Reaching beyond the review of research evidence: a qualitative study of decision making during the development of clinical practice guidelines for disease prevention in healthcare

Abstract

BackgroundThe judgment and decision making process during guideline development is central for producing high-quality clinical practice guidelines, but the topic is relatively underexplored in the guideline research literature. We have studied the development process of national guidelines with a disease-prevention scope produced by the National board of Health and Welfare (NBHW) in Sweden. The NBHW formal guideline development model states that guideline recommendations should be based on five decision-criteria: research evidence; curative/preventive effect size, severity of the condition; cost-effectiveness; and ethical considerations. A group of health profession representatives (i.e. a prioritization group) was assigned the task of ranking condition-intervention pairs for guideline recommendations, taking into consideration the multiple decision criteria. The aim of this study was to investigate the decision making process during the two-year development of national guidelines for methods of preventing disease.MethodsA qualitative inductive longitudinal case study approach was used to investigate the decision making process. Questionnaires, non-participant observations of nine two-day group meetings, and documents provided data for the analysis. Conventional and summative qualitative content analysis was used to analyse data.ResultsThe guideline development model was modified ad-hoc as the group encountered three main types of dilemmas: high quality evidence vs. low adoptability of recommendation; insufficient evidence vs. high urgency to act; and incoherence in assessment and prioritization within and between four different lifestyle areas. The formal guideline development model guided the decision-criteria used, but three new or revised criteria were added by the group: ‘clinical knowledge and experience’, ‘potential guideline consequences’ and ‘needs of vulnerable groups’. The frequency of the use of various criteria in discussions varied over time. Gender, professional status, and interpersonal skills were perceived to affect individuals’ relative influence on group discussions.ConclusionsThe study shows that guideline development groups make compromises between rigour and pragmatism. The formal guideline development model incorporated multiple aspects, but offered few details on how the different criteria should be handled. The guideline development model devoted little attention to the role of the decision-model and group-related factors. Guideline development models could benefit from clarifying the role of the group-related factors and non-research evidence, such as clinical experience and ethical considerations, in decision-processes during guideline development.

A systematic review and quality appraisal of bereavement care practice guidelines

“…Regardless of how well bereavement care practice guidelines may be written, it is likely that compromises will be made between the practice ideal and pragmatism when being implemented . Recent surveys paint a sobering picture of the extent to which current bereavement care practice guidelines are implemented in palliative care services.…”

Exploring nurses’ experience about facilitating factors in medication administration based on clinical judgment of nurses: A content analysis

“…If those guidelines were not available, the nurses would then need to resort to doctors’ ideas and experiences to carry out medical orders. The most appropriate condition for clinical judgment is situational utilization of evidences such as guidelines in accordance with the systematic examination of patient and ideas of colleagues ( 33 ). The results of our research were in line with the previous researches and showed that carrying out medical orders in the cases of emergency is a mixture of resorting to clinical guidelines and specialists’ ideas, which are the most appropriate facilitators.…”

Developing value-orientations in family therapy trainees: A three-year investigation

“…Quality criteria, based on Lincoln and Guba's (1985) concept of trustworthiness, were taken into account. Further, the researchers aimed at establishing the quality of this research through performing systematic searches for and appraisals of research evidence ( Richter Sundberg, Garvare, & Nyström, 2017 ). Similar criteria, such as confirmability, credibility, transferability and dependability were used to establish rigour and support trustworthiness ( Shenton, 2004 ).…”