The Protocol Predicament

From The Floor

The Protocol Predicament

What happens when following the rules jeopardizes your patient?

By Genevieve M. Clavreul, RN, Ph.D.
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Protocols are an integral part of nursing practice. They instruct us in our daily work, covering everything from how often to turn a patient to minimize the risk of bedsores to how to respond during an emergency. Every healthcare facility has its own nursing protocols, whether it’s an acute care hospital, a school clinic or a rehabilitation center. Depending on your employer, department and specialty area, you may have hundreds of protocols for different situations.

In principle, protocols are a fine thing. They improve patient outcomes by promoting evidence-based practices and consistent standards of care, and protect the facility and its staff from legal liability. I think it’s safe to say that few of us would want to work in a facility that didn’t have them.

Unfortunately, protocols can also become a shackle for nurses, preventing us from following our own professional judgment or forcing us to act in ways that go against our patients’ best interests, common sense or even our consciences.

Quick Decisions

As I wrote in my previous column, my daughter was recently hospitalized due to a life-threatening condition. She’s back home now, although she has required home healthcare after discharge. This has given me the opportunity to chat with her home health nurse and swap stories about our respective nursing experiences.

This nurse, who works for a large pharmaceutical and home health company, told me about an incident she faced a while back in which her company’s protocols for a situation presented her with a difficult decision. She had been dispatched to a patient’s home to administer doctor-prescribed medication. Despite a prophylactic injection of Benadryl, the patient began to exhibit an allergic reactuib as soon as the medication was administered.

The nurse immediately called the doctor for instructions on whether to give the patient more Benadryl or use her EpiPen auto-injector, but the doctor was unreachable. Being unable to contact the doctor left the nurse in a tough spot. In such situations, her company’s protocol called for her to use the EpiPen, but with no standing order from the doctor, she was concerned about the legality of doing so and unsure whether the company would back her up if she did. (What do you do when your employer’s protocol calls for an action you’re not legally authorized to take?) On the other hand, time was of the essence and if she didn’t do something, her patient was in serious danger.

EpiPen in hand, the nurse called 911. The emergency operator advised her to wait for the EMTs, which she nervously did. Fortunately, the EMTs arrived quickly, but the nurse told me that if it had been much longer, she would have used the EpiPen as the protocol dictated, accepting the legal risk in order to save her patient.

A Harrowing 911 Call

In that incident, the protocol set by the nurse’s employer was at least intended to protect the patient, even if it might have put the nurse at risk. However, some policies and protocols may be more about minimizing the employer’s liability — even when a patient’s life is on the line.

One dramatic recent example was a much-publicized incident in Bakersfield this past February. An elderly female resident of the Glenwood Gardens retirement community’s independent living facility collapsed on the dining room floor one morning and lost consciousness. Someone on the scene dialed 911, which led to a lengthy argument between the 911 operator and one of the facility’s staff nurses, later identified as an LVN.

Despite the operator’s repeated pleas, the nurse refused to perform CPR on the fallen woman, saying that the facility’s policy prohibited staff members from attempting CPR. The increasingly desperate operator begged the nurse to make an exception (explaining that Bakersfield emergency services would indemnify her if she did) or to at least hand over the phone to another resident or a passerby on the street who wouldn’t be bound by the facility’s policy.

It was to no avail; the nurse steadfastly refused. By the time paramedics arrived, the elderly woman was not breathing and had no pulse. She was transported to a local hospital, where she later died.

Needless to say, when this story and the 911 call went public, the backlash was quick and harsh. Listening to the tape or reading the call transcript, many people — including me — simply could not comprehend the nurse’s apparent callousness; at one point during the call, she even complained that the operator’s pleas were stressing her out! Nonetheless, Glenwood Gardens spokespeople told the press that the nurse had correctly followed protocol.  

California Lawmakers Step Up: S.B. 633

Although the woman’s family later issued a statement declaring that they were satisfied with the facility’s actions, the incident provoked widespread outrage and a push for regulatory changes. While California’s so-called Good Samaritan law shields people from civil liability if they attempt life-saving measures during an emergency, the existing law isn’t designed to protect healthcare workers or employees from termination or legal action for defying their employer’s policy.

To change that, Assemblymember Rudy Salas (D-Bakersfield) authored A.B. 633, a bill that would prohibit employers from setting or enforcing policies that bar employees from performing CPR or other emergency medical services (except in situations where the patient has a standing DNR order or similar legal directive).

A.B. 633 has now passed both the Assembly and Senate and is awaiting Gov. Brown’s signature. If he signs the bill, hopefully fewer nurses will have to choose between obeying an inhumane policy and saving a life.

A Role for Good Judgment

While these life-or-death incidents are extreme cases, they illustrate a conundrum that many of us have had to face at one time or another: what to do when our protocol is at odds with the circumstances or the needs of the patient. Often, there’s no easy answer; as nurses, we may find ourselves in situations where any choice we make will have severe consequences. Unfortunately, as the number of protocols and policies continues to grow, the odds of such a conflict will only increase.

Back in 2011, Sarah Beth Cowherd, RN, who blogs about nursing issues at, lamented that that nurses “are being protocoled to extinction.” Cowherd argued that the proliferation of protocols is superseding nurses’ own good judgment and creating huge institutional roadblocks to innovation and creativity.

There’s no doubt that some of the new protocols will lead to better care. For example, back in 2011, UC San Francisco’s Integrated Nurse Leadership Program ran a 22-month collaborative effort with nine area hospitals to develop strategies for reducing deaths from sepsis. Using a combination of sepsis screening of all patients, fast-track diagnostic testing, timely treatment based on evidence-based protocols/order sets and ongoing nurse monitoring, the hospitals were able to reduce overall sepsis mortality by 44 percent during the study period. The reductions those strategies created proved to be sustainable, too: Post studies showed a 54.5 percent reduction in sepsis mortality one year after the study and a 49.8 percent reduction after two years. Those are results we can all applaud.  

At the same time, one has to wonder, for instance, why the American Association of Critical Care Nurses felt the need to issue an alert regarding protocols for bathing adult patients. Of course, adult patients may indeed need to be bathed daily, but do we really need a protocol to tell us that? What has nursing come to?

Adequate is Not Enough

Some of us in the nursing world — particularly those of us who began our careers in the 1970s or earlier — chafe at the ever-growing number of protocols and policies. Sometimes, it’s hard not to feel like our employers would rather replace us with machines that can be programmed to follow the rulebook without question or deviation. That might save hospitals some lawsuits, but at what cost?

In my experience, there’s a thin line between being a good nurse and an adequate nurse. Following all the protocols makes you an adequate nurse. Being a good nurse means learning to integrate nursing protocols with your own observations and critical thinking skills to provide care that is not only scientifically sound, but also patient-centric and patient-specific.

Above all, we must never forget that nurses are not robots. If we create a healthcare environment in which we must rely on some outside authority or policy committee to dictate our every action, I fear for our profession and our patients.

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