CC BY
22Articles
J Health Dev 2018; 2(27) Supplement:10-14
EVIDENCE-BASED NURSING CLINICAL GUIDELINES TO ENSURE THE QUALITY AND SAFETY OF NURSING PRACTICES. THE PROCESS OF DEVELOPING GUIDELINES IN THE REPUBLIC OF KAZAKHSTAN
Kivinen Eveliina1, Lehto Siru2, Heikkila Johanna3
1RN Lahti University of Applied Sciences, Senior lecturer, Nursing degree programme coordinator, Finland 2RN JAMK University of Applied Sciences, Senior lecturer, Finland 3RN JAMK University of Applied Sciences, Senior Advisor, Finland
Abstract
The aim: Description of a process of developing of nursing guidelines in the Republic of Kazakhstan.
Methods: We offer clinical guideline principles and present working groups, who develop patients care principles in the Republic of Kazakhstan.
Results: Currently the first four international clinical guidelines are being adapted. Within the next few years, 15 recommendations for patients caring are planned to be developed in the Republic of Kazakhstan.
Conclusions: Nursing clinical guidelines in Kazakhstan will be represent high level tools based on evidences which are accessible for everyone and contribute to safety and quality care. Key words: nursing, clinical guidelines, Kazakhstan
Дэлелдемелi медицинага негiзделген сапалы жене %ayíncí3 медициналык квмек корсету Yшiн мейiргерлерге арналган клиникальщ нускаулыктар.
Казахстан Республикасында едстемелш нускаулар куру процеа
Тужырымдама
Максаты: Цазакстан Республикасында эдiстемелiк нускаулар куру процесн сипаттау.
Эдiстерi: Бiз Цазакстандагы клиникалык тэжiрибенiц жетекшi npuH^nmepi мен наукастардыц ^miMÍHÍn жетекшi npuH^nmepÍH курастыратын жумыс тобы жайлы мэлiмет 6epdiK.
Нетижелерi: Цазipai тацда клиникалык тэжiрибенiц алгашкы терт халыкаралык жетекшi принциптерi бейiмделiп курастырылды. Бiрнеше жыл iшiнде Цазакстанда наукастардыц KYтiмiне арналган 15 нускаулыктар курастырылады деп жоспарлануда.
Цорытынды: Цазакстандагы мейiрaерлiк ютщ жетекшi клиникалык принциптерi жалпыга мэлiм накты деректерае CYйенaен сапасы жогары куралдар болып табылады. Олар наукастардыц KYтiмiн кауiпсiз эрi сапалы дээрежеде аткаруга септiaiн тиaiзедi.
Krnmmí свздер: жетекшi принциптер, мейiрaерлiк с, Цазакстан.
Клинические руководства сестринской службы для обеспечения качественной и безопасной медицинской услуги основанной на доказательной медицине. Процесс разработки методических инструкций в Республике Казахстан
Резюме
Цель: Описание процесса разработки руководящих принципов сестринского дела в Республике Казахстан.
Методы: Нами представлены руководящие принципы клинической практики и изложены рабочие группы, разрабатывающие руководящие принципы ухода за больными в Республике Казахстан.
Результаты: В настоящее время адаптируются первые четыре международных руководящих принципов клинической практики. В течение ближайших нескольких лет планируется разработать 15 рекомендаций по уходу за больными в Республике Казахстан.
Выводы: Клинические руководящие принципы сестринского дела в Казахстане будут представлять собой высококачественные инструменты, основанные на фактических данных, доступные всем и они будут способствовать безопасному и качественному уходу.
Ключевые слова: руководящие принципы, сестринское дело, Казахстан.
УДК 61:001.83(100) Corresponding author: Heikkila Johanna, Senior Advisor Ph.D (Health
Sciences/ Nursing Science), RN University of Applied Sciences JAMK, Recieved: 03.06.2018 Finland
Accepted: 12.06.2018 Address: P. O. Box 207 FI-40101 Jyvaskyla, Finland
Phone: +358 20 743 81 00 E-mail: Heikkila. johanna@jamk.fi
Introduction
Over the past decades, extensive research has been carried out on the methods underpinning clinical practice guidelines (CPGs). During this period, the CPGs have shifted from opinion-based to evidence-informed and an increasing number of terms, tools and acronyms have emerged [1]. Today CPGs are considered effective tools in delivering optimal, quality-focused, patient-centric, safe care and improving the quality and cost of healthcare. The evidence demonstrates that CPGs can also have a positive impact on nursing practices and patient outcomes [2]. Nursing clinical guidelines are intended to help nurses make informed, reasoned and evidence based decisions in nursing clinical practices.
