Improve Quality Of Care Research Articles

Workload-Related Issues among Nurses Caring for Patients with Behavioral and Psychological Symptoms of Dementia: A Scoping Review.

As the elderly population grows, the prevalence of dementia is rising, with 70-95% of patients in hospital settings exhibiting problematic behaviors such as aggression. These behaviors significantly contribute to increased nursing workloads, affecting nurses' well-being and patient care quality. This study aims to review workload-related issues among nurses caring for dementia patients, highlighting the need for targeted interventions to mitigate stress and improve care quality. A scoping review was conducted using the five-stage framework of Arksey and O'Malley. The literature search covered studies published between 2013 and 2023, focusing on quantitative research about nurses' workload-related stress when managing patients with dementia and problematic behaviors. Databases such as PubMed and PsycINFO were searched, and 13 studies were selected based on predefined inclusion and exclusion criteria. The review revealed that problematic behaviors, particularly aggression, significantly increase nurses' stress and workload. This stress has negative consequences on nurses' physical and mental health, often leading to burnout, decreased job satisfaction, and a decline in care quality. Inadequate staffing and support systems exacerbate these issues. Targeted education, sufficient staffing, and support are essential to reduce the workload and stress experienced by nurses caring for dementia patients. Implementing these strategies can enhance the quality of care provided and improve the well-being of healthcare professionals.

The Development of an Electronic Medical Record System to Improve Quality of Care for Individuals With Type 1 Diabetes in Rwanda: Qualitative Study.

Electronic medical record (EMR) systems have the potential to improve the quality of care and clinical outcomes for individuals with chronic and complex diseases. However, studies on the development and use of EMR systems for type 1 (T1) diabetes management in sub-Saharan Africa are few. The aim of this study is to analyze the need for improvements in the care processes that can be facilitated by an EMR system and to develop an EMR system for increasing quality of care and clinical outcomes for individuals with T1 diabetes in Rwanda. A qualitative, cocreative, and multidisciplinary approach involving local stakeholders, guided by the framework for complex public health interventions, was applied. Participant observation and the patient's personal experiences were used as case studies to understand the clinical care context. A focus group discussion and workshops were conducted to define the features and content of an EMR. The data were analyzed using thematic analysis. The identified themes related to feature requirements were (1) ease of use, (2) automatic report preparation, (3) clinical decision support tool, (4) data validity, (5) patient follow-up, (6) data protection, and (7) training. The identified themes related to content requirements were (1) treatment regimen, (2) mental health, and (3) socioeconomic and demographic conditions. A theory of change was developed based on the defined feature and content requirements to demonstrate how these requirements could strengthen the quality of care and improve clinical outcomes for people with T1 diabetes. The EMR system, including its functionalities and content, can be developed through an inclusive and cocreative process, which improves the design phase of the EMR. The development process of the EMR system is replicable, but the solution needs to be customized to the local context.

Incidence, Causes and Outcomes of Postpartum Hemorrhage in Eastern Ethiopia: A Multicenter Surveillance Study.

Maternal mortality remains an unfinished global agenda and postpartum hemorrhage (PPH) remains one of the leading causes. The aims of this study were to describe the incidence, underlying causes, and case fatality rate of PPH in public hospitals in eastern Ethiopia. This study was part of a larger Ethiopian Obstetric Surveillance System (EthOSS) project - a multicenter surveillance of women admitted to 13 public hospitals in eastern Ethiopia due to any of the five major obstetric conditions:obstetric hemorrhage, eclampsia, uterine rupture, sepsis, and severe anemia - conducted from April 1, 2021 to March 31, 2022. All registers in maternity units of those hospitals were reviewed to identify eligible women and collect data on sociodemographic and obstetric characteristics, management and maternal outcomes at discharge or death. Findings were reported using descriptive statistics. Among 38,782 births registered during the study period, 2043 women were admitted with at least one of the five major obstetric conditions. Of these 2043, 306 women (15%) had PPH corresponding with an incidence rate of 8 (95% CI: 7-9) per 1000 births. Uterine atony was the main underlying cause in 77%; 81% of women with PPH received at least one uterotonic drug, and 72% of women for whom blood was requested received at least one unit. Of the 70 hospital based maternal deaths, 19 (27%) died from PPH, making a case fatality rate of 6 per 100. Although the overall incidence of PPH appeared low, it was still the underlying cause of death in one out of four women who died. The contributing factors might be that one in five women with PPH did not receive any uterotonic drug and the low blood transfusion. Ongoing audit, followed by targeted action, is essential to improve care quality and reduce adverse maternal outcome. The relatively low incidence may reflect under-recording in paper-based records, implying that further research into methods to optimize the surveillance is needed.

