Please kindly summarize the attached article. Not less than 200 words. Thank you.

Nursing Policies and Protocols
Do Nurses Really Use Them?
Ursula Kelly, PhD, APRN, ANP-BC, PMHNP-BC, FAANP, FAAN;
Geneva Edwards, MHA, MSN, RN-BC; Susan E. Shapiro, PhD, RN, FAAN

ABSTRACT
Background: Nursing policies and protocols exist to promote high-quality, safe, and effective nursing prac-
tice; however, there is little evidence demonstrating how nurses actually use them to inform their everyday,
routine practice.
Purpose: The purposes were to explore the extent to which nurses use nursing policies and protocols to
guide their routine practice, and identify barriers and facilitators affecting the frequency with which nurses use
nursing policies and protocols.
Methods: Licensed nurses (N = 235) providing direct care to inpatients and outpatients in a large medical
center participated in an 18-question online survey.
Results: Most nurses access policies and protocols once a month or more; the greatest barrier to more
frequent access was length of the policy or protocol.
Conclusions: Organizations should make policies and protocols succinct, current, and easily accessible.
Studies are needed to determine how policies and procedures can best meet the needs of stakeholders,
including health care organizations, staff, and patients.
Keywords: nursing policies, nursing procedures, nursing protocols, nursing quality

Nursing policies and protocols promote safeand effective nursing practice by ensuring
it is evidence-based, standardized, and likely to
result optimal clinical outcomes; however, there
is little evidence demonstrating how nurses ac-
tually use them to guide their everyday, routine
practice. Toward that end, the aims of this study
were to: (a) explore the extent to which nurses
use policies and protocols to guide their usual,
day-to-day practice, and (b) identify barriers and

Author Affiliations: Nursing and Patient Care Services, Atlanta VA
Health Care System, Decatur, Georgia (Dr Kelly and Ms Edwards);
and Nell Hodgson Woodruff School of Nursing, Emory University,
Atlanta, Georgia (Drs Kelly and Shapiro).

This material is the result of work supported with resources and
the use of facilities at the Atlanta VA Health Care System.

The views expressed in this article are those of the authors and do
not necessarily reflect the position or policy of the Department of
Veterans Affairs or the United States government.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL
citations appear in the printed text and are provided in the HTML
and PDF versions of this article on the journal’s Web site
(www.jncqjournal.com).

Correspondence: Ursula Kelly, PhD, APRN, ANP-BC,
PMHNP-BC, FAANP, FAAN, Atlanta VA Health Care System, 1670
Clairmont Rd, Mail Code 118, Decatur, GA 30033
(ukelly@emory.edu; ursula.kelly@va.gov).

Accepted for publication: October 5, 2020

Published ahead of print: November 23, 2020

DOI: 10.1097/NCQ.0000000000000532

facilitators affecting the frequency with which
nurses use nursing policies and protocols. This
information may help health care settings better
support nursing quality and safety by effectively
deploying new and updated policies and proto-
cols in a manner that supports their utilization.

BACKGROUND AND SIGNIFICANCE
In nursing, the terms policies, protocols, and pro-
cedures often are used interchangeably and in
different combinations to describe health care or-
ganizations’ official written positions detailing
specific actions to take in clinical and nonclin-
ical situations. Unlike state regulations, these
documents serve as authorized descriptions of
institutional-specific nursing practice, serving 2
primary purposes: to standardize nursing prac-
tice based on current best evidence and reduce
organizational risk.1 As such, they are thor-
oughly developed statements designed to help
nurses decide appropriate action to be taken for
specific clinical circumstances.2 ,3 In this article,
the phrase nursing policies and protocols is used
to refer to all such organizational guidance and
directives.

