Financial Management Please respond to the following· Explain.docx

"Financial Management" Please respond to the following:
· Explain the three methods for calculating credit card interest
and your reason for going with a particular method.
· Provide an example of how you can use the power of
compounding interest to pay for a future expense.
· Discuss which practical application covered in the chapter you
think you will use within the next year and how you think
studying this topic will help you make wise financial choices in
the future.
ICU Nurses' Oral-Care Practices and the Current Best Evidence
Author: Ganz, Freda DeKeyser, RN, PhD; Fink, Naomi Farkash,
RN, MHA; Raanan, Ofra, RN, MA; Asher, Miriam, RN, BA;
Bruttin, Madeline, RN, MA; Nun, Maureen Ben, RN, BSN;
Benbinishty, Julie, RN, BA
ProQuest document link
Abstract:
The purpose of this study was to describe the oral-care practices
of ICU nurses, to compare those practices with current
evidence-based practice, and to determine if the use of
evidence-based practice was associated with personal
demographic or professional characteristics.
A national survey of oral-care practices of ICU nurses was
conducted using a convenience sample of 218 practicing ICU
nurses in 2004-05. The survey instrument included questions
about demographic and professional characteristics and a
checklist of oral-care practices. Nurses rated their perceived
level of priority concerning oral care on a scale from 0 to 100.
A score was computed representing the sum of 14 items related
to equipment, solutions, assessments, and techniques associated
with the current best evidence. This score was then statistically
analyzed using ANOVA to determine differences of EBP based
on demographic and professional characteristics.

The most commonly used equipment was gauze pads (84%),
followed by tongue depressors (55%), and toothbrushes (34%).
Chlorhexidine was the most common solution used (75%). Less
than half (44%) reported brushing their patients' teeth. The
majority performed an oral assessment before beginning oral
care (71%); however, none could describe what assessment tool
was used. Only 57% of nurses reported documenting their oral
care. Nurses rated oral care of intubated patients with a priority
of 67+/-27.1. Wide variations were noted within and between
units in terms of which techniques, equipment, and solutions
were used. No significant relationships were found between the
use of an evidence-based protocol and demographic and
professional characteristics or with the priority given to oral
care.
While nurses ranked oral care a high priority, many did not
implement the latest evidence into their current practice. The
level of research utilization was not related to personal or
professional characteristics. Therefore attempts should be made
to encourage all ICU nurses to introduce and use evidence-
based, oral-care protocols.
Practicing ICU nurses in this survey were often not adhering to
the latest evidence-based practice and therefore need to be
educated and encouraged to do so in order to improve patient
care.
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Headnote
Abstract
Purpose: The purpose of this study was to describe the oral-care
practices of ICU nurses, to compare those practices with current
evidence-based practice, and to determine if the use of
evidence-based practice was associated with personal
demographic or professional characteristics.
Design: A national survey of oral-care practices of ICU nurses
was conducted using a convenience sample of 218 practicing
ICU nurses in 2004-05. The survey instrument included

questions about demographic and professional characteristics
and a checklist of oral-care practices. Nurses rated their
perceived level of priority concerning oral care on a scale from
0 to 100. A score was computed representing the sum of 14
items related to equipment, solutions, assessments, and
techniques associated with the current best evidence. This score
was then statistically analyzed using ANOVA to determine
differences of EBP based on demographic and professional
characteristics.
Findings: The most commonly used equipment was gauze pads
(84%), followed by tongue depressors (55%), and toothbrushes
(34%). Chlorhexidine was the most common solution used
(75%). Less than half (44%) reported brushing their patients'
teeth. The majority performed an oral assessment before
beginning oral care (71%); however, none could describe what
assessment tool was used. Only 57% of nurses reported
documenting their oral care. Nurses rated oral care of intubated
patients with a priority of 67±27.1. Wide variations were noted
within and between units in terms of which techniques,
equipment, and solutions were used. No significant
relationships were found between the use of an evidence-based
protocol and demographic and professional characteristics or
with the priority given to oral care.
Conclusions: While nurses ranked oral care a high priority,
many did not implement the latest evidence into their current
practice. The level of research utilization was not related to
personal or professional characteristics. Therefore attempts
should be made to encourage all ICU nurses to introduce and
use evidence-based, oral-care protocols.
Clinical Relevance: Practicing ICU nurses in this survey were
often not adhering to the latest evidence-based practice and
therefore need to be educated and encouraged to do so in order
to improve patient care.
Key words
Oral care, intubated patient, evidence-based nursing practice
Some members of the Israeli Cardiology and Critical Care

Nursing Society took the initiative to organize a work group
dedicated to promoting critical care nursing research and
evidence-based practice. The group first heard lectures about
evidence-based practice and how it can clinically affect patient
care and how to critically review the literature. Following these
lectures, the group conducted lengthy discussions about the
purpose of the group and what projects could be realistically
completed. Members of the group came to the conclusion that
they wanted to conduct a national project related to a clinical
area that is exclusive to nursing, could apply to all types of
intensive care units, had some evidence in the literature, and
could affect patient outcomes.
At the time of the beginning of the project (late 2003 to early
2004), several studies were published that found that poor oral
hygiene might be associated with an increased risk for
pneumonia with its concomitant increased morbidity and
mortality. One specific article caught the attention of the group
(Grap, Munro, Ashitani, & Bryant, 2003). These authors
reported that intensive care unit (ICU) nurses' oral care
practices were not documented nor were they in accordance
with the most recent evidence. Oral care of intubated patients
was then chosen as the topic for the project. Members of the
group also believed that no consistent practices related to oral
care existed, even within the same unit, and that most nurses
had little or no knowledge of the current best evidence-based
practice. Because the primary purpose of the group was to
promote evidence-based practice, members were interested in
determining what factors could be associated with the use of
evidence in practice so that future interventions could be
directed toward those groups to improve clinical practice and
patient care. Therefore the purpose of the project was three
fold: (a) to describe oral-care practices of ICU nurses, (b) to
compare those practices to the current evidence, and (c) to
determine whether personal demographic or professional
characteristics were related to evidence-based, oral-care
practice.

