How to Develop a Hospital Nursing Protocol

Dag Hammarskjold, first secretary general of the United Nations, once said, "Constant attention by a good nurse may be just as important as a major operation by a surgeon." In order to provide the best possible care for their patients, nurses use a set of standard criteria, known as a protocol, to determine what treatment a patient needs. Protocols protect both patients and nurses, because they enable patients to get the care they require, and they save nurses from physical danger as well as legal liability. The hospital administration must be responsible for enacting and enforcing protocol, which keeps patients and nurses safe and healthy.

Instructions

• 1

  Gather nurses, doctors and hospital administrators to create a nursing protocol committee. Using their expertise in the field of patient care, this committee will develop protocol that will be easy to follow, clear and safe . The Georgia Department of Health requires that its state nursing protocol committee meet every two years to review and develop protocol.

• 2

  Outline a protocol standard which needs to include whether the practice fits the definition of nursing protocol, whether the potential protocol complies with laws and hospital policies and whether the intervention called for by the protocol will be cost efficient.

• 3

  Draft a standard format for publishing nursing protocols. Even though nurses in different departments carry out different tasks, a standard protocol format will reduce confusion. The protocol format should clearly spell out the definition of the condition, contributing factors, symptoms, physical examination and laboratory findings, an assessment and a treatment plan.

• 4

  Differentiate between nursing skills which require medical decisions and those that do not. Drug administration, for example, represents a skill which requires making a medical decision. Guidelines on when to change sheets, for example, do not require such a decision. Medical decisions should be part of the physicians' protocol, not that of the nurses.

• 5

  Publish and distribute the nursing protocols across the hospital. Nursing protocols by nature must be written down. In order for nurses to refer to the protocol during the course of a shift, it needs to be accessible. The protocol should be available in every hospital department where nurses work.

• 6

  Conduct orientation sessions to familiarize the nursing staff with the protocol. Every member of the nursing staff must attend these sessions. To ensure that nurses have assimilated the information, test them on their knowledge afterwards.