Gold standards: ANA and nurse experts promote using national guidelines to inform, intervene with patients

Consumers these days contend with a lot of mixed messages on how to best take care of themselves: Have a glass of red wine a day…or stick to nonalcoholic beverages. Eat more protein than carbohydrates…or go for more carbs. Or—to bring up a recent and highly debated issue—hold off on getting a routine mammogram…or not.

It’s nurses, however, who can help consumers understand and incorporate federal and other key healthcare guidelines into their lives, as well as explain the strengths and weaknesses of various, and sometimes conflicting, research findings. It’s also up to nurses to ensure they know which guidelines are reliable and to use appropriate healthcare recommendations and solid evidence in their own practice.

“We know that when we deliver evidence-based health care, patient outcomes are at least 28% better,” says Bernadette Melnyk, PhD, RN, FNAP, FAAN, dean and distinguished professor in Nursing, Arizona State University College of Nursing and Health Innovation, and Arizona Nurses Association member. “But it is estimated that only 15% to 50% of healthcare decisions are evidence-based.”

And which recommendations are implemented often is determined by either the chief nursing officer, chief surgeon, or other hospital administrators, notes Melnyk, who is also a member of the U.S. Preventive Services Task Force (USPSTF), which develops evidence-based recommendations that form the basis of clinical standards for primary care providers throughout the United States.

But ANA, other nurse organizations, and individual RNs are working to boost nurses’ involvement in developing, promoting, and implementing evidence-based national guidelines and practice.

“Nurses are critical to disseminating and translating information to patients,” says Lisa Summers, DrPH, CNM, senior policy fellow, ANA’s Department of Practice and Policy. “So they need to know which guidelines can promote their patients’ health and be able to explain how population-focused recommendations can support, not take away from, patients’ individualized decision-making.”

Further, ANA wants to help set priorities for the nation’s comparative effectiveness research (CER) agenda —which ultimately could form the basis of future national guidelines. CER typically involves exploring which treatments, processes, or medications produce the best results.

ANA believes nurses can make significant contributions by determining what should be studied to improve patient care and consumer health, including how best to deliver primary care, as well as participating in research activities.

Looking beyond the controversy

Most consumer-oriented healthcare guidelines get a fair amount of media attention when released. But when the USPSTF released its revised breast-cancer screening recommendations in November 2009, a controversy was born.

Lucy Marion, PhD, RN, who just rotated off a 5-year term on the multidisciplinary task force of experts that released the recommendations, acknowledges that initial communications around the guidelines could have been better. That said, the controversy also brought to the forefront the importance of nurses knowing exactly what’s in these and other guidelines so they can accurately explain them to their patients or alter their practice.

In the case of the breast-cancer screening guidelines, the task force never said women aged 40 to 49 should not receive mammograms, as was widely reported, according to Marion, dean and professor, School of Nursing, Medical College of Georgia and Georgia Nurses Association member. Instead it recommends that, rather than automatically screening every woman annually or biennially, clinicians first talk with their patients about the benefits and harms of undergoing routine screening mammograms based on their personal and family health history, overall health, values, and preferences.

“Contrary to the belief that ‘if a little is good, more is better,’ that is not necessarily true with screening,” Marion says. The scores of evidence the task force reviewed showed that a high number of false positives occurred within this age group, leading to unneeded procedures, such as biopsies and radiation, as well as patient anxiety. Furthermore, overdiagnoses occur when mammograms detect cancers that may never progress and unnecessary treatments follow.

Marion and Melnyk also note that the process of developing the guidelines was lengthy and scientifically rigorous, which is something nurses should look for when assessing the credibility of any healthcare recommendation.

Additionally, nurses should examine what level of evidence the recommendations are based upon and whether there is any information about how the guidelines can be incorporated into their practice.

