December 2020A Model for Developing Evidence-based Clinical Practice Guidelines for School Nursing

A Model for Developing Evidence-Based Clinical Practice Guidelines for School Nursing
The Journal of School Nursing
2020, Vol. 36(6) 415-422
© The Author(s) 2019
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DOI: 10.1177/1059840519880938
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Robin Adair Shannon, DNP, RN, NCSN, PHNA-BC¹

, andErin D. Maughan, PhD, MS, RN, APHN-BC, FNASN, FAAN²

AbstractSchool nurses need evidence-based clinical practice guidelines (CPGs) to provide quality care for students with special healthcare needs. However, a gap analysis revealed a paucity of rigorous school nursing CPGs. To fill this gap, a Model for Developing Evidence-based Clinical Practice Guidelines for School Nursing (School Nursing CPG Model) was designed under the auspices of the National Association of School Nurses to offer school nurse scholars, school health leaders, and pediatric clinical experts a standardized structure and systematic process to create rigorous evidence-based CPGs. The aim is to employ the School Nursing CPG Model to build a repository of CPGs that are projected to improve the quality of school nursing practice, thereby improving health and educational outcomes for students with special health-care needs. The School Nursing CPG Model is anticipated to apply to CPG development for other nursing specialties.Keywordsbest practices/practice guidelines, evidence-based practice, school nurse education, standards of care, leadershipApproximately 50.7 million children attend public school and 5.9 million children attend private school in the United States (U.S. Department of Education, National Center for Education Statistics, 2018). It is estimated that 20% of public school students have special health-care needs resulting from developmental, medical, or mental/behavioral conditions lasting over 1 year that require prescribed medications or therapeutic interventions (U.S. Department of Health and Human Services [USDHHS], Health Resources and Services Administration, Maternal and Child Health Bureau, 2014). All students with health conditions have the right to a free and appropriate public education under the Rehabilitation Act (1973) and the Individuals with Disabilities Education Improvement Act (2004). These federal civil rights laws protect against discrimination at school based on disability and mandate the provision services necessary for school attendance and participation, including nursing services.To provide quality nursing care for students with special health-care needs, school nurses must engage in evidencebased practice (EBP), which is grounded in the best available research and data, clinical expertise, and the values of the student population (Maughan & Yonkaitis, 2017; Melnyk & Fineout-Overholt, 2015). However, school nurses commonly face significant barriers to EBP, including professional isolation, inadequate staffing and support, and limited time and resources, as well as insufficient skills to access and appraise the current health science literature (Yonkaitis, 2018).Scientifically developed clinical practice guidelines (CPGs) lower barriers to school nursing EBP and are critical to providing quality care for students with special healthcare needs (Shannon, 2018). Evidence-based CPGs are “specific practice recommendations grouped together that have been derived from a methodologically rigorous review of the best evidence on a specific topic” (Grinspun, Melnyk & Fineout-Overholt, 2015, p. 12). Although CPGs contain important recommendations for practice, they do not replace nursing judgment. CPG implementation requires the school nurse to use astute clinical decision-making skills according to the nursing process and individualize care to meet the unique health-care needs of the given student.The National Association of School Nurses (NASN) recognizes the importance of evidence-based CPGs for school nursing practice to support their strategic plan goals: “(1) Inform school nurses in the application of data to practice. (2) Facilitate collection, analysis, dissemination and use of data” (NASN, 2018, para. 8). NASN’s Framework for 21st