Week 3 Discussion: Procedures and Evidence (Graded)

As a nurse leader first step is to call attention to the issue and bring it straight to my manager as well as the policy and procedure committee. Evidence based practice is mainly how the committee discovers and creates its policies. I would also run the order past the physician to gain approval and see if this may be altered to give a better outcome. I may receive a verbal order from the doctor to override this and bring attention back to the committee and nurse manager so they may follow up with a revision. Immediate treatment or possible harm to the patient is the main concern and must be the highest concern. In response to the nurse I would help aide in the discussion with the physician and do what I may to assist the care and foster the best outcome for our patient.

As a nurse leader I think that policy and procedure updates should always be stressed as we are always gaining knowledge about equipment, data, and new medical options. Policies are a problem-solving solution by definition. They give specific steps that outline ways to solve problems when they occur. There is without a doubt always going to be risks if outdated policies are still being used and can even become larger than just patient care problems but also affect reimbursement for the hospital itself. We are obligated to follow a set of code and ethics. We must follow these as they are put there for everyone’s safety. “Health care organizations develop and implement safety check lists and time out polices for procedures to promote a safe work culture.” (SAMPATH, 2019)

As a nurse leader it is important that we make sure policies are up to date and revised yearly and when recommended when needed. Making revisions it is important that it will be run through the policy committee so everything can be accurate and decided as a whole, as well as making sure the policies are made known to everyone. Joint commission also may come into the hospitals and review your procedures to make sure everything is up to date and reviewed properly. (SAMPATH, 2019)


Finkelman, A. (2020). Leadership and management for nurses: core competencies for quality care (4th ed). Pearson.


What would you do as a nurse leader if your policy or procedure conflicts with the most recent evidence? Describe your response to this nurse.

First of all, it is essential to know the obsolete system of rules or practices claimed by the nurse. I would study after this has been completed to figure out which new policies/procedures are possible; and if any new procedures are available to the nurse. I would carry out due diligence to determine the discrepancies between the two sets of methodologies upon determining that there are new procedures. If it has been confirmed that the protocols have still changed, I will warn the leadership of the healthcare association and all healthcare workers about the latest changes. Although the protocols must be approved by the administration, I will monitor and ensure that it is completed properly. For instance, assume that the hospital practices and protocols disagree with the most current data. Under that scenario, I will upgrade the framework instantly with the permission of the administration and recommend the nurse to use the current facts when caring for the patient. Besides, I will also ensure that the procedures are revised in sufficient time so that the nurse can continue without any delays with the operation.

Why is it important to update policies and procedures? What are the risks if they are outdated?

As policies and procedures guarantee adherence with fixed laws and regulations, so, they are essential. They guarantee that healthcare practitioners adopt evidence-based procedures and reduce differences in practice. Modifying procedures and processes help clinicians to make sound choices that align with best practice, thus promoting the wellbeing of patients and workers. Using obsolete protocols and techniques will lead to acts by healthcare practitioners who are not compatible with industry-recognized standards and can cause patient injury and allegations of malpractice (Avraham, 2014). It could also influence the healthcare organization’s reputation.

Besides, constantly reviewing nursing practices and protocols are important as new information arises from time-to-time. To improve health conditions for the patient, research is still underway. The research leads to more reliable processes and strategies for providing treatment. Consequently, to ensure that patients receive the highest quality treatment, it is important to review the policies and procedures. Updating policies periodically is important because laws and rules shift from time to time. Inability to amend policy could lead to healthcare practitioners working counter to the rules, facing litigation, or losing their licenses for practice (Rodziewicz, Houseman & Hipskind, 2020). Modifying policies and practices often mean that medical mistakes inside the organization are minimized because when delivering services, the new guidelines and treatment techniques are used (Stokes, 2020). The possibility that the protocols are not modified results in a higher risk of medical mistakes. It is important to revise procedures and policies because it lets healthcare staff use organizational technologies and other tools and lower the cost of healthcare. The threat of obsolete programs is that the cost of healthcare will increase.

What is your role as a nurse leader in assuring policies or procedures are up to date?

My responsibility as a nurse leader is to investigate and recognize any developments in professional practice, evidence-based treatment, and laws and regulations that concern nursing. The nurse leader is responsible for ensuring protocols and practices applicable in the hospital are up-to-date. The nurse leader must provide the nurses with protocols and practices understood by the industry and ensure that they obey the above rules. In reminding all affected workers before the effective date of a new or updated policy/procedure, the nurse leader has a role. I need to amend the policy of the organization after finding the above changes to reflect the most recent changes. To ensure consistency with policy and legislation, I will need to remind the nurses of the recent changes and include any preparation needed. Innovations in the sector should still be notified by the nurse leader to ensure that the majority of the team members are aware.


Avraham, R. (2014). Overlooked and Underused: Clinical Practice Guidelines and Malpractice Liability for Independent Physicians. Retrieved 18th Jan 2021, from https://opencommons.uconn.edu/cgi/viewcontent.cgi?article=1122&context=ciljLinks to an external site.

Rodziewicz, T. L., Houseman, B., Hipskind, J. E. (2020). Medical Error Prevention. Retrieved 18th Jan 2021, from https://www.ncbi.nlm.nih.gov/books/NBK499956/Links to an external site.

Stokes, M. A. (2020). Evidence-Based Policy and Procedure Review System. Retrieved 18th Jan 2021, from https://scholarworks.gvsu.edu/cgi/viewcontent.cgi?article=1123&context=kcon_doctoralprojects

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