Which of the following lists are essential members of groups who design nursing care protocols?

Clinical pathway:

Clinical management plans that specify the optimal timing and sequencing of major patient care activities and interventions by the interprofessional team for a particular diagnosis, procedure, or health condition and are designed to standardize care delivery (Coffey et al, 2005); clinical pathways may also be called critical paths, practice protocols, or care maps; clinical pathways support the implementation of clinical practice guidelines.

Clinical practice guidelines:

Recommendations for appropriate treatment and care for specific clinical circumstances; guidelines are developed though a systematic process to integrate the best evidence for treating specific medical conditions and assist health care providers to make decisions about appropriate treatment (Institute of Medicine [IOM], 1990).

Nursing care delivery model:

Also called care delivery system or patient care delivery model; details the way work assignments, responsibility, and authority are structured to accomplish patient care; depicts which health care worker is going to perform what tasks, who is responsible, and who has the authority to make decisions.

Patient acuity:

Indication of the amount and complexity of care required for any particular patient; high acuity indicates a need for more intense, complex nursing care as compared with lower acuity, which indicates a need for moderate, less complex nursing care.

Patient classification system:

Method used to group or categorize patients according to specific criteria and care requirements and thus help quantify the patient acuity, or amount and level of nursing care needed.

Staff mix:

Combination of categories of workers employed to provide patient care (e.g., RNs, LPNs, or licensed vocational nurses [LVNs], or unlicensed assistive personnel [UAP]).

Staffing:

Ensuring that an adequate number and mix of health care team members (e.g., RNs, LPNs or LVNs, UAP, clerical support) are available to provide safe, quality patient care; usually a primary responsibility of the nurse manager.

Unlicensed assistive personnel (UAP):

An unlicensed individual who is trained to function in an assistive role to the RN by performing patient care activities as delegated by the nurse; may include nursing assistants, clinical assistants, orderlies, health aides, or other titles designated within the work setting.

Nursing protocols in high-acuity and critical care settings help prevent complications, promote faster recovery, enhance patient safety, increase nursing autonomy and reduce costs, according to expert critical care nurses such as Ramon Lavandero, RN, MA, MSN, FAAN, director, communications and strategic alliances for the American Association of Critical-Care Nurses and clinical associate professor at Yale University School of Nursing in New Haven, Conn.

Protocols provide an evidence-based, systematic approach to a particular aspect of nursing care, Lavandero said. “The most beneficial protocols for high acuity and critical care settings address the situations clinicians encounter most frequently, such as the monitoring of cardiac rhythms; respiratory waveforms and pulse oximetry; care of mechanically ventilated patients; creating healing environments; and issues in palliative and end-of-life care,” he said.

“At MetroHealth Medical Center in Cleveland, we look at them (protocols) as evidence-based treatment plans — recipe for quality, so to speak,” said Kathleen Kerber, RN, MSN, CCRN, ACNS-BC, a clinical nurse specialist for critical care nursing at MetroHealth.

Patient safety has been the biggest benefit of using protocols, she said. Protocols easily can be linked with outcome measures and can address high-risk, high-volume and problematic activities, she said.

Not a blanket solution

Protocols may be valuable tools, but they still require nurses to think critically and closely assess their patients, the experts said. “AACN practice protocols are not intended to be used as step-by-step procedures or all-encompassing education resources,” Lavandero said.

Nurses need to reconcile the framework of the protocol with the reality of the individual patient and his or her condition. One does not trump the other. “The message is yes, the protocols are essential but not to be used blindly without the nurse’s informed clinical judgment based on assessment of that patient at that point of time,” Lavandero said.

Said Kerber, “There will always be patients for whom protocols won’t be appropriate. But a good protocol will identify those situations. The nurse makes the clinical judgment and then collaborates with team members to come up with alternatives to the protocol.”

Using protocols as a measuring stick

Protocols also can be used to assess how high acuity and critical care nurses’ clinical practice measures up to current evidence and evaluate whether they need to change their practice regarding a particular aspect of care, Lavandero said.

“The simplistic view on implementing a protocol would be, ‘OK, here’s the new protocol; start following it,’” he said. “Instead, a new protocol should be used as an assessment tool or measuring stick.”

