title: Protocol-based care: impact on roles and service delivery*.
abstract: OBJECTIVE
  To evaluate the impact of protocol-based care on nursing roles, practice and service delivery.
  
  
  METHODS
  Case study evaluation informed by realistic evaluation methodology. Qualitative data collection methods were used including non-participant observation, post-observation interviews with nurses and patients, key informant interviews, tracking patient journeys and document review.
  
  
  METHODS
  141 participants took part including 73 nurses, midwives and health visitors, 4 allied health professionals, 20 doctors, 5 support staff and 39 patients.
  
  
  METHODS
  Five sites were purposively sampled and included acute and primary care service provision.
  
  
  RESULTS
  As a mechanism for standardization, the use of protocol-based care approaches such as guidelines, care pathways, protocols and algorithms was patchy and dependent on contextual, professional and individual factors. Protocol-based care approaches were commonly used as checklists and for reference; nurses and doctors expressed concern that such use could lead to a 'tick box mentality' and restricted judgement. By using standardized care approaches nurses were taking on new tasks and developing skills beyond the traditional scope of practice including prescribing, diagnosing, ordering tests and sometimes deciding on treatments. The ability to perform these roles meant that they were able to run clinics or services independently. The extension of roles to incorporate prescribing, for example, meant that nurses were able to provide a more streamlined service for patients because they did not have to refer to doctors. In turn, it was reported that this reduced doctors' workload. Protocol-based care was viewed as a 'nurses' thing'; however, some General Practitioners and junior doctors were using available standardized care approaches.
  
  
  CONCLUSIONS
  The potential of standardization was mediated by the patchy use of protocol-based care approaches and negative perceptions about standardization. Use of protocol-based care has the potential to impact on nurses' roles, increasing their autonomy and subsequently impacting on service delivery.
authors.affiliation: Centre for Health-Related Research, School of Healthcare Sciences, Bangor University, Fron Heulog, Bangor, UK. j.rycroft-malone@bangor.ac.uk
authors.forename: Jo
authors.initials: J
authors.lastname: Rycroft-Malone
authors.forename: Marina
authors.initials: M
authors.lastname: Fontenla
authors.forename: Debra
authors.initials: D
authors.lastname: Bick
authors.forename: Kate
authors.initials: K
authors.lastname: Seers
mesh_terms: D000465:Algorithms; D001291:Attitude of Health Personnel; D001294:Attitude to Health; D002983:Clinical Competence; D002985:Clinical Protocols; D019091:Critical Pathways / Q000458:organization & administration*; D011307:Drug Prescriptions / Q000451:nursing; D004739:England; D055317:Evidence-Based Practice / Q000193:education / Q000458:organization & administration; D006801:Humans; D008503:Medical Staff / Q000193:education / Q000458:organization & administration / Q000523:psychology; D024802:Nurse's Role / Q000523:psychology; D015404:Nursing Methodology Research; D009740:Nursing Staff / Q000193:education / Q000458:organization & administration / Q000523:psychology; D010819:Physician's Role / Q000523:psychology; D017410:Practice Guidelines as Topic; D017009:Professional Autonomy; D036301:Qualitative Research; D013222:State Medicine / Q000458:organization & administration; D011795:Surveys and Questionnaires; D016526:Workload