Background
Ventilator-associated pneumonia (VAP) is considered to be the
most common nosocomial infection (Vincent, 2004) and has
been found to be a major cause of morbidity and mortality in
ICUs (Bercault & Boulain, 2001; Elward, Warren, & Fraser,
2002; Relio et al., 2002). In a review of VAP literature, Chastre
and Fagon (2002) concluded that VAP is a complication in 8%-
28% of patients receiving mechanical ventilation and causes a
high mortality rate of 24%-50%.
Several reports of studies have been published that indicated
that oral decontamination might be associated with decreased
risk for VAP (Bergmanns et al., 2001; Hubmayr, 2002; van
Nieuwenhoven et al., 2004). Therefore, nurses could directly
affect the level of VAP by providing effective oral care to
decrease this contamination.
Some investigators have shown that nurses based their oral-care
practices on tradition, used many different techniques and
products for oral care, and had no uniform method of oral
assessment (Binkley, Furr, Carrico, & McCurren, 2004;
Bowsher, Boyle, & Griffiths, 1999; Curzio & McCowan, 2000;
Evans, 2001; Furr, Binkley, McCurren & Carrico, 2004; Grap et
al., 2003; Jones, Newton & Bower, 2004; McNeill, 2000; Munro
& Grap, 2004; Munro & Grap, 2004; Stiefel, Damron, Sowers &
Velez, 2000; White, 2000). Grap et al. (2003) concluded that
ICU nurses' oral-care practices were not documented nor were
they in accordance with the most recent evidence. Similar
results were found in several later studies conducted in the
United States (Binkley et al., 2004; Cutler & Davis, 2005;
Hanneman & Gusick, 2005) and in a survey of 59 European ICU
nurses (Relio et al., 2007); but not by Jones et al. (2004) who
found that UK nurses did perform appropriate oral care
methods.
When our evidence-based nurse (EBN) group was trying to
decide which protocol to recommend, we found no consensus in
the literature about what was the best evidence related to oral
care. In a recent systematic review, Berry, Davidson, Masters,

& Rolls (2007) concluded that scarce evidence exists related to
oral care practices of intubated ICU patients. The Centers for
Disease Control and Prevention (CDC) staff have developed
guidelines for preventing VAP (R). These guidelines include
hand washing; education of healthcare workers about
nosocomial pneumonia and its prevention; wearing of gloves;
sub-glottic suctioning; head of bed elevation; and use of
Chlorhexidine for cardiac-surgery patients.
The last element of the CDC guideline for preventing VAP is
the development of a comprehensive oralhygiene program;
however, details are lacking about what the program should
include. Another relevant set of guidelines from the CDC and
the American Association of Critical Care nurses is the
"ventilator bundle," that includes steps to reduce the incidence
of VAP for mechanically ventilated patients. This bundle
includes elevating the head of the bed, continuous subglottal
suctioning, changing ventilator circuit no more than every 48
hours, and hand washing before and after contact with each
patient. This protocol does not even mention oral care
(Tolentino-DelosReyes, Ruppert, Shyang-Yun, & Shiao, 2007).
Therefore, even though, in principle, oral care is considered of
great importance to intubated and ventilated patients, its place
in many guidelines related to these patients is unclear.
Many studies have been conducted in order to determine what
barriers are associated with a lack of evidencebased practice
(EBP). Most of these studies have used the Barriers
questionnaire developed by Funk and colleagues (1991), which
groups these barriers into four basic categories: qualities of the
research; presentation and accessibility of the research; setting
or organizational barriers and limitations; and nurses' research
values, skills, and awareness. Few researchers have investigated
whether individual characteristics of nurses may be related to
such perceptions.
In many other countries around the world, there is access to
nursing research (for example access to the Internet), but the
culture of nursing research is not well developed. Ricart and

colleagues (2003) comment that variability in following
evidence-based guidelines may be because of differences in
training or cultural aspects of the country. In a recent article,
Rassin (2008) found that nursing research was rated last in a list
of 20 professional values among Israeli hospital nurses.
This result is not surprising given the fact that nursing research
capacity and exposure is relatively low in Israel (Ehrenfeld,
Itzhaki, & Baumann, 2007; Glazer & DeKeyser, 2000). Most
research is conducted by nurses obtaining an advanced degree
and no national mechanisms are in place for designated funding
for nursing research or for promoting EBP.
Because no information was available about the current state of
evidence-based oral care practice in Israel, the group decided to
conduct a survey describing current oral-care practices of ICU
nurses with intubated patients and to determine whether
evidence-based practices were related to personal demographic
or professional characteristics.
Methods
Sample
A convenience sample of 218 practicing ICU nurses was
obtained in 2004-2005. Members of the EBN group recruited
nurses from their own ICUs, with some also recruiting nurses
from other units within the same organization. Nurses in the
survey worked in 12 different ICUs, 5 in general-respiratory
ICUs, 3 in cardiovascular-surgical ICUs, 2 in neurosurgical
ICUs and 2 in cardiac care ICUs.
Instrument
The survey included two major sections. The first section
contained questions about demographic and professional
characteristics including age, gender, nursing education, years
of ICU experience, postbasic ICU certification, type of ICU,
work full or part time, and shifts worked.
The second section contained a checklist which included a
listing of the current oral-care practices including type of
equipment used, solutions used, technique, and the type and
timing of oral assessment. Nurses were asked to check off all