This article presents the development of nursing clinical guidelines in the Republic of Kazakhstan. The development was launched in 2018 in accordance with the comprehensive nursing development plan for 2019 [3] in «Social Health Insurance Project: increasing the availability, quality, cost-effectiveness and financial protection» activities concerning Modernization of Education System for Nurses. In the Project, Finnish experts mentor, support and monitor the development process regarding nursing clinical guidelines. The development process started with creating manuals on how to develop nursing clinical guidelines and training the Research committee in January 2018 in Astana. The Research committee was then divided into Development groups, which are currently adapting the first nursing clinical guidelines. Over the next few years, the plan is to develop 15 nursing clinical guidelines for the Republic of Kazakhstan. The first four international CPGs are currently being adapted.
The materials and methods section of this article introduces the clinical practice guidelines and sets out the working groups developing the nursing clinical guidelines in the Republic of Kazakhstan. Thereafter, the results section presents the main results of the development work so far; the manuals for writing nursing clinical guidelines, training of the Research committee and the four (4) first guidelines to be published in the autumn 2018. At the end this article discusses the future steps regarding the development of nursing clinical guidelines.
Materials and methods
Critically appraised and synthesized scientific evidence has become very important in healthcare. In clinical practice, it is challenging for professionals to keep up to date with the volume of new evidence-based information. Therefore, quality clinical practice guidelines synthetizing current research evidence are important tools also for nursing professionals. However, guideline development processes vary, some guidelines do not meet basic quality criteria [4] and professionals are unknowingly following recommendations that have not undergone rigorous development [5].
IOM (2011) describes CPGs as important documents able to enhance clinician and patient decision making by clearly describing and appraising the scientific evidence and reasoning (benefits and harms) behind
clinical recommendations and making them relevant to the clinicians. Evidence-based guidelines help nurses to explain and justify nursing interventions and standard national guidelines, rather than organisations using different guidelines, are required to develop a more advanced role for nurses in healthcare [6].
In the beginning of the process, the different definitions of the CPGs were considered. In the Republic of Kazakhstan, the nursing clinical guidelines were defined as documents synthesizing current evidence and recommendations for nursing professionals about the care of patients with specific conditions. CPGs use preventive, diagnostic, therapeutic and rehabilitation actions in the management of patients based on evidence-based medicine and nursing. Nursing clinical guidelines were considered to be statements of recommended best practice which have been systematically developed in a specific clinical area with the aim of providing direction for nursing professionals in their practice [7]. Nursing clinical guidelines assist nurses with the implementation of evidence-based, patient safe and competent nursing care.
CPGs can be introduced into clinical practice in a variety of ways. The development of a new (de nuovo) clinical guideline involves months of dedication from the professionals involved. Therefore, developing new CPGs is considered to be time-consuming and expensive. The adoption, contextualisation and adaptation of the recommendations from existing CPGs is considered to be more efficient. In adoption, the CPG recommendations are implemented into clinical practice without any changes being made to them. Contextualisation means that the local situation is taken into account in the implementation. In adaptation, the recommendations are adapted to the local environment. In adaptation, some changes can be made to the recommendations so that the care provided is relevant in a new environment [8].
In Kazakhstan, adaptation was defined as a systematic approach in considering the use and/or modification of existing guidelines produced in one cultural and organizational setting for application in a different context. Adaptation is considered to be a participative process involving local key stakeholders. In adaptation, guidelines are customized to be suitable for local contexts [9]. The adaptation process improves the quality of guidelines and ensures that recommendations are relevant to nursing practices in the Republic of Kazakhstan.
In the development of nursing clinical guidelines, coordination is important for quality outcomes. At the beginning of the process, the working groups for the development of nursing clinical guidelines were planned together with local experts. It was agreed, that for the development of nursing clinical guidelines in the Republic of Kazakhstan, there would be five (5) different working groups; the coordination group, the development group, the steering group the guideline methodologists and the external review group with consultants [7]. The Development group has the main role and responsibilities regarding the development of guidelines (Figure 1).
