• Jo Rycroft-Malone, Marina Fontenla, Debra Bick, and Kate Seers.
• Centre for Health-Related Research, School of Healthcare Sciences, Bangor University, Fron Heulog, Bangor, UK. j.rycroft-malone@bangor.ac.uk
• J Eval Clin Pract. 2008 Oct 1; 14 (5): 867-73.

ObjectiveTo evaluate the impact of protocol-based care on nursing roles, practice and service delivery.DesignCase study evaluation informed by realistic evaluation methodology. Qualitative data collection methods were used including non-participant observation, post-observation interviews with nurses and patients, key informant interviews, tracking patient journeys and document review.Participants141 participants took part including 73 nurses, midwives and health visitors, 4 allied health professionals, 20 doctors, 5 support staff and 39 patients.SettingsFive sites were purposively sampled and included acute and primary care service provision.FindingsAs a mechanism for standardization, the use of protocol-based care approaches such as guidelines, care pathways, protocols and algorithms was patchy and dependent on contextual, professional and individual factors. Protocol-based care approaches were commonly used as checklists and for reference; nurses and doctors expressed concern that such use could lead to a 'tick box mentality' and restricted judgement. By using standardized care approaches nurses were taking on new tasks and developing skills beyond the traditional scope of practice including prescribing, diagnosing, ordering tests and sometimes deciding on treatments. The ability to perform these roles meant that they were able to run clinics or services independently. The extension of roles to incorporate prescribing, for example, meant that nurses were able to provide a more streamlined service for patients because they did not have to refer to doctors. In turn, it was reported that this reduced doctors' workload. Protocol-based care was viewed as a 'nurses' thing'; however, some General Practitioners and junior doctors were using available standardized care approaches.ConclusionsThe potential of standardization was mediated by the patchy use of protocol-based care approaches and negative perceptions about standardization. Use of protocol-based care has the potential to impact on nurses' roles, increasing their autonomy and subsequently impacting on service delivery.

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