How do nurses, midwives and health visitors contribute to protocol-based care? A synthesis of the UK literature.
OBJECTIVE
To explore how nurses, midwives and health visitors contribute to the development, implementation and audit of protocol-based care. Protocol-based care refers to the use of documents that set standards for clinical care processes with the intent of reducing unacceptable variations in practice. Documents such as protocols, clinical guidelines and care pathways underpin evidence-based practice throughout the world.


METHODS
An interpretative review using the five-stage systematic literature review process. The data sources were the British Nursing Index, CINAHL, EMBASE, MEDLINE and Web of Science from onset to 2005. The Journal of Integrated Care Pathways was hand searched (1997-June 2006). Thirty three studies about protocol-based care in the United Kingdom were appraised using the Qualitative Assessment and Review Instrument (QARI version 2). The literature was synthesized inductively and deductively, using an official 12-step guide for development as a framework for the deductive synthesis.


RESULTS
Most papers were descriptive, offering practitioner knowledge and positive findings about a locally developed and owned protocol-based care. The majority were instigated in response to clinical need or service re-design. Development of protocol-based care was a non-linear, idiosyncratic process, with steps omitted, repeated or completed in a different order. The context and the multiple purposes of protocol-based care influenced the development process. Implementation and sustainability were rarely mentioned, or theorised as a change. The roles and activities of nurses were so understated as to be almost invisible. There were notable gaps in the literature about the resource use costs, the engagement of patients in the decision-making process, leadership and the impact of formalisation and new roles on inter-professional relations.


CONCLUSIONS
Documents that standardise clinical care are part of the history of nursing as well as contemporary evidence-based care and expanded roles. Considering the proliferation and contested nature of protocol-based care, the dearth of literature about the contribution, experience and outcomes for nurses, midwives and health visitors is noteworthy and requires further investigation.
Ilott
Irene
I
Knowledge Translation Project Lead, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK. Irene.Ilott@Sheffield.ac.uk
Booth
Andrew
A
Rick
Jo
J
Patterson
Malcolm
M
D002985:Clinical Protocols; D003152:Community Health Nursing / Q000458:organization & administration*; D019091:Critical Pathways; D004059:Diffusion of Innovation; D055318:Evidence-Based Nursing / Q000458:organization & administration*; D006291:Health Policy; D006801:Humans; D016294:Models, Nursing; D009721:Nurse Midwives / Q000458:organization & administration*; D024802:Nurse's Role; D009731:Nursing Audit; D015399:Nursing Research / Q000458:organization & administration*; D017410:Practice Guidelines as Topic; D057184:Practice Patterns, Nurses' / Q000458:organization & administration; D017009:Professional Autonomy; D012107:Research Design; D013222:State Medicine / Q000458:organization & administration; D000078202:Systematic Reviews as Topic; D006113:United Kingdom