PLAISIR^© system starts from the basic principle that at all levels, decisions must be oriented according to the needs of each client and not according to available resources.

It operationalizes this basic premise by focusing on services required by the client instead of the services which are given.

Required services are defined as the nursing care and assistance required by the dependant client to answer his aid needs.  The client's aid needs are assessed by (a) professional(s) according to :  

• the client's (and family's) perception of his aid needs as communicated to the professional(s);
  
  

• the client's present bio-psycho-social profile and history.

The professionals form from this starting point, their perceptions of the client's aid need.  On this basis, they determine the specific services required by the client.  This determination takes into account their care philosophy which translates into a certain number of rules, norms, professional standards that specify in a more or less precise and objective fashion, the way to respond to different aid needs.

Care given does not always correspond to care required as just defined.  This may be due to a lack of resources, a poor evaluation of the client's needs or the regulations of an institution.  Hence, nursing staff may assist a client to walk once a day (care given); yet, standards of care stipulate (care required) that the client should receive help to walk three (3) times a day to activate blood flow and prevent muscular atrophy in the lower limbs.  In the FRAN^©, one would indicate for this nursing action; "walk with assistance" at 10:00 - 15:00 -20:00 "every day", instead of "walk with assistance" at 15:00, "every day".

As mentioned above, the philosophy of care as well as the norms and professional standards which are derived from it, influence the determination of care required.  These philosophies, norms and standards vary from one institution to the other.  Hence, if one did not frame the determination of what is required within a set of rules, required care for the same client (in terms of services and consequently in terms of resources) would vary from one institution to the other.  This poses an important problem of equity if the results of PLAISIR^© evaluations are used, as is the case in Quebec, to distribute a regional budget between the different programs or institutions of a region, according to the resources required by their clients or to determine individual clients allocations as is the case in Europe.

Thus, it is necessary to define standards of care which all institutions must adhere to for the purpose of PLAISIR^© evaluation.

The following standards of care and assistance correspond to current good practice in the nursing homes and extended care hospitals of Quebec.  No studies have been done to establish their clinical validity.  They simply stem from observations made in the facilities and, in the opinion of the nurses consulted, although they do not correspond to optimal care, they still ensure that the client has an acceptable sense of well-being and security.  Considering the presently available resources, nursing personnel are currently finding it impossible to do better in general and unfortunately, in certain cases, cannot even offer the care and assistance corresponding to these standards.

The standards are not prescriptive but only indicative. The nurse evaluator can move away from a standard, providing that she justifies this deviation by the particular needs of the client she is evaluating.  Therefore, each time the nurse evaluator uses a frequency or an intensity that is different from the standard frequency or intensity for a particular nursing action, she must explain her reasons in writing in the FRAN^©.

Finally, it must be noted that if it is necessary for everyone to adhere to the same standards in order to ensure equity when allocating the resources, it is nevertheless possible, once these resources have been made available to the different institutions, for each facility to set its own standards. However, the facility's proper standards will be constrained by the resources allocated on the basis of common standards.  This is the price to pay in order to achieve equity in the allocation of resources.

One must however note that in the application of PLAISIR^© in Switzerland, Germany, France, Italy and Belgium, the committees of nurses of these countries have defined the standards of care which correspond to their respective practices and which are different amongst themselves and different from Quebec standards.  Finally, it is important to note that the utilization of common standards of care by all the institutions of a country or region is only necessary when there is a collective application of PLAISIR^© system.  An institution which implements the system solely for its internal needs of information could very well use its own standards.  Yet even in such a case, a certain uniformity is necessary; in fact, if one wishes to compare the units of the institution amongst themselves, it is then necessary that all adhere to the same standards of care.  Thus, even in such a situation, one cannot bypass the explicitation and the formalization of the standards of care of the institution without losing the ability to compare units amongst themselves.

One will find, below, the list of care standards currently being used in Quebec.