Effect of clinical guidelines in nursing, midwifery, and the therapies: a systematic review of evaluations

Background-Although nursing, midwifery, and professions allied to medicine are increasingly using clinical guidelines to reduce inappropriate variatio ns in practice and ensure higher quality care, there have been no rigorous overviews of their effectiveness. 18 evaluations of guidelines were identif ied that meet Cochrane criteria for scientific rigor. Methods-Guideline evaluations conducted since 1975 which used a randomised controlled trial, controlled before and after, or interrupted time series d esign were identified through a combination of database and hand searching. Results-18 studies met the inclusion criteria. Three studies evaluated guid eline dissemination or implementation strategies, nine compared use of a gu ideline with a no guideline state; six studies examined skill substitution: performance of nurses operating according to a guideline were compared wit h standard care, generally provided by a physician. Significant changes in the process of care were found in six out of eight studies measuring proces s and in which guidelines were expected to have a positive impact on perfor mance. In seven of the nine studies measuring outcomes of care, significant differences in favour of the intervention group were found. Skill substitu tion studies generally supported the hypothesis of no difference between pr otocol driven by nurses and care by a physician. Only one study included a formal economic evaluation, with equivocal findings. Conclusions-Findings fi om the review provide some evidence that care drive n by a guideline can be effective in changing the process and outcome of ca re. However, many studies fell short of the criteria of the Cochrane Effect ive Practice and Organisation of Care Group (EPOC) for methodological quali ty.