Graduate nursing programs increasingly ask students to judge the quality of a guideline before relying on it. This guide explains the AGREE II instrument, how to score each domain, how to calculate scaled scores, and how to write an appraisal your faculty will trust.
Quick answer. AGREE II (Appraisal of Guidelines for Research and Evaluation) is an internationally used tool for assessing how rigorously a clinical practice guideline was developed and reported. It has 23 items in six domains, each rated on a seven-point scale, followed by two overall judgments. A high score means a guideline was developed and reported well; it does not by itself mean the recommendations fit your setting.
Clinical practice guidelines vary widely in quality. Some are based on systematic reviews and transparent processes; others reflect the views of a small group with unclear methods or conflicts of interest. Before a guideline anchors a DNP project, a protocol change or a practice recommendation, you need evidence that it was developed rigorously.
Appraisal also strengthens your project. A committee that sees you appraised the guideline with a recognized tool is far more confident in the practice change you propose.
| Domain | Items | What it assesses |
|---|---|---|
| 1. Scope and purpose | 3 | The guideline's objective, health questions and target population |
| 2. Stakeholder involvement | 3 | Whether relevant professional groups and patients' views were included, and the target users defined |
| 3. Rigor of development | 8 | Systematic search, evidence selection, strengths and limitations of evidence, methods for recommendations, benefits and harms, link to evidence, external review, updating procedure |
| 4. Clarity of presentation | 3 | Specific, unambiguous recommendations, options presented, key recommendations easy to identify |
| 5. Applicability | 4 | Facilitators and barriers, implementation tools, resource implications, monitoring criteria |
| 6. Editorial independence | 2 | Influence of the funding body, and recording and addressing competing interests |
Domain 3, rigor of development, is usually the most important for judging whether recommendations can be trusted, and it requires the closest reading of methods documents. Applicability, by contrast, often scores lowest, because many guidelines say little about costs, barriers or audit criteria.
Each item is rated from 1 (strongly disagree) to 7 (strongly agree). The AGREE II user's manual describes what each item looks for and how to judge it.
Look beyond the main guideline document. Many guideline developers publish methods, evidence reviews and conflict-of-interest declarations separately. Not finding information that exists elsewhere is a common cause of unfairly low scores.
Domain scores are calculated by summing all item scores in the domain across all appraisers, then scaling the total as a percentage of the possible range:
Scaled domain score = (obtained score − minimum possible score) ÷ (maximum possible score − minimum possible score) × 100
For example, with two appraisers scoring Domain 1 (three items):
| Item 1 | Item 2 | Item 3 | Total | |
|---|---|---|---|---|
| Appraiser A | 6 | 5 | 6 | 17 |
| Appraiser B | 7 | 5 | 5 | 17 |
| Obtained score | 34 | |||
The six domain scores are calculated independently and should not be added together into one total score.
Share the guideline and your assignment brief. A specialist can help score each AGREE II domain and write a clear, justified appraisal. The price is shown before you pay.
After scoring the domains, each appraiser makes two overall judgments:
The AGREE II manual does not set cut-off scores for high or low quality, so these judgments require reasoning. Many appraisers give particular weight to Domain 3 and Domain 6. If you or your program set a threshold, such as recommending only guidelines above a certain rigor score, state it in advance and explain it.
A strong written appraisal is organized by domain and explains the reasoning behind each score.
Example justification: "Domain 6 scored 42% because, although competing interests were declared, the guideline did not describe how these were managed, and the funding body's role in drafting recommendations was not stated."
Some assignments and DNP projects ask you to compare two or more guidelines on the same topic. Appraise each with AGREE II, present domain scores side by side, and explain which guideline is most rigorous and most applicable to your setting. Where guidelines conflict, the appraisal helps you justify which one to follow.
The AGREE Enterprise has also produced AGREE-REX, which focuses on the clinical credibility and implementability of recommendations, and reporting checklists for guideline developers. Systematic reviews are appraised with different tools, such as AMSTAR 2, and individual studies with tools such as the Joanna Briggs Institute checklists or CASP. Use the tool designed for the type of evidence you are appraising.
Suppose you are appraising a falls prevention guideline for older inpatients. For Domain 3, you would look for the following, often across the guideline and its methods supplement:
Recording page or section references for each judgment as you score makes the written appraisal much easier and lets a second appraiser compare reasoning when your scores differ.
The instrument and user's manual are freely available from the AGREE Enterprise website, along with training resources.
Many course assignments involve a single appraiser. The developers recommend at least two, so note single appraisal as a limitation, or work with a classmate if your instructor allows it.
AGREE II does not define cut-off scores. Judge quality using the domain scores, especially rigor of development and editorial independence, and explain your reasoning.
No. AGREE II is designed for clinical practice guidelines. Systematic reviews are appraised with tools such as AMSTAR 2.
A guideline is only as trustworthy as the process that produced it. Appraising it with AGREE II shows your faculty or committee that your practice recommendation rests on rigorously developed evidence, and it prepares you to explain why you chose one guideline over another.