Nurses in critical care and high acuity settings such as progressive care can use protocols to see how their existing approaches to care match up with the evidence. A unit’s practice already may match a protocol closely and just need fine tuning in places, Lavandero said. Or maybe nurses notice an element of a protocol the unit has overlooked.

On the other hand, there may be a valid reason why a unit’s practice cannot follow an aspect of a protocol because of its unique environment, Lavandero said. This is where nursing judgment and critical thinking become important, he added.

Who develops protocols?

Nursing protocols are developed by experts who craft a concise set of recommendations in their areas of expertise for clinicians to incorporate into the care of patients with a particular condition or device. The recommendations are based on a comprehensive review of current science, Lavandero said.

Ideally, sources of evidence include only ones based on extensive research or expert consensus, he said. But a clinical problem must be addressed even when evidence is limited. That’s why AACN and other expert groups rate the level of evidence for each source, he said. Sometimes small studies and manufacturer’s information are all that’s available.

At MetroHealth, protocols can be nurse-driven or collaboratively driven with members of other disciplines, Kerber said. For example, MetroHealth’s progressive mobility protocol allows critical-care nurses to assess patients to see whether they meet certain physical and psychological criteria. If they do, their mobility can be advanced without waiting for a physician order.

The sedation and weaning protocol for patients on mechanical ventilation is an example of a collaboratively driven protocol. Thomas S. Ahrens, RN, PhD, FAAN, a research scientist at Barnes-Jewish Hospital in St. Louis, helped develop sedation and weaning protocols in the mid-1990s when nursing protocols first started being considered for use.

The Barnes-Jewish sedation protocol, developed with respiratory therapists, pharmacists and physicians, allows nurses to assess a patient and decide whether the sedation can be decreased based on certain physiological criteria. If a patient tolerates a decrease in sedation and fares well, the nurse can further decrease it, until eventually is it no longer required, Ahrens said.

“By doing that, we were able to show that patients could be extubated more quickly,” he said.

Ahrens is developing protocols on stroke volume optimization.

Keeping up with the evidence

Nursing experts continuously monitor and weigh new evidence to see whether existing protocols need to be updated. At MetroHealth, nurses and clinicians from other disciplines routinely meet to evaluate protocols and see whether they need to be modified, Kerber said.

AACN issues periodic Practice Alerts that are developed with the same rigor as protocols, said RoseMarie Faber, RN, MSN/ED, CCRN, a clinical practice specialist with the AACN. Practice Alerts include expected practice, supporting evidence, levels of evidence, actions for nursing practice, references, and a link to an AACN clinical practice specialist for more information.

Practice Alerts may supplement topics addressed in published protocols, and their content is considered when a complete protocol is updated, Faber said. “However, a single new study does not necessarily mean a protocol needs to be changed,” she added.

The newest AACN Practice Alerts address family visitation, delirium assessment and management, prevention of aspiration and catheter-associated urinary tract infections.
MetroHealth critical care nurses already were looking at a possible protocol to avoid delirium in patients when AACN’s Practice Alert on delirium was released recently.

“There is an abundance of evidence as to what we as nurses can do to reduce delirium,” Kerber said. For example, nurses are screening patients to see which ones can be allowed four hours of uninterrupted sleep at a time.

Barriers to implementation

Nurses, physicians and other team members may at times be resistant to the development or implementation of protocols.

“Resistance may be a sign of change fatigue because today’s clinician is often overloaded with continuous changes in every aspect of clinical practice,” Lavandero said. “The changes are often well intentioned and will ultimately improve practice, but the frequency of changes and their volume challenge even the most skilled clinician to keep up.”

Effective communication and education about protocols can reduce resistance to protocols from nurses and physicians, Kerber said. For example, medical residents may not be familiar with a particular unit’s protocols because they are constantly rotating through different units and hospitals. If they are not informed about the protocols, they may not understand their value, she said.

Successfully developing and implementing new nursing protocols requires working within the existing culture and structure of the hospital; securing a physician who will provide medical guidance; and most importantly getting buy in from the nursing staff, Ahrens said. “Involvement of the nursing staff is the key to the whole program,” he said. “Make sure they see that this is something beneficial for them and their patients.”

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