edition of Evidence-Based Geriatric Nursing Protocols for Best Practice. Prior to the third edition of this book, each chapter author individually gathered and synthesized evidence on a particular topic and then developed a “nursing standard of practice protocol” based on that evidence. There was no standard process or specific criteria for protocol development nor was there any indication of the “level of evidence” of each source cited in the chapter (i.e., the evidence base for the protocol). In the third edition and this fourth edition, the process previously used to develop the geriatric nursing protocols has been enhanced. This chapter is a guide to understanding how the geriatric nursing protocols in these third and fourth editions were developed and describes how to use the process to guide the assessment and/or development and updating of practice protocols in any area of nursing practice. DEFINITION OF TERMS Evidence-based practice (EBP) is a framework for clinical practice that integrates the best available scientific evidence with the expertise of the clinician and with patients’ preferences and values to make decisions about health care (Levin & Feldman, 2006; Straus, Richardson, Glasziou, & Haynes, 2005). Health care professionals often use the terms recommendations, guidelines, and protocols interchangeably, but they are not synonymous. A recommendation is a suggestion for practice, not necessarily sanctioned by a formal, expert group. A clinical practice guideline is an “official recommendation” or suggested approach to diagnose and manage a broad health condition (e.g., heart failure, smoking Rona F. Levin and Susan Kaplan Jacobs 1 Developing and Evaluating Clinical Practice Guidelines: A Systematic Approach 2 Evidence-Based Geriatric Nursing Protocols for Best Practice cessation, or pain management). A protocol is a more detailed guide for approaching a clinical problem or health condition and is tailored to a specific practice situation. For example, guidelines for falls prevention recommend developing a protocol for toileting elderly, sedated, or confused patients (Rich & Newland, 2006). The specific practices or protocol each agency implements, however, is agency specific. The validity of any of these practice guides can vary depending on the type and the level of evidence on which they are based. Using standard criteria to develop or refine CPGs or protocols assures reliability of their content. Standardization gives both nurses, who use the guideline/ protocol, and patients, who receive care based on the guideline/protocol, assurance that the geriatric content and practice recommendations are based on the best evidence. In contrast to these practice guides, “standards of practice” are not specific or necessarily evidence based; rather, they are a generally accepted, formal, published framework for practice. As an example, the American Nurses Association document, Nursing: Scope and Standards of Practice (American Nurses Association, 2010), contains a standard regarding nurses’ accountability for making an assessment of a patient’s health status. The standard is a general statement. A protocol, on the other hand, may specify the assessment tool(s) to use in that assessment—for example, an instrument to predict pressure-ulcer risk. THE AGREE INSTRUMENT The AGREE (Appraisal of Guidelines for Research & Evaluation) instrument.agreecollaboration.org/), created and evaluated by international guideline developers and researchers for use by the National Health Services (AGREE Collaboration, 2001), was initially supported by the UK National Health Services Management Executive and later by the European Union (Cluzeau, Littlejohns, Grimshaw, Feder, & Moran, 1999). Released in 2001 in its initial form, the purpose of the AGREE instrument is to provide standard criteria with which to appraise CPGs. This appraisal includes evaluation of the methods used to develop the CPG, assessment of the validity of the recommendations made in the guideline, and consideration of factors related to the use of the CPG in practice. Although the AGREE instrument was created to critically appraise CPGs, the process and criteria can also be applied to the development and