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The Process of Developing Best Practice Guidelines for Nurses in Ontario: Risk Assessment and Prevention of Pressure Ulcers
In order to meet consumer expectations for quality care, healthcare professionals are required to apply knowledge and expertise that reflects current best practice.1
The provision of healthcare services in Canada is mandated and funded by the provinces and territories; therefore, healthcare policy and professional practice is largely overseen at this level. The Registered Nurses Association of Ontario (RNAO), in cooperation with the Ontario Ministry of Health and Long Term Care (MOH/LTC), has played a lead role in this area. Following a major review of nursing in Ontario,2 the RNAO and the MOH/LTC established an initiative to assist nurses with complex healthcare situations across the continuum of healthcare. The main goal was to ensure that nursing practice in Ontario would be supported by current clinical evidence. In an initiative known as the Nursing Best Practice Guidelines (NBPG) Project, the RNAO, with funding from the MOH/LTC, convened selected panels to develop guidelines for best practice and through a province-wide competition, selected pilot implementation sites to evaluate use of the guidelines.
The RNAO project was specifically mandated to review, update, and synthesize recommendations from all good quality international guidelines for application in Ontario. The Panel was concerned that the 1992 Agency for Health Care Policy and Research (AHCPR)3 guideline had not been updated since its release. However, on conclusion of the process, the AHCPR guideline on pressure ulcer prevention remained valid. A recent review showed it to be one of the few AHCPR guidelines that remained valid as of 2000.4 If the panel had not reviewed recent guidelines and evidence, the process would have been less credible to Ontario practitioners. The background and process used to develop the RNAO practice guidelines for nurses, using the example of one panel's work in developing best practice guidelines for risk assessment and prevention of pressure ulcers, is described.
Background
Clinical practice guidelines are intended to offer concise instructions on how to provide healthcare services.5 The most important benefit of clinical practice guidelines is their potential to improve the process of care provided by professionals as well as patient health outcomes.6,7 However, their benefits are contingent on 1) a guideline development process that is methodologically rigorous, 2) content that incorporates the best evidence available, and 3) demonstrated successful implementation of the resulting guideline.8,9
Increasingly, professional associations such as the RNAO recognize that the development of evidence-based guidelines requires a systematic and structured process. The process gains validity when both formal and informal consensus development occurs along with a systematic review and appraisal of the literature.10 This project incorporated a number of positive features of guideline development and appraisal processes.11-15 In addition, continuous RNAO support for literature searches, meetings, teleconferences, and secretarial assistance helped the project succeed.
Initially, a full-time project director was recruited to facilitate the NBPG project.16 In the planning phase, the RNAO conducted two focus groups. The first group, comprising nurse leaders from across the province who represented practice, research, education, and administration, identified key populations and health problems where nurses could use evidence-based practice to make a difference. The second focus group consisted of gerontology experts who identified four clinical areas as priority for development of NBPGs: risk identification and prevention of falls, continence management, skin and wound care, and prevention of constipation. Subsequently, three respective panels were appointed to develop recommendations for best practice. Each panel consisted of nurses with clinical expertise from acute care, community care, rehabilitation, or long-term care, as well as a nurse scientist who provided methodological support. Panels selected their own leaders who became the liaisons to the RNAO throughout the process. The first four NBPGs were disseminated early in 2002; two more cycles are still in the development phase for a total of 17 guidelines (see Table 1). The remaining guidelines will be introduced in 2002-2003.
Two supports established by the RNAO were key to the success of the process. The first was the assistance of researchers with expertise in implementing evidence-based practice. They supported the panels' quality appraisal of existing guidelines. The second was a university-based evaluation team; although this team was not involved in the panel process, it was given the mandate to determine outcome indicators and conduct an evaluation of the draft guidelines pilot implementation.
The four phases of the NBPG project were: 1) guideline development, 2) pilot implementation, 3) evaluation, and 4) dissemination. A description of each phase as it pertains to the panel for prevention of pressure ulcers follows.