Century School Nursing Practice (NASN, 2016) depicts a dynamic practice with student, family, and community at the core surrounded by four overlapping dimensions of school nursing practice: community and public health, care coordination, leadership, and quality improvement. Enveloping all dimensions of the Framework for 21st Century School Nursing Practice are the School Nurse Standards of Practice, which include CPGs. Specifically, CPGs support school nurses to be competent in Standard 13: Evidence-based Practice and Research of the School Nursing Scope and Standards of Practice which stipulates that “the school nurse integrates evidence and research findings into school nursing practice” (American Nurses Association [ANA] & NASN, 2017, p. 74).¹ University of Illinois at Chicago, IL, USA² National Association of School Nurses, Silver Spring, MD, USACorresponding Author:
Robin Adair Shannon, DNP, RN, NCSN, PHNA-BC, University of Illinois at Chicago College of Nursing, 845 S. Damen Avenue, Rm 1038 (MC 802), Chicago, IL 60612, USA.
Email: rshann2@uic.eduFig1Yet a gap analysis revealed a paucity of evidence-based CPGs for the specialty of school nursing. Existing school nursing CPGs vary markedly in methodology and rigor. Furthermore, CPGs developed for primary and tertiary health-care settings may not translate well to the community setting of schools. To fill this gap, a Model for Developing Evidence-based Clinical Practice Guidelines for School Nursing (School Nursing CPG Model) has been designed through an academic partnership between the University of Illinois at Chicago College of Nursing and NASN. The School Nursing CPG Model was validated through a trial CPG project (Lepkowski, Shannon, & Maughan, 2020).
Under the leadership of NASN, the School Nursing CPG Model establishes a rigorous and standardized process for building a robust repository of quality CPGs for practicing school nurses. School nurse scholars and leaders are encouraged to partner with NASN in using the School Nursing CPG Model to create new CPGs on priority student health conditions. Opportunities are limitless for school nurse/nurse researcher teams to collect data and study outcomes related to the implementation of evidence-based CPGs developed using this model. There is confidence that the rigor of the structure, process, and outcomes of the School Nursing CPG Model will prove germane to the development of evidence-based CPGs for other nursing specialties as well. Evidence-based CPGs are projected to positively impact the quality of school nursing practice and in turn improve health and educational outcomes for students with special health-care needs.PurposeThe purpose of the School Nursing CPG Model is to offer school nurse scholars, pediatric clinical specialists, school health content experts, and school nursing leaders a professional structure, standardized process, and rigorous methodology to create evidence-based CPGs for school nursing practice under the auspices of NASN. The goal of CPGs for the specialty of school nursing is to ensure that strong EBP recommendations are accessible to improve health, wellbeing, and educational outcomes for students with special health-care needs.Conceptual FrameworkThe School Nursing CPG Model begins with the definition of the clinical problem, then follows a Donabedian (1988) framework that outlines the structure and process needed to achieve the outcome of a quality evidencebased clinical guideline for school nursing practice (Figure 1). NASN has research priorities to study the outcomes of school nursing CPG implementation related to student health and learning indicators.RigorThe benefits of CPGs are directly related to their quality. Therefore, a high standard for systematic guideline development that incorporates rigorous methods is imperative to the successful application of guideline recommendations into practice (Institute of Medicine [IOM], 2011). The School Nursing CPG Model is designed to meet the standards for CPGs established by the USDHHS Agency for Healthcare Research and Quality (AHRQ, 2014), IOM (2011), and the Appraisal of Guidelines for REsearch and Evaluation Instrument (AGREE Next Steps Consortium, 2013). Quality CPGs shouldTab1