Outcomes of real-time continuous glucose monitoring in adults with type 1 diabetes - quality improvement in diabetes care in a regional diabetes service in Ireland

Outcomes of real-time continuous glucose monitoring in adults with type 1 diabetes - quality improvement in diabetes care in a regional diabetes service in Ireland

Monitoring and management of inpatients on systemic glucocorticoids - quality improvement for inpatient care

Monitoring and management of inpatients on systemic glucocorticoids - quality improvement for inpatient care

Forensic Pathologists and Clinical Trauma Reviews: Performance Improvement, Public Health, and a Concise Autopsy Documentation Guide.

As a powerful tool for discovering and documenting injury, the forensic autopsy has been incorporated into trauma care quality improvement. Autopsy findings are used to determine the Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) to assess a patient's trauma severity. Clinical trauma services use autopsy reports to educate, improve patient care, and strengthen the information used in epidemiological and injury prevention studies. However, there is sometimes a disconnect between the forensic pathologist's injury descriptions and the information needed by the trauma service and for AIS/ISS coding.We formed a collaboration between forensic pathologists and trauma teams to improve this communication. Accordingly, we describe injuries that are commonly overlooked or poorly described in autopsy reports, useful injury terminology, opportunities for trauma care improvement revealed by autopsies, and which medical examiner/coroner cases will most benefit from attention to specific injury details. We demonstrate how differences in injury description impact AIS/ISS results, and distill the detailed AIS manual into a pragmatic, concise, "quick reference" autopsy-directed guide for the forensic pathologist. Collaborations between trauma teams and forensic pathologists benefit each other and help communicate autopsy findings in a more clinically useful way to stakeholders to further benefit the living.

SWOT Analysis as the Basis for Marketing Strategy Formulation at RSIA YPK Mandiri Jakarta to Increase Patient Visits in 2016

This study examines the SWOT analysis conducted at RSIA YPK Mandiri Jakarta to develop effective marketing strategies aimed at increasing patient visits. Facing stiff competition within Jakarta’s healthcare sector, the hospital needs to strengthen its position to sustain its operations and growth. By focusing on internal strengths, such as specialized healthcare services in maternity and pediatric care and strategic infrastructure, the hospital can address some of the challenges posed by external factors like low public perception and economic fluctuations. The analysis identifies key weaknesses, including a limited service range and underutilization of hospital resources. Opportunities for collaboration with insurance providers like BPJS and the possibility of expanding service offerings to appeal to a broader demographic are also highlighted. Recommendations include service diversification, digital marketing strategies, and enhancing patient satisfaction through improved care quality. By leveraging its strengths and mitigating threats, RSIA YPK Mandiri is better positioned to boost patient engagement and meet evolving healthcare demands.

Survival of the fastest? A descriptive analysis of severely injured trauma patients primarily admitted or secondarily transferred to major trauma centers in a Danish inclusive trauma system

BackgroundTrauma systems are crucial for enhancing survival and quality of life for trauma patients. Understanding trauma triage and patient outcomes is essential for optimizing resource allocation and trauma care.AimsThe aim was to explore prehospital trauma triage in Region Zealand, Denmark. Specifically, characteristics for patients who were either primarily admitted or secondarily transferred to major trauma centers were described.MethodsA retrospective descriptive study of severely injured trauma patients was conducted from January 2017 to December 2021.ResultsThe study comprised 744 patients including 55.6% primary and 44.4% secondary patients. Overall, men accounted for 70.2% of patients, and 66.1% were aged 18–65 years. The secondary patients included more women—34.2% versus 26.3% and a higher proportion of Injury Severity Score of ≥ 15—59.6% versus 47.8%, compared to primary patients. 30-day survival was higher for secondary patients—92.7% versus 87%. Medical dispatchers assessed urgency as Emergency level A for 98.1% of primary patients and 86.3% for secondary patients. Physician-staffed prehospital units attended primary patients first more frequently—17.1% versus 3.5%. Response times were similar, but time at scene was longer for primary patients whereas time from injury to arrival at a major trauma center was longer for secondary patients.ConclusionsSecondary trauma patients had higher Injury Severity Scores and better survival rates. They were considered less urgent by medical dispatchers and less frequently assessed by physician-staffed units. Prospective quality data are needed for further investigation of optimal triage and continuous quality improvement in trauma care.

