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Grading of the Practice Guideline

Grading of the Practice Guideline

Mental health illnesses are a leading cause of morbidity and mortality globally. One of the mental health disorders of clinical significance is schizophrenia. This disorder remains a cause of suffering among the elderly groups. The American Psychiatric Association (APA) outlines best practices in managing schizophrenia. The third edition of the schizophrenia management guideline designed by APA details the available treatment options. This paper scrutinizes this guideline.

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Selection of the Guideline

The APA guideline for the treatment of schizophrenia was chosen because of its relevance to physiatric nursing and the pursuit of bettering mental healthcare across the globe. Schizophrenia is one of the most common mental health disorders. It affects over 20 million people globally. In the U.S., the prevalence of this disorder stands at 1%. The elderly group is more likely to be affected by the disease. As the elderly population grows, the number of clients presenting with schizophrenia and schizophrenia spectrum disorders is likely to increase (Ayano et al., 2019). This highlights the need to manage this disorder. Comprehensive management of schizophrenia focuses on maintaining a high quality of life for persons with the disease. A combination of psychosocial and pharmacotherapy modalities exists in this respect. However, optimization of the available management strategies is required to enhance clinical outcomes (Crellin et al., 2022). It is for this reason that guidelines on the treatment of schizoaffective disorders become necessary in nursing. Their utilization will help nurses select the appropriate and most effective therapeutic modalities to apply to their clients and enhance the quality of managing the disorder.

Use of Agree II Tool

Agree II is an international tool utilized in appraising clinical guidelines. This tool is used to assess the quality and presentation of guidelines. The Agree II tool outlines a systematic stepwise approach to assessing a practical guideline. The tool details a consortium of 23 steps that healthcare providers can use to scrutinize clinical guidelines. These steps are consolidated into six domains. These domains are scope and purpose, stakeholder involvement, the rigor of development, clarity of presentation, applicability, and editorial independence (Brouwers et al., 2010). These domains apply to guidelines on disease management and other aspects of care provision in the health continuum. Agree II guideline appraisal tool is intended for use by many stakeholders, including guideline developers, policymakers, healthcare providers, and health educators.

All items of the Agree II tool are graded on a seven-point scale. The scale ranges from strongly disagree to strongly agree, with each point denoting the degree of alignment of the guideline development process with the Agree II tool provisions. Many stakeholders reviewed and evaluated this guideline. It was graded based on how it met the criteria set by the Agree II tool. Higher scores corresponded with higher compliance with the provisions of the tool, as reflected by how the author met the operational definitions of each item in the tool.

The grading taxonomy was useful. Its stratification into items enabled detailed scrutiny of the guideline. The entire exercise of appraising the guideline is critical in nurses’ development and evolution to doctorate-level learning and degree.

Critical Appraisal

Evaluation of the APA guideline for treating schizophrenia revealed that the author followed five domains highlighted in the Agree II tool when developing this guideline. The criteria set by the Agree II tool were met. The scope and purpose domain was rated with a score of 21. During the guideline development process, the objectives were clearly described. Per the guideline, the process was intended to meet the quality maintenance and enhancement in mental healthcare outlined by the Institute of Medicine (IOM). The author also described the clinical question the guideline addressed and the targeted patient population. The guideline under scrutiny targets patients presenting with schizophrenia and is essential for all caregivers involved in the comprehensive management of schizophrenia and schizoaffective disorders.

The author also demonstrated stakeholders’ involvement. This domain was graded 28. The development group included eight psychiatrists with general and clinical research skills, all APA members, clinical and scientific experts, the public, and allied organizations. Additionally, input from patient advocacy groups was invited. During the review process, responses from these groups were addressed, their comments received, and views reflected in the final draft. This process was in concert with the Agree II provisions and affirmation of the validity of the guideline.

The third domain of rigor of development was graded 52. The author demonstrated the use of the provisions listed in the Agree II framework of the rigor of development. Scientific evidence in the form of research, patient preferences, and expert options were used in developing the guideline. The Agency for Healthcare Research and Quality (AHRQ) systematic review and the treatment of schizophrenia databases were the major sources of evidence used in developing the guideline. Additionally, information was obtained from systematic review and meta-analysis studies from databases such as MEDLINE and PsychInfo. The evidence was selected based on its applicability to the question being addressed. The evidence selected were systematic reviews and meta-analysis studies that touched on the treatment of the disorder by McDonagh et al. (2017) and AHRQ’s recommendations on the comprehensive management of schizophrenia and schizophrenia spectrum disorders.

Formulations of the recommendations on the guideline followed a systematic approach that drew several stakeholders. The guideline development groups reviewed each piece of evidence, denoting each person’s level of confidence. The AHRQ’s guidelines on rating research evidence were used to rate the available evidence. The evidence was then assessed across the primary domains of risk of bias, the consistency of the study findings, the relevance and directness of their effect on the health outcomes, and the precision of the estimated health outcome. Highly rated pieces of evidence were then condensed and used to draw recommendations for the guideline. A voting system was used to come up with the recommendations. Committee members voted on the recommendations, with final recommendations reflecting the views and opinions of 10 of 11 members.

