NURS 716 Week 5 Assignment 3: Evaluating Professional Practice Standards Example

Evaluating a Professional Practice Standard With AGREE II: An Appraisal of the 2019 International Guideline on Preventing and Treating Pressure Ulcers and Injuries

The Guideline and the Instrument

The professional practice standard appraised here is the international guideline on the prevention and treatment of pressure ulcers and injuries developed jointly by the European Pressure Ulcer Advisory Panel, the National Pressure Injury Advisory Panel and the Pan Pacific Pressure Injury Alliance (2019). It is the most widely cited guideline for the perioperative pressure injury project developed in this course.

AGREE II assesses the methodological rigor and transparency of guideline development (Brouwers et al., 2010). Its 23 items fall into six domains, and each item receives a rating on a seven-point scale anchored by strong disagreement at one end and strong agreement at the other. A scaled domain score is calculated as the obtained score minus the minimum possible score, divided by the maximum possible score minus the minimum possible score. With one appraiser, a domain of three items has a minimum of 3 and a maximum of 21. AGREE II recommends at least two and preferably four appraisers, so the scores below, from a single student appraiser, should be read as a learning exercise rather than a definitive rating.

Domain 1: Scope and Purpose

The guideline states its overall objective, the health questions it addresses and the populations it applies to, including adults and children in all care settings who have or are at risk of pressure injuries. The questions are framed broadly rather than as PICO questions, which makes some less specific. Ratings: objectives 7, questions 5, population 6. Scaled score: 15 of the 18 points available above the minimum, or 83%.

Domain 2: Stakeholder Involvement

The guideline was developed by an international group of clinicians and researchers from multiple disciplines, and it describes efforts to seek the views of patients and informal caregivers through a consumer survey. Target users, including health professionals across care settings, are clearly defined. Ratings: professional groups 7, patient views 5, target users 7. Scaled score: 16 of 18, or 89%.

Domain 3: Rigor of Development

This domain, with eight items, carries the most weight for clinical use. The guideline reports systematic searches, criteria for selecting evidence, a method for grading the strength of evidence and for assigning strength to recommendations, explicit links between recommendations and supporting evidence, and an external review process. Benefits and harms are considered, though unevenly across topics. A procedure for updating is described. Ratings: search 6, selection criteria 6, strengths and limitations of evidence 6, formulating recommendations 6, benefits and harms 5, link to evidence 7, external review 6, updating 5. Scaled score: 39 of the 48 points available above the minimum of 8, or 81%. A guideline that shows its search, grades its evidence and ties each recommendation to that evidence earns the trust a practice change needs.

Domain 4: Clarity of Presentation

Recommendations are specific and unambiguous, different options are presented, for example among support surfaces and dressings, and key recommendations are easy to identify in summary tables. Ratings: specific 6, options 6, identifiable 7. Scaled score: 16 of 18, or 89%.

Domain 5: Applicability

This is the guideline's weakest domain for the perioperative project. It discusses facilitators and barriers to implementation and offers some implementation advice, but resource implications and monitoring criteria are less developed, and perioperative recommendations are a small part of a very long document. Ratings: facilitators and barriers 5, advice or tools 5, resource implications 3, monitoring criteria 4. Scaled score: 13 of 24, or 54%.

Domain 6: Editorial Independence

The guideline describes its funding by the partner organizations and reports management of competing interests among developers. Some details of how individual conflicts were handled required searching supporting documents. Ratings: funding body 6, competing interests 5. Scaled score: 9 of 12, or 75%.

Summary of Domain Scores

Limitations of This Appraisal

This appraisal has three limitations. It was completed by a single appraiser, while AGREE II's developers recommend at least two, because individual ratings vary and averaging reduces that variation. It focused on the guideline's methodology and perioperative sections rather than every chapter of a very long document, so some items may have been rated on incomplete information. And AGREE II measures how well a guideline was developed and reported, not whether each recommendation is correct, so a high score does not settle every clinical question the project will face.

Overall Assessment

The overall quality rating is 6 of 7. The guideline was developed with rigor and transparency and presents its recommendations clearly. Its main limitation for this project is applicability: it gives the operating room relatively little implementation guidance and limited information on resource implications. The recommendation is to use the guideline with modifications.

Newer evidence fits with the guideline's direction. Since its publication, a randomized trial in elective surgery found fewer intraoperative pressure injuries with a sacral soft silicone foam dressing (Wang et al., 2026), and a meta-analysis of ten randomized trials found silicone foam dressings reduced sacral and heel injuries (Fu et al., 2025). These findings strengthen the case for applying the guideline's dressing recommendation in long surgeries.

Modifications for the Perioperative Project

Three modifications will adapt the guideline to the operating room. First, a local protocol will specify which patients receive dressings, based on surgery length and risk factors such as age and anesthesia risk class. Second, it will assign responsibility for application and inspection to the circulating nurse and the recovery nurse. Third, it will add the monitoring criteria the guideline leaves undeveloped: application rates, injuries within 72 hours and dressing costs. These modifications address the domain that scored lowest while preserving the guideline's well-supported recommendations.

Conclusion

The international pressure injury guideline scores well on five of six AGREE II domains and is suitable as the foundation for a perioperative prevention project, provided local protocols supply the implementation, resource and monitoring detail it lacks. A second appraiser should review these scores before the guideline is formally adopted.

References

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), E839-E842. https://doi.org/10.1503/cmaj.090449

European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, & Pan Pacific Pressure Injury Alliance. (2019). Prevention and treatment of pressure ulcers/injuries: Clinical practice guideline. The international guideline (E. Haesler, Ed.; 3rd ed.). EPUAP/NPIAP/PPPIA.

Fu, T., Wu, X., & Yu, B. (2025). Efficacy of silicone foam dressings in preventing pressure injuries in the sacral and heel areas of patients: A meta-analysis. Frontiers in Medicine, 12, Article 1644290. https://doi.org/10.3389/fmed.2025.1644290

Wang, C. Y., Liao, H. H., Hsieh, M. Y., & Lee, C. H. (2026). Soft silicone foam dressing for preventing intraoperative pressure injuries: A randomized controlled trial. Journal of PeriAnesthesia Nursing. Advance online publication. https://doi.org/10.1016/j.jopan.2026.08.022