How to Write Nursing Policies & Procedures

by Linda Ray ; Updated September 26, 2017

Nursing policies and procedures are an integral part of the strategic management planning process of every health care facility. Although a business may have overall employee policies and procedures, each division should have its own set of clear rules and guidelines. The owners or chief executive officers should include the nursing policies and procedures in the company business plan with the assistance of nursing management.

Start by reviewing the company goals and mission. If monetary gains to stockholders is the primary goal of an institution, the policies guiding overtime or pay rates may differ from a health care organization whose primary mission is to serve the community or to grow the patient load.

Include head nurses, shift managers, union reps, facility accounting professionals, human resource representatives and the IT department in your early policy-making efforts. Feedback from each department is vital to make sure all the aspects of a nurse's employment are covered by the policies and procedures you create. Use the information that each department can bring to the discussion to craft policies that are feasible, legal and can be integrated in the system's electronic programs.

Incorporate policies and procedures that already have been created through government agencies and peer organizations. For example, the U.S. Department of Health and Human Services offers complete guidelines on patient safety to health care organizations through the Agency for Healthcare Research and Quality (AHRQ). The National Guideline Clearinghouse (NGC) makes available more than 700 plans that have worked in institutions, through collaboration between the AHRQ and the American Medical Association.

Build in regular reviews to examine the veracity of the policies and how they affect the workplace. By revisiting the initial policies, you can address problems that were not considered originally as well as make accommodations for changing economic environments, customer demands and possible nursing shortages. Changes should be made as needed following each review stage. Business climates, market trends and technological advancements demand current and regularly updated procedural planning to allow a company to be competitive and successful.


  • Subscribe to weekly updates sent out through the NGC and other professional publications such as those put out by the National Association Directors of Nursing Administration to keep up with changing medical laws and technology updates that could affect your policies and procedures.

About the Author

Linda Ray is an award-winning journalist with more than 20 years reporting experience. She's covered business for newspapers and magazines, including the "Greenville News," "Success Magazine" and "American City Business Journals." Ray holds a journalism degree and teaches writing, career development and an FDIC course called "Money Smart."

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