By October 25, 2017faqs


I am looking for information and documentation on why a RN should not downgrade a protocol. I have never done that but I have a nurse manager who wants our telephone triage RNs to be able to downgrade. What do you think?


Although standard practice in the past has been to avoid downgrading, I have concerns about whether that is a reasonable practice or not. We call them Decision Support Tools, but when policies allow upgrading and prohibit downgrading, the message we’re sending the nurse is that they’re Decision Making Tools. The bottom line is that critical thinking is key. There’s no way that a protocol can ever cover the vast range of factors that a nurse must consider in making a decision about disposition. Time of day, distance from care, comorbidities, patient preference, available resources, and other factors must be incorporated in decision making.

The usual argument against downgrading is that if there’s a bad outcome, and you’ve downgraded, you won’t have a leg to stand on in court. In fact, in my experience, it’s not so much whether you followed the protocol as whether you used critical thinking and applied clinical judgment to your decision making. Protocols can be very helpful, but they can also be harmful if they are a substitute for nursing judgment.My opinion is that nurses should use decision support tools to guide the triage process, decrease ambiguity in decision making, and standardize practice, but they should never supersede nursing judgment. If your manager wants to allow you to deviate both up and down as indicated, I applaud her/him and congratulate you on having such a forward-thinking boss.Best of luck to you… remember to always: think worst possible, err on the side of caution, and don’t be afraid of “over-reacting”. Safe care is the key! We must act in the patients’ best interest… they’re counting on us!


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