Running head: IMPROVING PATIENT CARE WITH A CLINIC PROTOCOL

Improving Patient Care with a Clinic Protocol/ Procedure Manual

Megan J. Stucki
Dixie State University

IMPROVING PATIENT CARE WITH A CLINIC PROTOCOL

Improving Patient Care with a Clinic Protocol/Procedure Manual

Relationship-based care (RBC) is a vital component of healthcare. That being the case it
is interesting to note that one study states that only 53% of 800 patients surveyed believe they
received compassionate care (Lowen, Rosen & Marttila, 2011). It is also noted that only 58% of
physicians surveyed believe that the health care system provided compassionate care. This study
goes on to say that strong evidence exists to support that compassionate care or RBC improves
patients experiences and health outcomes. So what is RBC? And why is it such an important
aspect of nursing care?
Relationship-based care: Defined
We experience the essence of care in the moment when one human being connects to
another. When compassion and care are conveyed through touch, a kind act, through
competent clinical interventions, or through listening and seeking to understand the
others experience, a healing relationship is created. This is the heart of RelationshipBased Care (Koloroutis, 2004, p. 4).
This human compassion and connection is displayed through three crucial relationships
in RBC (Koloroutis, 2004). The first is the connection made between the nurse and the patient,
as well as their family. This is perhaps the most important relationship in patient-centered care,
but RBC also relies upon two others. The relationship a nurse has with her/himself and how they
treat their colleagues are also vital components. A nurses colleagues extend far beyond fellow
nurses to include other medical professionals, non-medical personnel and any others who a part
of the treatment or care of each patient.
Jean Watson, the creator of the human caring theory of nursing, states that health and
healing is related to our shared humanity, including relationships with others (Schneider & Fake,
2010). Nurses who work in residential treatment have a unique opportunity to develop

IMPROVING PATIENT CARE WITH A CLINIC PROTOCOL

therapeutic relationships with the clients they care for. This is in part due to the often lengthy
stay of each client and is therefore more easily accomplished, despite the difficult nature of
treatment or care.
Due to the challenging nature of nursing care for these adolescents it is crucial to
understand facility or program structure, therapy provided (in all its various forms), medical
procedures and protocol, various members of staff and their particular function (expectations/
responsibilities), as well as boundaries. Without a clear understanding of these attributes it would
be difficult to employ patient-centered care, let alone ensure positive health outcomes. All of
these factors were taken into account while creating an indispensable procedure/ protocol clinic
manual. It was intended for the use of new medical personnel in addition to seasoned employees
needing clarification on basic and more advanced points. It was made available in written and
electronic formats.
Literature Review
Widely known are the benefits of evidence-based practice (EBP) and nursing protocol,
especially in written or electronic form. One study by Engvall, Padula, Krajewski, Rourke &
McGillvray (2014) emphasizes the importance of involvement of direct-care nurses in nursing
research. It mentions that as protocol and procedures are developed by these nurses more
accountability for the care they provide is created along with a transition from tradition-based to
evidence-based practice.
Upon review of the article by Felicilda-Reynaldo, Rhea & Utley (2015) it was noted that
the Institute of Medicine acknowledged evidence-based practice as a core competency in
nursing. The basics of EBP include using critical thinking skills in order to make the best clinical
decision based on the most current research evidence. The articles states that while using this