responses that applied to their practice. Some of the items on
the checklist were based on current best evidence, for example
the use of Chlorhexidine or toothpaste; however, other items
listed were not recommended, such as bicarbonate or lemon
water. Nurses were also asked their perceived level of priority
of oral care on a scale from 0 to 100. This question had a visual
analogue format in which descriptors were placed at each end
(highest priority= 100; lowest priority=0) on a 10-cm line.
Nurses were asked to mark an X on the place that corresponded
with the level of priority they gave to oral care.
The survey instrument was based on the literature and
constructed by a committee of experienced ICU nurses. Content
validity of the tool was improved by including questions
suggested by members of the EBN task force and consultants.
The survey was also sent for review to an instructor of dental
hygiene and to other ICU nurses for obtaining content validity.
Reviewers were asked to suggest additional items or remove
those which were listed. The final survey questionnaire was a
conglomeration of the items suggested by the EBP group and
those of the reviewers. The use of Cronbach's alpha for this tool
was not deemed appropriate because the questionnaire is a
checklist.
Data Collection
Each member of the EBN group obtained both ethical and
institutional approval to collect the data. Then group members
explained the study to nurses in a staff meeting, obtained
informed consent from participants, and distributed the
questionnaires on an individual basis. Nurses were asked to
return the questionnaires to an envelope placed in a convenient
location on each unit.
Data Analysis
Descriptive statistics, including measures of central tendency
and dispersion and frequency data were used to describe the
sample as well as responses to the oralcare practices survey.
Not all participants completed all of the items - and these were
not included in missing-data analyses.

An EBP score was also determined, which was defined as the
number of items on the checklist that were checked off by the
nurse and considered to be necessary for proper oral care
according to the literature. Supplies listed included a
toothbrush, suction and suction catheter, toothpaste,
Chlorhexidine, and petroleum jelly (6 items). Technique items
included care of the upper and lower mouth, tongue, and
brushing of the patient's teeth (4 items). Assessment questions
were about doing an assessment upon admission to the unit and
at each shift (2 items). Use of an assessment tool and results of
the assessment and oral care were to be charted accordingly (2
items) - for a total of 14 items.
Each nurse obtained a score corresponding to the total number
of evidence-based items checked off (from ?? 4). A higher score
shows higher use of evidence-based practices. This total score
was then correlated with demographic and professional
characteristics to determine if such characteristics were
associated with oral-care EBP. Data were collected on
questionnaires that were delivered to one of the researchers,
who then coded the data into an SPSS data file (Version 12).
This score was then analyzed to determine whether a difference
in EBP scores existed based on personal demographic or
professional characteristics using ANOVA. Interval level
independent variables were categorized as follows: age (years):
20-29, 30-39, 40-49, 50+; years of clinical experience (as RN,
as an ICU nurse, and in this particular ICU): 0-5, 6-9, 10-14,
15-20, 20+; percentage of time worked: <50%, 50-75%, 75-
99%, 100%). All other variables were categorical (gender,
education, type of ICU).
Results
The majority of the sample was female (?= 172, 82%) with an
average age of 37.4+8.6 years. Nurses were mostly registered
nurses with a baccalaureate degree who had completed a
postbasic certification course (see Table 1). According to the
latest available statistics of the Nursing Division of the Israel
Ministry of Health (Nursing Division, Ministry of Health,

2007), 76% of nurses in Israel are registered nurses; 25% have a
baccalaureate degree or higher; and 41% have completed some
form of postbasic certification. One tenth of nurses were male
and 39% of all nurses were age 30-44 years. Nurses in this
sample were better educated than the general population of
Israeli nurses but otherwise seemed to be similar.
The most commonly used supplies were gauze pads (n=182,
84%), followed by tongue depressors (n=118, 55%), and
toothbrushes (n=73, 34%). Often nurses attach gauze pads to a
tongue depressor to use for oral care - a practice that substitutes
for the use of sponges or swabs attached to a stick sometimes
done in other countries. Chlorhexidine was the most commonly
used solution (n=161, 75%) followed by petroleum jelly (n=87,
40%), and toothpaste (n=72, 33%). Almost all nurses performed
oral care (n=198, 91%); however, less than half (n=96, 44%)
brushed their patients' teeth. Only 57% (n=120) of nurses
reported documenting oral care. On a scale of 0-100, nurses
rated oral care for intubated patients with a priority of 67+27.1,
where 44% (n=96) rated it on a priority of 90%-100%. The
mean EBP score was 9/14 or 68%. All participants stated that no
known written oral-care protocol existed on their unit (see
Table 2).
No significant relationship was found between the use of
evidence-based practices and demographic or professional
characteristics or with the priority given to oral care.
Discussion
While nurses ranked oral care as a high priority, many did not
implement the latest evidence into their current practice. The
level of evidence-based practice was not related to personal
demographic or professional factors.
Perceived level of priority of oral care practices has been
measured differently in different studies but for the most part
many studies have shown that critical care nurses rate oral care
with a moderate to high priority, including the nurses in this
study (Binkley et al., 2004; Grap et al., 2003; Jones et al., 2004;
Relio et al., 2007).