For example, the USPSTF notes that starting regular, biennial screening mammography before age 50 is a “Grade C” recommendation, meaning clinicians should offer or provide this service only if other considerations support it, such as a family history of breast cancer or personal preference of the woman. To read the recommendations, go to the Agency for Healthcare Research and Quality (AHRQ) website at www.Ahrq.gov/clinic/USpstf/uspsbrca.htm. For more information from ANA, go to www.nursingworld.org/HomepageCategory/NursingInsider/Archive_1/2009-NI/Dec09NI/Advisory-on-USPSTF-Guidelines-on-Breast-Cancer-Screening.aspx.

Using cardiovascular guidelines in nursing practice

Cardiovascular nursing expert Joanna Sikkema, MSN, ANP-BC, routinely uses national guidelines, such as those focusing on weight reduction, blood pressure management, and smoking cessation, when advising her primary care patients and teaching nursing students.

For example, cholesterol guidelines spell out target goals and strategies for interventions, including lifestyle modifications and pharmacologic measures, according to Sikkema, Florida Nurses Association member, a member of ANA’s Congress on Nursing Practice and Economics, and past president and current board member of the Preventive Cardiovascular Nurses Association (PCNA).

But problems can arise when certain organizations produce different guidelines.
“Patients and consumers can get caught in the middle—not knowing which recommendations to follow,” Sikkema says. “When I use guidelines to make evidence-based decisions, especially when determining healthcare interventions, I often have to explain to my patients why I chose a certain strategy to manage their health care and why there may be differing guidelines.”

Sikkema notes that PCNA created two useful tools that are designed not only for cardiovascular specialty nurses, but also for any RN or advanced practice registered nurse (APRN) interested in promoting cardiovascular health.

One booklet is the 2009 “National Guidelines and Tools for Cardiovascular Risk Reduction,” a pocket-sized booklet that bedside nurses and others can use when talking to their patients about their health.

Another PCNA pocket-sized, one-page tool is “Elevated Triglycerides and Low HDL-C: A Quick Look at Patient Evaluation.” More information on both is available at the PCNA website, www.pcna.org.
Sikkema is currently on an American Heart Association-American College of Cardiology committee that is drafting guidelines on the management of stable ischem­­ic heart disease.

“When we are writing guidelines, we are looking at a plethora of research so we can recommend the most cost-effective, evidence-based strategies for patient management,” she says. “And that translates to quality care, which what evidence-based practice and the comparative effectiveness research movement is all about.”

Keep these points, tools in mind

Catherine Ruhl, MS, CNM, director of women’s health programs for the ANA organizational affiliate, the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), agrees that using national guidelines is essential to quality care. She notes that her organization has been a pioneer in the area of developing evidence-based guidelines specifically for maternal and neonatal nursing care.

Ruhl says nurses who are looking for healthcare guidelines can start by going to the National Guideline Clearinghouse (www.guideline.gov), an initiative of AHRQ.

If nurses can’t find the nursing practice guidelines they need, AWHONN recently revised a key resource, “Achieving Consistent Quality Care: Using Research to Guide Clinical Practice, Second Edition,” by Shannon Scott, PhD, RN. The document leads nurses through the process of guideline development. (For more information, go to www.awhonn.org/store.)

And when looking at any set of national or specialty guidelines, Ruhl suggests the following:

  • Know who developed the guidelines and what the objective was.
  • Understand whom the recommendations target.
  • Go beyond the sound bite or headline to learn what the guidelines really say.

“Nurses are experts in patient education, and it’s our responsibility to know the guidelines that can support patients in making informed decisions about their health,” Ruhl says.

Melnyk agrees, saying “Our primary goal is to promote the highest level of care for our patients, and evidence-based practice and national guidelines are the gold standards. Every interaction with our patients is an opportunity to educate them on health promotion.”

And finally, Sikkema urges all nurses to get involved in developing national guidelines.

“Nursing is not represented on many national guideline-writing committees, yet we are the healthcare providers who use guidelines—or should use them—every day in our practice.”

Susan Trossman is the senior reporter in ANA’s communications department.

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