Litteraturliste
Axelsen, M., & Rydahl, E. (september 2013). Modul 1. Hentet 2. april 2014 fra fronter.com:
https://fronter.com/metropol/links/files.phtml/1532132034$576243911$/Information/Modulbesk rivelse+1+rev+sept+2013.pdf
Blok, A., & Jensen, T. (2009). Vidensakbsantropologi. I A. Blok, & T. Jensen, Bruno Latour - hybride tanker i en hybrid verden. København K: Hans Reitzels Forlag.
DSOG. (u.d.). Om guidelines. Hentet 3. april 2014 fra dsog.dk: http://dsog.dk/wp/guidelines-2/om-guidelines/
Herlev Hospital; Gynækologisk-obstetrsik afd. G. (26. februar 2014). Normal Fødsel. Hentet 3. april 2014 fra vip.regionh.dk: http://vip.regionh.dk/VIP/Admin/GUI.nsf/Desktop.html
Jensen, T. (2005). Aktør-netværksteori - Latours, Callons og Laws materielle semiotik. I A. Esmark, C.
Laustsen, & N. Andersen, Socialkonstruktivistiske analysestrategier (s. 185-210). Roskilde: Roskilde Universitetsforlag.
Jordemoderforeningen. (u.d.). Etiske retningslinjer for jordemødre. Hentet 3. april 2014 fra jordemoderforeningen.dk:
http://www.jordemoderforeningen.dk/fileadmin/Fag___Forskning/Etiske_retningslinjer/Etiske_Ret ningslinjer_2010.pdf
Justesen, L. (2005). Dokumenter i netværk. I N. Mik-Meyer, & M. Järvinen, Kvalitative metoder i et interaktionistisk perspektiv. Interview, observationer og dokumenter (s. 215-234). København K:
Hans Reitzels Forlag.
Kjærgaard, J., Hansen, M. N., & Mainz, J. (2004). Kliniske retningslinjer. I J. Kjærgaard, J. Mainz, T.
Jørgensen, & I. Willaing, Kvalitetsudvikling i sundhedsvæsenet (1. udgave, 2.oplag udg., s. 143-158).
København: Munksgaard Danmark.
Kotaska, A. (juni 2011). Guideline-centered care: A two-edged sword. Birth(38), s. 2.
Kristensen, K. (2011). Sundhedsjura, Patienters retsstilling, Sundhedspersoners ansvar, Myndigheders tilsyn.
København: Gads Forlag.
Launsø, L., Olsen, L., & Rieper, O. (2011). Forskning om og med mennesker - Forskningstyper og forskningsmetoder i samfundsforskning. København K: Nyt Nordisk Forlag Arnold Busk.
Lindgren, H., Brink, Å., & Klingberg-Allvin, M. (6. 11 2011). Fear causes tears - Perineal injury in home birth settings. A Swedish interview study. BMC Pregnancy and Childbirth, s. 1-8.
Malterud, K. (2006). Kvalitative metoder i medisinsk forskning. Oslo: Universitetsforlaget.
Martinsen, K. (2006). Samtalen, skønnet og evidensen. (A. Schou, Ovs.) København: Gads Forlag.
Ministeriet for Forskning, innovation og videregående uddannelser. (26.. januar 2009). Bekendtgørelsen om uddannelsen til professionsbachelor i jordemoderkundskab. Hentet 19. maj 2014 fra
retsinformation.dk: https://www.retsinformation.dk/Forms/R0710.aspx?id=123208 Ministeriet for Sundhed og forebyggelse. (14.. september 1998). Bekendtgørelse om information og
samtykke og om videregivelse af helbredsoplysninger mv. Hentet 21.. maj 2014 fra retsinformation.dk: https://www.retsinformation.dk/Forms/R0710.aspx?id=21075 Ministeriet for Sundhed og Forebyggelse. (8. august 2001). Vejledning om jordemødres
virksomhedsområde, journalføringspligt, indberetningspligt mv. Hentede 3. marts 2014 fra Retsinformation: https://www.retsinformation.dk/Forms/R0710.aspx?id=21704
Ministeriet for Sundhed og Forebyggelse. (13. juli 2010). Sundhedsloven. Hentet 5. april 2014 fra retsinformatik.dk: https://www.retsinformation.dk/forms/R0710.aspx?id=130455#K5 Ministeriet for Sundhed og forebyggelse. (4.. august 2011). Bekendtgørelse af lov om autorisation af
sundhedspersoner og om sundhedsfaglig virksomhed. Hentet 13.. maj 2014 fra retsinformation.dk:
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Sundhedsstyrelsen. (1. oktober 2001). Cirkulære om jordemodervirksomhed. Hentet 13. april 2014 fra sundhedsstyrelsen.dk:
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Walsh, D. (Juli 2006). NICE draft intrapartum guideline: Join the consultation and have your say. British journal of midwifery, 14(7), s. 406.
