select the most relevant National Safety and Quality Health Service (NSQHS) Standard or Aged Care Quality Standard (ACQS) to undertake your nursing audit. Briefly discuss the most relevant NSQH (2017) related to your nursing practice audit.

• Standard 1 – Clinical Governance Standard
• Standard 2 – Partnering with Consumers Standard
• Standard 3 – Preventing and Controlling Healthcare-Associated Infection Standard
• Standard 4 – Medication Safety Standard
• Standard 5 – Comprehensive Care Standard
• Standard 6 – Communicating for Safety Standard
• Standard 7 – Blood Management Standard
• Standard 8 – Recognising and Responding to Acute Deterioration Standard.

Alternatively, briefly discuss the most relevant ACQS (2021) related to your nursing audit if you work in an aged care setting.

• Standard 1 – Consumer dignity and choice
• Standard 2 – Ongoing assessment and planning with consumers
• Standard 3 – Personal care and clinical care
• Standard 4 – Services and supports for daily living
• Standard 5 – Organisation’s service environment
• Standard 6 – Feedback and complaints
• Standard 7 – Human resources
• Standard 8 – Organisational governance.

4. Describe your chosen nursing audit and the steps you will implement to undertake your audit:

• Work with your unit nursing leaders to access an audit tool currently used in your healthcare facility or ward. Alternatively, you can create an audit tool if a tool does not exist for the nursing practice you want to audit. If you create your own audit tool, ensure that the tool is reviewed by your nursing management support and check with the NURS20169 unit coordinator (Dr. Leanne Jack). Review the audit to identify what measures of compliance are used to audit the nursing practice within the selected Standard. Briefly describe the audit, its components, and the steps you will use to undertake your audit. Recommendations to guide you include:

a. Describing your audit might include identifying if your audit is in paper/digital format, prospective or retrospective, the number of observations to be undertaken, how many questions are in your audit, describe your audit questions (yes, no, not applicable, open-ended questions), the frequency of auditing, how will you analyse your audit, who will you report your audit findings to

b. Consider the quality improvement cycle to describe the steps you will implement to undertake your nursing audit.

Set your assignment up using the following headings that aligns with the 4 Steps of this assessment task:

• Clinical governance in healthcare organisations
• Nursing practice to be audited
• National Safety and Quality Health Service Standard or Aged Care Quality Standard
• Description of the audit tool
• Steps to undertake audit (optional sub-heading to the description of audit tool)
• References

Literature and references

In this assessment use at least five contemporary references (5 years or less) to substantiate your information. You may use seminal scholarly literature where relevant. Suitable references include peer-reviewed journal articles as well as textbooks and credible websites. When sourcing information, consider the 5 elements of a quality reference: currency, authority, relevance, objectivity, and coverage. Grey literature from the internet must be from reputable websites such as from government, university, healthcare organisations, or peak national bodies, for example, the Australian College of Nursing. Note, websites such as Stat Pearls, Life in the Fastlane, and Wikipedia are not suitable for this assessment task.

Requirements

• Have a cover page to your assessment that includes your name, student number, unit code, workplace, and in-text word count.
• Use a conventional and legible size 12 font, such as Times New Roman, with 2.0 line spacing and 2.54cm page margins (standard pre-set margin in Microsoft Word).
• Include page numbers on the top right side of each page in a header.
• Write in the third-person perspective.
• Use formal academic language.
• Start your reference list on a separate page to the body of your assignment.
• Use the seventh edition American Psychological Association (APA) referencing style. The CQUniversity Academic Learning Centre has an online CQU APA Referencing Style Guide.
• The word count is considered from the first word of the introduction to the last word of the conclusion. The word count excludes the reference list but includes in-text references and direct quotations. Avoid direct quotes as this reflects the knowledge of others and not your unique interpretation of the evidence.