As in previous studies (Binkley et al., 2004; Grap et al., 2003;
Relio et al., 2007; Ricart et al., 2003), the level of EBP has
been questionable. Many nurses in this sample did not
implement the latest evidence in their practice. The American
Association of Critical Care Nurses produced a "practice alert"
based on the current best evidence, describing recommended
oral care in the critically ill (American Association of Critical
Care Nurses [AACN], 2007).
AACN recommendations included developing an oralcare
hygiene program which includes brushing patients' teeth, gums,
and tongue at least twice a day, using a soft pediatric or adult
toothbrush, moisturizing oral mucosa and lips every 2-4 hours,
and in precardiac surgery patients - using oral Chlorhexidine
gluconate (0.12%) rinse twice a day. All of the nurses in our
study stated that no organized protocols or programs related to
oral hygiene existed on their units. Most did not brush their
patients' teeth. It is not known what type of toothbrush was used
among those that did brush their patients' teeth. However,
almost all of the respondents (8491%) claimed to clean their
patients' tongue and upper and lower mouth. Petroleum jelly, a
substance used to moisturize the lips, was used by many of the
respondents; however, the frequency of use was not reported.
The majority of nurses on all of the units reported using
Chlorhexidine, a substance that has received scientific support
for use in a very limited population-precardiac surgery patients.
This solution was not recommended for other patient
populations.
A wide range of practices was found in this study among nurses
working within the same unit and between units, partially
because of the fact that no known written oral-care protocols
existed. Several authors have commented on the importance of
using written protocols in guiding oral care (Cason, Tyner,
Saunders, & Broome, 2007; Cutler & Davis, 2005; Steifel et al.,
2000).
None of the individual nurse characteristics in this study were
found to be related to evidence-based practice or priority of oral

care. The only characteristics found in the literature to be
related to evidence-based practice were educational level,
nursing position, and experience. Several investigators have
found that the higher the level of academic nursing education,
the more positive the attitude toward nursing research and EBP
(Bonner & Sando, 2008; Bucknall, Copnell, Shannon, &
McKinley, 2001; Fink, Thompson, & Bonnes, 2005; Furr et al.,
2004; Hannes et al., 2007; Kajermo et al., 2008); however, Oh
(2008) and Roxburg (2006) found the opposite results. In a
recent study of Israeli hospital nurse values (Rassin, 2008), the
findings were that nurses with a baccalaureate degree valued
nursing research more than any other type of nurse, including
those with a master's degree. The authors did not explain this
result but the finding is in keeping with a discrepancy in the
literature.
The literature is also ambiguous regarding the influence of
nursing position on attitudes toward research and EBP. While
several authors (Bonner & Sando, 2008; Egerod & Hansen,
2005; Oh, 2008) found that higher level positions were
associated with more positive attitudes, Bucknall et al. (2001)
found the opposite result. Oh (2008) determined that level of
nursing experience was associated with more positive attitudes,
while Furr et al. (2004) found the opposite. In these studies, the
researchers defined attitudes toward EBP differently and the
studies were conducted using different designs and in different
cultures therefore conflicting findings are not too surprising.
However, many of the studies using the barrier scale found that
one of the greatest barriers to evidence-based practice was the
nurses' assessment of her lack of skills related to use of
research. Perhaps increased education, experience, and a higher
position may be related to increased feelings of competence
related to research.
Based on the results of this study, where no oral care protocols
were reported and where there were no differences between
nurses based on personal or professional characteristics related
to the use of EBP, it is recommended that standardized, written,

evidence-based protocols related to the oral assessment and care
be introduced into all ICUs admitting intubated patients. Nurses
at all levels should be informed and encouraged in its use.
Further research could include investigating other barriers
related to EBP in this area and in this culture, as well as what
other factors are associated with the introduction and use of
evidence-based protocols.
Conclusions
While nurses ranked oral care as a high priority, levels of EBP
were found to be relatively low. Demographic and professional
characteristics were not found to be associated with the use of
EBP. Therefore, all nurses, regardless of personal
characteristics, should be involved in educational programs
related to oral care and evidence-based practice and should be
encouraged to introduce and utilize written protocols based on
the latest evidence in an attempt to decrease VAP on their units.
Acknowledgements
This study was supported by the Israeli Cardiology and Critical
Care Nursing Society.
Clinical Resource
* Practice Alert of the American Association of Critical Care
Nurses: http://www.aacn.org/WD/ practice/docs/oraLcare Jn
_the.critically.ill.pdf
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Tolentino-DelosReyes, A. F., Ruppert, S.D., Shyang-Yun, &
Shiao, P.K. (2007). Evidence-based practice: Use of the

