Voices in clinical guideline development: a qualitative study of Irish guideline developers’ perspectives on developing recommendations

Background: Guidelines are essential tools for improving healthcare decision-making. Over the last few decades there has been substantial investment in developing international standards and frameworks to support the technical or methodological aspects of making recommendations. However, exploration of the social processes involved has been more limited. Objective: To explore the perspectives and experiences of stakeholders on the social processes of developing recommendations in decision-making contexts in Ireland. Methods: A descriptive qualitative study using data from 14 semi-structured interviews was conducted with former guideline development group and expert advisory group members via MS Teams (February-August 2024). Interviewees included clinicians, methodologists and managers. Interviews were transcribed verbatim, analysed thematically and reported in accordance with the Standards for Reporting Qualitative Research. Findings: Voices was identified as a central theme. Strong voices and hierarchies may influence decision-making, leveraging pre-existing hierarchies of professions and hierarchies of evidence. This can be exacerbated when a chair embodies this hierarchy. Our data highlighted a lack of alignment of goals and expectations between the chair and patient voices which, at times, could dominate group discussions. Methods for mitigating dominant voices included forming groups through combinations of personal and professional networks, multidisciplinary voices, briefing and debriefing patient and public representatives, and anchoring the discussion within the evidence and frameworks. Conclusions: The study highlights the varied voices and social structures shaping the evidence to recommendation journey, with mechanisms to mitigate against dominance within guideline development processes.