This article presents independent research commissioned by the National Institute for Health Research (NIHR) Service Delivery and Organisation (SDO) Programme (SDO/78/2004). The views expressed in this publication are those of the authors 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.
Protocol-based care: impact on roles and service delivery*
Version of Record online: 31 OCT 2008
© 2008 The Authors. Journal compilation © 2008 Blackwell Publishing Ltd
Journal of Evaluation in Clinical Practice
Special Issue: Evidence Based Medicine
Volume 14, Issue 5, pages 867–873, October 2008
How to Cite
Rycroft-Malone, J., Fontenla, M., Bick, D. and Seers, K. (2008), Protocol-based care: impact on roles and service delivery . Journal of Evaluation in Clinical Practice, 14: 867–873. doi: 10.1111/j.1365-2753.2008.01015.x
- Issue online: 31 OCT 2008
- Version of Record online: 31 OCT 2008
- Accepted for publication: 10 March 2008
- case study;
- evidence-based practice;
- protocol-based care;
- realistic evaluation
Objective To evaluate the impact of protocol-based care on nursing roles, practice and service delivery.
Design Case study evaluation informed by realistic evaluation methodology. Qualitative data collection methods were used including non-participant observation, post-observation interviews with nurses and patients, key informant interviews, tracking patient journeys and document review.
Participants 141 participants took part including 73 nurses, midwives and health visitors, 4 allied health professionals, 20 doctors, 5 support staff and 39 patients.
Settings Five sites were purposively sampled and included acute and primary care service provision.
Findings As a mechanism for standardization, the use of protocol-based care approaches such as guidelines, care pathways, protocols and algorithms was patchy and dependent on contextual, professional and individual factors. Protocol-based care approaches were commonly used as checklists and for reference; nurses and doctors expressed concern that such use could lead to a ‘tick box mentality’ and restricted judgement. By using standardized care approaches nurses were taking on new tasks and developing skills beyond the traditional scope of practice including prescribing, diagnosing, ordering tests and sometimes deciding on treatments. The ability to perform these roles meant that they were able to run clinics or services independently. The extension of roles to incorporate prescribing, for example, meant that nurses were able to provide a more streamlined service for patients because they did not have to refer to doctors. In turn, it was reported that this reduced doctors' workload. Protocol-based care was viewed as a ‘nurses' thing’; however, some General Practitioners and junior doctors were using available standardized care approaches.
Conclusions The potential of standardization was mediated by the patchy use of protocol-based care approaches and negative perceptions about standardization. Use of protocol-based care has the potential to impact on nurses' roles, increasing their autonomy and subsequently impacting on service delivery.