Development of the Pressure Ulcer Prevention Guideline
The panel consisted of eight nurse representatives from across Ontario: two advanced practice nurses who specialize in wound care; three enterostomal/wound therapists; one gerontology/rehabilitation staff nurse; one nurse researcher; and one registered practical nurse. (The function of registered practical nurses is similar to Licensed Practical Nurses in the U.S.) The RNAO set five key deliverables for the group (see Table 2).
At the start of the panel's work, two factors limited the focus of the guideline. First, a 3-month time limit was imposed on the panel to develop the guideline; thus, they chose just one aspect of skin and wound care, namely Risk Assessment and Prevention of Pressure Ulcers in Older Adults, as a manageable undertaking. Second, panel members had limited experience in developing guidelines. In retrospect, the learning curve for all participants was considerable.
In the development phase, the panel's work consisted of five stages: systematic review of the literature on practice guidelines, quality appraisal of existing guidelines, identification of the best quality guidelines, adoption or adaptation recommendations into the guidelines, and editing the draft recommendations based on stakeholder feedback. In the initial search for existing guidelines, the panel decided that only guidelines meeting the following criteria would be considered:
* published in English
* dated 1995 or later
* limited to risk assessment and pressure ulcer prevention only
* evidence-based, or at a minimum, providing references to the scientific literature
* accessible online or from a publication
Systematic searching for guidelines. The search for guidelines began with a review of the published literature from 1995 to 2000. Databases searched included MEDLINE, Cumulative Index to Nursing & Allied Health Literature (CINAHL), Embase, and Cochrane Library. Search terms included: pressure ulcers, pressure sores, decubitus ulcers, clinical practice guidelines, and practice guidelines. The Internet also was searched for guidelines, including five selected practice guideline websites included in the sites listed in Table 3. Another thorough Internet search was conducted at the final revision stage to ensure no newly released guidelines appeared since the start of the process. None were identified.
In total, five guidelines were identified, retrieved, and deemed suitable for quality appraisal. The selected guidelines were: The Agency for Health Care Policy and Research (AHCPR) Guideline, Pressure Ulcers in Adults: Prediction and Prevention3; the Northern Ireland Clinical Resource Efficiency Support Team guideline17; A Policy Statement on the Prevention of Pressure Ulcers from the European Pressure Ulcer Advisory Panel18; Effective Health Care's bulletin, "The Prevention and Treatment of Pressure Sores: How Useful are the Measures for Scoring People's Risk of Developing a Pressure Sore?"19; and the Research Based Protocol: Prevention of Pressure Ulcers from the University of Iowa Gerontological Nursing Interventions Research Center.20 Although questions about the current validity of the AHCPR guidelines have arisen, the AHCPR was a key reference for many subsequently published guidelines. van Rijswijk and Braden21 note that the AHCPR agency is not currently updating existing guidelines, but the organization now known as the Agency for Healthcare Research and Quality continues to make relevant information available and encourages input from multiple disciplines.
Appraising the quality of existing guidelines. The panel used a slightly modified version of the Appraisal Instrument for Clinical Practice Guidelines22 to appraise the quality of the five selected guidelines. This instrument, which has been shown to be reliable and valid, was developed to help healthcare personnel (general or specialist clinicians, managers, and researchers) assess and make comparisons between guidelines.23,24 It has been used by the National Health Service (NHS) of the UK to assess all guidelines funded by the NHS through the National Clinical Guidelines Group. Recently, more than 200 Canadian drug therapy clinical practice guidelines were assessed using the instrument.15 A strength of the tool is that three dimensions of quality are considered; rigor of guideline development (20 items), context and content (12 items), and application (five items). In addition, two global assessment components measure internal consistency. Analysis of the NBPG panel members' appraisal of the guidelines was carried out by researchers Harrison and Graham, who subsequently provided the results to the panel in both written and verbal formats.26
Systematically conducting a quality appraisal of existing guidelines assisted the panel's consensus process. The appraisal allowed identification of the relative methodological strengths and limitations of each guideline to help identify issues for panel focus and improve understanding of the essential development components of the RNAO guideline. The quality appraisal process of existing guidelines became the first step in filtering the large amount of information from which the panel was working.
