VOL: 97, ISSUE: 09, PAGE NO: 3
Amanda Tong, BN, RGN, FAETC, is a lecturer in tissue viability, Buckinghamshire Chilterns University College
The promotion of clinical effectiveness in the NHS has been declared a key priority by the present government. This has resulted in increased interest in the potential for clinical guidelines to reduce variations in health care and its cost. Nurses are encouraged to actively foster and utilise an ever-increasing number of clinical guidelines when carrying out a variety of practice interventions. However, anecdotal evidence and personal experience at practice level suggest that, far from supporting clinical decision-making, such initiatives can result in confusion and conflict.
The most important issue impacting on the value of clinical guidelines is the ambiguous use of terminology. A number of authors acknowledge the misleading use of a variety of terms, including ‘protocols’, ‘policies’ and ‘standards’ (Mansfield, 1995; Appleton and Cowley, 1995; Duff et al, 1996; NHS Executive,1996; Fennessey, 1998), but together they do little to clarify the situation.
Finnie (2000) attempted to differentiate between guidelines and protocols in terms of the amount of operational detail they contain. She suggested that guidelines may be developed at a national level and contain intentionally broad statements aimed at providing general advice (national guidelines). In order to reflect local service provision, it is recommended that these guidelines are then adapted to contain more specific detail, thereby becoming protocols.
This would seem a reasonable suggestion, as it should increase the relevance of the recommendations as well as ownership and implementation, but such a process can also result in inconsistencies. Difficulties arise when discrepancies in recommendations have been identified not only between national and local guidelines but also between two sets of national guidelines. With reference to the management of venous leg ulcers it is acknowledged that sustained graduated compression provided by multi-layer or short-stretch bandage systems is the most effective therapy (NHS Centre for Reviews and Dissemination, 1997). Although the RCN guidelines (1998) recommend the application of either system, the Scottish guidelines (SIGN, 1998) do not acknowledge research relating to the effectiveness of short-stretch bandages. This surely reduces patient choice and denies access to an effective intervention.
The extent of local guideline development independent of the national guidelines is based on anecdotal evidence. However, support for the fact that such problems are not unique to wound care is evident in the literature. Appleton and Cowley (1997) reported that, during their research aimed at analysing the validity of clinical practice guidelines for use in a specific aspect of health visiting, some trusts supplied copies of two or more different types of guidelines they claimed their employees were using. This raises the question as to whether employers as well as employees were aware of the purpose and nature of guidelines.
The role of individual trusts in the dissemination of guidelines is not identified in the literature, but it would seem obvious that, for a policy to be implemented, there is a need for effective organisational support (Feder et al, 1999).
The RCN (1997), together with the Department of Health (NHS Executive, 1996), are very clear that recommendations contained in clinical guidelines should be based on sound scientific evidence provided by high-quality randomised controlled trials rather than the subjective opinion of individual practitioners. As such they aim to provide a more research-based and rigorously reviewed guide to clinical decision-making than the standards and policies most nurses will have been used to.
However, within wound care alone there are a number of guidelines in which most of the recommendations are based on the weakest grade of evidence. This is due to a lack of high-quality randomised controlled trials (Dickson, 1996; Renvoize et al, 1997; Haycox et al, 1999) and has been blamed for undermining the reliability of many guidelines.
The format in which guidelines are presented has been suggested as being influential in promoting their use in practice (NHS Centre for Reviews and Dissemination, 1994). The RCN guideline for the management of patients with venous leg ulcers is available in three formats: a brief version for practitioners (available free of charge), a version containing the full rationale on which recommendations are made (available at a price), and a technical report detailing the methods by which the guideline was developed.
However, it is now more than two years since publication, and discussions with practising nurses with a role in leg ulcer management indicate that many are not aware of the existence of the guidelines in any format. The cost of the full document is an obvious barrier to its effective dissemination and personal experience also suggests that obtaining a copy can be difficult and time-consuming.
Essentially, all practitioners in this field should be familiar with and have immediate access to, at the very minimum, a summary of guideline recommendations relevant to their area of practice. It is encouraging to see that in some areas practitioners are given handbooks containing evidence-based wound care guidelines (Baeyens, 2000), although these were developed independently and required considerable commitment from all involved.
In view of the number of points raised with regard to the validity of guidelines, their professional and legal standing must also be questioned. The government clearly removes itself from all responsibility for the use of guidelines (NHS Executive, 1996), leaving this to the professional bodies. While the guideline developers have a responsibility to ensure that guidelines reflect a reliable body of medical or nursing opinion, ultimately responsibility appears to rest with the practitioner as to how the guideline is implemented. This is apparent from the RCN and the SIGN leg ulcer guidelines, which include what amounts to a disclaimer by the guideline developers.
Variations in the application of clinical guidelines have featured in a number of court cases (Tingle, 1997). The essential issue, when guidelines are used in a legal context, appears to be the explicit documentation of the guideline development process. Although it is assumed that in the event of a legal challenge this evidence would be available, it is largely inaccessible to most practitioners.
Inevitably there are resource implications associated with the effective implementation of guidelines, and inadequate funding will provide a significant barrier to the execution of the recommendations.
The RCN and the SIGN leg ulcer guidelines both provide examples of recommendations, such as follow-up care and referral patterns, that are difficult to implement, given staff shortages, poor professional development opportunities and lack of specialist input in some areas.
Responsibilities resulting from numerous clinical effectiveness and cost-efficiency initiatives, together with resource management issues, only increase the demands on nurses, making it more difficult for them to keep abreast of clinical practice developments. Very few have the time, skills or inclination to search and critically appraise all relevant research-based evidence (Baeyens, 2000). Unless information is provided in a useful and readily accessible format, nurses cannot be expected to be aware of its existence, much less implement it.
The potential for appropriate and rigorously produced clinical guidelines to improve the quality of care and achieve health gain has been established (NHS Centre for Reviews and Dissemination,1994). Most of the literature reviewed, however, was medically oriented, and there appears to be little evaluation of the impact of clinical guidelines on nursing practice or other professions allied to medicine.
The NHS research and development agenda, as highlighted in the report of an expert advisory group (Department of Health, 1995), identified that there was a need for a systematic review of the effectiveness of guidelines for disciplines other than medicine. In response to this, a review of the literature, carried out by Thomas et al (1998), failed to identify an adequate number of high-quality and methodologically sound studies on which to draw conclusions.
Many guidelines are yet to be audited, and therefore their true validity cannot be determined. Therefore there is no evidence to date to suggest that clinical guidelines are effective in bringing about changes in nursing practice that will ultimately result in health gains.
Despite inherent problems, guidelines are part of a move towards efforts to improve patient care to which the Department of Health and the RCN are committed. A great deal of work remains to be done in ensuring that clinical guidelines achieve the health gains and reduced costs they claim to be able to influence.
With the continued proliferation of guidelines into clinical practice, practitioners have a professional duty to challenge issues that may influence their effectiveness. Ultimately, this can only contribute to higher-quality guidelines.