Showing my workings: Early and late drafts of teaching materials

Alongside my reflections on what I had learned working on K101, I also found my first and late drafts of some of the material. I’ve stitched them together here with a little commentary on why the later version is (IMNSHO) better.

It was a section on the place of protocols and guidelines in health and social care practice. Initially I wrote:

In the previous section we looked at what is meant by the phrase ‘evidence-based practice’.  We also considered how evidence is created and what sorts of evidence are valued by different people. We saw that there are several reasons why evidence-based practice is important in current health and social care services.  One of these reasons is that many people trust care workers less than they used to partly because of some of the difficulties and scandals discussed in Block 5.  In this section we look at one of the main ways evidence can be put into practice – protocol and guideline-based care.

As you saw in the previous section, finding and evaluating the research on a particular topic is time-consuming and complex.  Individual care workers rarely have the time or the resources to find out what the evidence says about an issue they are facing in their job.  Protocols and guidelines are designed to help with this by collecting together the evidence on a particular topic and then turning it into a way of working.

1. What are Protocols and Guidelines?

Protocols and guidelines are authoritative statements about what should happen in health and social care settings. They are usually written down and staff are expected to be aware of them in their everyday practice. Guidelines are usually general statements of principles whereas protocols are usually more specific and particular to a place of work.  However, sometimes the terms ‘protocol’ and ‘guideline’ are used interchangeably and sometimes they are used differently in different workplaces.  Just to further complicate the issue, sometimes people also use terms like ‘integrated care pathway’ to describe something that looks very similar to a protocol.  But don’t worry about this because the underlying principles are very similar and the underlying principles are what we are focusing.

Many guidelines and some protocols are developed as a national level by organisations such as the National Institue for Health and Clinical Excellence, the Royal College of Nursing and the General Social Care Council.  Protocols are more likely to be developed specifically for a workplace or a group of workplaces, like all the GP practices within a group or a multi-agency team.  They are more commonly found in health care than in social care settings.  Social care settings are more likely to use more general guidelines.  A typical health care protocol might cover, for example, which medication should be prescribed, what treatment should happen when, and which staff will be involved in providing care.

In the next activity, you are going to use a very simple protocol to help you decide what treatment to offer to a patient, Iain.  Don’t worry if you don’t understand all the technical terms in the protocol – we’ve put explanations at the bottom and you don’t need to understand them all.

Activity:

Iain Ferguson is 13 and has felt ill and had a sore throat for about a fortnight.  His stepmother has brought him into the GP practice because she is worried.  In this practice, patients arriving with symptoms of common ailments like colds, sore throats and ear infections see a nurse first and are only referred on to the GP if necessary.  Iain has a fever and his tonsils are inflamed.  He does not have a runny nose or cold symptoms, nor does he have any signs of meningitis.  Use this protocol to work out what treatment he should be offered and whether he should see the GP

[Here there was a diagram, which showed the protocol]

Explanations of medical terms:

Rhinorhoea – runny nose!  (usually spelled rhinorrhoea)

Afebrile – no fever

Meningism – symptoms of menigitis

Paracet – paracetamol

Lymphadenopathy

Circumoral Pallor –

Streptococcal

Erythromycin – an antibiotic

Paul Bunnel for Glandular Fever – a test for Glandular Fever

Commentary

Unlike many of the activities you have done on the course, there is a ‘right’ answer to this activity.  According to this protocol, the correct response to Iain’s symptoms is to recommend that he be given penicillin, or erythromycin if he’s allergic to that, and if that doesn’t clear it up, to check for glandular fever.  At this stage, he doesn’t need to see the GP. Here’s how you get to this answer [add no.s to decision points on diagram and then talk through].

We will look at the advantages and disadvantages of this sort of approach in more detail in the next sections but for now make some notes on what you thought and felt while you were doing this activity.

I’ m not ashamed to have written this, but it’s not very good. It’s very wordy and not very attention-grabbing to start with. It starts with general principles, rather than the case study which I think is part of what makes it seem waffly and dull. There’s too much ‘we’ voicing. Who is this we?! The discussion of terminology is deeply offputting! The idea of using a real-life protocol for the Activity is a good one but the protocol chosen doesn’t seem very suitable if all those terms need explaining. The instruction to ‘make some notes on what you thought and felt’ is vague and not very helpful.

