Newhouse, Robin P. PhD, RN, NEA, BC, CNOR
Author Affiliation: Assistant Dean, Doctor of Nursing Practice Program, and Associate Professor, University of Maryland School of Nursing, Baltimore.
Correspondence: School of Nursing, University of Maryland, 655 West Lombard St, Baltimore, MD 21201 (firstname.lastname@example.org).
In this department, Dr Newhouse highlights hot topics in nursing outcomes, research, and evidence-based practice relevant to the nurse administrator. The goal is to discuss the practical implications for nurse leaders in diverse healthcare settings. Content includes evidence-based projects and decision making, locating measurement tools for quality improvement and safety projects, using outcome measures to evaluate quality, practice implications of administrative research, and exemplars of projects that demonstrate innovative approaches to organizational problems. In this article, the author explores nursing's readiness to engage in guideline appraisal and development and offers suggestions to prepare for accelerated involvement.
Healthcare in the United States has wide variances in quality, is expensive, and falls short of expectations.1 Compared with international benchmarks, the United States receives a woeful score of 65/100 across 37 performance indicators.1 Reliable, unbiased evidence is needed to effect policy to (1) constrain healthcare costs, (2) reduce geographic variation in the use of services, (3) improve quality, (4) enable consumer-directed healthcare, and (5) make healthcare decisions.2 High-quality research evidence focusing on the effectiveness of care should be summarized in the form of systematic reviews, which can then inform guidelines for practice.2
Clinical Practice Guidelines
Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.3(p39) To be credible, guidelines should conform to established standards and provide documentation of adherence to standards; panels involved in setting guidelines should include diverse stakeholders with divergent views and disclosure of conflicts of interest; and all healthcare providers, systems, payers, and patients should use the recommendations.2 The National Guideline Clearinghouse is an established source of guidelines. (See Figure 1 for guideline resources.) Criteria for guideline submission include a systematically developed statement (with recommendations, strategies), produced by a medical specialty association, and be based on a systematic literature search and review of scientific evidence with the full text of the guideline available in English.4
Nursing has a long history of engaging in interdisciplinary teams to develop clinical guidelines that are site specific for high-volume or problem-prone patient populations. The issue is that today, the development and evaluation of clinical guidelines will require that nursing span boundaries to transprofessional groups, articulate the nursing-specific perspective and effective interventions, and acquire a new set of advanced skills. Is nursing ready?
Is Nursing Ready to Generate and Use Practice Guidelines?
The answer is no, not yet. At least not at the level that will be required over the next 5 years. The preferred future includes comparative effectiveness research to test nursing interventions that work, transdisciplinary teams focused on a common patient problem, nurses with advanced skills in systematic review to summarize evidence important to practice, and nurses with advanced skills in guideline development.
Nursing administrators will need to work locally in their organization and nationally as a political force to prepare for their role in the future healthcare system. The sphere of influence requires action at organizational, political, and academic levels. Figure 2 includes prospective action to prepare for an engaged future.
What Instruments Are Available to Critically Appraise Practice Guidelines?
There are publicly available instruments to critically appraise or guide the development of guidelines. These tools include the Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument5 and the Conference on Guideline Standardization (COGS) checklist.6
A good starting point is to evaluate the clinical guidelines used within the organization. The AGREE Instrument can be used to appraise new, existing, or updated guidelines.5 A team of reviewers can use the instrument to calculate domain scores representing the quality of the clinical practice guidelines.5 Domains include scope and purpose (overall aim of the guideline, the specific clinical questions, and the target patient population), stakeholder involvement (extent to which the guideline represents the views of its intended users), rigor of development (process used to gather and synthesize the evidence), the methods to formulate the recommendations and to update them, clarity and presentation (language and format of the guideline), applicability (organizational, behavioral, and cost implications of applying the guideline), and editorial independence (independence of the recommendations and acknowledgement of possible conflicts of interest from the guideline developers).5
The COGS checklist was developed to be used for the prospective development of guidelines.6 The checklist includes 18 topics that include overview, focus, goal, users/setting, target population, developer, funding source/sponsor, evidence collection, recommendation grading criteria, method for synthesizing evidence, prerelease review, update plan, definitions, recommendations and rationale, potential benefits and harms, patient preferences, algorithm, and implementation consideration.6
Are Clinical Guidelines Based on Research?
Nursing is not alone in the need to improve the quality of clinical guidelines. The first issue is that guidelines have been endorsed that are largely based on expert opinion instead of research evidence. There has been a trend toward inclusion of expert opinion in guidelines, in contrast to inclusion of research alone.7 In a recent assessment of the American College of Cardiology and the American Heart Association guidelines, 48% of recommendations (1246/2711) from 16 guidelines reporting evidence levels were based on level C evidence.8 Level C evidence is expert opinion, case studies, or standards of care.8
Second, guidelines often do not include the strength of the evidence to indicate the level and quality of evidence on which the guideline is based. For example, strength of recommendations was not included in 52.7% and was inaccurate 6.6% of the time in 1,275 recommendations reviewed.9 This disadvantages the user, who makes the assumption that the guidelines are based on credible research evidence.
Third, guidelines may not be useful for practitioners. Developers may not follow standards for guideline development, leading to recommendations that are influenced by the interests of parties involved or not usable for practitioners. Potential bias may be related to conflicts of interest or narrowly focused guidelines.7 A centralized system that prioritizes development of flexible guidelines that differ with patient attributes and setting will have higher usefulness for practice.7
The quest for quality requires that nursing engage fully to appraise and develop guidelines for practice as a member of transdisciplinary teams. Despite opportunities for nursing in conducting systematic review,10 and evidence of weaknesses in use of research evidence and rating systems in the generation of guidelines, the science of systematic review is evolving and strengthening. Better systematic review provides the basis for the construction of meaningful guidelines to accelerate the translation of research to practice. Nursing leadership is fundamental to promoting the development of nurses to participate in guideline development, evaluation, and implementation and to nursing's contribution in transdisciplinary recommendations for practice.
2. Committee on Reviewing Evidence to Identify Highly Effective Clinical Services, Board on Health Care Services. Knowing What Works in Health Care: A Roadmap for the Nation
. Washington, DC: The National Academies Press; 2008.
3. Institute of Medicine. Clinical Practice Guidelines: Directions for a New Program
. Washington, DC: National Academy Press; 1990:39.
5. The AGREE Collaboration, ed. Appraisal of Guidelines for Research & Evaluation Instrument (AGREE)
. London, UK: St George's Hospital Medical School; 2001.
6. Shiffman RN, Shekelle P, Overhage JM, Slutsky J, Grimshaw J, Deshpande AM. Standardized reporting of clinical practice guidelines: a proposal from the Conference on Guideline Standardization. Ann Intern Med
7. Shaneyfelt TM, Centor RM. Reassessment of clinical practice guidelines: go gently into that good night. JAMA
8. Tricoci P, Allen JM, Kramer JM, Califf RM, Smith SC Jr. Scientific evidence underlying the ACC/AHA clinical practice guidelines. JAMA
9. Hussain T, Michel G, Shiffman RN. How often is strength of recommendation indicated in guidelines? Analysis of the Yale Guideline Recommendation Corpus. AMIA Annu Symp Proc
10. Newhouse RP. Evidence synthesis: the good, the bad, and the ugly. J Nurs Adm
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