Legitimation of nurses' knowledge through policies and protocols in clinical practice

Health care professionals use policies and protocols in varying ways to gui de their clinical activities and to promote quality patient care. The criti cal ethnographic case study upon which this paper is based, involved a rese arch group comprising six registered nurses who worked in a critical care s etting. Research methods included professional journalling, participant obs ervation, and focus group and individual interviews. This paper examines th e power relations at play between doctors and nurses, and among nurses, and the ways in which nurses used policies and protocols as a means of mediati ng communication. While policies and protocols provided nurses with legitim acy of their knowledge in the clinical arena, doctors tended to rely on the ir past experience and background to inform their knowledge and activities. For nurses to believe that they provided valued and collaborative input in patient decisions, they actively sought out written evidence through polic ies and protocols to confirm and support their knowledge. Policies and prot ocols of critical care activities provided nurses with expected standards o f care, which they used to legitimize their knowledge and to communicate wi th doctors about 'undesirable' medical decisions. The doctors valued their professional authority and autonomy over policies and protocols, while nurs es used these written guidelines to assert power and demonstrate resistance . Policies and protocols do not exist in isolation; they occur within a com plex network of power relations that create tensions in clinical practice. In challenging these tensions, it is important that nurses and doctors esta blish a fine balance between using policies and protocols to provide direct ions for practice, and to allow sufficient latitude and flexibility in addr essing the complexities of patient care.