Here’s a much later version:

2      Working with protocols and guidelines

One of the ways in which Marie and Isabel are made accountable for their practice is that they have to follow guidelines which tell them what to do in particular situations –  for example, if a resident has a fit or if there are serious worries about someone’s safety. In this section you will look in more detail at protocols and guidelines like these and you will consider whether they do help make care better and safer – whether they contribute to getting care right.

2.1    Introducing protocols and guidelines

Here is part of the guidelines about child protection from Isabel’s organisation:

Child protection guidelines at Women’s Aid

8     If a child discloses abuse to a member of staff or a volunteer

8.1  Women’s Aid staff or volunteers will:

• Stay calm and listen carefully.
• Reassure the child that s/he was right to disclose what happened and that the abuse is not her/his fault.
• Explain to the child that in these circumstances confidentiality cannot be maintained.
• Assure the child that the issue will be taken seriously.
• Fill out an incident form immediately stating what was said by both the child and the member of staff, and recording facts rather than opinions.
• Discuss this with the member(s) of staff responsible for dealing with child protection issues, decide on the appropriate course of action and record this decision.

8.2  If the abuse is recent or continuing, staff or volunteers will also

• Tell the child what action is likely to be taken, who will be informed and what the consequences may be.
• If the child has sufficient understanding, discuss options realistically, including talking with the mother/carer with a staff member present (if the mother/carer is not the abuser).
• Keep the child informed throughout the entire process.

8.3  The staff member will then discuss the allegations with the designated person or child protection team, who will decide on a course of action depending on the nature and seriousness of the abuse and consult with Children’s Services at the earliest opportunity regarding whether a referral to Children’s Service is needed.

This is one section from a larger set of guidelines which tell Isabel how to proceed if she has worries about the safety of a child. As you have seen, this particular section tells her what to do if a child lets her know that they are being abused. The guidelines contain general advice on how to behave (e.g. ‘stay calm and listen carefully’, ‘reassure’, ‘[record] facts rather than opinions’) as well as specific steps to take (e.g. ‘fill out an incident form’ and ‘discuss this with the member(s) of staff responsible for dealing with child protection issues, decide on the appropriate course of action and record this decision’). Isabel can refer to these guidelines to check that she has done everything necessary. Written instructions like these can be particularly useful when dealing with an upsetting issue like possible child abuse. The guidelines also are one of the ways in which Isabel is made accountable for her actions. If, for example, it later came to light that she had not filled in an incident form or she had not discussed it with her colleague, she could be disciplined.

A protocol is another term for this sort of guidance. It is more often found in health care settings than in social care organisations. It is sometimes used to describe quite detailed step-by-step instructions or rules by which organisations agreeto be bound. However, one study, which examined how people used the different terms for this sort of guidance, found that the terms ‘protocol’, ‘guideline’, ‘guidance’ and ‘pathway’ were all used interchangeably in different contexts (Ilottet al., 2006). For the purposes of this unit the distinction between protocols and guidelines does not matter.

Guidelines and protocols tell you what to do in a particular set of circumstances. They are designed to standardise some aspects of care in order to improve care outcomes and make care safer (NHS Modernisation Agency / National Institute for Health and Clinical Excellence, 2002). They formalise the ways in which health and social care workers are supposed to carry out their jobs. Of course, there have always been procedures and instructions within workplaces. But in recent years there has been an increased emphasis on formalising everyday work into guidelines and protocols. There has also been more emphasis on making care workers accountable for whether they have followed their guidance.

Protocols and guidelines make it possible for staff to undertake more complex tasks. So, for example, many home carers nowadays change catheter bags. Traditionally, this was a task for nurses but protocols have been written which detail the process to be followed and the problems to look out for. This makes it possible for home carers to change catheter bags safely without having specialist nursing knowledge. And this in turn gives district nurses more time to work with service users who need more complex care, enabling people to stay at home rather than going into hospital or into residential care.

[Insert Picture AX1T2B here: close-up of someone connecting two tubes]

Picture caption: Home carers can safely change over catheter bags because they have access to written protocols which tell them exactly what to do

Of course this is far from perfect  (and it’s much wordier than we would write nowadays for online working) but it’s much better. It starts with a concrete example involving people they have already met (Isabel and Marie). The protocol chosen is much more comprehensible to a general audience. It makes much more explicit links to why they are learning about this stuff (links back to the Block themes of making care safer and the previous section on Accountability). The discussion of variant terminology is handled much more elegantly and the assertion that the terminology doesn’t really matter is backed up with an (at the time of writing) up-t0-date citation to the literature. The voice is more direct and clear (and without all those ‘we’s)