Resources

• National Safety and Quality Health Service (NSQHS) or Standards or the Aged Care Quality Standards (ACQS).
• You can use unit provided materials and other credible sources (e.g. journal articles, books) to reference your argument. The quality and credibility of your sources are important. Please note, lecture notes are not primary sources of evidence and should not be used in this assessment.
• We recommend that you access your discipline specific Nursing Resource Guide.
• For information on completing written assignments and academic writing please go to the Academic Learning Centre Moodle site. The Academic Communication section has many helpful resources including information for students with English as a second language.
• You may wish to submit a draft to Studiosity.
• Submit at least one draft before the due date to review your Turnitin Similarity Score before making your final submission. Instructions are available here.

Submission

Submit your assessment via the unit Moodle site in Microsoft Word format only and by the due date.

Marking Criteria

Refer to the marking rubric below for details on how marks will be assigned in this assessment.

To achieve a passing grade for this unit you are required to pass this assessment item. If you do not receive a passing grade, you may be eligible for a re-attempt. A re-attempt is where you are given a second opportunity to demonstrate your achievement of one or more of the unit’s learning outcomes before you can progress to new learning or participate in subsequent learning activities. You may be given the opportunity to re-attempt an assessment but will only achieve a mark no greater than the minimum for a pass standard for the assessment. You must:

• have shown a reasonable attempt to complete the initial assessment task
• be granted a re-attempt by your Unit Lead/Coordinator
• make changes to the nominated assessment task which you have failed and resubmit the revised work for marking within seven consecutive days, no assessment extensions will be approved.

Please note: Only one opportunity for a re-attempt is allowed.

Learning Outcomes Assessed

1. Explain the concept of clinical governance and justify its relevance to the clinical setting and nursing practice.
2. Apply a framework derived from the National Commission on Safety and Quality in Health Care to evaluate clinical governance in a clinical setting.

To achieve a pass in this assessment students must be successful in all major criteria (Structure and Presentation, Content, and Referencing).

To be successful in each of the major criteria students must be successful in one half of the given minor criteria i.e. 3/6; 4/8

Aim

The aim of this presentation is to demonstrate your applied understanding of clinical audits, and the associated quality standards, as part of the quality improvement cycle. Your analysis of the audit results will include compliance with, or deviations from, evidence-informed nursing practice in your clinical workplace, as you identified in Assessment One, the significance of the selected nursing practice and what will happen next as a result of the audit findings.

Instructions

This assessment is to be undertaken in the clinical setting where you currently practice and builds on Assessment One. Based on the National Safety and Quality Health Service (NSQHS) Standard or the Aged Care Quality and Safety Standard (ACQSS) selected in Assessment One, and in collaboration with your local nursing leadership team, undertake a nursing clinical audit and present your findings. You are not required to repeat information from Assessment One, unless brief detail is required to give context to your presentation. You are to present the audit cycle: the steps that you undertook to conduct your audit, the audit findings, and identify what actions were or will be undertaken as a result of your audit findings.

Please follow the steps below to complete your assessment task:

1. Using your audit plan from Assessment One:

• Review the audit tool
• In collaboration with your nursing management team/support determine the sample size for your audit (see explanation video on Moodle)
• Review the audit implementation steps
• Determine the timeframe for the audit, ensuring enough time to analyse and write up your report.

2. Ensure you have the NSQHS Standard or ACQSS selected in Assessment One for comparison or benchmarking to achieve compliance.

3. Design a poster using one slide in PowerPoint to report on the audit and give a 5-minute oral presentation. Your presentation should summarise your audit, including data collection, findings, recommendations, and references (this does not include your notes for you to deliver your 5-minute presentation).

• Students enrolled in a partnered program – Present your audit through a 5-minute oral poster presentation at your local health service

I. Students enrolled in the partnered program pathway do not have to upload their poster presentation to Moodle – you are assessed in your local health service within your graduate program.

• Students enrolled in the non-partnered pathway:

I. Register to attend a Zoom session to present your poster. The times and dates of the oral presentation Zoom sessions are identified in the ‘Due Date, then Presentation Date’ in this assessment task, thereby, giving you time to request rostered time off through your workplace rostering system to ensure your attendance.

