Abstract

This qualitative research tries to understand experiences and meaning that nurses have about nurse care protocols, since its nature, advantages, or disadvantages. Methods: some elements of ethnography were used for data recollecting, and grounded theory was used for analyzing information, 7 nurses, with wide experience in protocols development and implementation, were interviewed. Results: the main categories were that protocols are necessary, but in some cases, nurses do not follow protocols and nurses follow them excessively, in both cases, a care deconstruction takes place, results were analyzed from Betty Neuman theory. Conclusion: protocols should be rethought, they might be called just guidelines, nurses should think systematically and critically, caring is more than following protocols, when nurses just do what protocols suggest, they are not caring, they are breaking the care as a concept and as a practice, nurses have to care of caring in order for caring people.

1. Introduction

Quality of health services is determined by some factors, such as continued changes in political, economic and health context, new technology and social media diffusion, this has contributed to the population becoming more aware of their rights, thus, patients are and will be increasingly demanding ¹. Another factor could be metamorphosis of hospitals in companies, so quality in that context is more an economic than a health issue ², so that quality indicators of hospitals not always are an image of reality, sometimes they are just a checklist to meet a requirement. In the same way, protocols emerge as a quality strategy, due to the constant scientific advances that make medicine continually define what is scientifically correct, and not just protocols, also clinical guidelines, algorithms and consensus ³. All these tools have the objective of improving health quality and standardizing health practices, in such a way that acting outside of these norms may, in principle, constitute an infringement of what is called lex scientiae ⁴.

Basically, protocol is an ordered sequence of behaviors, techniques, treatments or caring to be applied to a patient to improve his clinical course ⁵. In other words, a tool for caring but not essentially caring. This tool, initially, was developed for patient benefit, but now they are used as institutional policy, to inform insurance coverage, for deriving quality of care criteria, and for medicolegal liability standards ⁶. For this reason, a protocolization of nurse caring has happened, which means that nurses often do not think and just follow the protocol.

What is the problem with protocols or guidelines? Integration of clinical practice guidelines with the original articles, textbooks, and experiences, together with the patient's personal situation, they are essential for the appropriate use of clinical practice guidelines. This integration sometimes does not happen. The question is why, why do not nurses think? and ¿what kind of thoughts do we need? Even worse, why don't we ask about protocol objectives and nature?

2. Objective

To understand the experiences and the meaning that nurses has about nurse care protocols, since its nature, advantages or disadvantages

3. Methods

The investigation question was answered through historical hermeneutical, naturalistic, or qualitative logic. Since, it has been explored from the perspective of the participants, their experiences and meanings that they have had around the nurse care protocols, Providing a constructivist look, in which “reality is conceived as a form of multiple constructions, socially and experientially grounded, local and specific, which depend on their form and content on the people who maintain them” ⁷. Given that, it was explored from the perspective of participants, their experiences and meanings around “nurse care protocols”, adopting the “emic” (or interior) perspective ⁷, to take the phenomenon to be studied in a comprehensive and complete way, through an inductive research process, in which, the researcher interacts with the participants and the data, generating abstractions and interpretations, that is, with an “etic” perspective of a given context ⁸. This approach was chosen for the development of this study, because it allows the approach to knowledge from a small group of health professionals with experience in the care and implementation of care protocols.

A group of professional nurses with at least 1-year experience in direct patient care and referred experience about implementation and application of nursing care protocols. Participants were selected for convenience, through a theoretical or intentional sampling, all participants were working at different hospital and different services, ICU, surgery, emergencies, public health, and general wards. Some features of participants are described in chart 1.

The information was obtained through documentary review, semi-structured interview, and field diary to obtain clear and concise information, 2 interviews were online due to pandemic ages. The collection, analysis and interpretation of the data was carried out simultaneously to document, archive, check and clean the data from the moment it is recorded ⁹, since from the transcription, analysis, coding and In the categorization of each interview, it is possible to identify which other conceptual references should be investigated and which ones should not continue to be investigated, in this way it will be possible to understand perceptions and experiences that nurse professionals have about nursing care protocols.

Once the information was collected, the detailed and textual transcription of field diaries, observation guides and interview recordings was started, simultaneously a parallel analysis of the information was carried out, initially it was transcribed in Microsoft word. Subsequently, a manual open coding was carried out in which grouping and ungrouping of the data with a constant comparative analysis allows the concatenation of subtopics, and with it the generation of topics, subcategories and analysis categories, which facilitates establishing the connections between categories. and subcategories that contain the topics and subtopics, which ultimately leads to axial coding and generating a codified paradigm, placing nursing care protocols at the center of the analysis.