ventilator bundle to prevent ventilator-associated pneumonia.
van Nieuwenhoven, CA., Buskens, E., Bergmans, D. C, van
Tiel, F.H., Ramsay, G., & Bonten, M.J.M. (2004). Oral
decontamination is cost-saving in the prevention of ventilator-
associated pneumonia in intensive care units. Critical Care
Medicine, 32, 126-130.
Vincent, J. L. (2004). Ventilator-associated pneumonia. Journal
of Hospital Infection, 57, 272-280.
White, R. (2000). Nurse assessment of oral health: A review of
practice and education. British Journal of Nursing, 9, 260-265.
AuthorAffiliation
Freda DeKeyser Ganz, RN1 PhD1, Naomi Farkash Fink, RN,
MHA2, Ofra Raanan, RN, MA3, Miriam Asher, RN, BA4,
Madeline Bruttin, RN, MA5, Maureen Ben Nun, RN, BSN6, &
Julie Benbinishty, RN, BA7
1 Pi, Head, Master's Program, Hadassah-Hebrew University
School of Nursing, Jerusalem, Israel
2 Nursing Research Coordinator, Rabin Medical Center, Petach
Tikva, Israel
3 Instructor, Sheba-Tel Hashomer Medical Center, Tel
Hashomer, Israel
4 Rabin Medical Center, Petach Tikva, Israel
5 Instructor, Recanati School of Health Professions, Ben Gurion
University, Beer Sheva, Israel
6 Kaplan Medical Center, Rehovot, Israel
7 Instructor, Hadassah Hebrew University School of Nursing,
Jerusalem, Israel
AuthorAffiliation
Correspondence
DeKeyser Ganz, Hadassah-Hebrew University
School of Nursing, Kiryat Hadassah, P.O. Box
12000, Jerusalem. E-mail:
[email protected]
Accepted: December 1 , 2008.
dol: 10.1111/j.1547-5069.2009.01264.x

MeSH: Humans, Intensive Care Units -- statistics & numerical
data (major), Nurses -- statistics & numerical data (major), Oral
Hygiene (major), Physician's Practice Patterns -- organization &
administration (major)
Publication title: Journal of Nursing Scholarship
Volume: 41
Issue: 2
Pages: 132-8
Number of pages: 7
Publication year: 2009
Publication date: Second Quarter 2009
Year: 2009
Section: CLINICAL SCHOLARSHIP
Publisher: Blackwell Publishing Ltd.
Place of publication: Indianapolis
Country of publication: United Kingdom
Publication subject: Education--Higher Education, Medical
Sciences--Nurses And Nursing
ISSN: 15276546
CODEN: IMNSEP
Source type: Scholarly Journals
Language of publication: English
Document type: Journal Article
Accession number: 19538697
ProQuest document ID: 236343430
Document
URL: https://library.gcu.edu:2443/login?url=http://search.proqu
est.com/docview/236343430?accountid=7374
Copyright: Copyright Blackwell Publishing Ltd. Second Quarter
2009
Last updated: 2014-06-28
Database: ProQuest Central
Contact ProQuest
Copyright © 2014 ProQuest LLC. All rights reserved. - Terms
and Conditions

Journal of Evaluation in Clinical Practice,
12
, 3, 347–352
©
2006 Blackwell Publishing Ltd
347
Blackwell Science, LtdOxford, UKJEPJournal of Evaluation in
Clinical Practice1356-1294Blackwell Publishing Ltd 200512
3347352
Original Article
Grading strength of guideline recommendationsE. Roddy
et al.

Correspondence
Edward Roddy
Academic Rheumatology
Clinical Sciences Building
Nottingham City Hospital
Hucknall Road
NG5 1PB
UK
E-mail:
[email protected]
Keywords:
clinical guidelines,
evidence-based medicine, strength of
recommendation
Accepted for publication:
27 April 2005
Evidence-based clinical guidelines: a new system to better
determine
true strength of recommendation
Edward Roddy MRCP (Specialist Registrar in Rheumatology),

1
Weiya Zhang PhD (Senior Lecturer in
Musculoskeletal Epidemiology),
1
Michael Doherty MA MD FRCP (Professor of Rheumatology),
1
Nigel K. Arden MD MSc MRCP (Senior Lecturer in
Rheumatology),
2
Julie Barlow PhD (Professor of Health
Psychology),
3
Fraser Birrell MA PhD MRCP (Senior Lecturer in
Rheumatology),

4
Alison Carr PhD (Special Lecturer
in Musculoskeletal Epidemiology),
1
Kuntal Chakravarty FRCP (Consultant Rheumatologist),
5
John Dickson FRCP MRCGP (Community Specialist in
Rheumatology),
6
Elaine Hay MD FRCP (Professor of
Community Rheumatology),
7
Gillian Hosie FRCP (General Practitioner),
8

Michael Hurley PhD (Reader in
Physiotherapy & ARC Research Fellow),
9
Kelsey M. Jordan MRCP (Rheumatology Research Fellow),
2
Christopher McCarthy PhD (Research Physiotherapist),
10
Marion McMurdo MD FRCP (Professor of Ageing and
Health),
11
Simon Mockett MPhil (Senior Lecturer),
12
Sheila O’Reilly MD MRCP (Consultant Rheumatologist),

13
George Peat PhD MCSP (Research Fellow),
7
Adrian Pendleton MD MRCP (Specialist Registrar in
Rheumatology),
14
Selwyn Richards MA MSc FRCP (Consultant Rheumatologist)
15
1
Academic Rheumatology, Clinical Sciences Building,
Nottingham City Hospital, Hucknall Road, Nottingham, UK
2
MRC Epidemiology Resource Centre, Southampton General

