Guidelines for clinical practice: development, dissemination and implementation

Abstract

Clinical guidelines are one of the most promising and effective advances for defining and improving the quality of care (Journal of Nursing Care Quality 11(5) (1997) 48; Medical Care 39(8 Suppl. 2) (2001) II-46). However, their development, dissemination and implementation in practice are rarely straightforward. Within nursing practice, guidelines have the potential to ensure the clinical application of research findings, thus ensuring that the profession rejects ineffective practices while employing those shown to work. Nevertheless, the benefits and limitations of clinical guidelines should be carefully considered by practitioners, managers and consumers of health care alike.

Introduction

The effectiveness of clinical care and treatment is central to the quality of health care (Thomson, 2000). However, during the last decade variations in practice, inappropriate care and rising health-care costs have been persistently highlighted (Cluzeau et al., 1994; Shaneyfelt et al., 1999). Health-care providers are being challenged to define their practice and the expected patient outcomes resulting from their processes of care delivery (Yoos et al., 1997) while pressure is also exerted on them to ensure that their practices are effective, safe and efficient (Forbes and Griffiths, 2002).

The development and implementation of clinical guidelines are two of the promising and effective advances for defining and improving the quality of care (Yoos et al., 1997; Grol, 2001). Potential benefits include reduced morbidity and mortality, improved efficiency and cost containment (Cluzeau et al., 1994) as well as providing users with consistent advice and common points of reference for assessing their performance against the measurable criteria (Cluzeau and Littlejohns, 1999). As a framework for decisions, guidelines also enable practitioners to justify their practices and legitimise their activities as well as work collaboratively with other health-care providers within a shared framework of understanding and activities (Parker, 2002).

The emergence of clinical guidelines as a tool for improving the quality of care is international. In the United Kingdom, professional and governmental contributions to evidence-based guidelines are uniting, in England and Wales, through the recently established guidance on commissioning cancer services (Department of Health (1997), Department of Health (1998), Department of Health (1999)) and in Scotland through the longer established Scottish Intercollegiate Guidelines Network (SIGN) collaboration between the Scottish Medical Royal Colleges and the Scottish Executive. Preparing evidence-based clinical guidelines begins with the synthesis of available evidence and is facilitated by high-quality systematic reviews from the NHS Centre for Reviews and Dissemination, the UK Cochrane Centre and technology assessments from the NHS Research and Development Programme. However, the subject of guidelines is a complex one and the increasing volume of publications has fuelled the debate that continues to range between guidelines being thought of as ‘the best thing since sliced bread’ on one hand and being decried as ‘cookbook medicine’ on the other.

This review article will firstly summarise the main issues surrounding clinical guidelines, their development, content and intended use before considering the use of guidelines in relation to nursing practice. It is not intended as a systematic review of the literature; however, rigorous search methods were used to identify key literature including database searches of Medline and CINAHL (between 1980 and present) as well as reference lists within the identified literature.