• Manias Elizabeth PhD, MPharm, RN,

  • Aitken Robyn MEd, RN,

  • Dunning Trisha AM, PhD, RN

Elizabeth Manias, Associate Professor of Nursing, School of Nursing, The University of Melbourne, Level 1, 723 Swanston St, Carlton, Victoria 3053, Australia. E-mail:


We would like to thank Gerry Armitage for providing a comprehensive and cohesive commentary on our study (2007). Effective protocol use is a valuable way in which patients’ medications can be safety managed. Australian government reports refer to a variety of strategies to promote medication safety, including the need for collaborative decision making, partnership and consultation between health professionals, patients and carers about managing medications (Australian Pharmaceutical Advisory Council 2005). Also promoted is the use of computerized prescribing with clinical decision support systems and the need for clear medication administration procedures (Australian Council for Safety and Quality in Health Care 2002). Unfortunately, Australian government reports do not specifically comment on how protocols could help bring about effective management of medications. Generally, managers of health service organizations advocate the effective use of protocols among health professionals. Government bodies should also take a leadership role in demonstrating how protocols at the micro-context level of consumers, family members and health professionals relate to the broader macro-context level of medication policy and legislative development.

We wish to take this opportunity to address some of the issues raised in Armitage's commentary, using the following headings: adherence to protocols, selection of protocols for consideration, selection of hospital site for observation, number of observations and interviews and follow-up with participants.

Adherence to protocols

In relation to the reasons for graduate nurses’ adherence or lack of adherence to protocols, a number of tensions were in force within the study. Nurses accessed protocols to learn about the medications they were required to administer. They also used protocols to enable them to follow particular structured medication administration activities without the need to seek permission from doctors; therefore, promoting a sense of autonomy. Further insight on nurses’ use of protocols can be gained from an extensive critical ethnographic study completed in a critical care unit on the power relations relating to protocol use between doctors and nurses, and among nurses (Manias & Street 2000). In that study, nurses and medical consultants, who were permanent employees of the unit, had extensive knowledge of unit protocols. Nurses were observed to follow discrete steps of protocols for the preparation and administration of medications. They scrutinized themselves and each other to ensure that procedures were completed in the correct manner. These protocols were so ingrained that the effect was to produce and sustain a particular standard. Any deviation from the normal meant that nurses were singled out by their peers because they did not conform. Nurses also used information from protocols to mediate with doctors, especially with medical consultants who were also familiar with these protocols, and with other nurses. On the other hand, registrars and residents, who worked in the unit for a few weeks, had a shallow knowledge of protocols and placed little value on their importance in daily practice. These doctors tended to use knowledge from past experience, education and information gained from literature, in making clinical decisions, which often created tensions with nursing staff.

In our study, nurses believed they learned a great deal about medications by accessing and using protocols. However, they expressed anxiety when a slight deviation from a protocol led to disciplinary action from more experienced nurses, even if the deviation was out of their control. It appears as though nurses chose to adhere to protocols because this practice enabled them to exercise power, maintain control, boost their confidence and influence practice. Clearly, the choice to adhere to protocols is bound by complex professional and environmental issues that require further exploration.

Selection of protocols for consideration

Reflecting on the research method, Armitage indicated that the advanced selection of protocols might have influenced the emergence of themes generated. The research team did not select the protocols before data collection; instead, protocols were randomly chosen at the time of data analysis. Data collection was guided by observation and interview schedules, which provided a focused approach for data collectors, while at the same time being broad enough to facilitate the gathering of data of wide social relevance to the research topic.

Selection of hospital site for observation

A limitation of the study involved the collection of data in a single metropolitan hospital. We did not believe this limitation affected generalizability, which is a premise of pure quantitative studies. In this respect, we agree with Armitage's stance. Rather, we were concerned the results may not resonate with the experiences of nurses of different backgrounds, such as those employed in rural or private hospital settings. In these settings, doctors are usually present for limited periods during the day. There may also be differences with respect to roles and responsibilities of nurses in managing patients’ medications, which could impact on how they use protocols. Obviously, this issue requires further investigation.

Number of observations and interviews

Despite the small number of observations and interviews conducted, it is reassuring that other investigators with similar research objectives (see for example, Lawton & Parker 1999), presented complementary findings. Nevertheless, it would be invaluable to determine if similar practices are found in different hospital settings. It is also important to consider observed behaviours and activities in nurses and doctors with different levels of experience and in pharmacists where protocol use for managing medications has rarely been examined.

Follow-up with participants

As noted by Armitage, one of the benefits of this study was the opportunity to discuss the findings with participating nurses in a conducive and supportive environment. This process enabled nurses to reflect on practices in the context of the busy clinical setting where they worked.

In summary, this study has generated new knowledge on nurses’ use of protocols in managing patients’ medications in the metropolitan hospital context. This area of research has important implications for patient safety in the micro-context and in broader levels of government policy. Again, we wish to thank Armitage for writing the commentary, and for lucidly critiquing our study in relation to his own important work and other relevant studies.