Nr Søgeord Antal hits Antal relevante hits
1 Midwifery 24548 -
2 Labor 26497 -
3 Clinical judgement 394 -
4 Decision making 75148 -
5 Practice guidelines 48815 -
6 Professional
judgement
130 -
7 Evidence-based
medicine
3739 -
8 Qualitative study 20466 -
9 1 AND 7 12 0
10 1 AND 4 663 -
11 1 AND 3 3 0
12 1 AND 6 6 0
13 1 AND 5 282 0
14 1 AND 4 AND 5 14 0
15 1 AND 2 AND 4 157 0
16 1 AND 2 AND 4
AND 8
17 1
17 1 AND 2 AND 4
AND 5
1 0
Nr Søgeord Antal hits Antal relevante hits
1 Midwifery 29131 -
2 Labour 124037
3 Clinical
judgement
10915 -
4 Decision making 17917 -
5 “Practice
guidelines as topic” [MAJR]
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6 Professional
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7 Evidence-based
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8 1 AND 7 10421 -
9 1 OR 4 6002 -
10 1 AND 5 55 0
11 1 AND 3 OR 6 70 2
12 1 OR 2 AND 3 OR 5 982813 -
1 Gennemgangen af søgeresultaterne viste at evidence-based medicine ikke var relevant for vores problemstilling
2 Gennemgangen af søgeresultaterne viste at decision making ikke var relevant for vores problemstilling
3 Gennemgangen af søgeresultaterne viste at tilføjelsen af labour ikke var relevant for vores problemstilling
International Journal of Nursing Practice 2005; 11: 142–149 lynn, School of Nursing and Midwifery, Uni- nd. Email: Angela.Flynn@ucc.ie
✠SCHOLARLY PAPER✠
or in g th e re la ti on sh ip b et w ee n nu rs in g pr ot oc ol s an d nu rs in g pr ac ti ce i n an Ir ish intensiv e car e unit
Angela V Flynn RGN BSc(Hons) PGDip(Ed) MSc Lecturer, School of Nursing and Midwifery, University College Cork, Cork, Republic of Ireland Marlene Sinclair RN RM RNT DASE BSc(Hons) MEd PhD turer, Institute of Nursing Research, University of Ulster, Newtownabbey, County Antrim, Northern Ireland Accepted for publication January 2005 Flynn AV, Sinclair M.International Journal of Nursing Practice 2005;11: 142–149 ing the relationship between nursing protocols and nursing practice in an Irish intensive care unit longer relies on tradition or ritual; instead, it is based on research and empirical evidence. The empha- nursing, as well as standardization of nursing practice, has resulted in the production of policies, pro- aimed at directing numerous aspects of nursing care. The aim of this study was to explore the these documents and actual nursing practice. To this end, this descriptive study employed a case study the experiences of nurses in an Irish intensive care unit with a protocol on endotracheal tube suc- interviews of 17 nurses in six focus groups provided a significant insight into the experiences of these policies, protocols and guidelines. Analysis of the data afforded some highly relevant findings, includ- ses adapt clinical protocols as they see fit, thus demonstrating the importance that they place on their and autonomy. clinical protocols, critical care, endotracheal tube suctioning, professional autonomy. ROUND owing interest in protocols, policies nursing literature alongside an for evidence-based nursing prac- imperative that these documents are e manner; that is, they must actually of the nurses for whom they were excess of subjective literature exam- potential benefits or disadvantagesof policies and protocols. Conversely, there is little empir- ical evidence of their tangible effect or influence on nurs- ing practice. The concept of a guide for practice is not a new phe- nomenon in nursing; indeed, ward procedure books and manuals have been in existence for many years. How- ever, such sources often lacked research or evidence for recommendations, which historically have been based on professional consensus. Harrison describes the current interest in clinical guidelines and protocols as reflecting ‘the move towards evidence based practice and stems from concerns about variations in practice . . .’.2 Although there has been an evident surge in interest Impact of nursing protocols on practice within the literature in relation to policies,protocols and guidelines for use in the clinical setting, there remains considerable confusion over the exact meanings of the terms. Fennessy points out that the terms ‘protocols’and ‘guidelines’have been used interchangeably to mean something about guiding practitioners in the decision- making process.3 Generally, guidelines are described as broad statements of good practice developed at a regional or national level that contain little operational detail. The Institute of Medicine in the United States of America (USA) produced a useful and much-cited working defini- tion, which describes clinical guidelines as ‘systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances’.4 So functional is this definition that it has been adapted by English and Scottish authorities5 and used verbatim by the governing body of nursing in Ireland, An