Prevalence, predictors and outcomes of self-reported feedback for EMS professionals: a mixed-methods diary study

BackgroundProviding feedback to healthcare professionals and organisations on performance or patient outcomes may improve care quality and professional development, particularly in Emergency Medical Services (EMS) where professionals make autonomous, complex decisions and current feedback provision is limited. This study aimed to determine the content and outcomes of feedback in EMS by measuring feedback prevalence, identifying predictors of receiving feedback, categorising feedback outcomes and determining predictors of feedback efficacy.MethodsAn observational mixed-methods study was used. EMS professionals delivering face-to-face patient care in the United Kingdom’s National Health Service completed a baseline survey and diary entries between March-August 2022. Diary entries were event-contingent and collected when a participant identified they had received feedback. Self-reported data were collected on feedback frequency, environment, characteristics and outcomes. Feedback environment was measured using the Feedback Environment Scale. Feedback outcomes were categorised using hierarchical cluster analysis. Multilevel logistic regression was used to assess which variables predicted feedback receipt and efficacy. Qualitative data were analysed using content analysis.Results299 participants completed baseline surveys and 105 submitted 538 diary entries. 215 (71.9%) participants had received feedback in the last 30 days, with patient outcome feedback the most frequent (n = 149, 42.8%). Feedback format was predominantly verbal (n = 157, 73.0%) and informal (n = 189, 80.4%). Significant predictors for receiving feedback were a paramedic role (aOR 3.04 [1.14, 8.00]), a workplace with a positive feedback-seeking culture (aOR 1.07 [1.04, 1.10]) and white ethnicity (aOR 5.68 [1.01, 29.73]). Feedback outcomes included: personal wellbeing (closure, confidence and job satisfaction), professional development (clinical practice and knowledge) and service outcomes (patient care and patient safety). Feedback-seeking behaviour and higher scores on the Feedback Environment Scale were statistically significant predictors of feedback efficacy. Solicited feedback improved wellbeing (aOR 3.35 [1.68, 6.60]) and professional development (aOR 2.58 [1.10, 5.56]) more than unsolicited feedback.ConclusionFeedback for EMS professionals was perceived to improve personal wellbeing, professional development and service outcomes. EMS workplaces need to develop a culture that encourages feedback-seeking to strengthen the impact of feedback for EMS professionals on clinical decision-making and staff wellbeing.

Positive Deviance Theory: Leveraging Compliments Data to Guide Strategic Planning for Patient Experience Improvement in a Large Rural Health Care System.

Patient-centered care (PCC) has been called for as a solution to improving care quality and patient outcomes. Patient experience, termed care experience, is a measurable aspect of PCC and aligns with coproduction. Identifying patterns of positivity and high performers is a Positive Deviance approach that can inform strategic improvement of the care experience. To identify the characteristics of positive deviances from voluntary, unsolicited compliments from patients and family members about their care experiences. The authors conducted a mixed-method analysis, including content and a thematic analysis of unsolicited comments from patients and families, submitted between January 2021 and January 2022. After removing duplicates and miscategorized comments, 213 compliments were included in the analysis using a single, blinded inductive coding to synthesize thematic statements. The main campus received the most compliments by location (89%); the most widely used patient sentiment was thankful (36.8%). Compassionate (26.8%), together with six others: competent (11.6%), communication (10.6%), cared for (8.5%), care team (8.0%), and supportive (8.0%), made up approximately 80% of drivers of care quality. Physicians (37.3%) and nurses (34.2%) were the most complimented personnel, although surgery (17.0%) were the most complimented services team. Similar characteristics were reported for exemplary individuals and their associated care teams. The results align with previously reported work by the Beryl Institute and CMS 5-star rating on key drivers of patient experience. This approach provides a method by which exemplars can be identified within health systems, and that information is used to guide improvement and organizational planning.

Prostate Cancer Care in Rural Primary Care Contexts: A Narrative Review.