Nursing policies and protocols have a long
history, dating back to Florence Nightingale’s
time, when they were intended as instructions for
nurse trainees.1 In their current forms, nursing

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J Nurs Care Qual • Vol. 00, No. 00, pp. 1–6 • Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. www.jncqjournal.com 1

mailto:ukelly@emory.edu

mailto:ursula.kelly@va.gov

2 Nursing Policies and Protocols Journal of Nursing Care Quality

policies and protocols are intended to opti-
mize patient safety and quality care and to
improve clinical outcomes,4-6 assist nurses to in-
tegrate new knowledge into practice, promote
nurses’ decision-making capacity in challeng-
ing situations, and increase nurses’ autonomy
and accountability.4 ,5 By standardizing practice,
nursing policies and protocols may help health
care providers, patients, and organizations by
reducing the risk of harm to patients, reducing
work load, and facilitating maximum benefit to
the organization.1 ,5-8 Other sources cite conflict-
ing evidence, noting wide variations in in the use
of and adherence to nursing policies and proto-
cols across settings.1,9-13

Regardless of these disparate findings, the col-
lective evidence is limited in its ability to describe
nurses’ use of policies and protocols to guide
their day-to-day routine practice. These stud-
ies took place in specialty clinical settings such
as intensive care units, pediatric palliative care,
and transplant programs; were focused on use
of specific policies or protocols; or covered issues
indirectly related to accessing and using policies
and protocols to guide daily practice.1 To our
knowledge, there are no published studies on the
actual routine use of nursing policies and proto-
cols to guide day-to-day care for patients.

Both organizational and individual factors
have been identified as barriers and/or facilita-
tors to nurses’ use of policies and protocols.
Alley3 found that the culture of a health care sys-
tem has a significant influence on what a nursing
policy addresses and how it is perceived and/or
managed by a nurse; it can produce both or-
der and conflict.3 For example, one study found
that nurses did not follow a nursing proto-
col to document medication errors due to fear
of punitive action, such as termination of em-
ployment, professional discipline, or a charge
of malpractice.5 Additionally, policies and pro-
tocols may be poorly written and difficult to
understand,3 ,14 and nurses may lack knowledge
of the health care organizations’ nursing policies
and protocols.12 ,15 Another organizational factor
that has been identified as a barrier to nurses’ use
of policies and protocols is workload, which is
seen most commonly in inpatient settings.2 One
shortcoming of these studies is that they either
were completed in specialized settings or were re-
lated to singular policies or protocols.

Several individual factors act as facilitators or
barriers to nurses’ use of policies and protocols.
Porter et al16 reported that nurses’ perceptions

of the value of the nursing policy influenced
their adherence to the policy (ie, if the policy
was viewed as benefitting the patient, reducing
the nurse’s workload, or standardizing practice,
the nurse was more likely to adhere to it
than if perceived otherwise). Nurses’ perceptions
that following nursing policies and protocols
is time consuming is another individual factor
that results in nurses’ failure to use them.2 Per-
haps more troubling is the finding that nurses’
decisions to use policies and protocols were de-
pendent on their assessment of patients’ acuity,
with nurses stating they were more likely to con-
sult policies or protocols when their patients
were more acutely ill,2 raising concern for guid-
ance related to day-to-day care. Again, these
studies focused on adherence to selected policies
or protocols and did not examine how frequently
nurses used policies or protocols to guide their
daily routine practice. To overcome limitations in
the previous studies, this study recruited nurses
from a large health care system, including all
licensed nurses in both inpatient and outpa-
tient settings, and inquired about utilization of
nursing policies and protocols generally and not
pertaining to a specific policy or protocol.

METHODS
This exploratory, descriptive study was con-
ducted in a large Veterans Affairs Health Care
System (VAHCS) in the southeast United States.
The study was approved by the appropriate
university Institutional Review Board and VA re-
search oversight committees and entities.

Target study population and recruitment
The target population was all licensed nurses
providing direct care to patients in both out-
patient and inpatient settings. Excluded were
nurses in supportive roles such as care co-
ordinators, nurse managers, quality managers,
performance improvement analysts, and tele-
phone advice nurses. Advanced practice nurses
also were excluded since their work is guided
more by clinical practice guidelines than nurs-
ing policies and protocols. Of the approximately
1000 nurses employed at this facility, it was esti-
mated that between 70% and 80% were in direct
patient care roles, with 60% of those working
in inpatient areas and the remainder working
in outpatient clinics. Based on these estimated
numbers of total nurses and direct care staff, the
approximate response rate for the survey was
31.3%.