II. Upload your poster to the Assessment Two submission portal on the Unit Moodle site by the due date.

III. Attend your selected Zoom session and present your 5-minute oral poster presentation.

Literature and references

In this assessment use at least 5 contemporary references (5 years or less) to support your discussion. You may also use seminal scholarly literature where relevant. Suitable references include peer-reviewed journal articles as well as textbooks, and credible websites. When sourcing information, consider the 5 elements of a quality reference: currency, authority, relevance, objectivity, and coverage. Grey literature from the internet must be from reputable websites such as government, university, or peak national bodies, for example, the Australian College of Nursing. Note, websites such as Stat Pearls, Life in the Fastlane, and Wikipedia are not suitable for this assessment task. Lecture notes are not primary sources of evidence and should not be used in this assessment.

Requirements

• Use a conventional legible font. If you use a background or embedded photo or picture in your poster, this must be published with a Creative Commons (CC) licence and the source attributed as per the requirements of their CC licence.
• Use formal academic language.
• Write in the third-person context, however you may use first-person context for the actions you undertook to complete your audit.
• You must include in-text citations, and a reference list, however both can be included in small font to reduce the visual impact. Remember, that your referencing should be readable to your audience and presented on the one PowerPoint slide.
• Use the seventh edition American Psychological Association (APA) referencing style. The CQUniversity Academic Learning Centre has an online APA Referencing Style Guide.

Resources

• National Safety and Quality Health Service (NSQHS) or Standards or the Aged Care Quality and Safety Standards (ACQSS)
• You can use unit provided materials and other credible sources, e.g., journal articles, books, to reference your argument. The quality and credibility of your sources are important. Please note, lecture notes are not peer reviewed primary sources of evidence.
• We recommend that you access your discipline specific Nursing Resource Guide.
• For information on academic communication, writing and referencing please go to the Academic Learning Centre Moodle site. The Academic Communication section has many helpful resources including information for students with English as a second language. There are also Oral Presentation resources.
• For information on using PowerPoint please go to the Academic Learning Centre Computing Basics section – How to use PowerPoint.
• For information on using Zoom to present your assessment, please go to Zoom web conferencing.
• Submit at least one draft of your assessment before the due date to review your Turnitin Similarity Score before uploading your final submission. Instructions are available here.

Submission

Submission instructions are related to if you are enrolled in a partnered program or not.

Marking Criteria

Refer to the marking rubric on the Moodle site for more detail on how marks will be assigned.

If you do not receive a passing grade, you may be eligible for a re-attempt. A re-attempt is where you are given a second opportunity to demonstrate your achievement of one or more of the unit’s learning outcomes before you can progress to new learning or participate in subsequent learning activities. You may be given the opportunity to re-attempt an assessment but will only achieve a mark no greater than the minimum for a pass standard for the assessment. You must:

• have shown a reasonable attempt to complete the initial assessment task
• be granted a re-attempt by your Unit Lead/Coordinator
• make changes to the nominated assessment task which you have failed and resubmit the revised work for marking within seven consecutive days, no assessment extensions will be approved.

Please note: Only one opportunity for a re-attempt is allowed.

All students (partnered and non-partnered students) who are offered an assessment re-attempt are to email the Unit Coordinator (l.jack@cqu.edu.au) to establish a presentation date for assessment re-attempt.

Learning Outcomes Assessed

3. Explain the use of clinical audits as part of a quality improvement cycle to improve nursing practice and patient care.

4. Identify deviations from best practice and discuss areas for improvement.

Assessment One Marking Rubric

Student name: ______________________________ Student ID: ______________________________

To achieve a pass in this assessment students must be successful in the Content criteria and at least 2 of the other criteria.

To be successful in each of the major criteria students must be successful in one half of the given minor criteria i.e., 2/4; 3/6