Prostate cancer is highly prevalent among older men and poses significant health challenges, particularly in rural areas where access to specialized care is limited. This narrative review aims to evaluate the quality of prostate cancer care in rural primary care settings, identify gaps, and suggest strategies for improvement. A comprehensive narrative review was conducted using PubMed to identify relevant studies published between April 2000 and August 2024. The search focused on articles discussing prostate cancer management in rural primary care, including challenges, outcomes, and collaborative practices. Thirteen studies met the inclusion criteria and were analyzed to assess the quality of care and potential areas for enhancement. The review highlighted significant disparities in prostate cancer care in rural areas, including limited access to urologists, variability in PSA testing practices, and socioeconomic and geographic barriers. Innovative models like telehealth and 'One Stop' Prostate Clinics(OSPCs) showed promise in addressing these challenges. However, gaps in long-term symptom management and follow-up care persist, emphasizing the need for comprehensive survivorship plans and targeted educational interventions for primary care physicians. Rural primary care settings face unique challenges in managing prostate cancer, necessitating tailored strategies to improve care quality. Enhancing collaboration between primary care physicians and urologists, expanding access to innovative care models, and addressing socioeconomic and geographic disparities are critical to improving outcomes for prostate cancer patients in rural areas. Future research should focus on developing and evaluating these strategies to ensure equitable care for all patients.

Improving Engagement in Residential Treatment for Substance Use Disorders: An Integrated Care Quality Improvement Project for Individuals With Mental Health and Substance Use Disorders

Substance use disorder continues to pose significant challenges in the United States, with increasing opioid-related fatalities. Residential recovery treatment programs are effective; however, high attrition rates impact successful long-term outcomes. This quality improvement project aimed to enhance patient engagement in treatment for mental health and substance use disorder to improve retention rates. It also implemented an integrated care approach incorporating psychotherapy, psychopharmacologic interventions, and recovery support services. The project was conducted using a 2-group predesign and postdesign, analyzing 134 admissions. The approach resulted in a statistically significant increase in patient engagement in treatment from 24% to 92%. Substance use relapse rates significantly reduced from 25% to 12%, and a clinically meaningful increase in the 3-month retention rate was noted. Integrated care is a promising strategy to improve outcomes for individuals receiving care for co-occurring disorders via residential treatment settings. Future studies should explore integrative models of care, patient motivation, and retention in residential treatment centers.

Efficacy of Teleconsultation Versus Usual Care in Improving Quality of Life Among Geriatric Patients Aged 60 and Above: A Randomized Controlled Trial.

Introduction The geriatric population, aged 60 years and older, is rapidly growing worldwide. This demographic shift has led to a higher prevalence of chronic diseases, comorbidities, and functional impairments, placing immense pressure on healthcare systems. Teleconsultation, which uses telecommunication technologies to deliver healthcare services remotely, offers a potential solution. This study aimed to assess the efficacy of teleconsultation versus usual care in improving the quality of life among the geriatric population aged 60 years and older. Methods A parallel, randomized controlled trial with a 1:1 allocation ratio was conducted. Eligible participants, aged 60 and above, were recruited at the triage emergency department (ED) following a baseline eligibility assessment. Inclusion criteria included the ability to communicate in English or Hindi, possession of International Organization for Standardization (ISO-certified) instruments for self-monitoring, and willingness to comply with study procedures and provide written consent. Participants were randomly assigned to experimental and control arms using a computer-generated sequence, with allocation concealment achieved through sequentially numbered opaque sealed envelopes (SNOSEs), which were opened in front of participants after obtaining baseline data. A total of 2,000 participants (1,000 per arm) were enrolled and randomly assigned to either the teleconsultation or usual care group. Results In the teleconsultation group (n=1,000), 36.5% of participants (365) were female and 63.5% of participants (635) were male. Similarly, in the usual care group (n=1,000), 37.1% of participants (371) were female and 62.9% of participants (629) were male. The teleconsultation group significantly outperformed the usual care group in several domains pre-intervention, with higher mean scores in the physical health domain (11.16 vs. 10.96, P = 0.009), psychological domain (11.74 vs. 11.62, P = 0.020), and environment domain (12.44 vs. 12.26, P = 0.0001). No significant difference was observed in the social relationships domain (P = 0.452). The teleconsultation group significantly outperformed the usual care group in all domains post-intervention, with higher mean scores in the physical health domain (14.49 vs. 12.74), psychological domain (13.75 vs. 12.35), social relationships domain (14.05 vs. 12.90), and environment domain (13.91 vs. 12.94) (P < 0.001 for all). Conclusion These findings suggest that teleconsultation significantly improves the quality of life for elderly patients by providing a more accessible and convenient means of healthcare delivery and addressing the physical, emotional, and social challenges associated with chronic illnesses.

