Legitimation of nurses’ knowledge through policies and protocols in clinical practice

Abstract

Health care professionals use policies and protocols in varying ways to guide their clinical activities and to promote quality patient care. The critical ethnographic case study upon which this paper is based, involved a research group comprising six registered nurses who worked in a critical care setting. Research methods included professional journalling, participant observation, and focus group and individual interviews. This paper examines the power relations at play between doctors and nurses, and among nurses, and the ways in which nurses used policies and protocols as a means of mediating communication. While policies and protocols provided nurses with legitimacy of their knowledge in the clinical arena, doctors tended to rely on their past experience and background to inform their knowledge and activities. For nurses to believe that they provided valued and collaborative input in patient decisions, they actively sought out written evidence through policies and protocols to confirm and support their knowledge. Policies and protocols of critical care activities provided nurses with expected standards of care, which they used to legitimize their knowledge and to communicate with doctors about 'undesirable' medical decisions. The doctors valued their professional authority and autonomy over policies and protocols, while nurses used these written guidelines to assert power and demonstrate resistance. Policies and protocols do not exist in isolation; they occur within a complex network of power relations that create tensions in clinical practice. In challenging these tensions, it is important that nurses and doctors establish a fine balance between using policies and protocols to provide directions for practice, and to allow sufficient latitude and flexibility in addressing the complexities of patient care.

The habitus of ‘rescue’ and its significance for implementation of rapid response systems in acute health care

“…Interprofessional differences in adherence and violations associated with EWS use were socially sanctioned. Doctors strongly advocate the freedom to reject protocols or innovate in individual cases, and are less likely to report violations or judge the behaviour of colleagues negatively, even in cases with a bad outcome (Manias & Street 2000, Parker & Lawton 2000.…”

“…At both sites the EWSs were used to mediate the nurse (HCA) -medical boundary. Local use of the tools reflected professional and epistemological differences in utilisation of protocols (Manias & Street, 2000).…”

“…The purpose of the EWS was perceived to aid nurse recognition and referral of a potential problem to the medical team, so the doctor could then assess the clinical significance of the call for help. The exercise of professional power was legitimated by the systems (Manias & Street, 2000 The addition of the CCOT at Westward provided a welcome resource for junior medical staff learning how to manage the patient without necessarily calling in senior medical support.…”

Delivering Interprofessional Care in Intensive Care: A Scoping Review of Ethnographic Studies

“…The same researcher or team of researchers published several articles on the same study. [24][25][26][27][28][29][30][31][32][33][34] In 8 studies, the researchers collected data across several ICUs, but and covered interprofessional interactions (between 2 or more professional groups). One autoethnographic article 23 was excluded, for a final sample size of 23.…”

“…Manias and Street published 3 articles [24][25][26] from an ethnography in Melbourne, Australia. Their first article 24 indicated the different value placed by physicians and nurses on policies and protocols in the ICU. Nurses turned to these documents more systematically and used them to police themselves, decide upon care strategies, and justify resistance to a course of action suggested by a physician.…”