The importance of clinical protocols and training

Posted Dec 13, 2013

Good risk management involves the development of systems, standards and processes that reduce the likelihood of patient harm. Diane Baylis, clinical risk manager at the Medical Protection Society discusses how protocols allow nurses to practise the same way, and the right way

Clinical protocols represent the framework for the management of a specific disorder or clinical situation and define areas of responsibility. They reduce variation, maintain the quality of patient care and are documentary evidence of the standard of care to be provided.

Producing clinical protocols is a useful educational exercise that allows the team to review their current practice in light of national guidelines. In MPS's experience many practice nurses, although adhering to national guidance, do not have locally produced clinical protocols.

You should ensure that your local practice protocols address the following:

Knowledge and skills framework to assess clinical competency
Risk assessment of the procedure and environment
Documentation and record keeping
Evidence/research base in line with national guidance e.g NICE,¹ NCGC,²
Reflect local services
Identify who carries out key parts of the care or treatment
The use of Patient Group Directions, and Patient Specific Directions where appropriate
Consent

There is a danger that protocols can be developed by one individual in isolation, resulting in a lack of ownership by other members of the practice team. This can result in protocols that are rarely adhered to, and are only occasionally updated. This will detract from their usefulness and result in members of the practice team working in different ways, with variable standards, to the detriment of patient care. Protocols should be:

Discussed and agreed by the relevant members of the practice team
Developed with contributions from relevant representatives from different parts of the practice (e.g. doctor, nurse and administrator)
Revised regularly and amendments made if necessary
Easily accessible for all appropriate members of the practice team

Protocols need to be clearly marked with dates of creation, ratification and future review, the version number of the policy and they should be reviewed annually. Outdated protocols should be retained for at least eight years, in case of litigation (which could occur many years after an event). Failure to retain copies of historic policy documents can make it difficult to successfully defend claims. Claims can date back many years and it is essential that the practice is judged against the expectations and knowledge at that time.

PATIENT GROUP DIRECTIONS

Patient group directions (PGDs) are written agreements for the supply and administration of medicines by registered nurses (who are not prescribers) to a group of patients who may not be known before they present for treatment. Since August 2000, they have been a statutory instrument and are legally binding and they should be individually negotiated between the nurse and employer. PGDs must be signed by a doctor and pharmacist and must meet specific criteria.³And since 1 April 2013, the responsibility for the authorisation of PGDs rests with the Clinical Commissioning Groups (CCGs). The National Institute for health and Care Excellence (NICE) has recently published guidance regarding PGDs.⁴

Examples of common patient groups in general practice are:

Infants and children requiring immunisation as part of a national programme
Those requiring immunisation for foreign travel
Those requiring medication for common acute or chronic illness

PATIENT SPECIFIC DIRECTIONS

The Nursing and Midwifery Council (NMC) states: 'A Patient Specific Direction (PSD) is a written instruction from a qualified and registered prescriber for a medicine including the dose, route and frequency or appliance to be supplied or administered to a named patient.'⁵

The PSD must include:

Name of patient and/or other individual patient identifiers
Name, form and strength of medicine (generic or brand name where appropriate)
Route of administration
Dose
Frequency
Start and finish dates
Signature of prescriber

The employers, who in general practice are typically the GP partners, are responsible for ensuring that staff are properly trained and undertake only those responsibilities specified in their job descriptions. If non-regulated staff, such as healthcare assistants, are to administer medicines using a PSD, those delegating the duty must ensure that the healthcare assistants are trained and competent to do so safely. PSDs must be supported by a practice protocol.

TRAINING

Nurses have a professional responsibility to keep up to date with fast changing legislation, policy and practice. They must maintain their registration by meeting the post registration and practice (PREP) standards set by the NMC.⁵However, the NMC is in the process of reviewing and updating the standards for the maintenance and renewal of registration, in preparation for the introduction of revalidation, which is expected to be launched in 2015. A portfolio of training is recommended to help nurses keep up to date, and employers have a duty to support staff to meet their training needs.

Training should include:

Annual mandatory updates training such as CPR, safeguarding, health and safety, fire safety and infection control
Reflective practice
Individual learning needs identified at appraisal
Personal development plan

NURSE INDEMNITY

Since October 2013, professional indemnity has become a mandatory requirement for all registered nurses.⁶While many nurses working in NHS Trusts will be covered by their employer, for nurses working in general practice this is not always the case. Practice nurses and nurse practitioners have a professional obligation to ensure that adequate indemnity arrangements are in place and that this indemnity reflects the risk associated with their practice.

SUMMARY

In the high pressure, busy environment of general practice, the role of the practice nurse continues to develop and diversify. It is imperative that nurses adhere to protocols and are trained sufficiently in their role to enable them to continue to practice safely.

REFERENCES

1. National Institute for Health and Care Excellence (NICE)

http://www.nice.org.uk/

2. National Clinical Guidance Centre (NCGC)

http://www.ncgc.ac.uk/

3. Royal College of Nursing. Patient Group Directions: guidance and information for nurses (2004)

http://www.rcn.org.uk/__data/assets/pdf_file/0008/78506/001370.pdf

4. National Institute for Health and Care Excellence, Good practice guidance for PGDs. August 2013

http://www.nice.org.uk/media/3A5/A4/GPG2Guidance_020813.pdf

5. Nursing and Midwifery (2010) Standards for medicines management

http://www.nmc-uk.org/Documents/NMC-Publications/NMC-Standards-for-medicines-management.pdf

6. Nursing and Midwifery Council: PREP standards.