The Impact of Protocol-Based Care on the Working Lives of Nurses, Midwives and Health Visitors

1. The Impact of Protocol-Based Care on the Working Lives of Nurses, Midwives and Health Visitors

2. Structure • Policy background to the study • Research objectives • Method and sample description • Theory & research perspectives on the study • Preliminary findings from 35 opinion leaders • A framework for understanding the findings • Next steps

3. Policy Context • NHS policy places emphasis on the need for health services to be driven by evidence of clinical and cost effectiveness, patient safety and consistency of care • PBC has emerged as a key tool for meeting these objectives • PBC aims to provide evidence based guidance on best treatment through clear statements, standards and procedures

4. Policy context: modernisation “By 2004 the majority of NHS will be working under agreed protocols identifying how common conditions should be handled and which staff can best handle them. The new NHS Modernisation Agency will lead a major drive to ensure that protocol based care takes hold throughout the NHS. It will work with the National Institute for Clinical Excellence, patients, clinicians and managers to develop clear protocols that make the best use of all the talents of NHS staff and which are flexible enough to take account of patients’ individual needs” (p83). Department of Health (2000) The NHS Plan. A plan for investment. A plan for reform. London: The Stationery Office.

5. Why study the impact of PBC on staff? • NHS is the UK’s largest employer • Little is known about the impact of PBC on practitioners’ experience • Theory and research on workflow formalisation suggests the implications could be profound • NHS funded three year research programme

6. Research Questions • How do nurses, midwifes and health visitors contribute to the development and implementation of protocol based care? • What is the impact of their contribution on organizational and patient outcomes, on costs, quality and effectiveness of care? • How does the introduction of protocol based care impact on nurses, midwives, health visitors’ experience of their work?

7. Opinion Leader Interviews: • One strand of a multi method research programme • 38 semi structured interviews (25-90 minutes) • Interviews recorded & transcribed • Thematic analysis undertaken • Two coders

8. Formalisation • Extent of written rules, procedures, and instructions • Considerable research on the impact of formalisation on attitudes and well-being • Conflicting assessments on the effect of formalisation

9. Formalisation • Negative path - stifles innovation, reduces autonomy, and demotivates employees. Negative assessments with well-being, absence, satisfaction, powerlessness, alienation • Positive path - provides needed guidance and role clarity, reduces role stress, and increases self-efficacy, helps staff be and feel more effective • Tension between compliance and technical efficiency

10. Emergent Themes ”I think some people see protocols as being restricting, inflexible and constraining on their individual care decisions. Whereas others see them as being supportive and informing and supporting and facilitating care of an equal standard rather than inconsistent decision making” Practising nurse

11. Positive Themes (I) • Self efficacy Nurses talking about increased confidence in providing appropriate care • New roles/empowerment Expanded roles for nurses eg Consultant nurses with enhanced clinical responsibilities • Nurse voice Confidence to challenge senior colleagues

12. Positive Themes (II) • Support for decision making in difficult care situations (safety net) E.g. End of life care pathways • New staff Providing guidance to inexperienced practitioners

13. Negative Themes (I) • Restricted clinical autonomy Reduces practitioners decision latitude • Care ‘by rote’ / mindlessness Care giving becomes mechanical and the care giver disengages from the process • Restricts learning on the job Incomers understand what to do but not why

14. Negative Themes (II) • Stifles innovation ‘Tick box’ approach discourages new ways of doing things - ‘fossilisation’ • Inappropriate care Unnecessary interventions from fear of stepping outside the protocol Lack of individualised care Following the protocol - not treating the person • Emotional repercussions

15. Threats & Benefits (II) • The same themes emerged in both positive and negative experiences of PBC • Not so much the specific theme as the local context in determining whether something is a threat or a benefit to the nursing experience e.g. autonomy • Need to understand what factors determine why something that is beneficial in one setting is a threat in another

16. A Framework for Interpretation • Coercive and enabling bureaucracy Adler & Borys, 1995) • Enabling factors codify best practice, enhance user skills and fully use employee capabilities • Coercive factors force reluctant compliance and lead to deskilling • Enabling Bureaucracies deliver ‘efficiency without enslavement’

17. Goal congruence Formulating procedures Internal transparency Global transparency Flexibility Repair Decentralisation of power, skills, and knowledge. Employee voice Features of Enabling Bureaucracies

18. Conclusions • Protocol based care can be either a threat or a benefit to health practitioners experience of work dependent upon local understanding and implementation • Coercive and enabling bureaucracies offers a framework for exploring the conditions under which protocols are a threat or a benefit • Next steps…

19. …thank you m.patterson@sheffield.ac.uk