Hospital, Tremona Road, Southampton, Hampshire, UK
3
Interdisciplinary Research Centre in Health, School of Health
and Social Sciences, Coventry University, Priory St,
Coventry, UK
4
Musculoskeletal Research Group, University of Newcastle upon
Tyne, UK
5
Haroldwood Hospital, Gubbins Lane, Romford, Essex, UK
6
Langbaurgh PCT, Langbaurgh House, Bow Street, Guisborough,
Cleveland, UK
7
Primary Care Sciences Research Centre, Keele University,
Staffordshire, UK

8
Primary Care Rheumatology Society, Northallerton, North
Yorkshire, UK
9
King’s College London, Rehabilitation Research Unit, Dulwich
Hospital, East Dulwich Grove, London, UK
10
The Centre for Rehabilitation Science, University of
Manchester, Oxford Road, Manchester, UK
11
Department of Medicine, University of Dundee, Ninewells
Hospital, Dundee, UK
12
Division of Physiotherapy Education, School of Community
Health Sciences, University of Nottingham, Nottingham City
Hospital, Hucknall Road, Nottingham, UK

13
Derbyshire Royal Infirmary, London Road, Derby, UK
14
Craigavon Area Hospital, 68 Lurgan Road, Portadown, Co
Armagh, UK
15
Poole Hospital, Longfleet Road, Poole, UK
Abstract
Rationale, aims and objectives
Clinical practice guidelines often grade the
‘strength’ of their recommendations according to the robustness
of the sup-
porting research evidence. The existing methodology does not
allow the
strength of recommendation (SOR) to be upgraded for
recommendations
for which randomized controlled trials are impractical or
unethical. The pur-

pose of this study was to develop a new method of determining
SOR, incor-
porating both research evidence and expert opinion.
Methods
A Delphi
technique was employed to produce 10 recommendations for the
role of
exercise therapy in the management of osteoarthritis of the hip
or knee. The
SOR for each recommendation was determined by the
traditional method,
closely linked to the category of research evidence found on a
systematic
literature search, and on a visual analogue scale (VAS).
Recommendations
were grouped A-D according to the traditional SOR allocated
and the
mean VAS calculated. Difference across the groups was
assessed by one-
E. Roddy
et al.
348

©
2006 Blackwell Publishing Ltd,
Journal of Evaluation in Clinical Practice
,
12
, 3, 347–352
way
ANOVA
variance analysis.
Results
Mean VAS scores for the tradi-
tional SOR groups A-D and one proposition which was ‘not
recommended’
showed significant linearity on one-way

ANOVA
. However, certain recom-
mendations which, for practical reasons, could not assessed in
randomized
controlled trials and therefore could not be recommended
strongly by the
traditional methodology, were allocated a strong
recommendation by VAS.
Conclusions
This new system of grading strength of SOR is less con-
strained than the traditional methodology and offers the
advantage of
allowing SOR for procedures which cannot be assessed in RCTs
for prac-
tical or ethical reasons to be upgraded according to expert
opinion.
Introduction
Clinical guidelines have been defined as ‘systemati-
cally developed statements to assist practitioner
and patient decisions about appropriate health care
for specific clinical conditions’ (Field & Lohr 1990).
Guidelines that employ an evidence-based format
currently grade each recommendation in two ways:
first, by classifying the ‘category of evidence’ and,
second, by giving a ‘strength of recommendation’.
Although several methods of producing such grades

are described, in most of these, including the method
most commonly used by clinical guidelines in rheu-
matology (Pendleton
et al
. 2000; Jordan
et al
. 2003;
Dougados
et al
. 2004; Zhang
et al
. 2004; Roddy
et al
.
2005), the latter is strongly dependent on the former
(Shekelle

et al
. 1999) (Table 1). That is, the strength
of recommendation (SOR) primarily reflects the
robustness of the research evidence, with evidence
from randomized controlled trials (RCTs) and
systematic reviews automatically conferring the
strongest recommendation. However, although this
traditional method allows a downgrading of the SOR
for reasons including side effects or inconsistent
studies, it does not allow an upgrading of recommen-
dations in situations where RCTs are impractical or
unethical, e.g. total joint replacement, but effective-
ness is not in doubt. Furthermore, the practice of
evidence-based medicine requires the integration of
clinical expertise with the best available evidence
from systematic research (Sackett
et al
. 1996). Dur-
ing the development of recent recommendations for
the role of exercise in the management of osteo-
arthritis (OA) of the hip or knee (Roddy
et al
. 2005),

we found that the SOR allocated by this method was
often discordant with the consensus opinion of the
Table 1 Traditional hierarchy for category of evidence and
strength of recommendation (Shekelle
et al
. 1999)
Categories of evidence
1A. meta-analysis of RCT
1B. at least one RCT
2A. at least one CT without randomization
2B. at least one type of quasi-experimental study
3. descriptive studies (comparative, correlation, case-control)
4. expert committee reports/opinions and/or clinical opinion of
respected authorities
Strength of recommendation
A. Directly based on category 1 evidence
B. Directly based on category 2 evidence or extrapolated
recommendation from category 1 evidence
C. Directly based on category 3 evidence or extrapolated
recommendation from category 1 or 2 evidence
D. Directly based on category 4 evidence or extrapolated
recommendation from category 1, 2 or 3 evidence

RCT, randomized controlled trial; CT, controlled trial.
Grading strength of guideline recommendations
©
,
12
, 3, 347–352
349
panel. Therefore, we developed an alternative
method to better capture the true opinion of the
panel, whilst still requiring them to consider the
research evidence. We examined whether this alter-
native approach affected the support afforded to
each recommendation.