Legal aspects in digital cardiology

Digital assistants have become an indispensable tool in modern cardiology. The associated technological progress offers asignificant potential to increase the efficiency of medical processes, enable more precise diagnoses in ashorter time, and thus improve patient care. However, the integration of digital assistants into clinical cardiology also raises new challenges and questions, particularly regarding the handling of legal issues. This review article aims to raise awareness of individual legal issues resulting from the use of digital technologies in cardiology. The focus is on how to deal with various legal challenges that cardiologists face, including issues related to treatment freedom, professional confidentiality and data protection. The integration of digital assistants in cardiology leads to anoticeable improvement in efficiency and quality of patient care, but at the same time, it involves avariety of legal challenges that need to be carefully addressed.

Ecological care in nursing practice: a Walker and Avant concept analysis

BackgroundToday, the human population faces an increasing array of emerging environmental challenges. Despite its importance, nurses often neglect ecological issues, which can compromise patient health. While the ecological nursing perspective has the potential to lead to innovative care approaches that benefit patients, the nursing profession, and the environment, the concept of ecological care lacks a clear definition and its dimensions remain unclear. This study aimed to analyze and clarify the concept of ‘ecological care’ in the nursing discipline.MethodsWalker and Avant’s analysis method was used to identify descriptions, antecedents, consequences, and empirical referents of the concept of ‘ecological care’ in nursing. We searched the databases (PubMed, Scopus, PsycINFO, CINAHL, ERIC, SID, and IranDoc) using the keywords “ecological,” “nurse,” and “nursing” using Boolean operators “AND” and “OR” in the title and abstract fields both in English and Persian to identify relevant literature on ecological care in nursing.ResultsEcological care, as a multidimensional concept, encompasses ecological thinking, ecological attitude, ecological awareness, ecological sensitivity, and ecological literacy. This entails the optimal utilization of environmental factors to provide patients with high-quality care and preserve ecological sustainability through environmentally friendly behaviors.ConclusionsThe findings highlight the need to elucidate, endorse, and solidify ecological thinking in all aspects of nursing care including nursing management, education, and research, which can lead to improved care quality, patient safety, and sustainability. Within this framework, nursing educators could play an essential role in integrating ecological care into nursing education. The study emphasizes the need to integrate ecological thinking into all aspects of nursing.

The role of human involvement and support in digital mental health interventions for people with schizophrenia spectrum disorders: a critical review.

Schizophrenia spectrum disorders (SDD) are characterized by a complex array of psychosis symptoms, and typically require ongoing and long-term support, including pharmacological and nonpharmacological management. Digital mental health interventions (DMHIs) have been suggested as a novel therapeutic approach to enable low-cost, scalable improvements in quality of care for adults living with SSD. However, the types and role of human involvement and support within DMHIs is currently unknown. Several recent systematic reviews and meta-analyses have investigated the potential efficacy of DMHIs for people with SSD, with scant yet emerging systematic evidence on the effects of human support within DMHIs on mental health outcomes. Further, several recent individual studies examined the efficacy of DMHIs with human support among people with SSD and provided valuable insights into the potential key elements of such support on outcomes relevant to this population. The current critical review provides the first narrative synthesis of available evidence to guide clinicians and intervention develops in designing DMHIs with adequate human support that may enhance long-term outcomes of people living with SSD.

Inpatient palliative care in metastatic adrenocortical carcinoma: a retrospective analysis using the National Inpatient Sample database.

The use of inpatient palliative care (IPC) in advanced cancer patients represents a well-established guideline recommendation. This study examines the utilization rates and patterns of IPC among patients with metastatic adrenocortical carcinoma (mACC). Relying on the Nationwide Inpatient Sample database (2007-2019), we tabulated IPC rates in mACC patients. Estimated annual percentage changes (EAPC) analyses as well as multivariable logistic regression models (MLRM) predicting IPC use were fitted. Of 2040 mACC patients, 238 (12%) received IPC. Overall, the rate of IPC increased from 3.7% to 19.1% between 2007 and 2019 (EAPC +9.6%, P=0.001). During the same period, in-hospital mortality remained unchanged from 12.1 to 13.8% (EAPC 0.1%; P=0.97). Younger age at admission (<60 years; MLRM OR=0.70, P=0.013), solitary metastatic site (OR=0.63; P=0.015), and non-brain metastases (OR=0.62; P=0.033) were all associated with lower IPC use. In mACC patients, IPC use has increased from a marginal 3.7% to a moderate annual value of 19.1% in the most recent study year. These rates were not driven by a concomitant increase in in-hospital mortality (12.1% to 13.8%; P=0.9). and may be interpreted as an improvement in quality of care. Despite this encouraging increase, some patient characteristics herald lower IPC use. In consequence, younger patients, those with solitary metastatic sites, and non-brain metastases should be carefully considered for IPC to decrease or completely reduce the IPC access barrier maximally.

