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Nurse-driven protocols

Barto, Donna DNP, RN, CCRN

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doi: 10.1097/01.CCN.0000560104.63793.d9
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Empowering nurses to make decisions fosters a sense of autonomy and job satisfaction.1 Autonomy is the ability of a nurse to make decisions and carry them out based on their scope of nursing practice. Autonomy is one of the most common variables correlated with job satisfaction among nurses.2 Currently, nurses need to notify a licensed independent practitioner (LIP) to obtain an intervention order. Nurses may report higher levels of job satisfaction if the clinical setting allowed for more independent decision-making opportunities. Nurse-driven protocols, formal agreed-upon hospital policies, can enable nurses to make certain decisions based on their scope of nursing practice without contacting a physician or NP for intervention orders. For a summary of some current nurse-driven protocols as well as their outcomes, see Summary of select nurse-driven protocols in critical care. Nurse-driven protocols provide nurses with a sense of empowerment and autonomy, two critical elements of a healthy work environment. This article discusses the benefits of nurse-driven protocols, describes outcomes, and outlines the step-by-step process of creating a new successful nurse-driven protocol.

Summary of select nurse-driven protocols in critical care

Benefits of a healthy work environment

A healthy work environment is a setting in which nurses desire to work, feel valued by their organization, and stay with the organization rather than seek employment elsewhere. The essential characteristics of a healthy work environment include shared and effective decision-making at all levels, communication and collaboration, a sense of empowerment among staff, appropriate staffing, meaningful recognition, and authentic leadership.14-16 Healthy work environments lead to increased nursing job satisfaction rates, which have been shown to lead to increased nursing retention rates and patient satisfaction levels, two important cost-saving measures for healthcare institutions.17

Step 1: Review evidence-based practices

The first step in designing a nurse-driven protocol is to establish the need for one. Begin by gathering and examining clinical evidence from the literature and determining if the unit is following best-practice recommendations. A medical librarian can assist in gathering the evidence published by a specialty practice organization, such as the American Association of Critical Care Nurses or The American Nurses Association. Clinical nurses can also query other organizations about how they are successfully implementing evidence-based practices. Nurses can also conduct their own literature searches. Choosing the research studies that have the highest level of evidence for the change in practice is recommended.

After this literature review is complete, determine if the unit is carrying out the best-practice recommendations. Look at the unit's quality outcomes to determine areas for improvement. Then, determine if a nurse-driven protocol could improve the quality metric. Quality metrics can be national, such as the Centers for Medicare and Medicaid Services (CMS) core measures, Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS), or National Database for Nursing Quality Indicators (NDNQI), or internal benchmarks established by the facility or unit.

Step 2: Establish buy-in

If the unit is not meeting the quality metrics, determining the cost of the fallout could be a way to convince management that a nurse-driven protocol could save the unit money. The CMS has a reimbursement model that rewards inpatient hospitals for achieving certain metrics in quality care as well as patient satisfaction (HCAHPS). Healthcare institutions that do not meet their metrics will not only lose reimbursement from the CMS for that patient stay but will have their metrics posted on the CMS website for public view. Consumers using this website will likely choose healthcare facilities with better metrics.18 Find a way to quantify the situation. The involved staff must make sure that their organization's corporate level of management is in favor of creating a new nurse-driven protocol and can provide the necessary support. Support could include such items as paying the staff the hours it takes them to research, write, and educate on the new protocol, providing meeting spaces, and allowing staff to have access to technology such as computers to assist with the process.

Step 3: Design a new protocol

After agreeing with management to pursue a nurse-driven protocol, it is time to design the new protocol. Any affected stakeholder should have a representative on the team designing and implementing the protocol. For example, if the nurse-driven protocol is to allow nurses to begin weaning a patient off the ventilator without an LIP's intervention order, representatives from nursing, respiratory therapy, and physicians should collaborate. Key to the successful implementation of a nurse-driven protocol is having a team of champions who will design the protocol, implement the protocol and change the current unit culture to achieve staff acceptance, monitor for staff adherence, and fix any problems that arise because of the change. Depending on the size of the unit and the personnel involved in designing the protocol, the champions could be the same group as the multidisciplinary team or a smaller more select group from the originators of the protocol.