Finalizes the scope and the clinical question
Searches existing guidelines/evidence
(Conducts systematic reviews)
Evaluates the evidence/international guidelines
Formulates/adapts the recommendations
Writes the guideline/adaptation
Prepares a draft plan for implementation
Figure 1 - Development group responsibilities for the development of guidelines
The Coordination group monitors and coordinates the nursing clinical guideline work in the Republic of Kazakhstan. In the future, this group will set up the policies, review the guideline proposals, update the manuals and inform the public. The Development group has a major responsibility to be actively involved in the new guideline/ adaptation processes. Development groups vary in their size depending on the scope of the guideline. The groups should be multidisciplinary and include representatives from relevant professional groups, patients, carers and representatives from appropriate voluntary organisations. Each Development group names one representative (chair) in the Steering group. The responsibility of the steering group is to evaluate the development processes for nursing clinical guidelines. In the near future, it is also important to name guideline methodologists, local experts who can support Development groups in their work. During the Project, Finnish experts will be working as an external review group [7].
Results
Nursing clinical guideline development in the Republic of Kazakhstan started in the beginning of 2018 and co-operation between Finnish and local experts has been effective and productive. To date, the manuals providing step by step instructions on the technical and procedural aspects of building nursing clinical guidelines can be considered one of the key results of the co-operation. The development of knowledge and skills of the local actors can also be considered as one of the key results. The third key result of the development work are the four guideline adaptation processes.
In the beginning of 2018 two manuals for nursing clinical guideline development were written. Manual 1. «Methodological recommendation how to develop nursing clinical guidelines» concentrates on new guideline development and Manual 2. «Methodological recommendations how to adapt international nursing clinical guidelines» on guideline adaptation. The development process for the manuals started by making a search strategy, conducting a literature search and reviewing identified literature. In addition, internet search engines were used.
Three Finnish experts went through the search results and selected methodological articles and handbooks for closer review.
Handbooks reviewed included the WHO handbook for guideline development (2014) [10], NRF handbook for nursing clinical guideline (2013) [11], NICE manual for developing guidelines (2014) [12], SIGN guideline developer's handbook (2015) [13] and ADATPE recourse toolkit for guideline development (2009) [9]. In addition, The Ministry of Health and Social Development (2016) [14] regulations on the development /revision of clinical protocols in the Republic of Kazakhstan and the process description on guideline development [15] were also reviewed. While writing the manuals, evidence-based information on guideline development was utilized and manuals providing step by step instructions on the technical and procedural aspects of writing nursing clinical guidelines were designed.
Both manuals have a clear structure guiding the members of the Development group. Manual 2. «Methodological recommendations how to adapt international nursing clinical guidelines» presents the process of adaptation. The adaptation process was planned to have six (6) stages and fifteen (15) steps showing how to adapt international guidelines (Table 1).
Table 1 - The stages and steps of nursing clinical guideline adaptation in The Republic of Kazakhstan
Stages Steps Development process
1. Proposing a Step 1 Consider the proposal and establish a Development group guideline
development or Step 2 Ensure and justify the need for a guideline adaptation and
adaptation draft the scope
2. Preparation of a Step 3 Organize different working groups and schedule the work to guideline be done
adaptation process Step 4 Write the scope and determine criteria for guideline selection
3. Finding and Step 5 Identify existing international guidelines assessing
internati°nal Step 6 Assess the suitable guidelines
guidelines Step 7 Review the assessments and select a guideline for adaptation
4. Adapting Step 8 Make a decision to adapt assessed guideline and guideline translate the guideline into Russian recommendations
Step 9 Adapt guideline recommendations and write a draft of the guideline
Step 10 Plan for update and aftercare of the guideline
5. Subjecting the Step 11 Seek feedback and consultation adapted guideline Step 12 Finalize the adapted guideline to external review
6. Approving and Step 13 Approve the adapted guideline publishing the Step 14 Publish the adapted guideline adapted guideline Step 15 Implement the adapted guideline
The second main result so far has been the competency development of the local experts. During the spring of 2018, two Master classes were organized for the purpose of training the methods for guideline development. The classes included advanced information on evidence-based nursing, nursing research and guideline development. The Master classes were practical and the Development groups have been able to proceed in their guideline development in the workshops. As a result, in the Republic of Kazakhstan there is a Research committee, 15 local experts competent in nursing clinical guideline development. Finnish experts continue to mentor and support these Research committee members.
The third main result is the progress regarding four adaptation processes. In January 2018 the Research committee was divided into four Development groups and each Development group was given a theme area (Asthma, Diabetes, Heart failure and Hypertension). The Development groups proceeded to write the scope, clinical question and determine criteria for guideline searches. An individual guideline search using the template designed for the purpose was conducted and the Development groups selected quality CPGs for AGREE evaluation [16]. After that, each Development group selected 2-3 CPGs for
further evaluation and the content, how up to date they were and the consistency of the guidelines were evaluated [9]. In May 2018, each Development group selected one CPG and permission to use the guideline for adaptation was requested. Having been translated the guideline recommendations are currently being adapted.
