Nurses: Protocol -ed to Extinction?

If you have been at your nursing job for a while, you’ve probably almost forgotten.

Forgotten what it was like to come in to the healthcare system you now work for and realize there are hundreds of new protocols for you to learn and adhere by as a nurse. After years of routine, you now go about your day as if you actually have some choice in the way you give care.

At one point you probably did. I was not around during this age of nursing. The age when we had autonomy. Freedom to practice. Freedom to be innovative.

Today, I am somewhat saddened by the current state of the nursing profession. Don’t get me wrong: I LOVE what I do. I am so thankful for the opportunities set before me.

But whatever happened to “nursing judgment”? Or “nursing decision”?

I can’t tell you how much recently I’ve heard the phrase, “It is hospital policy that…” “You can’t do that, it is protocol that…”

I understand the need for protocols. They help us in the case that something goes wrong and the hospital gets sued. Did the nurse adhere to the protocol? If not, they will be subject to disciplinary action and take the fall. If something goes wrong and there is no protocol, the hospital can say in its defense: “There is now a protocol in place.”

Maybe a less cynical need for protocols: promote and regulate evidenced-based practice among nurses. Evidenced-based practice was developed for a reason: it brings good outcomes and protects the patients.

Even so, to me it seems we are being protocoled to extinction.

When nursing sprang up, before it was considered a profession, nurses had to make due with what they had. They were forced to be innovative. I heard this once in a seminar on preventing pressure ulcers: the reason we turn patients “every two hours” is not from a scientific experiment that proved people won’t get bed sores if they are turned this often. It was from the very roots of nursing itself. When nurses were (how do I put this nicely?) prostitutes and drunks. They would walk down the room and turn all the patients to one side. Then they would sit and have a drink. When they were done with this, about 2 hours later, they would get up and turn everyone the other way. And repeat.

Even today you will read some “protocols” that require nurses to document turning patients every 2 hours. Some recent studies have shown that slightly repositioning (and not completely turning) patients every hour or even every 30 minutes has had better outcomes.

Now if I used this method of preventing pressure ulcers and did not “turn” my patients every two hours, I would be breaking protocol. I would also be forced to “lie” in my repositioning documentation.

This is just one example. I surely don’t mean to argue we should have no protocols in place.

My point is that at times, the red-tape forces nurses into a corner. We may not be creative for fear of disciplinary action.

One more story: While working night shift with a coworker and friend of mine, we had a patient with dementia that kept complaining that air was drifting on her. She was hallucinating. My friend decided to make a tent. A tent of blankets around her bed. The nurse used the IV pump, the bedside light (turned off, of course), and the sides of the bed. (Keep in mind, this patient was not ambulatory, nor did she have the strength to sit up or attempt to leave the bed.) This was so she felt safe. She felt as though there was no air blowing at her anymore. She finally got some rest for the first time in her hospital stay.

At 6am, my coworker made a point of going into the room to take down the “tent”. Management was coming in. “I’m not trying to get fired”.

Get fired? For making use of what she had? For helping the patient sleep without sedatives? For being innovative and realistic?

We may not be extinct, but we sure are endangered species.

Sarah Beth Cowherd, RN, is a hospital nurse in Virginia. She blogs at SarahBethRN.com.

20 replies »

  1. You said it. I remember when nurses used Nursing Judgement. We truly had the ability to formulate critical thinking skills. What is happening today in healthcare is absolutely frightening. Who needs nurses? You might as well have a monkey or robot there to pretend to care for the patient. I call it Computer Nursing. I’ve seen my share of nurses that only look good on the computer. Boy, they have their i’s dotted and their t’s crossed! Their patients are a mess and completely neglected. They have no idea what is really going on with the patients. But their computer charting looks fine! I hope and pray I die in my own bed and not go to a hospital to die. I don’t like what I am witnessing. If you speak up to management regarding such unsafe practices, THEY GET RID OF THE PATIENT ADVOCATE NURSES! Heaven help us all.

  2. Protocols and evidence based medicine were created for one reason: to promote high quality care to our patients. Over the years it has converted itself more under the caveat of something for hospitals to give their lawyers to avoid getting sued.
    It’s a shame we have compromised our patients and their care just to avoid financial ruin. I am a nurse and I agree there are so many protocols, charting, and paperwork to fill out in one shift to document that you are doing the right thing for your patients that there is no time left to actually spend time with them. Back in the day nursing was about taking care of your patients as well as treating them as a holistic being and that there is more to people than their disease. The idea of CORE measures is a great concept and is also designed to protect the patient, but the fact that I gave lovenox an hour late and being written up due to being with a critically ill patient is ridiculous.
    But I do know that actually taking the time and effort to create all the protocols and evidence based recommendations is a lot of work and as nurses we should appreciate it I just wish we could take a break from charting and actually take the time to learn something about our patients…..

  3. I have no problem with evidence based practice, I resent being written up if I cannot follow protocol in their time frame due to priority of care. I mean we are working with people. If I am cleaning poop and entering physician orders, then i should not be penalized by being 30 minutes late giving an aspirin to a patient within 24 hours for an Acute MI Core Measure. Especially if I am not the first nurse who has encounted this patient.
    I think it is unfair for the Government to penalize the hospital system for missing that aspirin by 30 minutes.
    I resent that I am nursing my computer by having to chart everything in a timely fashion or it it is considered not been done, rather than spending that time with my patients.

  4. My Mistake, Ms G-A, but I missed it because the comment seemed veiled to me. Perhaps sometimes saying it outright may minimize mistaken interpretations.

