1. CBAHI Nursing
Standards
3rd Edition 2015
Joven Botin Bilbao, RN, MAN
Deputy Chief Nurse Officer
Clinical and Accreditation Educator

2. NR.1 Qualified Nursing Director is
responsible for managing
nursing services in the
hospital.
• Full time Nursing Director
• Licensed and registered with the Saudi
Commission for Health Specialties
• Bachelor's Degree in Nursing, 5 years
managerial experience

3. NR.2 Nursing Director assumes a
leadership position in the
hospital
• Represents the nursing staff as one of the
hospital leaders.
• Participates with other hospital leaders in
decision making processes.

4. NR.3 Nursing Director assumes authority,
responsibility and accountability for
assuring proper and effective nursing
services
• Establishes, oversees and approves nursing
policies and procedures and nursing
professional standards of care.
• Implements an effective method for organizing
the delivery of patient care.

5. NR.4 Nursing reference manuals and
policies are readily available and
accessible to all units.
• Nursing policies and procedures manual
• Current nursing practice manuals/books
• Infection Control Manual
• Safety Manual
• Operating Manuals for safe use of equipment
• Laboratory Services Guide
• Dietary Manual
• MSDS

6. NR.5 Nursing Director ensures the
competency of the Nursing
Staff
• Participates in the recruitment and hiring of
qualified nurses.
• Monitors the performance of the nursing staff
and assures their ongoing competency.

7. NR.6 Sufficient nurses are
available to meet the needs
of patients
• Develops a staffing plan that maintains an
adequate staffing level in all nursing units.
Nursing Staff are allocated according to the
skill level, qualifications, patients volume and
acuity and in accordance with laws and
regulations and nursing licensing boards.

8. NR.7 Nursing Department provides
regularly updated work
schedule.
• Nursing scheduling policy defines duration of
working shifts, assignment of overtime when
needed, on-call requirements, vacation
schedules, change of schedule, participation in
education activities, committees, departmental
meetings and quality improvement activities.
• Work schedule provides an adequate number of
staff every shift.

9. NR.8 There is a process for
assignment of nurses out of
their normal working areas.
• Ensures that nurses assigned out of their
normal working area have the competency
required for safe and effective patient care.
• Maintains a list of cross-trained nurses and
available for all nursing units.

10. NR.9 Nursing Services are provided
by qualified nurses.
• Licensed registered nurses are available to provide
nursing care.
• Each unit has Head Nurse with the required
nursing and managerial experience.
• Qualified registered nurses are available to provide
bedside nursing care to all patients 24 hours per
day, 7 days a week.
• Nursing assistants have education program,
clearly defined job description and responsibilities.

11. NR.10 There is a comprehensive
nursing assessment for each
patient upon admission
• Timely completed by a registered nurse.
• Scope and contents is defined in hospital policies and
includes:
History of patient's main complaint
Drug allergies
Physical condition
Psychosocial status
Pain assessment
Nutritional status
Discharge planning
Skin assessment
Fall risk assessment

12.  Why nursing assessment should be done
upon admission?
To identify nursing care needs for each patient
upon admission.
 Why patients are reassessed at appropriate
intervals?
To determine patient's response to treatment
and to plan for continued treatment and
discharge.

13. NR.11 There is a nursing plan for
each patient.
• Consistent with the medical plan of care and
reviewed every shift.

14. NR.12 Nursing Department ensures
adequate supplies and equipment
for the safe and effective
provision of care.
• List of adequate supplies and equipment are
updated and available.
• Par leveling policy and procedure and forms