ReviewHow do nurses, midwives and health visitors contribute to protocol-based care? A synthesis of the UK literature
Introduction
This paper explores how nurses, midwives and health visitors contribute to the development of protocol-based care in the United Kingdom. It is based on one of the first systematic literature reviews about the development, implementation and audit of protocol-based care. Although the term protocol-based care may be unfamiliar, it refers to well-established ways of working in many countries. This is because protocol-based care is a generic term for the use of documents that formalise working practices by making explicit ‘who should do what, when, how and why.’ There are many terms for such documents, including algorithms, protocols, integrated care pathways, clinical guidelines, care bundles, procedures and policies. Standardisation is at the heart of protocol-based care (Patterson et al., 2008). All these documents share the same purpose which is to set standards and to standardise care to reduce unacceptable variations in health care practice and patient outcomes (Ilott et al., 2006).
Standardised approaches to care are common in nursing and midwifery. Bail et al. (2009) describe how nursing procedural polices emerged in the late 19th century, commenting that ‘nursing work was often codified in hospital policies or standards’ (p. 1458). Flynn and Sinclair (2005) note that good practice guides, ward procedure books and manuals have been used in nursing for many years. Nearly twenty years ago in America, Worcester et al. (1991) identified four types of written guides for the management of cancer symptoms in elderly people living in home care agencies. These were organisational policies, nursing care plans, protocols and procedures. The last two are pertinent to protocol-based care. Protocols were said to be more specific and explicit about ‘the way an assessment or intervention is to be carried out’ (Worcester et al., 1991, p. 116) whereas procedures were detailed ‘how to’ guides for specific tasks. This categorisation is noteworthy because it pre-dates the emergence of care pathways, clinical guidelines and care bundles. The definition of protocols hints at the future role of protocol-based care in expanding the scope of nursing practice, in stating that:
some protocols may be written and signed by physicians … to expand the nurses ability to adjust interventions with clients without having to obtain physician orders that would be needed without the protocol (Worcester et al., 1991, p. 116).
Written guides are a feature of contemporary practice although many now reflect a different emphasis—that of evidence-based care. Such guides are a way of embedding research-based knowledge into organisations. Walters et al. (2004) describe an embedded model where research is distilled, codified and incorporated into organisational procedures, protocols and guidelines. The embedded model was illustrated in a recent survey of nurses in the United Kingdom (Gerrish et al., 2008) which found policy and procedure manuals ranked fourth amongst the sources of knowledge drawn upon by nurses. One of the principal differences between earlier and current generations of documentation is this emphasis upon evidence-based practice, in that many purport to draw upon the best available research rather than professional consensus.
Protocol-based care influences practice in traditional and new health care settings (Rycroft-Malone et al., 2008). As a way of working it has underpinned workforce and service redesign, particularly through expanded scope of practice, skill mix and new roles for nurses, in many parts of the world. For example, Wong and Chung (2006) describe how hospital endorsed protocols permit nurses to act as the first point of contact in nurse-led clinics in Hong Kong. Carryer et al. (2007) report how guidelines and protocols govern the practice of nurse practitioners in New Zealand and Australia. Blackwood and Wilson-Barnett (2007) studied the impact of nurse-directed protocolised-weaning from mechanical ventilation in intensive care units in Ireland. Such examples indicate the international relevance of protocol-based care or standardised approaches to care, not merely as a cost and quality control measure for health care systems, but as a pervasive and contested influence upon the working practices of nurses, midwives and health visitors (Bail et al., 2009, Hunter and Segrott, 2008).
In the United Kingdom, protocol-based care was launched in the NHS Plan (Department of Health, 2000), a policy which marked a commitment to extra funding for the National Health Service (NHS) in England in return for reform of working practices. Since the Labour Government was elected in 1997, the total NHS budget has trebled to around £90 billion per year (Department of Health, 2008, p. 118). The NHS Plan stated that by 2004 the majority of NHS staff would be ‘working under agreed protocols identifying how common conditions should be handled and which staff can best handle them’ and, that the NHS Modernisation Agency ‘will lead a major drive to ensure that protocol-based care takes hold throughout the NHS’ (Department of Health, 2000, p. 83).
