Nursing Protocols

The development of comprehensive nursing protocols is basic to a nursing quality control program. Most nursing tasks are carried out at the initiative of the nurses rather than in direct response to a physician order. The physician makes the medical decisions about medications, diet, and so on; but he nurses must fill in the details to ensure that the patient receives comprehensive nursing care. The nursing staff must also ensure that nursing services are rendered if the physician is derelict in writing basic orders. While a careful nursing staff will quickly call this problem to the attention of the attending physician, this can delay the patient's care. Since a principal goal of a legally effective quality control program is to reduce litigation through increased patient satisfaction, the delay poses a problem, since it will;l reduce patient satisfaction even if it does not result in an injury.

Beyond seeing that the patient's basic needs are met, the nursing protocols must spell out how to handle patient safety problems. For example, there should be written guidelines for the use of bed rails. Under the present standard of care for hospitals, the decision on when bed rails are needed is left to the nursing staff, unless there are specific physician orders addressing the issue. The use of bed rails is important because an impaired patient can easily fall out of bed. However, bed rails are also very inconvenient. They prevent an ambulatory patient's sense of well-being because they reinforce the patient's sense of helplessness. These disadvantages mitigate against a policy of always using bed rails to avoid having to exercise discretion.

In the case of bed rails, the protocols should be in two parts. First, there should be a list of all types of patients who should have bed rails. These might include postoperative patients, children under eight years of age, all patients in traction, all comatose patients, and so on. The second part of the protocols should give the nurse the authority to use bed rails in any other situation where they seem warranted. It is important that the nursing staff be encouraged to use their own initiative in preventing patient accidents. An overly rigid protocol can reduce this initiative. It should be emphasized, however, that the nurse's freedoms to innovate extends only to using a safety device when it is not normally required. The nurse is not free to disregard a safety device in a situation that is included on the mandatory list. In the case of bed rails, the nurse could use them on a patient who id not fit one of the delineated categories, but would be forbidden not to use them on a patient in one of the categories.

Nursing protocols often deal with procedures that are matters of medical opinion. A physician may order that a gram of penicillin be given the patient in one liter of 5 percent dextrose. The nurse will decide on the type of intravenous (IV) fluid set to use, the size and type of needle to use, and the location of the vein to be used. These decisions should be part of the nursing protocol. This will not create a problem unless the protocol that is followed is in opposition to a physician's order.

For example, assume the nursing protocol calls for a 10-gauge needle on the IV line. This is a relatively large needle and will allow a rapid flow rate. The physician prescribes a drug that is highly toxic if given too quickly. In order to provide an extra measure of protection against too rapid infusion of the drug, the physician specifies that it be given through a 25-gauge needle. With a needle this small it would be impossible to give the drug too fast. However, instead of following the physician's order, the nurse follows the protocol that calls for a 19-gauge needle. The drug runs through too fast, and the patient suffers an adverse reaction from the inappropriate dose rate. In this case, the hospital would be liable for the patient's injury because it allowed the nurse to substitute the nurse's judgment for the physician's, to the detriment of the patient.

It is important to note that the issue is not whether the nursing protocols invade the "practice of medicine." To be useful, nursing protocols must involve some exercise of medical judgment. The physician expects the nurse to know where to give a shot, which needle and drip rate to use on an IV, when an IV must be changed, and the other "routine" skills of drug administration. Yet these skills are different from how to feed a patient or change a bed. The physician will often modify the protocol on drug administration, yet will seldom, if ever, comment on the way the patient is fed or how the linen is changed.

Thus, it is useful to divide nursing duties into two types: (1) skills such as drug administration that involve medical decision making, and (2) skills such as feeding patients and changing linen that do not require medical decisions. Such a decision will facilitate the development of protocols by the hospital administration. The group of skills that involves medical judgment (such as drug administration) should be considered as "physicians' standing orders" rather than as a part of nursing protocol. In a sense, the physician for these standing orders is the medical staff itself. The drafting of such orders should be done in consultation with the medical staff. If the medical staff decides that a particular provision of the protocol should not be modified by an individual physician, the provisions should be delineated in either the medical staff bylaws or in the specialty section rules. This will shift the problem of a physician who wishes to modify a rule to the medical section and away from the nursing personnel. This will avoid conflicts between the nurses and the treating physician.

An example of this type of problem would be rules governing infection control in the hospital. A hospital needs rules on the isolation of patients with certain infectious diseases and how their nursing care is administered. A physician who does not want an infected patient isolated would create a threat to other patients in the hospital. In many hospitals, the job of enforcing infection control policies is handled by an infection control nurse under nursing system protocols. This is an effective mechanism for handling the problem. However, if the physician writes orders that are contrary to the protocol, the nurses will have to invoke procedures for reviewing physician orders. In this case, the burden is on the hospital (through the medical staff) to justify the challenge to the physician's order. If, however, the infection control protocol are part of the medical section rules or bylaws, the burden of justifying a deviation from the infection control protocol will be on the physician.

The shift in the burden of justifying a deviation from established routine derives from the genesis of the two different sets of rules. The nursing protocols that deal with duties such as feeding patients and changing linens are developed by the nursing supervisors, hospital administrators, and, in some cases, medical staff committees. These protocols tend to be totally internal documents. The nursing supervisors and the nursing staff must be familiar with them, but few members of the medical staff will ever see them. In contrast, if the nursing protocols involving medical decisions are incorporated in the medical staff bylaws or medical section rules, they are assumed to be approved by the entire section or medical staff. The bylaws are distributed to all physicians on the staff, and the section rules are distributed to all physicians on the staff, and the section rules are distributed to all members of the specialty section. The medical staff is charged with knowledge of the bylaws and appropriate section rules. Adherence to the bylaws and rules cannot be inflexibly applied in all cases, but the physician is charged with justifying any deviation from them. If the deviation results in a negligent injury, the physician will be liable. The hospital will be liable only if, as discussed later, it breached its duty to supervise the physician.