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INS Standards

Hello everyone!

I'm involved in an "Evidence-Based Practice" project here at Washington Hospital and I have a question regarding the INS Standards of Practice. We can use guidelines/standards as a reference, but we have to review the reliability & credibility of this document by using a "Rapid Critical Appraisal" form.

One of the questions is:

"Is each recommendation in the guideline tagged by the level/strength of evidence upon which it is based and linked with the scientific evidence?"

In revewing these standards, I can only see references of articles to support each "recommendation", I am unable to find a "Level/Strength" grading system, if you will, such as those found in the "CDC" Guidelines, (ie: Category 1A, 1B, etc...) It appears that this document isn't supported by the documentation of the "level of evidence"!!!  I was totally shocked because we all refer to these Guidelines as our "Bible" in IV therapy & Access!

This can't be true, please help clarify! Or direct me to someone who knows.


Thank you!

Raquel M. Hoag, RN, BSN, CRNI

Staff Nurse III, PICC Nurse

Washington Hospital, Fremont, CA

You are correct - there are

You are correct - there are no rankings or grading system used in the INS standards of practice. You are confusing the difference between a standard of practice and a guideline. SOP is what the nurse is expected to do. It is a yes or no proposition - there are no rankings or grades that can apply. The ANA standards do not have these rankings. 

On the other hand, a guideline is a set of recommendations for a specific patient population and they are frequently graded according to an established scale. 

INS standards have practice criteria that are statements intended to provide more information for the nurse to accomplish the actual standard statement. For instance, the standard states "Only one catheter shall be used for each cannulation attempt." This is a yes or no situation. Either the nurse only used one catheter for each attempt or she used one catheter for more than one attempt. Yes or no, there is no way to grade or rank this. The practice criteria is supported by the list of references after each section. It is my personal opinion that ranking or grading can be applied to this section, but the committee involved with this work would need a very long time to accomplish this for the entire document. I do not know what the next edition of the standards will include, however you can and should share your thoughts with INS about this. 

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

Thank you so much Lynn, as

Thank you so much Lynn, as always- you are a wealth of information.

I appreciate your response and will share these thoughts with INS. Since "Evidence-Based Practice" seems to be the hot "Buzz words" these days, I think it would be something for INS to consider for the future, if they haven't already.

Thanks again!


Raquel M. Hoag, BSN, RN, PHN, VA-BC

Great question, Raquel.

Great question, Raquel.  Our EBP committee has been working on this as well.  Looking at different models categorizing levels of evidence (Stetler, ARCC, IVAAP....), it seems that either "clinical guidelines" are in completely different levels, would have to examine the references to determine what level of evidence the specific clinical guideline would be categorized as.  

For example - if there were two guidelines, #1 had metanalyses of RCTs for references, #1 would have the highest level of evidence.  #2 had no RCTs, but references to cohort studies and quality data, it would be at a lower level of evidence.

I haven't read yet whether or not any specific model discusses in detail how to categorize standards of practice or clinical guidelines re: the references that support the statements - and we rely on them heavily for our policy and practice.  Unless someone has info that can clear this up for me, it seems like a challenging situation.  As Lynn stated, it seems it might be very laborious to do a lit review of each reference to determine it's level of evidence.

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT
Educator, Bard Access Systems 

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

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