From Evidence to Standard: The Role of Clinical Guidelines in Oncology Care

The development and implementation of guidelines for oncology nursing practice is a detailed, rigorous process where nurses are key members of an interprofessional team of experts. By identifying gaps in practice, assessing and reviewing the knowledge base, and following a system of best practices for development and implementation, oncology nurses are creating change in patient care and nursing practice through clinical guidelines.

The Importance of Guidelines

Clinical guidelines inform practice through rigorous examination of available evidence. Rebecca Morgan, PhD, MPH, executive director for Evidence Foundation in Cleveland, OH, and co-chair of the U.S. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Network, identifies what constitutes an appropriate guideline and the way it can influence practice.

“We consider a guideline to be any document containing recommendations for clinical practice or public health policy. They provide a way to structure and answer questions about clinical, public health, or policy interventions, in the pursuit of improving health care or health policy,” Morgan says. “For oncology nurses, guidelines provide actionable recommendations that inform how one should practice or provide care.”

A guideline’s usefulness is entirely dependent on how well practitioners and their institutions adopt it, according to ONS member Ann Berger, PhD, APRN-CNS, AOCNS^®, FAAN, professor and Dorothy Hodges Olson Endowed Chair at the University of Nebraska Medical Center College of Nursing in Omaha.

“In an ideal world, guidelines play a major role in all nursing practice—and specifically oncology nursing practice,” Berger says. “For this to occur, oncology nurses need to have the information available to them—even in a busy clinic setting—like having them accessible online or available at a moment’s notice. Guidelines must be endorsed by leaders and promoted for use by all clinicians. There’s a rigorous procedure for guideline development, and, through my work with ONS and the National Comprehensive Cancer Network (NCCN), I’ve seen great changes in care and treatment when guidelines are developed and implemented into everyday practice.”

Morgan says that part of the process of developing effective clinical practice guidelines is ensuring the message is clear to clinicians. Guideline documents must follow a format to provide focused, concise information for practice.

“Graded recommendations are presented in a standard format to convey a standard message,” Morgan says. “When writing guidelines, we use clear language to communicate whether a recommendation is strongly in favor or against an intervention, meaning that the majority of people would want to have it rather than the alternative. Or we make it clear that the evidence is conditionally in favor or against an intervention, meaning that more people would want it than not, but shared decision making should play a role.”

Guidelines or Best Practices—What’s the Difference?

Clinical practice guidelines can often be confused with—or referred to interchangeably with—best practices for care, Morgan says. However, the two have distinct differences, especially the amount of rigor and review to which guidelines are subjected.

“Best practices, or what we might refer to as good practice statements, represent recommendations that a guideline panel feels are important but not appropriate for formal rating of the quality of evidence,” Morgan says. “These occur in rare situations where the message is necessary for healthcare practice and the outcomes and downstream consequences from the intervention will result in a large, positive consequence. However, collecting and summarizing the evidence for a best practice wouldn’t be the best use of the guideline panel’s already-taxed resources.”

ONS’s Putting Evidence Into Practice (PEP) resources have been helpful for many oncology nurses, informing practice interventions and patient care. However, in 2019 ONS staff and members began working together to move those best practices toward official clinical practice guidelines, leading to even greater practice change and implementation throughout institutions.

“Some of the ONS PEP resources’ strengths include the comprehensive evidence that’s been compiled, the experts who have weighed the evidence, and the highlighted levels of effectiveness established for an intervention’s use in care,” Berger says. “However, they have weaknesses too. They only list the intervention that could be useable—for instance, physical activity—but don’t provide information for nurses to teach patients about how to exercise or be active. With ONS’s recent work to develop those resources into clinical practice guidelines, the benefits could include far greater visibility for practitioners and an improved uptake by interprofessional teams to implement the resources into practice. Undergoing the guideline process submits PEP resources to a further level of rigor and endorsement throughout the medical community.” 

Developing Guidelines for Practice

It’s a team effort to find and create lasting change in practice, and the process for producing guidelines requires many stakeholders and healthcare professionals. Morgan explains that ONS put together an interprofessional panel representing oncology nurses, allied health professionals, clinicians, academicians, patients and patient representatives, and methodologists to work on the PEP-to-guidelines project.

Additionally, the evidence support for each guideline needs to meet rigorous, established criteria, Morgan says. “The guidelines follow the GRADE approach, which serves as a framework to evaluate the quality of the evidence and use that evidence—along with other criteria—to inform decisions.”

Berger’s work on the NCCN Guidelines for Cancer-Related Fatigue provided her with critical experience with the process.

“As the NCCN guideline chair, I can work to inform ONS on the process of guideline development,” Berger says. “At NCCN, we have a team of experts, many of whom are mentoring new members, to evaluate the evidence for guideline development.”

Berger explains that representatives from all 29 NCCN member institutions meet annually through video conference calls to review data and further the process of creating clinical guidelines. Then, a team of experts and mentees reviews and edits the evidence. Another ONS member, Kathi Mooney, PhD, RN, professor and Louis S. Peery and Janet B. Peery Presidential Endowed Chair of Nursing at the University of Utah College of Nursing, serves as the panel’s vice-chair and also helps inform the guideline creation process.

Developing guidelines from the PEP resources offers ONS and its members clear benefits for the future of nursing practice.

“The guidelines provide clear and actionable statements to guide oncology symptom management across a diverse range of topics,” Morgan says. “In addition to making recommendations, the documents include information on how to implement and monitor the recommendations. They also highlight gaps in the current research and will inform future studies that could benefit nursing practice in the years to come.”
 

Informing Future Oncology Practice

Creating practice resources and informing the way nurses deliver the best possible care to their patients are just a few of the new ONS clinical practice guidelines’ many goals. The documents will change patients care and ensure nurses are practicing with most thoroughly reviewed, up-to-date evidence available. 

“ONS is recognizing the importance of evidence-based care and the complexities of healthcare decision making by adopting a framework that allows decision makers to consider the totality of the information,” Morgan says. “The GRADE approach takes into consideration the quality of the evidence, the benefits and harms, patients’ values and preferences, resource implications, health equity, acceptability to key stakeholders, and feasibility of implementation. All of those factors may vary when comparing prevention, management, and treatment considerations—and all should be taken into account when deciding on the best course of action for patients.”

Clinical guidelines inform how nursing care is delivered and what interventions are recommended, given the available evidence—both now and in the future.

“Nurses must consistently seek the most current evidence for practice and create new plans for how they will interact with patients,” Berger says. “Through my own work of developing nationally recognized guidelines, I have witnessed the transformation from experience-based care to evidence-based practice. The possibilities for future practice changes are endless—and the continued introduction of new guidelines, like NCCN’s tumor types and supportive care guidelines, are already peaking on the horizon. ONS can make a real difference and elevate care for patients, families, communities, and clinical sites through the development of nursing practice guidelines.”