IMPROVING PATIENT CARE WITH A CLINIC PROTOCOL

evidence a nurse must integrate the clients attributes, values, preferences, and circumstances-this is a central tenet of RBC.
The article Computerisation of a paper-based intravenous insulin protocol reduces errors
in a prospective crossover simulated tight glycaemic control study supports evidence for the
benefits of protocol in electronic format. In this study 620 responses were recorded of both
written and electronic protocols. The computerized responses elicited significantly fewer errors
as well as higher user satisfaction. This format also allowed users to be more efficient with their
time as it reduced the amount of time needed to complete the specified tasks. This article
supports the need for an electronic format of the clinic protocol and procedure manual and
therefore one was made available for the clinic staff.
As the facility and its residents present certain challenges research was done on nursedriven protocols. One article that supported such a position stated that prior to implementing the
protocol, which was nurse-driven, indwelling catheter use was 37.6% with a 0.77% catheterassociated urinary tract infection. Post-implementation catheter usage was 27.7% and infection
rate dropped to 0.35%. Application of nurse-driven protocol has its place and must be considered
on an individual basis.
The last article researched plainly says that procedure manuals are essential in order to
establish standards of practice in addition to ensuring quality care (Randall, Knee, & Galemore,
2006). Several school nurses were tasked with the responsibility of converting hard copy forms
into electronic format and making them available on the districts Virtual File Cabinet. Doing so
allowed for quick access to the most current information. It also allows for efficient updating and
future cost-savings.

IMPROVING PATIENT CARE WITH A CLINIC PROTOCOL

Application
In order to most effectively carry out this project the nurse manager was asked several
questions regarding clinic needs, common questions/ answers asked of her, as well as procedures
and protocol for health professional. Several areas of concern were broached. Areas that lacked
clarity or that were missing entirely were also noted. Time was also devoted to asking coworkers
about questions theyve had in the past or currently held and were not answered. These questions
were clarified with appropriate staff and included in the manual.
Facility goals, structure, employees and their corresponding responsibilities were also
researched. As part of an interdisciplinary team, mostly consisting on non-medical colleagues,
one can gage the importance of understanding the treatment goals and how they are reached. The
medical team plays its role more effectively in helping the students progress when an
understanding of facility structure is reached.
After a list of concerns and needs was compiled some attention was turned to a rough
manual; it was admittedly a rough work in progress. General consensus regarding this rather
large work was that it was a good idea, but very difficult to read due to length and layout. Many
needed updates were noted (see Appendix C for Standing Order), as well as areas that should be
omitted or included.
The lengthy task of typing organized manual entries then began. Medical structure was
addressed first (see Appendix A for a sample of Medical Structure), making sure to list
expectations, responsibilities and steps of med pass as concisely as possible. Commonly
performed tasks were included; such as, tuberculosis testing, results and what they mean, drug
testing, intake procedures, charting, and facility-specific tasks were noted. Other measures were
also included; for example, infection control, what situations or conditions necessitate student

IMPROVING PATIENT CARE WITH A CLINIC PROTOCOL

quarantine, and lice treatment, to name a few. Lastly, emergency medical procedures were
addressed (see Appendix B for a sample of Emergency Medical Procedures). Many questions are
asked of our nurse manager in the event that a client needs medical care which is not provided by
the clinic. This area was greatly emphasized by the clinic nurse manager who wished to clarify
as much as possible in order to avoid confusion during often stressful times.
All materials were organized into a binder with a table of contents and divider tabs. In
addition to the binder, a PDF document and WORD documents were also created on the
facilitys computer network. An electronic format eliminates the cost of printing; plus it allows
quick access and searching capabilities. An electronic format also allows for updates to be made
as employees change, responsibilities change, current evidence-based practices are improved or
as facility structure is modified. Each employee will be emailed a copy of the manual as soon as
possible.
Conclusion
As previously stated, these adolescents are a difficult population to work with, which is
why it is important to take into consideration all aspects of RBC. This is true of the nurses
relationship to self. Sharma & Jiwan (2015) state that without self-compassion a nurse might not
be able to display compassion to patients in their care. In addition, it is stated that compassionate
care elicits better treatment adherence, wound healing and well-being. All of which are critical
when working with this age group and their specific problems. It is widely known that selfcompassion or self-care on the part of nursing staff reduces the attrition rate, which is already
high for this type of nursing. Consistency in nursing staff also increases positive health
outcomes. In short, self-compassion plays a major role in RBC.