In accordance with the ethical principles of respect, autonomy, beneficence, justice set in Belmont report created on April 18, 1979 ¹⁰, and in Resolution 008430 of October 4, 1993, this study is classified as of minimal risk given that to address the problem under study, sensitive aspects of behavior can be touched, “where realities of the participant or group of participants are drawn and exposed, exposing themselves to risks that may arise from the detailed description of their actions, environments , work routines, daily life and interactions, intimate, private and restricted moments that will be revealed and may not have been previously planned, making them vulnerable” ¹¹.

This research will explore the experiences and meanings that nurses have about attending and caring for patients with protocols of care, their advantages and disadvantages. The purpose of this study is to understand the experiences and meanings of nurses and identify possible strategies to improve the care.

Participants and institutional names will be protected even after finishing this research. If any participant requires removing some of his statements, it will be removed.

4. Results

Professionals consider protocols necessary to care in several areas from emergency rooms until public health. According to this, a nurse said “ protocols are important, we need them, they give us rules and parameters for making all kinds of nursing procedures, for example steps to resuscitate a patient, or how to approach us for making a familiar intervention ” (nurse 1). Those steps generate calm, tranquility and certainty, some nurses improve their self-confidence about their caring acts, “if we do what protocols says, we will not be afraid about my actions, because that is a rule” (nurse 3). They feel like doing the right things because that document is universally true, they just must be excellent followers. Moreover a protocol is an answer for patients' questions, it is a special justification of health system and health care “when a patient asks for example why I cannot visit my father in covid age, I could say that is protocolized, even I might show a physical document if it would be necessary. (Nurse 3)

They also consider it as a shield, this statement illustrates that “ if I made a mistake, I would be judged according to the protocol, that is, if I followed their recommendations, I would probably be acquitted, I will be calm, because the error came from the clinic that made us follow that protocol or those who made the protocol " (n7) Some professionals believe that some good actions are bad if they are not included in protocol of care, not even something forbidden, whatever is out or forbidden is wrong, “just in a real emergency I could jump a guideline, because I would be thoughtful about bad consequences”, Professionals also reported, they were evaluated according to guidelines and protocols if they know and practice protocols, they are considered a good worker, a person who does not follow protocols seem to be punished or considered undisciplined. Health institutions require that kind rules, they are some cases a expenses justification and also quality requirement “Hospitals can justify certain practices through protocols and guidelines, thanks to this they can charge certain things, in addition, in the quality care system, protocols are essential, these are one of the quality indicators, they allow measuring, analyzing situations and make decisions according to adherence to them. It is not only the protocol as such but what comes after it”

In the same way being too flexible was one problem reported by participants, because if everyone is too flexible in protocols applying, caring practices will be disorganized, different, dangerous, it would be impossible to keep a continuous line in caring process, a nurse Stated “when people don't follow guidelines is a completely mess, for example if you don't respect traffic lights it could happen an accident, in health is the same, if you make a decision outside of recommendations, and imagine many professionals doing the same thing, nobody could agree, and patients would be treated in different ways by different people” but that is not all, participant continues “health insurers also use the protocols, they know the protocols and according to them, they can gloss” (Nurse 6) protocols are involved in all process of attention from health worker patient relationship to hospital, governments and health insurers companies relationship. A possible cause of being too flexible or not following the clinical recommendations were, when staff ignored protocol, its importance and benefit in nursing care, sometimes, this is caused by deficiencies in the realization and socialization of the guidelines. Another cause would be when the staff believe that they know much more than those who did the protocol, or are not in agreement with the recommendations, and finally when the patient's well-being and the real care needs are weighed.

If being too lax or flexible is a problem, being too disciplined is also a problem, sometimes due to selfishness, professional nurses do not think of welfare patients, instead of this, there is a prioritization of nurse interests, which means following rules just for avoiding punishment not by the otherness. These real stories can illustrate that issue:

“For example, where I work, underage relatives are not allowed to visit their relatives. Supposedly as a nurse of critical care unit, we can decide if we make an exception, but it is somewhat unusual, One day, before covid pandemic, one patient was dying, he was conscious and he wanted to see his granddaughter one more time, and also the girl wanted to hug her grandfather, but a colleague was afraid of being scolded and she said that she could not allow that visit, protocol was clear”

Another example by another nurse was:

“I was delivering a cardiac surgery patient to the intensive care unit, an unstable hemodynamically patient after a prolonged pump time, the first thing they (nurses and nurse assistant) did in the ICU, it was not to monitor him, but to turn him over to check the skin, not to take care of the patient, but to verify that if patient had any pressure injuries, this was not their responsibility. As the protocol says that the skin should be checked, and they evaluate that if they check it, sometimes the protocol or other things matter more than the patient himself”

Other problems related with excessive protocol practice are the cancellation of professional autonomy and the lack of critical thinking. One professional said “Some health workers feel like they don't need to think, because someone already thought for them, but it is difficult to adapt just one document for all patients” another nurse stated, sometimes they just follow a guideline, but in a decontextualized way. Sometimes we do not care, we just follow guidelines”. Regarding the cause of not thinking about the patient, only following the protocol in a decontextualized way, some professionals expressed work overload, being carried away by other colleagues, fear of going outside the norm, ignorance, and fear of making mistakes.

