Nursing Notes

June 1, 2011

How protocols are taking the decisions away from nurses

Illustration of Florence Nightingale

Image via Wikipedia

Here’s a wonderful article I found on Kevin MD‘s blog that is written by SaraBethRN.  As I read this article, I found myself shaking my head in agreement.  I felt like my own thoughts were printed right there in the article.  I immediately emailed her for permission to reprint here.  I hope you enjoy this article as much as I did.

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by Sarah Beth Cowherd, RN

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 SaraBethRN.com.

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