American Association of Critical-Care Nurses (Aacn)

Table of Contents


The standardization of nursing policies involves the review and revision of current policy documents. This is aimed at achieving a standardized policy framework that can be used by all practitioners. It also involves the identification of policies that should be used on various topics. The general objective is to create a holistic system with policies touching on all aspects of nursing.

Interview summary

The general mechanisms established to determine whether policies and procedures adhere to evidence are in constant change. However, this depends on whether the procedure or policy involves one nursing unit or many. The guidelines involving perinatal aspects have greatly evolved over the past in several ways. If a guideline is needed, then a literature review is done. Some professional guidelines such as ACOG/AWHONN have policies and procedures that they recommend based on the literature review done. They have different criteria for levels of evidence. When deciding on how an organization will carry out a certain task, there may not be evidence that one may use as a guideline. A person may want to choose another level. However, the individual may later be forced to adopt the opinion of an expert since there is no research done that negate or support a certain practice. When looking at a certain practice, the focus is on what has been collected by professional organizations and their recommendations. A literature review is then carried out. If no information supporting is obtained, further information is sort from other medical institutions about their practice.

The guidelines are reviewed by the nursing and medical directors. However, some issues will be reviewed by the OB executive committee. If the policy involves other departments in the hospital, the same procedure is followed. However, experts from other departments are tasked with the review of the policy. Finally, the policy is approved by the hospital clinical practice council. As a system, we are developing policies and procedures that have already been approved. The same happens with expert clinicians, educators, or whoever has been identified to examine the evidence, write and approve the policy. From this point, it is finally approved and implemented after it has been forwarded to COPICS, infection control, risk management, directors and CNOs.

Designation of evidence and practice policy and procedures

Melnyk’s Hierarchy of Evidence holds that various organizations have advanced levels or hierarchy of evidence based on scientific relevance and models. These levels assist medical staff to rank knowledge through assessing the strength of the evidence being reviewed. Evidence is valued basing on strength. Strength is evaluated by the validity and relevance of the evidence to a given case. Evidence can be from research and non-research sources and can be classified into seven levels ranked from the strongest to the weakest. These levels are labelled i to vii whereby (i) is the strongest whereas (vii) is the weakest. Strong evidence enhances the validity and relevance of a case. In practice, strong evidence would be the first choice. Some levels are classified on the basis of opinion or single studies instead of systematic methods or mega-analysis (Wright, Swiontkowski and Heckman, 2003).

In Joanne Briggs Institute Levels of Evidence, classification is made on grades of recommendation A, B and C. Grade A should include at least one randomized research as part of the literature reviewed (levels Ia, Ib). Grade B should have a well conducted clinical research with no randomized research (IIa, IIb, and III). Grade C should include evidence from expert committee reports (levels IV). In this case, a major weakness is not conforming to empirical research methods (MacKay, 1992).

The American Association of Critical-Care Nurses (AACN) prefers alphabetical scale to the numerical scale. The evidence ranking systems has alphabets from A to M. Here, level A is the highest whereas M is the lowest (Armola, et al, 2009).


There is no clear guideline that has been established to govern the evidence levels. Clinicians should make use of the most appropriate scale of ranking basing on the validity and relevance to the case at hand.


Armola, R.R. et al, (2009). AACN Levels of evidence: What’s New? Critical Care Nurse, 29 (4), 70-73.

MacKay, D.J.C. (1992). The Evidence Framework Applied to Classification Networks. Neural Computation, 4(5): 720-736.

Wright, J.C., Swiontkowski, M.F. and Heckman, J.D. (2003). Introducing Levels of Evidence to the Journal. J Bone Joint Surg Am, 85(1): 1-3.

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