Other examples can describe this problem better:

Surgery nurse

“According to the protocol of venous therapy we have to change all of the venous devices if a patient brings them to another hospital. However, a patient who needs emergency surgery, this cannot wait or be exposed to the removal of the device, on the contrary, this device should be used and when the patient is stable it could be removed, but even so, sometimes this type of patient in circumstances similar, the central catheters are removed” Or nurses do not know patient problems and necessities or it is a negligence problem.

ICU nurse

“Position changes should be every two hours, but sometimes some patients due to their clinical condition may require it more often and in others it may be harmful. One day I had to oppose the change of position of a patient who was already in the adequacy of therapies and who in the next few minutes was going to die”, what was the intention of that change of position, the protocol or the patient?

Surgery nurse

“In surgery is usual to use thick catheters, but sometimes patients do not have thick veins, and nurse or nurse assistant try to puncture a thin vein with a thick catheter many times, this could be obviated in many small surgeries that do not require large catheters, but even though it was unnecessary, I had to see it”.

Protocols are a necessity as a guide, but they are not enough for caring. The next diagram reflects mainly results, the both sides of protocols, not adherence or excessive adherence.

5. Discussion

It is necessary to delve into some etymological concepts and the relationship between them. quality comes from Latin qualitatem-qualitas ¹², which means class, type, or quality. Quality is not an object, it is not a being, but an attribute that is always defined in relation to another, it is an attribute of being in relation, not of being itself, but of being with another ¹³. Therefore, guidelines and protocols, as quality tools, cannot be perceived in a selfish way, they must be applied for and with the otherness.

Protocol comes from the Latin word Protocollum, which according to meant the authentic seal or sign stamped on the papers that would be public titles, in Greek it comes from protos, first and kollom, to paste, and refers to the first sheet pasted with paste. Besides, the use of protocol was to avoid falsifications the documents, so they should have a stamp or note attached, protos referred to the first page and kollaos, paste, referring to annotations of interest date ^{14, 15}. Thus, nurses are not wrong, because protocols were used for verifying legality, their fears have an etymological and practical basis, since protocols are demanding and legal, sometimes it could be difficult to skip them. Therefore, protocols should be replaced by guidelines, or if it is not possible, inside protocols must exist a paragraph specifying that a nurse is a professional with autonomy and knowledge for adapting protocol recommendations according to context and patient necessities.

Professional and patient autonomy is one of the most important values in health care, “the protocols should never be blunt and rigid orders, but advice loaded with prudence and authority, directed to intelligent and free beings. Endowed, by their very nature, with provisional validity and openness to progress and criticism, those who draft and enact them have the duty to imbue them with objective rationality, permanent updating, and ethical respect for their recipient patients, nurses and doctors”; professionals morally obliged to know them, as a qualified part of their continuing education, and to follow them with responsible freedom.

Nurses cannot be like Eichmann ¹⁶, when he was in his judgment, he said, he was following orders, all the crimes that he committed were justified in that expression, nurses cannot justify their acts in that document, we have knowledge and autonomy, thus, we have responsibility. Responding for caring, protocols or guidelines are just a tool, as a tool they are just a complement, that is, it helps care, but it does not cover care, the protocol is not enough to care, it is only a theoretical and technical tool, care needs protocols but it is not exhausted in them, hopefully the looks, the silences could be protocolized , the words of encouragement, the handshakes, but it is not possible, the spontaneity as the care cannot be protocolized. Today more than ever, it is necessary to take care of care, so that it transcends protocols, guidelines, and any type of technical, human or economic barriers. For this, nurses must appeal to professional autonomy, it is conceived as “liberty for acting in what is known” ¹⁷ autonomy implies knowledge, it is a circular relationship, and the conquest of autonomy ensures the right to professional practice ¹⁸. Humans are a finite being which means not just limited time, but also limited knowledge, the gasps and voids in knowledge cause fear and anguish ¹⁹, guidelines could help, but they are just tools for making easier and safer health care. Nursing care is more than a special concept, it must be a reflected everyday life, nursing acts have to care for the caring. The care is more than just a piece of paper, a recipe, or following recommendations, care is bigger. Individuals, families or communities should be viewed as an open system that interacts with its internal and external environment to maintain a balance between disrupting factors ²⁰. Nurses are also people, as a person they interact with everything, all is connected, so a systemic thought is necessary.

Acknowledgements

For all participants, for their willingness and generosity of time in these difficult times.

References