Bord Altranais.6 Often described as locally translated guidelines, proto- cols are, by their nature, a little easier to define. Generally assumed to imply more compulsion,they have been described as offering ‘an explicit framework for the pro- cess of care and members of the care team [who] can fol- low precise steps of practice’.3 Long traces the source of protocols, suggesting that they represent a: Modification of a national guideline for local application, giving operational detail, specifying, for example, who does what, when and how—and leading eventually to a more detailed clinical care plan.7 Similarly, within the medical field, Grimshaw and Rus- sell explain that in Scotland, the Clinical Resource and Audit Group has proposed that national guidelines are modified to produce local protocols.8 The most prominent feature of protocols, as opposed to guidelines, is their specificity. Not only do protocols instruct what to do, but they generally also specify who should do it and under what conditions. Thomas et al. found in their systematic review of the literature surrounding clinical guidelines, that the term protocol was more commonly used, but was applied to locally agreed statements of best practice and to ‘a complex structured intervention to enhance the quality of care’.9 Common to all definitions and nomenclatures is the fundamental tenet of a research base and, indeed, pro- tocols and guidelines are seen by many as crucial tools for research utilization. At the very least, they encourage evi-dence-based practice where otherwise ther been ritualistic care. Antrobus and Brown there might not always be research availab base the protocol: Protocols can be research-based, where research they may be augmented by consensus exper research is lacking, protocols may occasionall on the best clinical judgement.10 Policy, however, is less easily defined. Cheek son point to the abundance of ‘policy folder of Australian hospitals.11 In Ireland, the governing body of nursing distributed ‘Guidance to Nurses and Mid Development of Policies,Guidelines and Following the distribution of this to all reg and midwives, An Bord Altranais has encouraged participate in local policy and protocol stating that: . . .where review and expansion of nursing practice has been most successful, certain suppor present and are considered essential. These include policies or protocols . . .6 Consequently, policies and protocols form a more active part of nursing decision-making the Irish context. This attempt to raise aw need for evidence-based guides for practice isolation from similar developments in countries; for example, The National Institute Excellence in England and Wales, The Centr Based Nursing in the United Kingdom Scottish Intercollegiate Guidelines Netw Scotland. A variety of specialities within nursing ha the benefits of policies, protocols and guidelines practitioners in the USA, for example, have tocols as they provide a means for physicians specific tasks previously within the medical many states, jointly developed protocols go tice of nurse practitioners, meaning they practice independently of a physician but the benefit the patient by providing more efficient care. Within the field of practice nursing asserts:
AV Flynn and M Sinclair protocols are a mechanism for assuring excellence, or practice’, in the clinical setting, and their use has the to transform clinical practice from tradition to ch-based practice.13 unity nurses in the UK also have recognized the of protocols, as Seljeflot indicates: have clear benefits. They develop the role of the e, ensure safe and efficient delivery of care, and often tly improve the speed with which treatments are ered.14 y, the field of critical care nursing has doc- benefits from the use of protocols and guide- discusses the use of protocols to standardize nal support, suggesting that protocols can be used the process for guiding the selection of the the timing of the feeding, the route and content of well as trouble-shooting.15 Harrison refers to a European intensive care units (ICUs) which that ICUs that utilized protocols had more con- practice, with a lower mortality rate than those not use them.2 Similarly, a study in a hospital in demonstrated that the implementation of a pro- the care of long-term ICU patients resulted in a in resource utilization and, therefore, cost.16 , which has utilized protocols to protect a rising level of litigation, is that of midwifery. comments that: serve several purposes: in addition to advocating a etical equality of treatment, they aim to ensure that the of care given to the patients/clients does not fall a defined minimum standard, and in so doing provide a e against an allegation of negligence.17 and Quirk reported on the implementation of a by obstetric nurses for the management of the stage of labour.18 The nurses reported positive out- for their clients and were proud to be involved aluation of a protocol for a practice they knew Other specialities that have reported benefits otocols and guidelines include oncology nursing,19 nursing,20and accident and emergency .21 be erroneous, however, to assume that all the e surrounding policies, protocols and guidelines is
