Based on the best evidence available, but also noting that transforming the education and training of health workers requires changing a system that has not worked whilst using the evidence of that same deficient system to bring about change, the strength of the majority of the recommendations was conditional. It was the opinion of the Guidelines Development Group however, that in recommendation 10 on accreditation, although the quality of the evidence was assessed as low it was proposed as a strong recommendation. This was the same for the recommendation 5 on simulation methods. Although the quality of the evidence was moderate a strong recommendation was proposed.
The direction and strength of the recommendation reflects the extent to which the Guideline Development Group was confident that the desirable effects of following a recommendation are greater than the potential undesirable effects. In terms of implications, a strong recommendation can be adopted as a policy in most situations. A conditional recommendation implies the need for substantial debate and involvement of stakeholders in deciding whether or not to adopt the recommendation. In some cases, the panel may have decided to qualify the conditional recommendation by providing the “conditions” under which it should be considered. Examples of these conditions include: ensuring availability of experienced staff, space or equipment, conducting needs assessment and integrating the new intervention within existing programmes. One specific type of condition is implementing the intervention “in the context of close monitoring and evaluation”. This is appropriate when monitoring of the feasibility of the implementation of the intervention and evaluation of some short-term outcome can ensure optimal implementation and adaptation if necessary. Another specific type of condition is implementing the intervention “only in the context of rigorous research”. This is appropriate when there is a relatively high degree of uncertainty whether the desirable effects of following the recommendation is greater than the potential undesirable effects and the panel feels that the intervention should be adopted only when there is an opportunity to generate the needed evidence.
With respect to health service recommendations, the GRADE framework considers the following factors when deciding on the direction and strength of the recommendation: the magnitude of the problem, the balance of benefits and harms, resource use, equity, acceptability and feasibility (recorded in the decision tables at Annex 7). The decision table is a tool that: provides a systematic and explicit approach to making recommendations; makes transparent the judgements about the factors affecting the recommendations; provides supporting evidence to judgements; and provides guidance to policy makers on what to take into account when considering a recommendation.