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Policy: Nurses’ input is vital to guideline development

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Author Clare Lomas, BSc, BA, RGN, is news reporter, Nursing Times.

Clare Lomas explains how guidelines are developed and why nurses need to be actively involved in this process.

NICE issued its first guidance in April 2001. It has now published over 430 pieces (Box 1) and is in the process of developing many more.

Using the expertise of doctors, nurses, patients and carers, the evidence-based guidelines are designed to help healthcare professionals promote good health, and prevent and treat ill health.

Probably the guidance most relevant to nursing practice is the clinical guidelines. To date, NICE has published 64 clinical guidelines, ranging from the management of hypertension to the assessment and prevention of falls in older people. NICE’s clinical guidelines do not replace the knowledge and skills of healthcare professionals but set out recommendations on the most appropriate treatment and care of people with specific diseases and conditions.

Nurses can use NICE clinical guidelines to help develop standards for best practice, in education and training, to improve communication between patients and healthcare professionals, and to help patients make informed decisions.


Developing guidelines
Developing NICE guidelines is a lengthy process and takes about two years from inception to the publication of the final guidance. NICE considers topics for guidance from a variety of sources, including the Department of Health, healthcare professionals, patients, carers and the public (Box 2). If nurses want to suggest a topic they can complete a form that can be obtained by calling or emailing NICE, or they can download it from the NICE website at www.nice.org.uk.

NICE reviews each of the suggestions received, which are then assessed according to the DH’s selection criteria. This takes into account the morbidity and mortality of the disease, the cost to the NHS, inappropriate variations in practice and the urgency for guidance to be produced. The final decision on which topics are referred to NICE lies with the DH.


Guideline development groups
Once a topic has been selected, a National Collaborating Centre (NCC) is commissioned to prepare a scope, which details what the guideline will and will not cover. The NCC also sets up an independent guideline development group (GDG) for each clinical guideline that is being developed. The GDG, which includes healthcare professionals and patient or carer representatives, looks at all the available evidence and makes recommendations to produce a draft guideline.


Consultation and stakeholders
A consultation period then follows where registered stakeholders – healthcare professionals and groups representing patients and carers – can comment on the draft guideline. Nurses who are not registered stakeholders can provide comments but
NICE recommends that, because they work very closely with registered stakeholder groups, any comments or suggestions that nurses want to make should be made via
the relevant organisation. Information of how to register as a stakeholder can be found on the NICE website.

There is always at least one public consultation period on a draft guideline. This usually lasts for two months and an independent guideline review panel is responsible for making sure that all stakeholder comments have been taken into account.

At the close of the consultation process the GDG finalises the guideline recommendations and the NCC produces the final guidance. It is then formally approved by NICE and the official guidance is issued to the NHS.


Short clinical guidelines
In July 2007, NICE introduced the first of its short clinical guidelines, on the recognition of and response to acute illness in adults in hospital. Developed using the same methods as regular clinical guidelines, short guidelines are produced within
a shorter time period – usually 9–11 months – to help the institute respond faster to urgent NHS issues relating to specific parts of a care pathway. NICE aims to produce at least two of these types of guidelines per year, and these shorter guidelines will also be used to help update the guidelines already in existence.


Role of nurses in guideline development
Nurses have a key role to play in the development and implementation of NICE guidelines. Where guidance is particularly relevant to nursing practice, nursing groups, such as the Leg Ulcer Forum or the UK Association of Diabetes Nurses, may be consulted or involved in the guideline process.

In order to ensure their views are taken into account throughout the consultation process, nursing organisations can register as stakeholders. Individual nurses, who have a specialist interest in an area where a guideline is being developed, can apply to be a part of the guideline development group.

Implementing NICE guidance can be a challenging process, so NICE has set up a programme to help nurses and other healthcare professionals put the guidelines into clinical practice. This includes advice on costing tools, audit criteria and education tools (see p10).

