Review How do nurses, midwives and health visitors contribute to protocol- based care? A synthesis of the UK literature Irene Ilott a, *, Andrew Booth b , Jo Rick c , Malcolm Patterson c a Knowledge Translation Project Lead, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK b School of Health and Health Related Research, University of Sheffield, Sheffield, UK c Institute of Work Psychology, University of Sheffield, Sheffield, UK What is already known about the topic?  Protocol-based care is a generic term for standardised approaches to clinical care that aim to reduce unac- ceptable variations in practice and outcomes. Documents that standardise care include protocols, care pathways, clinical guidelines and care bundles.  Evidence-based care, skill mix and extending the scope of practice have contributed to the increasing formalisation of clinical care processes.  Little is known about the contribution of nurses, mid- wives and health visitors to the development, imple- mentation and audit of protocol-based care. International Journal of Nursing Studies 47 (2010) 770–780 ARTICLE INFO Article history: Received 5 September 2009 Received in revised form 14 December 2009 Accepted 30 December 2009 Keywords: Protocol-based care Systematic literature review Evidence-based practice ABSTRACT Objectives: To explore how nurses, midwives and health visitors contribute to the development, implementation and audit of protocol-based care. Protocol-based care refers to the use of documents that set standards for clinical care processes with the intent of reducing unacceptable variations in practice. Documents such as protocols, clinical guidelines and care pathways underpin evidence-based practice throughout the world. Methods: An interpretative review using the five-stage systematic literature review process. The data sources were the British Nursing Index, CINAHL, EMBASE, MEDLINE and Web of Science from onset to 2005. The Journal of Integrated Care Pathways was hand searched (1997-June 2006). Thirty three studies about protocol-based care in the United Kingdom were appraised using the Qualitative Assessment and Review Instrument (QARI version 2). The literature was synthesized inductively and deductively, using an official 12- step guide for development as a framework for the deductive synthesis. Results: Most papers were descriptive, offering practitioner knowledge and positive findings about a locally developed and owned protocol-based care. The majority were instigated in response to clinical need or service re-design. Development of protocol-based care was a non-linear, idiosyncratic process, with steps omitted, repeated or completed in a different order. The context and the multiple purposes of protocol-based care influenced the development process. Implementation and sustainability were rarely mentioned, or theorised as a change. The roles and activities of nurses were so understated as to be almost invisible. There were notable gaps in the literature about the resource use costs, the engagement of patients in the decision-making process, leadership and the impact of formalisation and new roles on inter-professional relations. Conclusions: Documents that standardise clinical care are part of the history of nursing as well as contemporary evidence-based care and expanded roles. Considering the proliferation and contested nature of protocol-based care, the dearth of literature about the contribution, experience and outcomes for nurses, midwives and health visitors is noteworthy and requires further investigation. ß 2010 Elsevier Ltd. All rights reserved. * Corresponding author. E-mail address: Irene.Ilott@Sheffield.ac.uk (I. Ilott). Contents lists available at ScienceDirect International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns 0020-7489/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2009.12.023