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00 2020 • Volume 00 • Number 00 www.jncqjournal.com 3

Recruitment was conducted via emails to
the nursing listserv, which included all licensed
nurses in the health care system. The email con-
tained a brief description of the study, including
the inclusion criterion of providing direct care to
patients and exclusion criteria of (1) performing
supportive roles (eg, care coordinators) and (2)
advanced practice nurses. The emails included a
hyperlink to the electronic survey that was used
to collect data. The online survey began with a
detailed description of the study, requisite infor-
mation for consent, and the option to consent
to participate or exit the survey. A total of 235
nurses consented electronically and completed
the survey. A few items, had missing values, yield-
ing a slightly smaller sample size. There was no
discernible pattern to missing data.

Data collection
Data were gathered using a survey developed
by the investigators; it was pilot tested among a
small sample of potential participants to ensure
questions were clear, responses yielded usable
data, and to estimate participant burden (<15 minutes to complete). The final survey con- sisted of 18 multiple-choice and short-answer questions covering (1) demographics (eg, nurses’ education, experience, and unit and shift as- signments); (2) the nurses’ use of policies and protocols (eg, How often do you refer to nursing policies and protocols? When was the last time you referred to a nursing policy or protocol?); (3) factors that affect how frequently and how eas- ily nurses use policies and protocols (eg, If you have not referred to nursing policy or protocol in the past month, what has prevented you from doing so?); and (4) possible barriers to access (eg, If you have not accessed a policy or proto- col in the past month, what has prevented you from doing so?). Surveys were accessible through a VA-approved electronic survey vendor during a 2-week period in early 2018. The identity and IP address of survey respondents were not iden- tifiable or traceable.

Data analysis
Data obtained from the survey vendor were
uploaded into SPSS v23 (IBM Corporation, Ar-
monk, New York). First, the sample was divided
into 2 groups: infrequent users (those who never
or rarely accessed policies and protocols) and fre-
quent users (those who did so occasionally or
frequently). These 2 groups then were compared

across demographic characteristics, identifying
any significant differences. A similar process was
used to differentiate those who had recently re-
ferred to a policy or protocol (ie, within the past
month) and those who had not done so. Re-
sults of univariate analyses then were used to
construct logistic regression models with the di-
chotomous outcome of recent referral to a policy
or protocol (within the past month) or no recent
referral. Using backward elimination, nonsignifi-
cant predictors were removed one at a time until
only significant predictors remained.

RESULTS
The characteristics of the analytic sample (N =
235) are summarized in Supplemental Digital
Content Table 1 (available at: http://links.lww.
com/JNCQ/A804). Most respondents (n = 197;
84%) were registered nurses (RNs); the remain-
der were licensed practical nurses (LPNs). Most
of the RNs (n = 185; 79%) indicated they had
a BSN or higher degree in nursing. Over 80%
of respondents (n = 190) indicated they had 6
or more years as a licensed nurse. Over half the
respondents (n = 125) had more than 6 years’
experience at the study site, and over half (n =
120) worked in the outpatient setting.

Analyses were conducted to determine pre-
dictors of how frequently respondents accessed
policies and protocols (frequency), and how re-
cently they had done so (recent). Univariate
analyses failed to identify any statistically signifi-
cant differences between infrequent and frequent
users based on demographic variables. However,
several factors did emerge that were related to
nurses accessing policies and protocols within
the past month. As can be seen in the Table,
the odds of having referred to a policy or proto-
col within the past month was 3.6 times greater
for those who listed no barriers to access than
for those who identified any barriers at all
(P < .0001). The odds of younger nurses (gener- ation Y/millennials, born 1981-2000) accessing a policy or protocol was 2.7 times the odds of older nurses (baby boomers, born 1946-1964; P = .032). The odds of RNs accessing a policy or protocol were 2.16 times the odds of LPNs (P = .036). Based on these results, further anal- yses focused on predictors of recent referral to a policy or protocol, not frequency of referral.