The author of the guideline details the process for reviewing the guideline. During such reviews, the guidelines may be updated. The current version is an update of the previous one with several iterations. These iterations are mainly based on quality improvement per the IOM’s recommendations on the quality of mental healthcare. In this guideline, the author highlights areas that require improvement. These areas may form the basis for updating the guidelines. However, the author does not document a systematic way of clearly updating the guideline, which explains the lower rating for this item.

The graded score of the clarity of presentation domain is 21. The recommendations of the guidelines are properly articulated and easily identifiable. Additionally, they are presented in simple language. They are also specific and relevant to the disease and the target population. Further, the graded score on the applicability domain was 25. The guideline details how the recommendations can be incorporated into mental healthcare. It highlights who can use the guideline and the population it targets. Under the implementation section, the author outlines the assessment process for these illnesses, the treatment goals, and the therapeutic modalities available for managing schizophrenia. All these are applicable in the comprehensive management of the disorder. Before its full implementation, piloting was done. However, there is not sufficient information on how the piloting was done. This includes the findings from such pilot programs and adjustments made from such programs. This accounted for the low score.

In the editorial independence domain, the graded score was 14. While APA reserved the responsibility to fund the guideline developmental process, there is minimal proof of its interference with the guideline developmental processes. All members were required to disclose any potential conflict of interest before the appointment and during the process. Members who disclosed any conflict of interest were required to recuse themselves from the process. However, no conflict of interest was reported in the case. Through external reviews, the guideline development process was also able to maintain independence and prevent internal interference.

Guideline References

The references were systematic reviews and meta-analysis studies with varying strengths of evidence.

Citation Type of evidence Level of Evidence Strength of Evidence
Acevedo, A., Garnick, D. W., Dunigan, R., Horgan, C. M., Ritter, G. A., Lee, M. T., Panas, L., Campbell, K., Haberlin, K., Lambert-Wacey, D., Leeper, T., Reynolds, M., & Wright, D. (2015). Performance measures and racial/ethnic disparities in the treatment of Substance Use Disorders. Journal of Studies on Alcohol and Drugs, 76(1), 57–67. Meta-analysis 1 IV
Achtyes, E., Simmons, A., Skabeev, A., Levy, N., Jiang, Y., Marcy, P., & Weiden, P. J. (2018). Patient preferences concerning the efficacy and side-effect profile of schizophrenia medications: A survey of patients living with schizophrenia. BMC Psychiatry, 18(1). Meta-analysis 1 IV
Addington, D., Abidi, S., Garcia-Ortega, I., Honer, W. G., & Ismail, Z. (2017). Canadian guidelines for the assessment and diagnosis of patients with schizophrenia spectrum and other psychotic disorders. The Canadian Journal of Psychiatry, 62(9), 594–603. Systematic review 1 IV
Addington, D., McKenzie, E., Smith, H., Chuang, H., Boucher, S., Adams, B., & Ismail, Z. (2012). Conformance to evidence-based treatment recommendations in schizophrenia treatment services. The Canadian Journal of Psychiatry, 57(5), 317–323. Meta-analysis 1 IV
Ahmed, S., Khan, A. M., Mekala, H. M., Venigalla, H., Ahmed, R., Etman, A., Esang, M., & Qureshi, M. (2017). Combined use of electroconvulsive therapy and antipsychotics (both clozapine and non-clozapine) in treatment-resistant schizophrenia: A comparative meta-analysis. Heliyon, 3(11). Meta-analysis 1 IV
Ajmal, A., Joffe, H., & Nachtigall, L. B. (2014). Psychotropic-induced hyperprolactinemia: A clinical review. Psychosomatics, 55(1), 29–36. Systematic review 1 IV
Alabed, S., Latifeh, Y., Mohammad, H. A., & Bergman, H. (2018). Gamma-aminobutyric acid agonists for antipsychotic-induced tardive dyskinesia. Cochrane Database of Systematic Reviews, 2018(4). Systematic review 1 IV
Alastal, Y., Hasan, S., Chowdhury, M. A., Hammad, T., Safi, F., Rapport, D., & Assaly, R. (2016). Hypertriglyceridemia-induced pancreatitis in psychiatric patients. American Journal of Therapeutics, 23(3). Systematic review 1 IV
Aleman, A., Enriquez-Geppert, S., Knegtering, H., & Dlabac-de Lange, J. J. (2018). Moderate effects of noninvasive brain stimulation of the frontal cortex for improving negative symptoms in schizophrenia: Meta-analysis of controlled trials. Neuroscience & Biobehavioral Reviews, 89, 111–118. Meta-analysis 1 IV
Ali, S. A., Mathur , N., Malhotra, A. K., & Braga, R. J. (2019). Electroconvulsive therapy and schizophrenia: A systematic review. Complex Psychiatry, 5(2), 75–83. Systematic review 1 IV

 Incorporation of the Guideline

The guideline details aspects of managing schizophrenia. It should thus be incorporated into psychiatric nursing practice. Elements of the guidelines remain central in psychiatric nursing. They not only aid in diagnosing the disorder but also help identify prognostic features of the disease. Incorporating this guideline into clinical practice will follow a systemic approach. As Beauchemin et al. (2019) report, structured implementation of medical practice guidelines improves adherence to the provisions of the guideline and increases its adoption by various healthcare providers. The first step in incorporating this guideline is to communicate the provisions to caregivers. This will be followed by establishing a care pathway or framework that utilizes these provisions in coordinating and managing patients with schizophrenia. The last step is monitoring and auditing the caregivers’ performances in utilizing the guidelines (Pereira et al., 2022). Feedback may be necessary when the performance is poor. Additional training may also be necessary.