of a positive nature. Although some celebrate their stan- dardizing nature,others bemoan their suppression of nursing intuition. For many, it is the specificity of proto- cols that has attracted criticism.SmithBattle and Diekemper warn of the dangers of ‘cookbook nursing’ and of reducing expert decision-making to merely follow- ing a flow chart.22 They go on to concede that although nursing practitioners, educators and administrators have welcomed the developments of standardized languages, taxonomies, pathways and practice guidelines, they are not so convinced of their benefits. They argue that these ‘standardized languages and formal models of care obscure how excellent nursing practice is situation- dependent and patient-specific, rather than abstract and objective’. They continue to enthuse about the interpre- tive, intuitive, contextual and practical knowledge of the expert practitioner. However, these are types of knowing that must be developed and cannot be learned without the safety net provided by structured care plans, protocols, guidelines and taxonomies tailored to guide the ever- learning practitioner in his or her decision-making. Also judicious in relation to policies in nursing, Cheek and Gibson warn of their dominating and constraining nature and call for nurses to scrutinize the issue of policies and question their effects on nursing practice. They fear that the celebrated ‘standardization’ of nursing practice has a deleterious effect on autonomy and individuality. The medical profession also fear this side-effect, as Delamothe stated: Guidelines are intellectually suspect:by reflecting expert opinion they may formalise unsound practice. Meant to tackle variations in practice, they risk standardising practice around the average, which is not necessarily the best. They may stifle innovation and prevent discretion in individual cases.5 Delamothe’s concerns point to a need to ensure the content of policies, protocols or guidelines are entirely accurate in their content and entirely up-to-date through regular review. Here, it can be seen that the magnitude of accurately creating and reviewing these documents cannot be overestimated if change and development of current practice is to be facilitated. Although An Bord Altranais has attempted to motivate nurses to develop these documents locally, the campaign lacks national coordination and nurses have received scant advice on the implementation of these documents. So how have these documents been implemented? What impact Impact of nursing protocols on practice have these policies, guidelines or protocols had on Irish nursing practice? Following the implementation of a clinical protocol, based on these guidelines given by An Bord Altranais, has practice changed? What are nurses’ feelings about policies, guidelines and protocols? In order to address these questions,this descriptive study was undertaken. METHOD To explore the issues surrounding policies, guidelines and protocols, it was considered pertinent to speak to those expected to develop, implement and,ultimately,use them. As the impact of these documents was to be exam- ined through the eyes of nurses, a case-study design was deemed most appropriate. The objectives were: 1.To examine the literature in relation to nursing and other health-care providers’ experiences with policies, protocols and guidelines. 2.To explore the values held by nurses in relation to clin- ical policies, guidelines and protocols. 3.To investigate how policies, guidelines and protocols can be implemented successfully so as to positively impact on nursing practice and patient outcomes. The case study focused on the staff of an ICU in a large university teaching hospital in the Republic of Ireland. Staff there had been active in developing an evidence- based protocol to guide their practice of endotracheal tube (ETT) suctioning. As the staff identified a need to clarify and agree regarding the procedure, they searched the relevant literature for guidance and wrote their pro- tocol,which was subsequently sanctioned by nursing management. Ethical approval of the study was secured from the Chair of the university ethics committee of the hospital early in the research process. Purposive, non-probability sampling provided 32 participants who each received a written invitation to take part in the interviews, with an explanatory letter and an ‘agree/do not agree to be inter- viewed’ slip. Of the 26 responses