Two years later, the NHS Modernisation Agency (MA) and National Institute for Clinical Excellence (NICE) produced a 12-step guide to developing and implementing protocols (MA/NICE, 2002). The steps are show in Fig. 1. The first step is selecting and prioritising a topic and the final one is reviewing the protocol.
The guide provides practical advice, offering a structure to the development process with annexes about decision support systems, how to prepare a project plan, a communication plan and a process map. The underlying approach is experiential and does not cite any theoretical or empirical evidence about change to inform the sequence or the content of each step. Although the stated purpose was to ‘offer one option for a step-by-step approach’ (MA/NICE, 2002, p. 2) the tone is positive. Benefits of protocol-based care are emphasised, for example in step 10, readers are told to produce evidence of effectiveness and in step 12, to measure the benefits of protocol-based care. The language is more prescriptive than optional, with 43 ‘shoulds’ stating what should be done throughout the 19 page guide (MA/NICE, 2002).
Considering the policy imperative to reduce unacceptable variations in health care in the United Kingdom and the professional imperative to embed evidence-based practice into nursing, midwifery and health visiting internationally, little is known about how protocol-based care is actually developed at a local level. Furthermore there has not been a systematic attempt to identify how nurses, midwives and health visitors contribute to this process. In a recent realist synthesis of the literature about protocol-based care, Rycroft-Malone et al. (2007) notes that authors tend to provide limited details about their approach to development. Some papers suggest a sequential approach, for example Gordon (1995) describes four phases and 24 steps for writing a critical pathway for pain management in a burn acute care unit in America. The content of the four phases of focus/recognition, assess/analyse, development and then implementation/evaluation are similar to the guide produced to support protocol-based care in England (MA/NICE, 2002). Our research aimed to address this knowledge gap by exploring the development process and by seeking to understand the contribution that nurses, midwives and health visitors make to the development, implementation and audit of protocol-based care.
Section snippets
Design
Systematic literature reviews provide an objective, comprehensive summary about what is known about a specific topic using an explicit, replicable method (Petticrew and Roberts, 2006). There are two broad approaches – aggregative and interpretative – to conducting literature reviews (Dixon-Woods et al., 2006). Aggregative reviews are concerned with assembling, pooling and summarising data that is comparable and well specified, using methods such as meta-analysis. In contrast, interpretive
Practitioner knowledge in context
Most of the papers contained practitioner knowledge in the form of tacit knowledge, the ‘everyday experience’ (Pawson et al., 2003, p. 49) made explicit by front-line practitioners. Just over half (17/33) were written by nurses in practice settings, describing and sharing their experience about a locally developed and owned protocol, guideline or pathway. The authors seem to be motivated to share their learning, with over a third (14/33) including the whole, or an extract from the protocol,
Discussion
It is tempting, when undertaking a thematic analysis and following the procedural process facilitated by the QARI software, to focus simply on the derivation of the findings, categories and synthesised themes. However, we found it helpful to step back and take stock of the practitioner knowledge as a whole. This enabled the identification of issues that were under represented in the literature.
Conclusion
This paper reports one of the first systematic literature reviews about the contribution of nurses, midwives and health visitors to protocol-based care. The narrative review summarised practitioner knowledge from 33 studies describing the development of protocols, guidelines and care pathways in the United Kingdom between 1991 and 2006. This showed that the development process was idiosyncratic, being embedded within a specific context and the multiple purposes of the protocol-based care. As
Acknowledgements
This article presents independent research commissioned by the National Institute for Health Research (NIHR) Service Delivery and Organisation (SDO) Programme. The views expressed in this article are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. The NIHR SDO programme is funded by the Department of Health.
We are grateful to Low Lee Lan, Research Officer, Institute for Health Systems Research, Ministry of Health, Malaysia, for acting as the
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