Methods
A multi-disciplinary panel employed a Delphi tech-
nique to produce 10 recommendations relating to
the role of exercise in the management of OA of
the hip or knee (Roddy
et al
. 2005). Following a
literature search and summary analysis of results,
the evidence for each recommendation was
assessed. The category of evidence and SOR was
assigned for each according to the method previ-
ously described (Shekelle
et al
. 1999). In addition,
each participant was asked to indicate how strongly
they rated each recommendation, based not just on
research evidence but also on all aspects relating
to their knowledge and clinical opinion. This was
recorded using a 10-cm visual analogue scale (VAS)
anchored with two descriptors labelled ‘not recom-
mended at all’ at the far left (0 cm) and ‘fully rec-
ommended’ at the far right (10 cm). The mean VAS
and standard deviation for each recommendation
were calculated. The recommendations were then

grouped according to their original SOR (A-D) and
the mean VAS and 95% confidence interval calcu-
lated for each group. A one-way
ANOVA
variance
analysis was performed to assess the difference
between the groups.
Results
The recommendations and the categories of evi-
dence, SOR and VAS for each, are shown in Table 2.
Figure 1 shows the mean VAS and 95% confidence
interval for recommendation groups A, C and D in
addition to one recommendation which was contra-
dicted by the research evidence and could not there-
fore be graded according to the traditional method
(‘not recommended’). No recommendations were
allocated a grade B SOR. The one-way
ANOVA
vari-
ance analysis identified a significant difference across
the groups (
P

<
0.001) and significant linearity
(
P
<
0.001).
Discussion
There was similarity between the SOR produced by
this method and the traditional methodology (Shek-
elle
et al
. 1999). The mean VAS for each recommen-
dation group (A, C, D) increased with the traditional
SOR, and therefore the category of evidence, and the

lowest mean was seen for the recommendation which
could not be recommended by the research evidence
ie was based solely on expert opinion.
This new system has the advantage of allowing the
SOR to be upgraded or downgraded based on ex-
pert opinion relating to global aspects of health
care delivery, such as generalizability, safety, cost-
effectiveness and patient preference, and common
sense. It therefore gives an additional dimension and
weighting to guideline recommendations other than
just the support from research evidence alone. In the
traditional system, the term ‘strength of recommen-
dation’ is almost a misnomer as it directly relates
to the category of evidence and provides little extra
information beyond that afforded by the ‘category of
evidence’. This is an important limitation of currently
practised evidence-based guideline methodology
that was overlooked in a recent critique of the meth-
odology of OA guidelines (Pencharz
et al
. 2002).
During the development of guidelines there are
many situations for which the existing SOR method-
ology (Shekelle
et al
. 1999) is not ideal. Interventions

for which placebo-controlled trials are impractical or
unethical (e.g. total joint replacement) cannot score
highly on the existing hierarchy and yet clearly may
Figure 1 Comparison of mean VAS (95% confidence
intervals) and traditional strength of recommendation.
VAS, visual analogue scale; NR, not recommended.
0
1
2
3
4
5
6
7
8
9
A C D NR
Strength of recommendation (Traditional method)
M
ea
n
V
A
S
(
cm

)
VAS = visual analogue scale, NR = not recommended
E. Roddy
et al.
350
©
,
12
, 3, 347–352
be very efficacious and warrant strong recommenda-
tion for clinical practice. The new method allows

the recommendation for such interventions to be
upgraded beyond that afforded by the category of
research evidence. Furthermore, when recommenda-
tions are not easily assessed in the setting of a clinical
trial yet have clear face validity, as with our third and
fourth recommendations (Table 2), the panel may
feel a much stronger recommendation is warranted
than that permitted by the current research-linked
method. For example, the mean VAS for both prop-
ositions 4 and 5B (Table 2) was 7.7, yet the SOR
according to the traditional methodology were D and
1B respectively. This reflects that although proposi-
tion 4 would be impractical to assess in the setting of
a RCT, it was highly supported by the expert panel
Table 2 Evidence-based recommendations for the role of
exercise in the management of osteoarthritis of the hip or
knee: category of evidence, strength of recommendation
(Shekelle
et al
. 1999) and visual analogue score (VAS)
Recommendation
Category of
Evidence (1–4)
Strength of
Recommendation (A-D)

Strength of
recommendation
(VAS) – Mean
(SD) cms
1. Both strengthening and aerobic exercise can
reduce pain and improve function and health
status in patients with knee and hip OA.
Knee 1B
Hip 4
A
C (extrapolated from knee OA)
8.9 (1.1)
6.3 (2.1)
2. There are few contra-indications to the
prescription of strengthening or aerobic
exercise to patients with hip or knee OA.
4 C (extrapolated from adverse
event data)
8.0 (1.5)
3. Prescription of both general (aerobic
fitness training) and local (strengthening)
exercises is an essential, core aspect of
management for every patient with hip or
knee OA.