received, 19 agreed to be interviewed, and seven declined participation. Partic- ipants were grouped into focus groups that were conve- nient to them and their work schedule. Analysis Qualitative interviews were tape-recorded, transcribed verbatim and analysed using a simple, interpretative pro- cess that was influenced by the frameworks of Colaizzi, Giorgi, and Streubert and Carpenter.23–25 Each interview transcript was read (on computer screen) neously listening to the tape to check for transcript and to add emphasis,wher according to tone of voice and exclamation. this, the author then printed out each transcr each one individually a number of times, notes and memos. The author was then able key themes that had emerged in all intervie review from a second expert nurse researc ined the audit trail,eight of these wer remaining two themes became subthemes). was numbered, colour-coded before each reread, and coded appropriately. The eight emerged from the interviews are shown belo these issues have common elements with and might overlap. THEMES THAT EMERGED THE INTERVIEWS •Use of professional judgement •Adhering to or deviating from protocol •Accessibility of protocols •Ownership/voice to change •Strategies for implementation •Benefits of protocols in practice •Who should develop protocols? •Multidisciplinary issues/protocols Although a significant range of relevant themes tified and examined within the original stud pose of this paper, one key theme, that judgement, will be discussed. The use of professional judgement and experience The overwhelming finding that emerged in of professional judgement was that protocols, guidelines could be (and were) adapted with and professional judgement. Some participants this was the correct thing to do and that it w patient: . . . it goes back to the whole thing of, if you fessional judgment and then you adapt the protocol using professional judgement . . . And you would have to make your own judgement ter of the patient . . . we can read a protocol it.
AV Flynn and M Sinclair appeared to hint at a natural pro- um of experience during which y use these protocols less and less. eloping that when you’re following the re given in the protocol. You’re using those w you’ve adapted them. Once you’ve read are following the protocol as standard, to go back to it. There wouldn’t be a epend on where you are on that scale. comment,the senior nurses inter- as their senior staff that deviated from more often. A similar finding was who investigated the use of research She identified a high level of resis- tion, particularly among more When discussing this finding, Camiah . care based upon traditional beliefs, sense and personal experience by a number of nursing staff . . .’. An I said earlier on, I think it is more senior that are doing that [deviating from pro- junior staff, anyway, doesn’t have the con- suction on their own, anyway. I mean, thing, as well. supporting Benner’s concept of the paid to explicit instructions by interesting insight into the concept staff many refer to as ‘experienced’ a prolonged length of service, might experience or might have completed e courses. Benner refers to experi- ily refer to longevity or length of time in refers to a very active process of refining ed theories, notions, and ideas when situations.27 raphics of the sample showed who had more than eight years pos- , 13 had completed a postgradu- sing course. Regarding the remaining
nine nurses, although they certainly appeared to have considerable experience in practice, they might not have revisited, through a formal course, the theory behind this skill for a number of years and so might not be in a position to ‘refine and change’in the way Benner describes. It appears that the fear which some writers have addressed in the literature, of the stifling nature of policies and protocols, might be somewhat unfounded in this sce- nario, as adherence is not viewed as crucial. Instead, an ability to make a clinical judgement based on experience is perceived as more creditable. An extract from the senior staff focus group appears to support this: But nobody can take away from peoples’ ability at the end of the day, and their ability to move on and to judge and their skills, and that can’t be written down . . . I mean, who’s to say the senior person has the skill anyway? It’s difficult to call any competency. A similar nuance of this theme emerged, suggesting that with certain clinical scenarios, the protocol is not fol- lowed. These scenarios were epitomized with the fre- quently cited example of the instillation of saline into a patient’s ETT, a practice that research has shown not to be beneficial and, in fact, is associated with many risks and complications:28 I think there’s the odd case, here and there, that it’s beneficial . . . when I started, everybody