IMPROVING PATIENT CARE WITH A CLINIC PROTOCOL

A clinic procedure and protocol manual that includes non-medical facility structure,
which is understood by all staff, facilitates cohesion, positive interdepartmental communication
and prevents much discord. In addition to these benefits it also allows the medical staff to
unequivocally support students in their treatment and other staff in approved actions when
challenged by difficult students. It prevents the students from manipulating staff and allows them
to have a clear expectation of what each staff member will do or not do. Without an
understanding of these concepts or a compassionate relationship with teammates is it impossible
to provide the consistency that affords an appropriate therapeutic environment of healing. That
environment, centered in relationship-based care, ensures that the patient feels safe and helps
build a relationship of trust which benefits the patient as well as the nurse (Schneider & Fake,
2010).
Patient-centered care, the heart of RBC, requires several things. Firstly, awareness is
needed, both of self and patient/family. Secondly, a caregivers reactions affect the patient and
their decisions about care (Lowen, Rosen & Marttila, 2011). Those reactions can be more
controlled and consistent with the utilization of standard practices laid out in the clinic manual.
Next, consistency is also maintained by supporting and understanding facility goals and
structure. This helps the nurse develop positive relationships with other non-medical staff as
well. Lastly, patient-centered care stresses that the patient deserves compassion, respect and
every effort to foster a healing environment.
In conclusion, the literature reviewed positively supports the use of nursing protocols and
procedures in any format, but especially electronic forms. Nursing manuals of protocol are a
quality assurance tool (Randall, Knee & Galemore, 2006). That quality assurance safeguards
caregiver satisfaction and positive health outcomes for every patient.

IMPROVING PATIENT CARE WITH A CLINIC PROTOCOL

References
Engvall, J. C., Padula, C., Krajewski, A., Rourke, J., McGillivray, C. G., Desroches, S., &
Anger, W., Jr. (2014). Empowering the development of a nurse-driven
protocol. Medsurg Nursing, 23(3), 149-54. Retrieved from
http://search.proquest.com/docview/1544897467?accountid=27045
Felicilda-Reynaldo, R., & Utley, R. (2015). Reflections of evidence-based practice in nurse
educators' teaching philosophy statements. Nursing Education Perspectives, 36(2), 8995. Retrieved from http://search.proquest.com/docview/1665115970?accountid=27045
Hewitt-Taylor, J. (2004). Clinical guidelines and care protocols. Intensive & Critical Care
Nursing, 20(1), 45-52. doi: http://dx.doi.org/10.1016/j.iccn.2003.08.002
Koloroutis, M. (Ed.). (2004). Relationship-based care: A model for transforming practice.
Minneapolis, MN: Creative Health Care Management.
Lee, A., Faddoul, B., Sowan, A., Johnson, K. L., Silver, K. D., & Vaidya, V. (2010).
Computerisation of a paper-based intravenous insulin protocol reduces errors in a
prospective crossover simulated tight glycaemic control study. Intensive & Critical Care
Nursing, 26(3), 161-8. doi:http://dx.doi.org/10.1016/j.iccn.2010.03.001
Lown, B. A., Rosen, J., & Marttila, J. (2011). An agenda for improving compassionate care: A
survey shows about half of patients say such care is missing. Health Affairs, 30(9),
1772-8. Retrieved from
http://search.proquest.com/docview/896866066?accountid=27045
Schneider, M. A., & Fake, P. (2010). Implementing a relationship-based care model on a large
Orthopaedic/Neurosurgical hospital unit. Orthopaedic Nursing, 29(6), 374-8; quiz 37980. Retrieved from http://search.proquest.com/docview/818560315?accountid=27045

IMPROVING PATIENT CARE WITH A CLINIC PROTOCOL

Sharma, B., & Jiwan, T. (2015). Self-compassion: Basis of quality nursing care. Asian Journal of
Nursing Education and Research,5(2), 279-282. Retrieved from
http://search.proquest.com/docview/1703436613?accountid=27045

