Algorithms or decision trees are used in some guidelines
to demonstrate a stepwise process for resolving a specific
clinical problem. Although evidence-based CPGs specify
good clinical practice, healthcare providers may not be
using them to their maximum potential. Clinicians,
patients, and healthcare systems stand to benefit when
guidelines are easy to follow and widely used.
Although guidelines may appear to be comprehensive,
they do not include all of the variables that clinicians encounter when managing
patient conditions or treatments. Guidelines are unable to address unique patient
characteristics. Social, psychological, emotional, spiritual, environmental, and
biomedical factors are not considered in the guidelines. Using guidelines can
result in making generalizations that can be problematic. Guidelines provide
a general approach to clinical management based on scientific evidence, but
caution must be exercised when applying them to individual patients.
Heath (2005) warned about the use of CPGs as an “instrument of sur-
veillance” (p. 269), whether it is for financial reward, measures of quality,
punitive action, or ethical or legal considerations. Manipulation of guidelines
for such purposes should be considered carefully because their primary
intent is to describe best practice for the typical patient. Nurses must be
aware that guidelines may also contain bias and therefore must critically
evaluate them. The IOM (2011) recommended that CPGs need to be trust-
worthy or of high quality for healthcare practitioners to improve decision
making and effect quality outcomes. CPGs need to show transparency in
how recommendations are derived and rated, allowing for external review
and timely updating.
To remedy some of the concerns about bias, the Appraisal of Guidelines
Research and Evaluation (AGREE II) instrument was developed as part of an
international collaborative of researchers and policymakers. The instrument
provides a standard framework for the development and implementation of
CPGs. A checklist of 23 items across six different quality domains provides a
useful tool for the generation and evaluation of guidelines (AGREE Collabo-
ration, 2009; Table 15-3). The AGREE II instrument is generic and can be
applied to all types of CPGs. It is based on evidence-based geriatric nursing
protocols (Levin & Jacobs, 2012). A tutorial is available to learn how to use
the tool and is useful for teaching EBP nursing in the classroom or clinical
setting (Levin, Ferrara, & Vetter, 2012). The instrument and tutorials can be
accessed at http://www.agreetrust.org/resource-centre/agree-ii-training-tools/.
CPGs will continue evolving because of the momentum generated by
EBP. Evidence is more available because of the increased capacity to search
FYI
Various professional associations and other
clinical entities have developed CPGs to be
used in practice settings. CPGs will continue
evolving because of the momentum generated
by EBP, and they will become more available
because of the increased capacity to search
the literature through computerization.KEY TERM
AGREE II: Appraisal
of Guidelines
Research and
Evaluation;
internationally
developed
instrument to
evaluate clinical
practice guidelines15.3 Clinical Practice Guidelines 415