Discussion
Nursing clinical guidelines are one of the best way to apply evidence-based nursing knowledge in practice. Evidence-based practice integrates the best evidence from well-designed studies and evidence-based theories with a clinician's expertise and a patient's preferences and values in making the best clinical decisions. CPGs are important tools that can reduce variations in the level of healthcare and improve patient outcomes. Therefore, they should be routinely incorporated into nursing practice [5].
CPGs can be developed, for example, at organizational, regional or national level. Many countries still lack high-quality national level nursing clinical guidelines. In the Republic of Kazakhstan, the development of nursing clinical guidelines has now been launched. In the Project manuals on how to develop nursing clinical guidelines have been created and the Research committee
has been trained. The first four international CPGs are in the adaptation process and will be published in September 2018. The publication of guidelines is, however, only part of the development of evidence-based nursing. After publication, the national implementation materials and procedures will be developed by Finnish experts in cooperation with local experts. In December, the first national guideline trainers will receive training to enhance the
implementation process.
The nursing clinical guideline development is to be expanded to include more healthcare specialists, patients, family members and local stakeholders. It is intended that the nursing clinical guidelines in the Republic of Kazakhstan will be high-quality evidence-based tools available to all and that they will promote safe and quality nursing care.
References
1. Kredo T., Bernhardsson S, Machingaidze S., Young M. et al. Guide to clinical practice guidelines: the current state of play. International Journal for Quality in Health Care. 2016; 28(1): 122-128.
2. JCI. Clinical Practice Guidelines: Closing the gap between theory and practice. A white paper by Joint Commission International, 2016. Web site. Retrieved 27.05.2018. Available: https://www.elsevier. com/.
3. Комплексный план развития сестринского дела в Республике Казахстан до 2019 года: утв. Министром здравоохранения Республики Казахстан 6 декабря 2016 года.Kompleksnyj plan razvitija sestrinskogo dela v Respublike Kazahstan do 2019 goda (Comprehensive plan for the development of nursing in the Republic of Kazakhstan until 2019) [in Russian]: utv. Ministrom zdravoohranenija Respubliki Kazahstan 6 dekabryia 2016 goda.
4. Qaseem A., Forland F., Macbeth F., Ollenschlager G., et al. Guidelines International Network: Toward international standards for clinical practice guidelines. Annals of internal Medicine. 2012; 156(7):525-531.
5. Melnyk B. Important information about clinical practice guidelines: Key tools for improving quality of care and patient outcomes. Worldviews on Evidence-Based Nursing. 2015; 12(1):1-2.
6. Senn B, Kobleder A., Schiess C. Evidence-based guidelines as a necessity for advanced practice nurses. Annals Nursing Practice. 2014; 1(2):1010.
7. Kivinen E, Hopia H, Jаrvinen S, Vааnаnen I. Manual 2. Methodological recommendation how to adapt international
nursing clinical guidelines. SHIP - Modernization of Education System for Nurses, 2018.
8. Dizion J., Machingaidze S., Grimmer K. To adopt, to adapt, or to contextualise? The big question in clinical practice guideline development. BMC Research Notes. 2016; 9:442.
9. ADAPTE collaboration. Guideline Adaptation: A Resource Toolkit, 2009. Web site. Retrieved 27.05.2018. Available: http://www.g-i-n.net/.
10. WHO. WHO handbook for guideline development. Second edition, 2014. Web site. Retrieved 27.05.2018. Available: http://apps.who.int/.
11. NRF. Handbook for nursing recommendations [in Finnish], 2013. Web site. Retrieved 27.05.2018. Available: http://www. hotus.fi/
12. NICE. Developing NICE guidelines: the manual, 2014. Web site. Retrieved 27.05.2018. Available: https://www.nice.org. uk/.
13. SIGN 50 A guideline developer's handbook. Scottish Intercollegiate Guidelines Network, 2015. Web site. Retrieved 27.05.2018. Available: https:// www.sign.ac.uk/.
14. The Ministry of Health and Social Development. Regulations on the development /revision of clinical protocols in the Republic of Kazakhstan, Astana, 2016.
15. McGowana J., Muratovb J., Tsepkec A., Issinad A. et al. Clinical practice guidelines were adapted and implemented meeting country-specific requirements the example of Kazakhstan. Journal of Epidemiology. 2016; 6:8-15.
16. AGREE Enterprise, 2018. Website. Retrieved 27.05.2018. Available: http://www.agreetrust.org/.
