Evid Based Nurs 13:114-115 doi:10.1136/ebn1092
  • Qualitative
  • Systematic review

Limited literature available regarding the role of nurses, midwives and health visitors in development and implementation of protocol-based care

  1. Jo Rycroft-Malone2
  1. 1King's College London, Florence Nightingale School of Nursing and Midwifery, London UK
  2. 2Centre for Health Related Research, School of Healthcare Sciences, Bangor University, Bangor UK
  1. Correspondence to Debra Bick
    Debra Bick, King's College London, 57 Waterloo Road, London SE1 8WA, UK; debra.bick{at}

Commentary on: [CrossRef][Medline][Web of Science]Google Scholar

What is protocol-based care?

Protocol-based care (PBC) refers to use of a range of documents, including protocols, guidelines and care bundles to standardise healthcare and support evidence-based practice. PBC has been at the core of UK government health reforms; however, little is known about the impact of PBC on nursing, midwifery and health visitor practice or patient outcomes, despite widespread use. This synthesis of UK literature aimed to explore how nurses, midwives and health visitors contribute to the development, implementation and audit of PBC.

How was the syntheses conducted?

An interpretive review was undertaken, informed by a five-stage literature review model. Literature was synthesised inductively and deductively using the Modernisation Agency/National Institute for Clinical Excellence (2002)1 guide to the development and implementation of PBC as a framework against which to compare practitioners' experiences.

How good was the evidence?

Most studies were descriptive, offering tacit practitioner knowledge and positive feedback on locally developed and owned PBC, which in the main were instigated to meet clinical need or service redesign. PBC development was a non-linear, idiosyncratic process, with use of ambiguous and interchangeable terminology. Development steps were omitted, repeated or completed in a different order. Implementation and sustainability were rarely mentioned or theorised as change.

What was the nursing contribution?

The nurses' role was almost invisible, with notable gaps on resource use costs, engagement of service users, leadership and impact of new roles on interprofessional relationships. The authors concluded that there was a dearth of literature on the contribution, experience and outcomes for nurses, midwives and health visitors of PBC, despite the proliferation and contested nature of the use of standardised decision tools.

Were the synthesis methods appropriate?

The authors targeted five major databases. A number of search terms were used to ensure studies using different terms to describe PBC were identified. Study selection and quality-assessment criteria seemed appropriate and robust, though the decision to include UK-only studies was made at the data-synthesis stage, rather than from the outset. The authors selected a purposive sample of 33 UK papers published between 1991 and 2006 for detailed analysis from 117 identified, in order to illustrate different specialities and organisational settings. Study selection was not a linear process and required the reviewers to decide whether a particular paper met the purpose of the review and whether research, rather than practitioner knowledge, was reported. The potential for bias is an issue as the international literature was not considered, with the possibility that other reviewers could reach different conclusions if the same approach to paper selection and synthesis were adopted. As the majority of the included papers reported nursing studies in acute care settings, applicability to midwifery and health-visiting may not be appropriate.

What were the advantages of this methodological approach?

As well as presenting synthesised themes, the authors were also able to highlight the idiosyncratic approach to PBC development. This challenged implementation guidance1 2, which presents PBC development as linear and resource-neutral, does not acknowledge the complexity of achieving change in health settings. Replication of the review drawing on the international literature was recommended.

Do findings support other research?

The synthesis confirmed findings of recently published studies of PBC use in NHS settings.3 It highlighted the breadth of use and localisation of PBC and major gaps in knowledge of PBC development and implementation, evidence of the contribution and impact of PBC on health professionals and patients, and equivocal evidence of effectiveness. An emerging issue from recent research is the potential negative impact on interprofessional relationships PBC can trigger if relevant stakeholders are not engaged from the outset, if there is a lack of clarity as to levels of evidence used to inform decision making, and if PBC decides to support rather than inform clinical decision making.3

So, is PBC a good thing?

Healthcare teams should not view the introduction of PBC as a ‘quick-fix’ solution to enhance healthcare and reduce variation in practice. They are complex interventions comprising various component parts, the effects of which may be difficult to untangle and need to be developed, implemented and evaluated as such. The influence of the context of care is also as likely to influence outcomes.

Limited attention has been paid to the implementation of PBC with an urgent need to address this. Given the complexity of healthcare, multi-method studies which include the use of realistic evaluation would seem appropriate. We also need more evidence of the clinical efficacy and cost-effectiveness of initiatives taken to standardise care.


  • Competing interests None.


This article has not yet been cited by other articles.

Free Sample

This recent issue is free to all users to allow everyone the opportunity to see the full scope and typical content of EBN.
View free sample issue >>

EBN Journal Chat

The EBN Journal Chat offers readers the opportunity to participate in discussion about research articles and commentaries from Evidence Based Nursing (EBN).

How to participate >>

Don't forget to sign up for content alerts so you keep up to date with all the articles as they are published.