Nurses can also apply to join the external reference group, which supplies NICE with informal feedback on implementation support tools. Information on how to join these groups, and other ways in which nurses can help implement NICE guidance and promote best practice can be found on the NICE website.


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Box 1. Types of NICE guidance

- Technology appraisals;
- Clinical guidelines;
- Intervention procedures;
- Public health guidance.

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Box 2. Process of guideline development

- Developing NICE guidelines takes about two years.
- NICE considers topics for guidance from the Department of Health, healthcare professionals, patients, carers and the public.
- Once a topic has been selected, a National Collaborating Centre (NCC) is commissioned to prepare a scope – what the guideline will and will not cover.
- The NCC sets up an independent guideline development group (GDG) to look at all the available evidence and makes recommendations to produce a draft guideline.
- A consultation period then follows where registered stakeholders can comment on the draft guideline.
- There is always at least one public consultation period on a draft guideline.
- At the close of the consultation process the GDG finalises the guideline recommendations and the NCC then produces the final guidance.
- The guidance is then formally approved by NICE and the official guidance issued to the NHS.

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Being part of the guideline development group

Dianne Crowe has been a gynaecology specialist nurse practitioner at Hexham NHS Trust in Northumberland for nine years. During this time she has been instrumental in leading a number of nurse-led initiatives, including setting up a one-stop clinic for abnormal uterine bleeding.

As a member of the RCN gynaecology steering group, Ms Crowe was invited to apply to join the guideline development group (GDG) on the NICE clinical guideline on heavy menstrual bleeding. She was accepted by NICE and the group first met in January 2005.
‘It was a big commitment to make but the subject is of special interest to me so I was glad to be part of the group,’ says Ms Crowe.

Being on the GDG meant she had to attend meetings in London every month, with teleconferences in between, and undertake specific reading and allocated work.
‘It meant some very early starts; when going to London I would be up at five in the morning and not get home until midnight,’ she says. ‘But in the current climate, where nurses are taking on a lot of the jobs that medics used to do, I felt it was essential for nurses to have a voice.’

Each time the group met they would look at specific parts of the topic. This involved examining current clinical practice, patient education and the latest research. They would then make recommendations based on the best available evidence. Part of Ms Crowe’s role as the only nurse on the group was to give presentations on examples of good clinical practice to the other members of the GDG.

‘In my presentation on patient information and education, I was able to demonstrate how nurses and doctors working in partnership in specialist clinics, such as our one-stop abnormal uterine bleeding clinic, were able to impact on patient outcomes,’ she says.
‘Seeing patients in a dedicated clinic – right environment, right staff and right equipment – can maximise their healthcare experience and deliver the right message. Our hysterectomy rate at Hexham has steadily reduced by 60% over the last 7–8 years as a result of high-quality patient information and a dedicated team. I clearly demonstrated the theory-to-practice gap, in that it is the “how” or the “process” that has a great impact on patient care.’

Ms Crowe says she was given the opportunity to have a lot of input into the guideline development, and it was a good opportunity to learn and share new ideas on clinical practice.

‘Although it can be quite daunting at first, inputting ideas became easier as time went on,’ she says. ‘We had a fantastic group chairperson who was really keen for the nurse and patient representatives to have their say.’

Being on the development group also meant that Ms Crowe was able to see first hand how changes were made in response to stakeholder comments and new evidence.

‘The group always took account of what the stakeholders had to say, and subtle changes were made all along the line. It was great to be the nursing link because, although you have to go with the evidence, it is possible to get carried away. You have to remember to bring it back and relate the practical points to patient care.’

Although it does involve a lot of commitment, Ms Crowe says she would recommend being on a GDG to other nurses. ‘Even if it was only in small ways, such as how things were worded, I do like to think that my input made a difference,’ she says. ‘Nurses can give a different slant on things and are essential in plugging the gap between theory and practice.’

The final NICE clinical guideline on heavy menstrual bleeding was published in January 2007 and is due for review in January 2011.

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