4 D 7.1 (2.5)
4. Exercise therapy for OA of the hip or knee
should be individualized and patient-centred
taking into account factors such as age,
co-morbidity and overall mobility.
4 D 7.7 (1.9)
5. To be effective, exercise programmes
should include advice
and education to promote a positive lifestyle
change with an increase in physical activity.
4
1B
D
A
6.1 (2.6)
7.7 (1.4)
6. Group exercise and home exercise are equally
effective and patient preference should be
considered.
1A
4
A
D

8.0 (1.5)
7.6 (2.3)
7. Adherence is the principal predictor of
long-term outcome from exercise in patients
with knee or hip OA.
4 D 5.1 (2.4)
8. Strategies to improve and maintain
adherence should be adopted, e.g. long-term
monitoring/review and inclusion of
spouse/family in exercise.
1B A 7.6 (1.5)
9. The effectiveness of exercise is independent
of the presence or severity of radiographic
findings.
4 Not recommended 4.5 (2.8)
10. Improvements in muscle strength and
proprioception gained from exercise
programmes may reduce the progression of
knee and hip OA.
4 D 4.2 (2.5)
Grading strength of guideline recommendations
©

,
12
, 3, 347–352
351
whereas robust evidence from RCTs exists to sup-
port proposition 5B. Finally, the traditional hierarchy
does not accommodate the scenario where research
evidence contradicts a recommendation, as with our
ninth recommendation (Table 2).
Other guideline methodology groups have
attempted to overcome these limitations and reduce
the dependence of the SOR on the category of
research evidence. However, the grading systems,
produced by American College of Cardiology/
American Heart Association (ACC/AHA) Task
Force (ACA/AHA 2004), the US Preventive Services
Task Force (2003), the National Institute for Clinical
Excellence (NICE) (NICE 2004) and the New
Zealand Guidelines Group (New Zealand Guide-

lines Group 2004), derive the SOR primarily from
the category of research evidence. The ACC/AHA
guidelines state that any combination of classification
of recommendation and level of evidence is possible
and that a recommendation can be strongly sup-
ported even if it is based entirely on expert opinion
and no research studies have ever been conducted on
the recommendation (ACA/AHA 2004). However,
this system does not provide for the incorporation of
factors such as cost-effectiveness and safety, and the
descriptive and quantitative criteria for assigning the
classification and evidence ratings weight research
evidence and clinical expertise equally, which may
not be appropriate for some modalities, e.g. total
joint replacement. The guideline development
methods of NICE state that when the evidence is
very strong, this should translate directly into a rec-
ommendation, yet when the literature search finds no
evidence to answer the clinical question, the guide-
line development group should consider using con-
sensus methods to identify current best practice,
suggesting that consensus methods are only needed
when there is no robust evidence (NICE 2004).
Furthermore, NICE produces guidance on the role of
individual treatments rather than disease-orientated
recommendations on global treatment strategies. The
recently published GRADE collaboration (Atkins
et al
. 2004), although highlighting the difficulties in
producing clinical guidelines and grading strength of
recommendation, has not produced a simple, practi-
cal solution. The VAS, on the other hand, has the

advantage of being simple to apply and allows all
facets to be incorporated, e.g. category of research
evidence, safety, cost-effectiveness, generalizability
and expert opinion.
A limitation of the VAS-SOR methodology is that
as the basis for the VAS is not based on explicit
criteria, it cannot be examined and assessed readily
by external groups. However, we recommend that
the VAS method should be used alongside the tra-
ditional method of determining the category of
research evidence supporting each recommendation.
Any discrepancy between the category of evidence
and SOR would therefore be highlighted and should
then be justified in the ensuing discussion. A further
limitation is that this method has only been used
in the setting of recommendations for exercise in
osteoarthritis by a single group of experts, so evi-
dence of its generalizability to other fields and other
groups is required.
Other possible methods for grading SOR include
the development of an ordinal scale. A numerical
scale, however, is commonly used to assess self-
reported pain and disability in clinical trials, and
applying this principle to SOR seemed preferable.
Although the numerical scale scores themselves do
not have intrinsic comparability between different
sets of guidelines, there is at least scope for grading
or even ranking of different recommendations within
each set of guidelines. Other groups that prefer
verbal scales may wish to develop an ordinal scale
with descriptors to help guide practice in a clinical
setting.

Our guideline development group concludes that,
in comparison to existing traditional methodology,
this new system of grading SOR is less constrained
and offers the advantage of allowing the SOR for
procedures which cannot be assessed in RCTs to be
upgraded according to expert opinion consistent with
the principles of evidence-based medicine (Sackett
et al
. 1996). We would encourage other groups that
develop management recommendations or guide-
lines to try this approach, so that its clinical applica-
bility and usefulness can be determined more widely.
Acknowledgements
We are grateful for an educational grant from
MOVE (http://www.move.uk.net) and are also
indebted to the Arthritis Research Campaign, UK
for financial support (ICAC grant D0593; WZ Senior
http://www.move.uk.net
E. Roddy
et al.

352
©
,
12
, 3, 347–352
Lectureship D0565). We would also like to thank Dr
Jinying Lin, a visiting scholar from The People’s
Hospital of Guangxi Province, China, for assistance
with data entry.
John Dickson during the past 5 years has received
support to attend or organize symposia, or has
received a speaker’s honoraria, or a board member’s
honoraria from one or more of the following com-
panies – MSD, Wyeth, Pfizer, BI, TSB Chemedica,
GSK. He has received research funding from Q-med.
He has shares in Merck and Pfizer.
Marion McMurdo is a Director of D D Develop-
ments Limited, a University of Dundee company

whose mission is to provide exercise opportunities
for older people. Profits go to ageing research.
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