evaluation of clinical practice protocols. Thus, the AGREE instrument has been expanded for that purpose: to standardize the creation and revision of the geriatric nursing practice protocols in this book. The initial AGREE instrument and the one used for clinical guideline/protocol development in the third edition of this book has six quality domains: (a) scope and purpose, (b) stakeholder involvement, (c) rigour of development, (d) clarity and presentation, (e) application, and (f) editorial independence. A total of 23 items divided among the domains were rated on a 4-point Likert-type scale from strongly disagree to strongly agree. Appraisers evaluate how well the guideline they are assessing meets the criteria (i.e., items) of the six quality domains. For example, when evaluating the rigour of development, appraisers rated seven items. The reliability of the AGREE instrument is increased when each guideline is appraised by more than one appraiser. Each of the six domains receives an individual domain score and, based on these scores, the appraiser subjectively assesses the overall quality of a guideline. Important to note, however, is that the original AGREE instrument was revised in 2009 (http://www.agreetrust.org/), is now called AGREE II, and is the version that we used for this fourth edition (AGREE Next Steps Consortium, 2009). The revision added one new item to the rigour of development domain. This is the current Item 9, which underscores the importance of evaluating the evidence that is applied to practice. Item 9 Developing and Evaluating Clinical Practice Guidelines: A Systematic Approach 3 reads: “The strengths and limitations of the body of evidence are clearly described.” The remainder of the changes included a revision of the Likert-type scale used to evaluate each item in the AGREE II, a reordering of the number assigned to each item based on the addition of the new Item 9 and minor editing of items for clarity. No other substantive changes were made. Table 1.1 includes the items that are in the rigour of development domain and were used for evaluation of evidence in the current edition of this book. The rigour of development section of the AGREE instrument provides standards for literature-searching and documenting the databases and terms searched. Adhering to these criteria to find and use the best available evidence on a clinical question is critical to the validity of geriatric nursing protocols and, ultimately, to patient safety and outcomes of care. Published guidelines can be appraised using the AGREE instrument as discussed previously. In the process of guideline development, however, the clinician is faced with the added responsibility of appraising all available evidence for its quality and relevance. In other words, how well does the available evidence support recommended clinical practices? The clinician needs to be able to support or defend the inclusion of each recommendation in the protocol based on its level of evidence. To do so, the guideline must reflect a systematic, structured approach to find and assess the available evidence. The Search for Evidence Process Models of EBP describe the evidence-based process in five steps: 1. Develop an answerable question. 2. Locate the best evidence. 3. Critically appraise the evidence. 4. Integrate the evidence into practice using clinical expertise with attention to patient’s values and perspectives. 5. Evaluate outcome(s). (Flemming, 1998; McKibbon, Wilczynski, Eady, & Marks, 2009; Melnyk & FineoutOverholt, 2011) Sample domain and items from the AGREE II instrument for critical appraisal of clinical practice guidelines with rating scale. Domain 3: Rigour of Development 7. Systematic methods were used to search for evidence. 8. The criteria for selecting the evidence are clearly described. 9. The strengths and limitations of the body of evidence are clearly described 10. The methods for formulating the recommendations are clearly described. 11. The health benefits, side effects, and risks have been considered in formulating the recommendations. 12. There is an explicit link between the recommendations and the supporting evidence. 13. The guideline has been externally reviewed by experts prior to its publication. 14. A