Symposium 14: Evaluating protocol-based care: a mixed method approach

Symposium lead: Irene Ilott, Research Associate, Institute of Work Psychology, University of Sheffield, Sheffield, United Kingdom irene.ilott@sheffield.ac.uk

Symposium chair: Dr Sue Read, RCN Fellow

Symposia focus

Protocol-based care is an umbrella term for a raft of practices, such as protocols, algorithms, clinical guidelines and care pathways that influence the way clinical care is delivered throughout the world. Current National Health Service (NHS) policy emphasises the need for services to be driven by evidence of clinical and cost effectiveness, patient safety and consistency of care. In this context, protocol-based care has emerged as a key tool for meeting these objectives. The symposium will provide the first report of the findings from a three-year, mixed method study assessing the impact of protocol-based care in nursing, midwifery and health visiting.

Aims

The aims of the study were to:

  • Identify the settings into which different models of protocol-based care have been introduced.
  • Examine the extent to which midwives, nurses and health visitors contribute to the development, implementation and audit of protocol-based care.
  • Identify the impact of their contribution on organisational, patient, staff outcomes, and on costs, quality and effectiveness of care.
  • Assess the overall impact of the introduction of protocol-based care upon the working lives of nurses, midwives and health visitors, their sense of professional identity and capacity.

Results

The key findings and recommendations arising from three different methods – the systematic literature review, a national survey and the midwifery case study - will be presented. The systematic literature will focus upon the lessons learnt about developing and introducing protocol-based care into practice. The quantitative findings from the survey will examine the impact of protocol-based care on important staff outcomes, such as well-being and job satisfaction. In the final presentation, discourse analysis is used to understand protocol-based care in the context of professional ideologies in midwifery. There will also be an opportunity for delegates to discuss the relevance of the recommendations for their practice.

Source of funding: National Institute for Health Research Service Delivery and Organisation Programme.

Level of funding: Fully funded

Abstract one: What do we know about the development, implementation and impact of protocol-based care? A systematic literature review

Irene Ilott, Jo Rick, Andrew Booth, Malcolm Patterson & Rose O’Neill Institute of Work Psychology and School of Health and Related Research, University of Sheffield, UK

Background and aims

The systematic literature review investigated the process and outcome of protocol-based care drawing upon the international literature to evaluate what is already known from the perspective of nurses, midwives and health visitors.

Review methods and findings

Initial searches based on 20 databases using the search term ‘protocol-based care’ (PBC) produced only 56 papers, half of which related to decision support software, confirming that PBC as a term was not yet established in the research literature. A second strategy using expanded search terms (protocols and guidelines or pathways) on a restricted set of data bases (n=5) yielded 6,744 papers. Titles and abstracts were sifted for relevance and resulting in the identification of 276 papers about development and implementation (including 120 on UK populations) and 95 papers about impact. The development/implementation and impact papers were reviewed separately and in different ways. A quarter of the 120 UK papers about development/implementation were analysed inductively using the Qualitative Assessment and Review Instrument (QARI) and by comparing the descriptive accounts with the official 12-step guide to developing protocols (MA/NICE 2002). Both methods revealed that development/implementation is seldom a linear process, rarely costed and with little patient engagement. It also became apparent that protocol-based care is instigated for multiple reasons and that adherence is challenging. A standard critical appraisal and synthesis approach was used for the impact papers. A number of positive and negative impacts of this way of working on staff outcomes such as expanded nursing roles and increased skills and knowledge, were identified.

Discussion

The findings confirm that protocol-based care is a contested, complex concept. We will discuss how practitioners and policy makers need to be clear about the purpose and implications of this way of working of professional identity.