The results of the first multivariate model,
including all variables, identified age group, ed-
ucation, and years of experience as significantly

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4 Nursing Policies and Protocols Journal of Nursing Care Quality

Table. Predictors of Recent Access

Policies and Procedures

Predictor

Recently
Used

(n = 134)

Not Recently
Used

(n = 100)
Odds Ratio

(95% CI) Wald χ 2 P Value

Barriers
Some listed 29 52 Reference
None listed 95 47 3.62

(2.04-6.43)
19.39 <.0001

Age (categorical)
Baby boomers (Born 1946-1964) 47 51 Reference
Gen X (1965-1980) 67 40 1.82

(1.04-3.17)
Gen Y/millennials (1981-2000) 20 8 2.71

(1.09-6.74)
6.89 .0318

Role
LPN 15 21 Reference
RN 119 77 2.16

(1.05-4.45)
4.39 .0361

Education
LPN/ADN/RN diploma 22 26 Reference
BSN 56 38 1.74

(0.86-3.51)
Masters/doctorate 56 35 1.89

(0.93-3.84)
3.40 .1830

Years of experience
<6 25 19 Reference ≥6 109 80 1.03

(0.53-2.01)
0.01 .9177

Years at health care system
<6 23 13 Reference ≥6 110 87 0.72

(0.34-1.49)
0.80 .3709

National certification
No 83 72 Reference
Yes 46 33 1.62

(0.94-2.81)
3.02 .0822

Setting
Inpatient 60 49 Reference
Outpatient 72 48 1.23

(0.73-2.07)
0.57 .4488

Abbreviations: ADN, associate degree-prepared nurse; BSN, baccalaureate-prepared nurse; Gen, generation; LPN, licensed practical nurse; RN, registered
nurse.

associated with recent referral to a policy or pro-
tocol (see Supplemental Digital Content Table 2,
available at: http://links.lww.com/JNCQ/A805);
younger nurses, those with a master or doctor-

ate in nursing, and those with 6 or more years
of experience had greater odds of recently refer-
ring to a policy or protocol than comparators.
After adjusting for all potential predictors (age

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00 2020 • Volume 00 • Number 00 www.jncqjournal.com 5

group, role, education, years of experience, years
at the facility, national certification status, and
setting), the odds of having recently used poli-
cies and procedures were 5.84 times higher in
those who listed no barriers compared to those
who listed some. Finally, stepwise elimination
of the nonsignificant variables and adjusting for
age group, education, role, and years of experi-
ence, multivariate modeling revealed the odds of
having recently used policies and protocols were
5.57 times higher among those who listed no bar-
riers when compared with those who listed some
barriers (P < .0001; see Supplemental Digital Content Table 3, available at: http://links.lww. com/JNCQ/A806).

Two sets of questions asked about barriers to
access. When asked what prevented referral to
policies and protocols in the past month, most
respondents (n = 168; 75%) indicated the ques-
tion was not applicable (ie, that they had no
need to, or no problem with referring to policies
and protocols when needed). Of the remainder,
14% indicated they had difficulty locating the
required information. Significantly fewer respon-
dents (n = 14; 7%) identified lack of time or
outdated policies. When asked more directly if
they had been able to use nursing policies and
protocols, here again, most (76%) stated they
were able to do so in a timely manner. When
asked what prevented them from timely access,
only the length of time it took to read the policy
or protocol to get to the important information
stood out (12% of respondents); lack of time, un-
clear language, and lack of knowledge that the
policy or protocol existed each were endorsed by
no more than 4% of respondents.

Suggestions for making access more user-
friendly included more effective communication
regarding the existence and location of the
relevant information (73%); providing more in-
service education, especially to off-shift and
clinic staff (56%); and removing outdated
screens from the electronic health record (37%).
Interestingly, although 76% of respondents in-
dicated they were able to access policies and
protocols in a timely manner, only 14% of re-
spondents (n = 33) indicated they found the
policies and protocols “user-friendly.”