be authorized by an official professional organization (e.g., medical or nursing specialty association, professional society, government agency, or health care organization),

include a systematic literature search and review of current relevant peer reviewed evidence,

contain EBP recommendations, strategies, and information that have been systematically derived to support practitioners in making informed clinical decisions in specific health-care contexts,

be current or updated within the last 5 years.

Components of the School Nursing CPG Development ModelCPG Project Structure and ManagementThe responsibility for CPG development is housed within a professional organization or government body to insure proper development and dissemination of the guideline as well as continuity and sustainability of the process (AHRQ, 2014). NASN is responsible for oversight of the structure and management of the school nursing CPG development (Table 1). NASN will uphold the eight Standards for Developing Trustworthy CPGs outlined by the IOM (2011): “(1) establishing transparency, (2) management of conflicts of interest, (3) guideline development group composition, (4) CPG-systematic review intersection, (5) establishing evidence foundations for rating strength of recommendations, (6) articulation of recommendations, (7) external review, and (8) updating” (pp. 2–3).The development of CPGs requires attention to the critical dimensions of relevance, quality, need, timeliness, and professional autonomy (Hewitt-Taylor, 2003). The NASN Director of Research sets priorities and time lines for CPG development, approves CPG proposals, and oversees NASN educational and research staff dedicated to guideline projects.Operationalizing the School Nursing CPG Model is a team endeavor and involves many key stakeholders. Effective teamwork is essential to success. Experts with the requisite skill set in school nursing EBP, school health, and/or pediatrics (e.g., school nurse scholars, nursing professors, and pediatric specialty providers) may submit proposals to or be recruited by NASN to develop CPGs. Advanced nursing degree students (graduate and doctoral) are encouraged to submit proposals for CPG development projects to NASN in coordination with qualified faculty mentors. Additionally, school health researchers and doctoral students are encouraged to submit research proposals to NASN with specific aims to study outcome indicators that are sensitive to the implementation of school nursing evidence-based CPGs.NASN oversees a two-step peer review process of each school nursing CPG. A clinical expert peer review panel chosen by NASN, including school nursing experts on the subject, will review the guideline’s clinical content for accuracy and relevance and make suggestions for improvement. Following appropriate revisions by the guideline team, NASN will convene a guideline expert appraisal panel with knowledge and experience in CPG critique who will evaluate the CPG according to a standardized CPG appraisal tool, such as the Appraisal of Guidelines for REsearch and Evaluation Instrument, commonly referred to as the AGREE II Instrument (AGREE Next Steps Consortium, 2013). Widely recognized as the standard for CPG development and appraisal, the AGREE II is a validated and reliable tool designed for use in developing and evaluating the quality of CPGs on health conditions across a spectrum of health-care settings (AGREE Next Steps Consortium, 2013; Grinspun, Melnyk, & Fineout-Overholt, 2015). After finalization and approval, the School Nursing CPG will be disseminated through the NASN website for use by practicing school nurses.CPG Development ProcessThe CPG Development Process outlines the methodology for the scholarly team to create a standardized quality CPG. This work is a dynamic and iterative process with interdependent components. The steps of developing an evidencebased CPG include the following: outline the rationale for the clinical guideline, specify the health condition and etiology, assemble and synthesize the literature, critically appraise the evidence, and translate the evidence into practice recommendations (Adams & McCarthy, 2007; Hewitt-Taylor, 2003; IOM, 2011; Maughan & Schantz, 2014; Rich, 2012; Sciarra, 2012; Titler & Adams, 2005; USDHSS, AHRQ, 2014). A School Nursing CPG is composed according to the following standardized format and instructions.Title: School Nursing Evidence-Based CPG: Students with (Health Condition).1. Rationale

Compose: A brief introduction that outlines the scope of the problem and the rationale for the CPG:

Health condition topic: diagnostic criteria and etiology

Prevalence and/or population at risk

Manifestations

Impact on learning

Gaps in current practice (demonstrate need for CPG)

Expected outcomes/benefits to the student population

2. Purpose State: “The purpose of this CPG is to give the professional school nurse EBP recommendations for quality care of (target student population) with (health condition) to improve student (expected outcomes).”
3. Methodology State: “This evidence-based CPG has been developed according to the Model for Developing Evidence-based CPGs for School Nursing. 4. Definition of terms
Provide: A glossary of terms, abbreviations, and common acronyms.
5. Systematic search and selection of relevant literature

Follow the CPG Evidence Decision Tree (Figure 2). Components in the decision tree are color coded to correspond with respective tables within the CPG Development Process.

Describe the literature search and selection methods:

Databases: List databases, hand searches, and assistance from librarians if indicated. Include Internet search methods.

Keywords: school nurse, clinical guidelines, evidence-based practice, (insert health condition, and other key words as appropriate)

Search inclusion criteria such as: English; peer reviewed research or practice journals; within 5 years unless it is a seminal source, or nothing is newer; types of articles; evidence–based Internet sources. Use primary sources when available.

Specify the number of sources identified by the search and the number of sources included for critical appraisal (e.g., use PRISMA, 2015, flow diagram).