Identifying best quality guidelines. Based on the data, the panel selected two guidelines that represented the most comprehensive and current evidence from which to make its substantive recommendations -the AHCPR and the Clinical Resource Efficiency Support Team (CREST) of Northern Ireland.3,17
Adaptation of Guideline Recommendations.
Substantive recommendations. The recommendations in the AHCPR and CREST guidelines were compared and a substantial literature review was conducted. Selection of content for the substantive recommendations generally was made on the basis of the stated evidence in the two identified guidelines. Recommendations from both guidelines were considered using criteria modified from AHCPR, CREST, and the Scottish Intercollegiate Guidelines Network.3,17,27
1. Recommendations directly based on evidence from well-designed randomized controlled trials (RCTs), meta analyses, or systematic review of RCTs (Strength of Evidence Level = A)
2. Recommendations directly based on prospective studies (non-RCTs or good observation studies), retrospective, and cross sectional studies (Strength of Evidence Level = B)
3. Recommendations directly based on evidence obtained from expert committee reports or opinions and clinical experience of respected authorities (Strength of Evidence Level = C).
The panel was particularly impressed by the CREST guideline. It not only provided clinical recommendations for the prevention of pressure ulcers but also made structural recommendations for agencies concerned with pressure ulcer care. Thus, specific care and systems recommendations were incorporated into the RNAO guideline under the following categories:
* Monitoring pressure ulcers including content for a quality monitoring program
* Discharge arrangements including information to provide when patients are moving between settings
* Developing a pressure ulcer prevention and treatment policy (eg, outline of an effective strategy)
* Audits covering clients, facilities, and communities.
A mandate of RNAO was to adapt guidelines for acute care, long-term care, and community care. The panel agreed, however, that their recommendations were appropriate for adults in all contexts of care and that the onus was on agencies to adjust recommendations to their specific needs.
Quick reference guide. Practitioners in busy care settings do not always have the time to refer to comprehensive guidelines, regardless of how user-friendly they appear. Therefore, a quick-reference guide was created to summarize key points from the substantive recommendations. The booklet format covers the substantive recommendations of assessment, planning, interventions, and transfer of care.
Stakeholder feedback. The RNAO process for developing best practice guidelines includes a peer review component. Thus, the panel sought feedback on the draft guideline through a consultation process with stakeholders that included both healthcare professionals and consumers. Stakeholders were identified and approached by the panel members. Once permission was obtained, the draft guideline was mailed to each stakeholder with four questions (see Table 4).
Seventeen stakeholders participated in the feedback process. Professional representation included nursing (clinical staff and administration), clinical dietitians, medicine (a family physician, a geriatrician, and a dermatologist with wound expertise), physiotherapy, and occupational therapy. Consumers were represented by a spokesperson for the Thalidomide Victims Association of Canada, a healthcare professional with paraplegia, and a family member of a nursing home resident. Both written and verbal feedback were received by panel members and included in the guideline revision. One example of stakeholders' input was the identified need for pre-planning the transfer of clients at risk for pressure ulcers. Receiving agencies should be made aware of the cost implications of special prevention products such as pressure reduction/relief support surfaces, gel cushions, wheelchairs that tilt, and pillows or foams for positioning clients, as well as additional staff involvement. This aspect of prevention had not been addressed in other guidelines.
Pilot Implementation
Through a formal "request for proposal" process, a consortium of six sites in one large Ontario city was selected to carry out a 7-month implementation trial of the guideline. The agencies represented the community, complex continuing care, palliative care, rehabilitation, and acute care. An advanced practice nurse was appointed as the clinical resource nurse to develop education tools and lead the project. She met regularly with a committee comprising representatives from the six sites to plan, monitor, and evaluate the implementation. In addition, site champions were selected to support the resource nurse by coaching staff in their respective agencies and monitoring changes. The RNAO project director and the panel leader held monthly teleconferences with the clinical resource nurse to monitor progress. Financial support for this phase of the project was provided by RNAO.
