Reviewing evidence for COVID-19 guidance
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Reviewing evidence for COVID-19 guidance

Dinah Gould Independent consultant and honorary professor of nursing, City, University of London
Edward Purssell Care team nurse, Little Havens Hospice in Essex

An independent investigation reveals guidelines issued to healthcare staff were confused and at times even contradictory

In January 2021 we were commissioned by the RCN to examine the evidence underpinning the UK recommendations to prevent and control the spread of COVID-19. This was in response to concerns raised by RCN members about the quality and comprehensiveness of the guidelines.

Nursing Standard. 37, 10, 57-57. doi: 10.7748/ns.37.10.57.s21

Published: 05 October 2022

We established that the guidelines provided by what was then Public Health England (now the UK Health Security Agency) were based on a series of rapidly generated literature reviews updated and released monthly throughout the pandemic.

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Picture credit: iStock

Research not reflected in updates

In the early days of the pandemic, guidelines to reduce transmission had to be generated quickly. We recognised that, at this stage, the review team would be unable to draw on the findings of a full systematic review of the literature because the necessary research had not been conducted.

Recommendations were based largely on what was known about the transmission of other respiratory pathogens thought to behave similarly, such as influenza, severe acute respiratory syndrome and Middle Eastern respiratory syndrome. Although not ideal, we accepted this was inevitable given the need for advice at a time when so little was known.

A year later we were asked to review the evidence and report how guidelines had been updated. We were astonished to discover that much of the evolving research had been ignored and national guidelines had not kept pace with emerging evidence.

We were alarmed by the inadequate methods used to search the literature to find the most up-to-date findings, and the failure to include the numerous systematic literature reviews that were available. A lack of transparency about the methods used to generate the rapid reviews was most worrying of all.

Challenging decisions with no clear evidence base

It was not clear why some information had been included while other material had not. One year on, more information had emerged, yet it had been ignored. We were unable to establish how or why recommendations in the national guidelines had been developed, who had undertaken the work or what their credentials were.

The experience of nurses on the front line throughout the pandemic has highlighted the relevance of evidence-based practice. Nurses need to know how evidence is obtained and used to generate recommendations to guide practice.

Evidence-based practice is essential for nursing leaders, too. They should have the knowledge, confidence and skills to challenge policy makers and question the absence of robust decision-making in the face of unprecedented research activity and the emergence of new evidence.

By the time of our second review, questions should have been asked about the confused and, at times, contradictory guidance in relation to face coverings. Where was the evidence that surgical masks offered meaningful protection? Why did guidelines for nursing homes and hospitals differ for so long? Why were there shortages of personal protective equipment in nursing homes at the time when it was needed most? These questions should have been repeated until satisfactory responses had been obtained – but they were not.

Why we must insist on more robust guidance

Nurses at the forefront of high-risk situations deserve protection derived from the best evidence available, updated as knowledge unfolds. Nurses should strive to develop their skills in identifying evidence-based practice to enable them to make their voices heard when guidelines are generated. Clinical nurses need to play a greater role in writing guidelines. The task should not be devolved to managers and academics.

As we face another winter, with perhaps another wave of COVID-19 and seasonal viruses, alongside threats from other emerging pathogens such as monkeypox, we need to ensure that guidance and the provision of essential equipment to enact it are sufficient. Confidence is linked to transparency: the issue is not whether we as individuals agree with recommendations, but whether we understand why they were made and to what extent they can be altered to meet the needs of a particular situation.

There are established methods for compiling guidelines and the evidence that underpins them. In undertaking this work on behalf of the RCN, we were surprised to discover that during the COVID-19 pandemic, they were not drawn on.

Links to the reports and an extended version of this article rcni.com/COVID-guidance-report

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