6. Critical appraisal of the evidence

Apply a systematic methodology for critical appraisal of evidence that has been approved by the NASN project lead. A sample collective findings table to document sources that meet the inclusion criteria for critical appraisal is offered in the NASN online format.

Grade the QUALITY of evidence from each source by assigning a Roman numeral grade according to the criteria in Table 2.

Grade the LEVEL of evidence from each source by assigning a numeric grade according to the criteria in Table 3.

Grade the STRENGTH of the evidence from sources that support practice recommendations by assigning a letter grade according to the criteria in Table 4.

7. Synthesis of evidence and translation into clinical practice recommendations

Derive evidence-based clinical practice recommendations.

Analyze the collective findings table to determine the domains of care which are general themes of school nursing practice (e.g., prevention, education/training, care coordination, self-care, medications/procedures, emergency action plan, educational modifications or accommodations).

Derive evidence-based clinical practice recommendations corresponding with the domains of care for each source.

For each domain of care, identify the sources as numbered from the collective findings table corresponding with each level of strength (A, B, C). Sources may support more than one domain of care or practice recommendation.

Organize the evidence-based clinical practice recommendations according to the nursing process/School Nursing Standards of Practice (ANA & NASN, 2017).

8. Composition of clinical practice recommendations

Compose the evidence-based clinical practice recommendations as formatted in Table 5.

State the evidence-based clinical practice recommendations according to the steps of the nursing process/School Nursing Standards of Practice (ANA & NASN, 2017) following the language prompts in Table 5.

Stipulate the associated domains of care and the identified sources for each domain by strength, quality, and level of evidence and associated numbered sources.

Additional EBP tools that support the CPG may be included as appendices.

Once the CPG draft has been composed, follow Steps 5–8 of the CPG Project Structure and Management (Table 1): (5) documentation and submission, (6) guideline review and appraisal, (7) revision and adoption, and (8) dissemination and education. NASN is responsible for managing the 5-year cycle of revision and allotting resources to ensure the sustainability of the CPG.Fig2
▸ Collect data on literature search criteria, including keywords, databases used, inclusion/exclusion criteria, specific time period, number of articles that met search criteria, and number of articles included as evidence.▸ If the literature meets the search criteria, review the abstract and conduct a rapid read of the article to apply the Quick Appraisal criterion:Is the source reputable?Is the information relevant to the student population?Is the information applicable to school nursing practice?▸ If the source meets the Quick Appraisal criterion, advance the source to Critical Appraisal (Step 6) and include in the Collective Findings.Tab2Tab3Tab4Implications for School Nursing PracticeUnder the auspices of NASN, A Model for Developing Evidence-based CPGs for School Nursing outlines a rigorous, standardized, and validated approach to deriving sound nursing clinical practice recommendations based upon the best available evidence. The School Nursing CPG Model outlines the structure and process by which school nurse scholars, school health leaders, and pediatric clinical experts can produce the outcome of a standardized CPG that addresses the priorities and complexities of nursing care for children with special health-care needs in the school setting. The School Nursing CPG Model is intended as the foundation upon which to build a repository of evidence-based CPGs to support delivery of quality school nursing practice. School health research is needed to study the impact of school nursing CPGs on student health and education outcomes. It is anticipated that the School Nurse CPG Model will be germane to developing CPGs for other nursing specialties.Tab5AcknowledgmentThe authors gratefully acknowledge the time and talent of Dr. Martha Dewey Bergren of the University of Illinois at Chicago College of Nursing in support of this project.Author ContributionBoth authors contributed equally to the conception of the article, acquisition, and analysis of the data involved, critical revisions, gave final approval, and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Article was drafted by the first author, Robin Adair Shannon.Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.FundingThe author(s) received no financial support for the research, authorship, and/or publication of this article.ORCID iDsRobin Adair Shannon, DNP, RN, NCSN, PHNA-BC

https://orcid.org/0000-0003-0036-5264
Erin D. Maughan, PhD, MS, RN, APHN-BC, FNASN, FAAN

https://orcid.org/0000-0002-0176-1499
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