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Appendix A
Sample of Protocol/ Procedure Manual
Med Structure
Med Structure
1. Student will come to window in alphabetical order (last name) and state name
2. Student will roll up sleeves, if applicable
3. Student will pour a FULL cup of water
4. Nurse will verify students identity and meds
5. Student will show med(s) on tongue to med tech/nurse
6. Student will drink full cup of water
7. Student will show empty cups to med tech/ nurse before discarding
8. Student will do a mouth check, cough and say 1 2 3 to nurse and then staff member (*please
ensure staff is doing proper mouth checks)
9. Student will sanitize hands
10. Student will sign MAR (ONLY for medication taken during that med pass)

Med Requests
Student may hand in med request at time of medication pass in order of last name. Student will need to
take scheduled medicine and return to end of line to have med request addressed {med techs note that
staff will have students with requests wait at back of line first and not come get their meds in order of
last name}
*Not all med requests will require immediate action or any action. Please use discretion.
*If med request is not filled out properly or expletives/ vulgar language is used NO action will be taken.
Student will be required to return with properly filled out med request during NEXT med pass.
*Clippers are placed in units med bag during dinner med pass.

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Appendix B
Sample of Protocol/ Procedure Manual
Emergency Medical Procedure

Emergency Medical Procedure

Consult with RN on duty to determine if student requires emergency medical attention.
If so:
1. Notify supervisor (Residential staff needed to accompany student during care)
2. Notify parent
a. You dont need permission from parent to take student to ED
3. MedTech is to escort student to ED with proper paperwork
a. Insurance
b. List of current medication
c. Bio
4. Emergency/ Urgent Care Providers
a. Instacare: Does NOT accept any out of state Medicaid
i. Hrs of operation: 0900-2100 7d/wk
ii. Closed Thanksgiving and Christmas days
b. NiteLite Pediatric Clinic (1240 E. 100 So. #14 - (435) 628-8034
i. Hrs of operation: 1800-2200 7d/wk
1. No appt necessary
ii. Closed Thanksgiving and Christmas days
iii. Arizona and Nevada Medicaid accepted only
iv. No x-ray available
c. ED
i. Hrs of operation: 24hr/day 365/yr
5. After receiving care contact parent again
6. Notify staff/ supervisor of any special instructions or concerns to watch for
7. Sports restrictions (if applicable)
a. Notify appropriate staff via email

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IMPROVING PATIENT CARE WITH A CLINIC PROTOCOL

Appendix C
Sample of Protocol/ Procedure Manual
Standing Medication Order from Pediatrician

Standing Order
Name:

___________________ Unit:

DOB:

Allergies:
Medical Hx:

[] Ibuprofen 200-400mg q 4-6 hrs PRN

[] Acetaminophen 500-1000mg q 4-6 hrs PRN
[] Cetirizine/ Loratadine 10mg q 24 hrs PRN
[] Bismuth Subsalicylate 524mg q 4-6 hrs PRN
[] Cold/Flu (Acetaminophen 325mg, Dextromethorphan 10mg, Guaifenesin 200mg,
Phenylephrine 5mg) 2 tablets q 4 hrs PRN
[] Calcium Carbonate 750mg chewable tablets BID PRN (Max dose 6 tabs/day)
[] Miralax 17gms in liquid (4-8 oz.) once per day. Give until BM normal.
[] Delsym (Dextromethorphan polistirex) 10ml q 12 hrs PRN
[] Mucinex (Guaifenesin) 400mg 1 tablet q 4 hrs
[] Naproxen 220mg q 8-12 hrs PRN (1st dose may be 440mg)
[] Anti-nausea Liquid (Phosphorated carbohydrate solution) 1-2 Tbsps. (max 5 doses/hr)
[] Urinary Pain Relief (Methenamine 162mg, Sodium Salicylate 162.5mg) 2 tablets q 8 hrs
__________________________
Pediatrician

Date: ____________________