Evaluation of the Pilot Implementation
An evaluation team comprised of academic researchers was contracted by the RNAO to collect data on the pilot implementation of the guideline. A random sample of 229 registered nurses, registered practical nurses, and healthcare aides was sent survey questionnaires; 59.7% responded. In addition, a random subsample of 16 staff participants and six managers participated in semi-structured qualitative interviews. The clinical resource nurse also was interviewed. Data analysis was completed and a summary report made available to the NBPG Panel. Of specific interest to the panel was whether the six categories of risk assessment in Braden's tool were being used to guide the development of client care plans. Verbal reports from the implementation team indicated that this strategy required more work.
Final Revision and Dissemination of the Guideline
At the end of the pilot implementation, the guideline panel received formal feedback from the site consortium and the substantive recommendations were revised. Some of the Evaluation Team's findings concurred with the pilot site's recommendations. The population focus was changed from the original mandate of older adults to include the entire adult population. An addendum was included stating that the RNAO will carry out a review and update of guidelines every 3 years. The third recommendation required the panel to enhance the multidisciplinary perspectives of the document, particularly for assessments and interventions. An additional request for specific directions on the selection of pressure-relieving surfaces and equipment relative to identified levels of risk - ie, Braden Scale risk scores - was an area that the panel felt had only limited support from current literature.
Dissemination of the guideline began through presentations by panel members at national and provincial wound care conferences. Early in 2002, the RNAO formally introduced the guideline to all its members via a mailed announcement about the availability of the guideline in both hard copy or at the website www.rnao.org.
Summary
Clinicians have access to a multitude of guidelines to influence their practice; however, discerning information based on current and convincing evidence is not always easy. The RNAO recognized the need to support nurses in their attempts to carry out best practice for specific populations and health problems. In collaboration with Ontario's Ministry of Health and Long Term Care, which was the funding source, RNAO led a process of development and dissemination of nursing best practice guidelines intended to enhance nurses' practice in the province of Ontario.
The example used here was the development of the guideline Risk Assessment and Prevention of Pressure Ulcers. Implications for practice, education and research are noted below.
Although the guideline is considered current and comprehensive, agencies and practitioners need to take the recommendations and adapt them to their specific client populations in acute, rehabilitation, long-term, or community care settings. Implementation of an agency-specific protocol, which was based on the guideline, enabled one of the authors to demonstrate a decrease in the prevalence of pressure ulcers on three complex continuing care units as part of a pilot project. Subsequently, the protocol was introduced to the rest of the healthcare center. Response from staff in the education sessions was positive when they understood that the information was current, valid, and that RNAO had carried out a credible process in developing the guideline.
From a scientific perspective, the rigorous process for guideline development used for this project demonstrates how good quality guidelines may be produced using objective evaluations of existing guidelines to aid in a consensus-building strategy. The use of a reliable and valid evaluation tool for assessing published guidelines is recommended. In addition, agencies should measure the impact of the guideline through pre- and post-implementation prevalence and incidence surveys. Finally, the guideline needs to be re-visited frequently to ensure it represents current research evidence in order to support best practice. The RNAO plans to update all 17 of its guidelines every 3 years.
Acknowledgments
The members of the RNAO Skin and Wound Panel are Frances MacLeod, RN, MScN, Panel Leader; Patti Barton, RN, PHN, ET; Karen Campbell RN, MScN; Margaret Harrison, RN, PhD; Kelly Kay, RPN; Terri Labate, RN; CRRN, GNC(c); Susan Mills-Zorzes, RN, BScN, CWOCN; and Nancy Parslow, RN, ET. Support for the panel's work was provided by Tazim Virani, RN, MScN, Project Director, and Heather McConnell, RN, MA(Ed), Project Coordinator.
This work was supported by the Ontario Ministry of Health and Long-Term Care and the Registered Nurses Association of Ontario.
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