had a small bit of saline down an ET but now we don’t do it, but there’s the odd case, here and there, that I think it is useful. How would you judge those cases? Usually, they keep suctioning and you can still hear it in the lower airways, or something, and usually, if you do it, on the rare occasion I’ve done it, you can get some secretions out, you know, you get some, . . . or something out. A further example from interview 1 demonstrates a perceived need to use professional judgement to deviate from the protocol in light of clinical need: . . . it can’t be set in stone either because if you’ve got a very productive ET, and the ET tube is full and the airway is blocked and somebody’s messing just doing it [suctioning as per protocol] and not really clearing the airway, then that’s Impact of nursing protocols on practice detrimental, as well. So, those people could be more vigorous going down and reaching down, that’s obviously, they have to do that, they have no choice! These examples could be interpreted in a number of ways. Nurses using their highly developed nursing intu- ition and, thereby, knowing the right thing to do for the benefit of the patient, or nurses who are persistent in car- rying out a procedure that is known to be harmful to the patient against written protocol. Many of the extracts appear to refer to ‘the benefit of the patient’ and, in a way, the participants in this study perceived a defence for their actions if they could prove that they had been, as the author believes would be their intent, for the benefit of the patient. Equally, participants also expressed a need for the protocols to standardize practice, a view that is cap- tured well in this extract: . . . but you have to have a standard, otherwise you could be doing anything,maverick behaviour, gung-ho, doing whatever . . . Although participants overwhelmingly expressed a need for protocols to be adapted with experience, a sig- nificant view was that a level of experience was required despite the presence of the protocol. It was not viewed as a suitable replacement for such experience: It’s a great support, it’s a great tool, but at the end of the day, it has to be tied in with the experience of the person at the end of the bed really, too. Once again, this opinion is reminiscent of some of the findings of the ‘Achieving Methods of Intraprofessional Consensus,Assessment and Evaluation’project,27on which much of Benner’s work was based. Gordon also refers to this project, stating ‘. . . protocols and formulas cannot substitute for judgment in some situations and the understanding of the situation that is necessary for that judgement’.29 Therefore, the participants in this study appear to feel that a nurse needs some level of experi- ence, even to follow a protocol, but with more experi- ence, the nurse will learn to adapt the protocol as they see fit and that a judgement can be made not to follow the protocol in certain clinical scenarios. A final meaning that emerged in relation to the theme of professional judge- ment was that, in some ways, protocols restrict nurses’ decision-making:
I feel very hands-tied, really, and if the protocol I would feel a less of a responsibility towards ba a ml of saline. I wouldn’t be drowning a per but a small bit of saline, I know it would m The nurse here is describing her intuitiv saline would benefit the patient, even though proven it to be detrimental. She is referring evidence base: that of her experience. The being referred to as a restriction that is limiting of care that she could deliver to the patient: . . . the bagging down the saline. That prac but, em, I have to say, I still find the nebuliz as effective, often. Every patient is different, some patients, the bagging saline would have patients. What is more, this restriction in decision-making deemed by some to deprive learners of an learn decision-making skills: P2: . . . maybe they [learners] might not get t tunity as we did to put their knowledge into pla are learning a different way. They are learning this [the protocol] now until they get the research and then you go from there. P1: Like when we didn’t have that [protocol], it as it came along . . . Although suggesting that they believe a rience is lost, no consideration is given to or learner comfort. As well as a learning learner nurses being absent, there is a suggestion the continuous learning through practice lost: . . . you can still base your guidelines on evidence-based tice and it gives you more scope to adapt mean, maybe we’re taking, the protocols are taking ing out of nursing sometimes, don’t they? This fear that protocols are ‘taking the nursing’ is well-founded and is reflected in literature. Dimmond emphasizes this, stating wife’s ‘independent judgement can never reliance on a set procedure’.30 However,