DISCUSSION
This study was undertaken to explore both the
extent to which nurses use policies and pro-
tocols to inform their day-to-day practice and
to identify the factors that facilitate or prevent

nurses from consulting policies and protocols.
Our results indicate that almost half the nurses
who responded to the survey referred to policies
or protocols within the previous 6 months, and
44% did so every 1 to 3 weeks. Reported barri-
ers to access, respondents’ age group (younger vs
older), and professional role (RN vs LPN) were
all significantly associated with recent use of a
policy or protocol. Age group and years of ex-
perience also were significantly associated with
recent access, but those relationships were some-
what contradictory. This apparent contradiction
(ie, that both younger nurses and those with
more experience reported more recent access to
policies and protocols than their comparison
groups) indicates the need for further research to
determine whether it represents a statistical arti-
fact or some underlying pattern that this sample
could not delineate.

It is notable that 75% or more of the respon-
dents indicated they had no difficulty accessing
policies and protocols when needed and were
able to do so in a timely manner. The few who
reported difficulties cited the time it took to read
through the relevant policy as the greatest barrier
to ease of use; other barriers (eg, lack of time to
access policies and protocols) were cited less than
4% of the time. Barriers to use of policies and
protocols cited in earlier studies (eg, limited time
due to workload2 or lack of knowledge regard-
ing the existence of policies and protocols)12 ,15

were not operative in this sample. For the mi-
nority who reported barriers to use, document
length seemed to be the biggest barrier. This is
consistent with findings by Alley3 and Drolet
et al.14

Results of this survey suggest health care orga-
nizations should keep policies and protocols as
succinct as possible and update them frequently
based on emerging evidence and changes in best
practices. In addition, it is important to commu-
nicate policy and protocol updates effectively to
intended end users; nurses cannot use policies
and protocols they do not know about. Clinical
leaders such as clinical nurse specialists and clin-
ical educators play critical roles in augmenting
electronic communications and ensuring nurses
are using new and updated policies and proto-
cols appropriately.

The respondents worked in all areas of a large
VA health care system and included both tenured
staff and those new to nursing and the system.
As such, they are likely representative of nurses
at this facility, and may not be generalizable

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6 Nursing Policies and Protocols Journal of Nursing Care Quality

to other VA health systems or beyond. Other
limitations include selection bias and response
bias, both of which are present in all surveys such
as the one used in this study.

CONCLUSIONS
The role of policies and protocols in contempo-
rary nursing is complicated, as Bail et al1 have
pointed out. Regulatory agencies at the state and
federal level expect health care organizations to
have comprehensive policies and protocols to
standardize administrative and clinical practices
and set behavioral expectations. Despite the
expectation that such policies and protocols be
updated regularly, rapid advances in medical
and nursing technologies and therapeutics, along
with the ever-changing health care system, may
leave institutions struggling to integrate evolving
evidence into their institutional documents in a
timely manner. Consequently, nurses sometimes
find themselves in the unenviable position of
having to choose between following an outdated
institutional policy or protocol or using updated
current best evidence to guide their practice.1

Electronic medical record vendors have incorpo-
rated some evidence-based protocols into their
products, but they must be kept relevant and in
line with rapidly changing best practice guide-
lines and that remains an ongoing challenge. The
practice changes mandated by the COVID-19
pandemic, for example, are great examples of
the challenge health care organizations and
practicing nurses face in maintaining congru-
ency between rapidly evolving evidence-based
care and institutional policies and protocols.

Finally, there is no accepted standard for how
frequently nurses should access policies and pro-
tocols during their routine, day-to-day practice.
Should newer nurses consult policies and pro-
tocols more frequently than mid-career nurses,
and if so, what should their focus be? Or should
nurses with more years of experience consult
policies and protocols more frequently to ensure
their practice is still current? Health care organi-
zations and nursing services generate numerous
administrative and clinical policies and proto-
cols, yet despite the time and attention to keep
these documents relevant, current, and accessi-
ble, little is known about how their use affects
system function and clinical outcomes. More
studies are needed to determine just how well
these documents are meeting the needs of the or-

ganizations that generate them, the staff they are
meant to serve, the health system overall, and
most importantly, the patients they are meant to
benefit.

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