Best practice guideline methodology

RNAO’s best practice guidelines (BPG) are systematically developed, evidence-based documents that include recommendations for nurses, interprofessional health teams, educators, leaders and policy-makers on how to improve outcomes for people and their support networks. Our BPGs are developed following rigorous international standards of guideline development approaches: 

  • GRADE (Grading of Recommendations, Assessment, Development and Evaluation) 
  • GRADE-CERQual (Confidence of Evidence from Reviews of Qualitative research) 

To develop BPGs, we engage in a seven-step process: 

Step 1: Selecting the topic

RNAO selects high priority topics to consider for development. A team of internal reviewers assesses each topic thoroughly to identify priorities for present and future BPG topics and any updates needed to previous BPG edition topics. Any person or organization may propose a guideline topic by making an online submission through our website. 

Once a topic is chosen, our BPG team conducts background development work to determine the purpose and scope of a guideline, including: 

  • conducting a guideline environmental scan and a preliminary literature review
  • interviewing key informants
  • convening discussion groups 
Step 2: Recruiting an expert panel

RNAO recruits a panel of experts to help develop the BPG. A typical expert panel is made up of a broad multidisciplinary team of health providers, and includes people with lived experiences in the BPG topic area. Panels often include pan-Canadian or international topic experts. Each expert panel reflects a broad spectrum of: 

  • expertise across the clinical practice, research, education, administration and policy domains
  • health service settings – for example, primary care, public health and acute care 
  • geographical diversity spanning urban, rural and remote practice settings
  • experience in living with a health condition 

Two panel co-chairs work closely with the expert panel and members of the RNAO BPG development team throughout the BPG development process. 

Step 3: Conducting systematic reviews

The expert panel identifies key recommendation questions that inform the research questions and systematic reviews to be conducted. Systematic reviews are conducted by two guideline development methodologists (GDM) to identify evidence that answers each research question. Each systematic review involves a multi-step process of title and abstract screening, full-text relevance review, data abstraction, quality appraisal and evidence synthesis.

Step 4: Developing recommendations

RNAO’s BPG team develops a set of evidence-based recommendations. Expert panel members review these draft recommendations and vote on the strength of each one to come up with a final list of recommendation. The GDMs draft the BPG, including recommendations and associated evidence. RNAO staff and the expert panel review the draft BPG. 

Step 5: Engaging external stakeholders

Once expert panel feedback has been incorporated, RNAO submits the draft BPG to external stakeholders for review and feedback. RNAO recruits stakeholders by two methods: 

  1. The BPG team and expert panel members identify potential stakeholders and invite them to sign up.
  2. RNAO invites potential external stakeholders to express interest via the website

These external stakeholders can be direct-care nurses or interprofessional health team members, nursing students, people with lived experience, or others who:  

  • have expertise in the BPG topic area;
  • will be involved in implementing the BPG in health-care settings; or
  • will be affected by its implementation.
Step 6: Publishing the guideline

After the BPG has undergone internal and external review, any changes needed are incorporated. The expert panel then approves the final draft for publication. Professional designers and editors create the final version of the BPG, which is then posted on the RNAO website as a free PDF. 

Note: BPGs that are published from 2015 or later are also available to purchase in hard copy. Please contact us if you wish to purchase a hard copy. 

Step 7: Reviewing and updating the guideline

RNAO commits to reviewing each BPG every five years after it is published and making revisions and updates arising from the review.


Contact us for any questions.