To incorporate the guideline recommendations, caregivers will be notified of its provisions. This will include formal and informal communication processes to prepare them for the change process. The simplicity of the guideline makes it easy to incorporate as it utilizes conventional therapeutic methods. Minimal modifications will, therefore, be required to fully implement these recommendations. A potential barrier to implementing this guideline may be a lack of organizational resources utilizable in managing schizophrenics and recommended by the guideline. Thus, this may impede the implementation process.


The APA guideline on treating schizophrenia details aspects of managing the disorder. A review of the guideline revealed the author’s compliance with the Agree II appraisal tool for medical guidelines. This reviewing experience gave insights into the systematized approach to appraising medical practice guidelines. Its provisions imparted the critical skills required when analyzing guidelines for their validity in practice. Notably, evidence-based practice guidelines are essential in healthcare. They help streamline healthcare practice and act as valuable guides to clinical decision-making. Their use enhances the efficiency and effectiveness of healthcare practices as they enable caregivers to choose from many options of care modalities that realize optimal outcomes. Evidence-based guidelines should thus be incorporated into practice.


Ayano, G., Tesfaw, G., & Shumet, S. (2019). The prevalence of schizophrenia and other psychotic disorders among homeless people: A systematic review and meta-analysis. BMC Psychiatry, 19(1).

Beauchemin, M., Cohn, E., & Shelton, R. C. (2019). Implementation of clinical practice guidelines in the Health Care Setting. Advances in Nursing Science, 42(4), 307–324.

Brouwers, M. C., Kho, M. E., Browman, G. P., Burgers, J. S., Cluzeau, F., Feder, G., Fervers, B., Graham, I. D., Grimshaw, J., Hanna, S. E., Littlejohns, P., Makarski, J., & Zitzelsberger, L. (2010). AGREE II: Advancing Guideline Development, reporting and evaluation in health care. Canadian Medical Association Journal, 182(18).

Crellin, N. E., Priebe, S., Morant, N., Lewis, G., Freemantle, N., Johnson, S., Horne, R., Pinfold, V., Kent, L., Smith, R., Darton, K., Cooper, R. E., Long, M., Thompson, J., Gruenwald, L., Freudenthal, R., Stansfeld, J. L., & Moncrieff, J. (2022). An analysis of views about supported reduction or discontinuation of antipsychotic treatment among people with schizophrenia and other psychotic disorders. BMC Psychiatry, 22(1).

McDonagh, M. S., Dana, T., Selph, S., Devine, E. B., Cantor, A., Bougatsos, C., Blazina, I., Grusing, S., Fu, R., Kopelovich, S. L., Monroe-DeVita, M., & Haupt, D. W. (2017). Treatments for Schizophrenia in Adults: A Systematic Review.

Pereira, V. C., Silva, S. N., Carvalho, V. K., Zanghelini, F., & Barreto, J. O. (2022). Strategies for the implementation of clinical practice guidelines in public health: An overview of Systematic Reviews. Health Research Policy and Systems, 20(1).


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Please review the information found on the Agree Trust Website about the “overview tutorial” “and tutorial and practice” for evaluation guidelines prior to completion of the assignment. The link to the website is to an external site.

Grading of the Practice Guideline

Grading of the Practice Guideline

Locate a practice current guideline from a database or professional organization that is of interest to you. See pages 236-237 of Melnyk book for suggested databases.
Please follow the rubric below to discuss your evaluation of the guideline.
Evaluate/grade the guidelines using the AGREE II tool. See the website above.
Evidence is used to support the development of guidelines. Evaluate the strength, grade, and level of evidence for research studies as well as expert opinions
It is important to know all the criteria listed below before one can determine whether or not to incorporate the recommendations into practice.
Paper length 6-8 pages excluding title page and references.

For this assignment, you are to search for a practice guideline, not a summary, which is being used. Be sure you choose a guideline. It should not be an article about a guideline or a summary of a guideline, but the actual guideline. Once you have found the guideline you are to evaluate/grade the guidelines regarding the strength of the research as well as expert opinion processes used to develop the guidelines. Grade the literature the guideline was based on. One question to be answered is how often the researchers review the guidelines. It is important to know all the criteria listed below before one can determine whether or not to incorporate the recommendations. Although not required, it would be beneficial to locate and evaluate a practice guideline that aligns with the topic you have selected (or are considering) for your PICOT question and DNP project.

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