    By the way, my comment about transparent commenters who are just trying to take advantage of profit mongering or over managing clinicians was not directed to you specifically. The usual suspects hopefully know who I am referring to.

  5. Evidence based medicine. Hmmm. Where is the evidence that the care disrupting protocols of EHRs and CPOEs are safe and efficacious? Where is the evidence that justifies spending $ billions on care controlling devices, or is it just religion? Not all evidence is believable, especially when the researchers were investors or well paid by the vendor of the product being researched.

    Sara Beth, tell us about your experiences with the protocols of using EHRs and CPOEs.

  6. Oh yeah, EBM is just about simple interventions like washing your hands.

    Gimme a break, it is more involved than that. EBM in many specialties is about setting standards in treatment interventions that are rarely interested in exceptions, even if exceptions are more prevalent than random chance, ie 1 in 20 cases. And yet, physicians, at least when I was trained, were trained to treat the person in front of them, but let’s have one moment of complete honesty and candor: the flow of care and services is being homogenized into basically one flavor, and that based on what is cheapest, always!

    And yet someone(s) are skimming whatever profit extract can be taken. Hence why the business model is now fighting what is amounting to a guerilla war to keep it’s place in the practice of health care. ‘Cause the money is real and still available. And isn’t that what drives addicts, knowing the fix is still accessible!?

    Some of the commenters here are transparent, they are just so high on the rush of what they think is easy money, they think they can fool those of us who see through the defenses of the addict: minimizing, rationalizing, projecting, and, oh yes, denial.

    Can’t you read that in some of these threads!?!?

  7. Well, maybe not all protocols are created equal.
    The checklists (or protocols) that Dr. Gawande advocates are simple things, more like reminders, to make sure nobody forgot anything, like washing hands for example. I don’t see what these have to do with creativity, innovation or clinical judgment. The facts are that people forget stuff, even the best people, and study after study shows that running through a short and surprisingly simplistic reminder list improves outcomes. So why not?

    There are several examples of these checklists here:

    This has very little to do with EBM in general.

  8. “I was not around during this age of nursing. The age when we had autonomy. Freedom to practice. Freedom to be innovative.”

    Yes. I was asking how old you are and how long you’ve been nursing?

  9. Let’s be frank, those who went into health care to have some autonomy and treat people as individuals: letting non clinicians make health care decisions has been one of the most glaring mistakes clinicians have made that has played a sizeable role in the degradation of health care. And who challenges these kind of comments the most? The same, lame, ignorant and profit focused defenders and apologists, if not the very policy driven intrusive writers themselves. Evidence based medicine and logarithm mentalities are not about treating people, it is about treating a disease that allegedly follows equivalent patterns in every single person who presents with the illness. What planet are these people on who come up with these almost literal cookie cutter interventions?

    People, who I firmly believe, have not treated patients at the time they come up with these alleged treatment interventions. Because, if they were providing actual active patient care, they would realize that guidelines will have exceptions a lot more often than they “prescribe” in their guidelines.

    But, Washington and Universities do not recruit individuals, they recruit followers and people who echo alleged leadership thinking.

    Which is why I do not and will not work for politicians or training programs!

  10. This challenge is a common one for physicians, nurses, and many other professions. Atul is an articulate and convincing author, attracting the attention of physicians not involved in day to day patient care

  11. Most protocols produce good care for the average patient. However, not all patients are average. If they aren’t then good care may force you to deviate. When you deviate, you need to argue why. Any provider forcing protocols on all patients denies them good care and insults its employees. Irrespective whether they are MDs or RNs.

  12. I would suggest you all read Toussaint & Gerard’s from-the-trenches book “On The Mend.” Patient-centered collaborative care solutions go way beyond simplistic false dichotomy complaints and old procedural paradigms.

  13. This is one reason I was so puzzled by the terrific reception (particularly among medical types) of Atul Gawande’s book “The Checklist Manifesto.”

    Checklists are great, but only if they’re concise and cover ONLY essential, life-and-death items (like the cockpit checklists used by pilots before a flight). I’m afraid too many have taken this concept one step too far, and now believe that EVERY action must be accompanied by a checklist or protocol, and as a result we’re not permitted to think— we just obey lists.

  14. The protocol ppl think we can all be replaced if they just had the right protocols. LOL! Be not afraid. The protocol ppl are idiots, not clinicians. Doctors and nurses provide a value added service with our expertise. I’m not worried about being replaced. But I would be terrified of being cared for by a high school dropout with a protocol sheet to go by.

  15. Hospitals frequently lose lawsuits because they have not followed their own policies and protocols. Decison for the plaintiff.

    That is why the policies all need to be scrapped in favor of a policy where each nurse shall provide custonized care to the best of his/her ability for each patient as ordered by the patient’s physician.

    Nurses ARE being protocoled out of usefulness. Doctors need nurses who will take care of the patient instead of the computer or the hospital.

    Thank the nursing profession itself for the destruction of nursing. Thank the Joint Commission. And of course thank the Centers for Medicare and Medicaid Services.

    Your turn, Bobby.

  16. “But whatever happened to “nursing judgment”? Or “nursing decision”?”

    replace “nursing” with “physician” and you get the same lament. EBM/’practice guidelines” frequently get irascibly dissed at “cookie cutter medicine.”

  17. I’m sure that you know that protocols incorporate best practices. They are designed to eliminate the random anecdotal evidence based decisions made by health care professionals which have been proven time and again to provide less than optimal care.
    I applaud you eagerness to innovate but this should be done as a well designed research protocol so that your innovation can improve the protocol. I’m sure your institution has a group that examines, modifies and adopts protocols. I think you would find a good purpose in joining this group where you could make a positive contribution with your creative thinking.