How protocols are taking the decisions away from nurses

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 corse), 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 is a nurse who blogs at

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  • Stalwart Hospitalist

    There are many physicians as well who lament the gradual but progressive loss of allowing nurses to use their judgment and initiative to provide proper patient care at the bedside.

    However, I would suggest that your post implies that the ever-growing list of protocols is the cause of this loss; my experience is the opposite.

    I have lost count of the number of occasions in which I was told that I wrote an order that was too “non-specific”, in that the order required the bedside nurse to “make a medical decision”, which would be “outside the scope of practice of nursing.” (The order “advance diet as tolerated” is a prime example of this: such an order is no longer recognized as legitimate at my institution.)

    In order to allow nurses to provide patient care under varying circumstances, and to avoid having to have physicians micromanage the patient orders, protocols sprang into existence. As you state, protocols do not defer clinical judgment to the bedside nurse; rather, they often consist of a litany of “if-then” scenarios with corresponding allowed orders for each situation. In this way, the nurse is not asked to make any decision that would be outside of his or her “scope of practice.”

    My question is the following: how is nursing scope of practice determined, and why has it evolved in this direction over time? Answer that question, and you’ll find your true primary source of the growth in protocols.

  • BladeDoc

    The pager and the cell phone sapped nurses of critical thinking skills and decision making capacity long before the advent of the protocol.

  • Colin

    As a general commentary, I defer to Barry Schwartz’s TED talk on “Using our practical wisdom.” Specifically, he talks about the growth of rules and incentives.

  • solo fp

    I’ve noticed a typical admission takes 12 or more screens of check off form questions. Many of the protocols are simply to meet Medicare quality standards. More fuss is made about dvt prophylaxis and the pneumonia vaccine than if the patient is sititng there about to code.

  • Denise

    We need tort reform.

  • Ellen Richter

    Very interesting post, Sarah Beth! I enjoyed reading it!

    I actually DID work in the days prior to protocols! (LOL, insert a big sigh.) Although it WAS different then, we were much more liable for our nursing care actions with no protocols in place. When there are no guidelines to follow in patient care, it allows individual nurses (or any health care providers) to do what they feel is the most appropriate in a given situation. As we all know, individuals vary in their ability to critically think! What is a priority to you may not be to me! With no guidelines, a facility has no way of providing organized, consistent patient care from nurse to nurse, shift to shift, & patient to patient.

    If you owned an independent nursing clinic & you hired 10 nurses to help you examine all your new patients, would you provide a procedure for them to use when examining? Or a guideline for charting? Or, would you let each nurse do their own thing? If a patient complained about the care they received, how would you be able to represent that nurse if she didn’t document a thorough assessment? What if the nurse didn’t examine the patient completely? With no protocols, the sky is the limit for possible nursing interventions, and, for some people, guidelines are truly required to keep their professional actions on-track and within current acceptable standards. Some nurses do not keep up with continuing education requirements, others have no requirements, and there are even some who do not read any current nursing literature. Practice can vary greatly from nurse to nurse. If we worked independently, then it would be different. We would each be responsible for all of our own actions. But, when working for an institution, we are part of a much bigger process with much greater liability.

    If we had no protocols, what would be the deciding factor in calling a doctor with a critical blood value? How high is high to you? How high is high to me? How critical is critical? With a protocol, it’s spelled out. High = X. Critical = Y. It’s a starting point for decision-making. If you feel X or Y are not critical for a given patient, based on your conversations with a doctor or other health care provider, then you can omit the normal steps of the protocol as long as you document it clearly.

    I never feel like my patient care is less beneficial because of protocols. I continue to make independent nursing care decisions based on critical thinking skills every day. And, then I use hospital or state or national protocols and guidelines to provide care based on my clinical decisions. Knowing that I follow protocols, I have peace of mind that my facility’s administration will support me up if there is a question as to my nursing care decisions.

    Most protocols are developed because they result in successful patient outcomes. And, as new studies come out, protocols and standards and guidelines are always changing & improving. It does not mean that individual care must follow these specific guidelines to a T. Alternate clinical decisions can always override a protocol if the ordering practitioner assumes responsibility for the deviation in practice and if the administering practitioner is able to provide that care. Many care providers disagree with written protocols & write specific orders to do something a different way. As long as it’s safe, covered under our nurse practice act, and beneficial to the patient, we can surely administer care that is not based on a protocol.

    Thanks for presenting this interesting subject! Remember, staff nurses working at a facility can be proactive & get involved in revising protocols or guidelines which may be outdated or ineffective. It’s all about safe practice.

    Enjoy! Ellen :)

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