Step 4: Change the unit culture

The Change Theory, proposed by Kurt Lewin, has been used in a variety of healthcare settings and has been applied to nursing. Lewin's underlying idea behind changing a process or behavior involves three steps: unfreezing, changing, and refreezing.19 In the unfreezing stage, the group needs to find a method of making it possible for staff to let go of a former behavior. This is the stage where resistance to change is addressed. In utilizing principles of change management, the effective group should realize that resistance is a natural response to change and should not waste a lot of time trying to eliminate all resistance.18 Next, the group is ready to move on to the changing state. The changing stage can also be classified as a moving stage in which new thoughts, feelings, and behaviors are initiated. This stage needs a detailed plan of action as well as staff engagement to test the proposed change.20 The final stage is the refreezing stage in which the newly implemented behavior is sustained.

Lewin used the concept of a force field to explain human nature's natural resistance to change. According to Lewin, “the stability of human behavior was based on quasi-stationary equilibrium supported by a large force field of driving and restraining forces.”19 To change the status quo of nurses contacting LIPs for an intervention order, the driving or restraining forces must be altered. The driving forces are anything that will drive change, whereas the restraining forces push in the opposite direction and counter the change. A balance of increasing the driving forces and decreasing the resisting forces must be obtained to make a lasting change; if concentration is placed solely on bolstering the driving forces, the resisting forces may also grow stronger and maintain the equilibrium.

Lewin's three-step process can be used to change the current practice of nurses contacting LIPs for intervention orders. Unfreezing the current practice consists of getting nurses and LIPs to let go of their beliefs and perceptions about the current practice and using nurse-driven protocols instead. The staff and LIPs need to be motivated to see that a change to this method is a worthwhile endeavor. Some strategies that can be used to unfreeze behavior could be conducting a gap analysis to show discrepancies between the desired and current state, distributing evidence-based articles on the topic, showing data related to the topic, identifying the driving and resisting forces and coming up with strategies to deal with them, and ensuring that all involved stakeholders collaborate to develop the protocol.20

As a clinical example, imagine that an institution wants to create a nurse-driven protocol to remove indwelling urinary catheters without a physician order. To unfreeze the current practice, evidence-based articles on the topic of decreased urinary tract infections associated with timely catheter removal could be distributed, and data showing the current urinary catheter utilization rate and the infection rate could be posted and discussed. An example of an intervention for resisting forces could be the use of a physician champion as the protocol spokesperson to show his/her medical colleagues the importance of this nurse-driven protocol. Use of driving forces could be including nurses and physicians on the protocol development team who have an interest in the enactment of the protocol. The moving stage, which would occur after the protocol development, would provide education about the new protocol for all stakeholders.

Information about the new protocol should be communicated in a variety of ways, such as during on-unit educational sessions, at unit-based council meetings, via staff and physician email, at practice council meetings, and on bulletin boards. The protocol should be easily available to all involved via paper and/or electronic format. Champions could be identified as resources for staff to approach with questions about the protocol. Clear and frequent communication is necessary during this stage to avoid losing sight of the new behavior. Refreezing, or process integration as part of the unit's culture, must be accomplished by continuous monitoring of the protocol usage. This could be completed by the designated champions, the clinical specialist, the assistant nurse manager, or the manager. Decreased use of the protocol must be addressed and reeducation provided as needed. The protocol should be incorporated as part of clinical orientation for new hires. Allowing the hospital campus to become aware and informed about the success of the protocol is one way to celebrate the accomplishment and refreeze the new practice.


The nurse-driven protocol can be viewed as being a tool to provide safe, equitable, and effective care. Some healthcare providers criticize protocols as “cook book” medicine where everyone follows the same “recipe” and clinical judgment is removed. But, in fact, clinical judgment does remain, as nurse-driven protocols give LIPs more time to focus on patients who do not exhibit the classic signs of a particular illness and cannot use the standardized protocol. Protocols are not meant to breed complacency or stifle learning; constant monitoring of the outcomes of the protocols are needed, as are updates based on best practices. Nurse-driven protocols have been shown to improve patient outcomes and provide nursing staff with a sense of empowerment.


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                          autonomy; Change Theory; intervention order; job satisfaction; nurse-driven protocol

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