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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.

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marlaKimberly S.v-nurseOctaviouspropensity Recent comment authors
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Kimberly S.
Guest

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… Read more »

v-nurse
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v-nurse

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… Read more »

Octavious
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Octavious

just don’t touch me with those creepy looking nails. jeesh.

DeterminedMD
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DeterminedMD

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.

propensity
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propensity

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.

Margalit Gur-Arie
Guest

Dr. D,

You are preaching to the choir… Reread my last sentence:
This has VERY LITTLE to do with EBM in general.

DeterminedMD
Guest
DeterminedMD

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… Read more »

Margalit Gur-Arie
Guest

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:
http://gawande.com/the-checklist-manifesto

This has very little to do with EBM in general.

Peter
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Peter

“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?

BobbyG
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DeterminedMD
Guest
DeterminedMD

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… Read more »

Gary Levin
Guest

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

Xander
Guest
Xander

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.

BobbyG
Guest

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.

SteveBMD
Guest

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.