References

Abstract two: An investigation into the impact of protocol-based care on nurses’ experience of work

Malcolm Patterson, Chrysanthi Lekka, Irene Ilott, Jo Rick Institute of Work Psychology, University of Sheffield, Sheffield, England, UK

Background and aims

Protocol-based care is underpinning much of the workforce re-design and role flexibilities in the health service in England. The National Health Service Plan (2000) stated that by 2004 the majority of staff ‘will work under agreed protocols’. However, research has shown that health professionals often circumvent them and very little is known about the factors that may affect ‘resistance’ to protocols and their impact on staff’s experience of work. Further, the majority of such previous research has relied on small sample sizes, non-validated questionnaire measures, often providing anecdotal evidence only.

In 2007 we conducted a national survey that aimed to:

  • Identify factors that may affect adherence to protocols; these may be individual (propensity to follow procedures) or organisational/contextual (procedures perceived as ‘supportive’ or ‘coercive’).
  • Investigate the impact of protocol-based care on nurses’ experience of work including their satisfaction and well-being.

Method

Survey data collected via both a postal and a web-based questionnaire, from a random sample of 4,000 registered nurses in England will be obtained between September and November 2007. This large-scale survey using validated scales, asks for nurses’ opinions on various issues pertaining to protocol-based care, their job role and organisation. Questionnaire development was driven by a review of the literature and a thematic analysis of interviews with 35 opinion leaders.

Results

Analysis of survey data will be conducted within a multiple regression framework to explore relationships between protocol-based care and key study outcomes. This analysis will be undertaken between November and December 2007.

Discussion and conclusions

We will discuss the implications of the findings, particularly the impact on nurses’ well-being and satisfaction at work and will provide recommendations about the factors that need to be considered in enhancing the experience of work for health professionals using protocol-based care.

References

  • Carryer, J., Gardner. G., Dunn, S., and Gardner, A. (2007). The capability of nurse practitioners may be diminished by controlling protocols. Australian Health Review, 31 (1), 108-115
  • Lawton, R. and Parker, D. (1999). Procedures and the professional: the case of the British NHS. Social Science and Medicine, 48, 353-361. Parker, D., Claridge, T., and Cook, G. (2005). Attitudes towards integrated care pathways in the UK NHS: a pilot study in one UK NHS trust. Journal of Integrated Care Pathways, 9.

Abstract three: Competing ideologies in maternity care: A discourse analysis

Rose O’Neill, Malcolm Patterson, Jo Rick Institute of Work Psychology, University of Sheffield, Sheffield, United Kingdom

Background

Powerful, emotionally charged ideologies, at the core of organisational cultures, serve to shape and legitimise organisational and individual behaviours, such as compliance with protocol-based care. Differing professions typically espouse differing, incompatible ideologies which individuals, in an effort to be recognised as authentic members of their profession, generally adopt and adhere to. This ideological incongruence is prominent in the midwifery profession, with midwifery and medical models of maternity care underpinned by competing ‘with woman’ and ‘with institution’ ideologies, respectively.

Aim

This presentation will describe the findings of a study exploring how the discourse of one particular group of midwives functions to construct their reality of these competing ‘with woman’ and ‘with institution’ ideologies. Approach Semi-structured interviews were conducted with a purposive sample of 8 midwives working within a large, teaching hospital comprising a midwifery-led care unit (‘with woman’ ideology) and a consultant-led care unit (‘with institution’ ideology).

Findings

Discourse analysis, drawing on the techniques of ‘interpretative repertoires’ was used to analyse the findings. Interpretative repertoires (discourses) concerning, for example, natural midwifery opposed to medical intervention, autonomy opposed to control, and guidelines opposed to protocols, were variously employed by the midwives, dependent upon their personal ideological preference, to construct the conflicting ‘with woman’ and ‘with institution’ ideologies.

Discussion

The implications of the findings will be discussed, particularly in relation to current calls for the reconfiguration of two kinds of midwifery practitioner and the importance of recognising the influence of ideological preference on midwives’ perceptions regarding the stringency of protocols and care guidelines.

References

  • Hunter, B. (2004). Conflicting ideologies as a source of emotion work in midwifery. Midwifery, 20, 261-272.