The state of (mis) trust: Human-centered technology development & implementation in intensive mental health settings

Innovative technology-based solutions in mental healthcare promise significant improvements in care quality and clinical outcomes. However, their successful implementation is profoundly influenced by the levels of trust patients hold toward their treatment providers, organizations, and the technology itself. This paper delves into the complexities of building and assessing patient trust within the intensive mental health care context, focusing on inpatient settings. We explore the multifaceted nature of trust, including interpersonal, institutional, and technological trust. We highlight the crucial role of therapeutic trust, which comprises both interpersonal trust between patients and providers, and institutional trust in treatment organizations. The manuscript identifies potential key barriers to trust, from sociocultural background to a patient's psychopathology. Furthermore, it examines the concept of technological trust, emphasizing the influence of digital literacy, socio-economic status, and user experience on patients' acceptance of digital health innovations. By emphasizing the importance of assessing and addressing the state of trust among patients, the overarching goal is to leverage digital innovations to enhance mental healthcare outcomes within intensive mental health settings.

Long term outcome of C1-esterase inhibitor deficiency.

Hereditary angioedema (HAE) is a rare hereditary disorder characterized by episodic swelling and life-threatening airway obstruction caused by laryngeal angioedema. In most HAE patients, reduced level of serum C1-Inhibitor (type-I-HAE) or presence of aberrant C1-Inhibitor (type-II-HAE) result in the lost of regulation of the complementary system and contact activation system with downstream over-activation of bradykinin - the chief mediator leading to angioedema. Type-III HAE (HAE-nl-C1INH) is rare without deficient or dysfunction of C1-Inhibitor, often with genetic aberrant related to the contact activation system. The prevalence of HAE in the population is estimated at 1 in 50,000 individuals, often with early onset, but due to the heterogeneity of the disease, there is frequently a significant delay in diagnosis. Recently, better awareness by physicians, more access to diagnostic tools, better management and prophylaxis has decreased morbidity and mortality. A focus in HAE patient care shift from management of attacks with on-demand medication, to use of prophylaxis to reduce attacks has improved the overall quality of life of patients with HAE. One area in HAE research that has not been emphasized is the long-term consequence of C1-INH deficiency in HAE patients, other than the typical manifestations of HAE, as evidence have emerged linking this disorder with increased risk of cardiovascular diseases, auto-immune disorders, and malignancy. This review aims to gather the current knowledge and evidence of potential consequence of C1-Inhibitor deficiency in HAE aside from angioedema with emphasis in the improvement of long-term care and overall quality of life for HAE patients.

A bottom-up framework for nurses' protocol-based care decision-making.

To develop a conceptual framework for nurses' protocol-based care decision-making. Miles & Huberman's bottom-up approach to developing conceptual frameworks was followed, using data collected from a multiple embedded case study examining protocol-based decision-making by nurses in three hospital wards within a university hospital in northern Spain. The qualitative data from the case study, obtained through documentary analysis, observations, and interviews, underwent a secondary analysis consisting of four steps: data reduction, data display, comparison, and drawing conclusions. The framework for protocol-based care decision-making comprises four components: (1) protocol-based care, as a balance between standardisation and individualised care, (2) the process, (3) the context, and (4) the elements of protocol-based care decision-making. These components and their relationship as a context-dependent, linear, variable and multifactorial process, directly influenced by the perception of risk, are described and illustrated. This study provides a rigorous bottom-up framework for nurses' protocol-based care decision-making. The framework could be a valuable resource for managers, clinical nurses, educators, and researchers to guide and evaluate nurses' decision-making, leading to improved care quality and reduced variability in clinical practice. Furthermore, the framework lays a foundation for further research and practical applications. This study addressed the problem of understanding nurses' protocol-based care decision-making and the need for a specific conceptual framework. The main findings of the study contribute to the development of a rigorous bottom-up framework comprising four components of protocol-based care decision-making. The framework has the potential to improve care quality, reduce variability, enhance patient safety, and increase healthcare efficiency by guiding nurses' decision-making in various healthcare settings. Patient or public contribution was not applicable since the study focused on nurses' decision making.