Qual Saf Health Care 19:509-513 doi:10.1136/qshc.2009.032565
  • Original research

How “should” we write guideline recommendations? Interpretation of deontic terminology in clinical practice guidelines: survey of the health services community

  1. R N Shiffman1
  1. 1Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, Connecticut, USA
  2. 2Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
  1. Correspondence to Richard N. Shiffman, MCIS Yale Center for Medical Informatics, 300 George St, Ste 501 New Haven, CT 06511; richard.shiffman{at}
  1. Contributors EAL is a paediatrician and postdoctoral fellow in medical informatics at Yale University. EAL wrote the survey instrument, solicited survey participation, analysed the data and is guarantor. GM designed and implemented the survey and database to which it connected. ZL provided statistical input and verification. RNS is the associate director of the Yale Center for Medical Informatics and has expert knowledge on guideline implementability and transformation into computerised decision support tools. RNS provided critical direction and oversight at each phase of the project, including study design, data analysis and revision of the manuscript. All authors had full access to all of the data.

  • Accepted 26 June 2009
  • Published Online First 10 August 2010


Objective To describe the level of obligation conveyed by deontic terms (words such as “should”, “may”, “must” and “is indicated”) commonly found in clinical practice guidelines.

Design Cross-sectional electronic survey.

Setting A clinical scenario was developed by the researchers, and recommendations containing 12 deontic terms and phrases were presented to the participants.

Participants All 1332 registrants of the 2008 annual conference of the US Agency for Healthcare Research and Quality.

Main outcome measures Participants indicated the level of obligation they believed guideline authors intended by using a slider mechanism ranging from “No obligation” (leftmost position recorded as 0) to “Full obligation” (rightmost position recorded as 100.)

Results 445/1332 registrants (36%) submitted the on-line survey; 254/445 (57%) reported that they have experience in developing clinical practice guidelines; 133/445 (30%) indicated that they provide healthcare. “Must” conveyed the highest level of obligation (median=100) and least amount of variability (interquartile range=5.) “May” (median=37) and “may consider” (median=33) conveyed the lowest levels of obligation. All other terms conveyed intermediate levels of obligation characterised by wide and overlapping interquartile ranges.

Conclusions Members of the health services community believe guideline authors intend variable levels of obligation when using different deontic terms within practice recommendations. Ranking of a subset of terms by intended level of obligation is possible. Matching deontic terminology to the intended recommendation strength can help standardise the use of deontic terminology by guideline developers.


  • Funding This study was supported by grant R01-LM07199, which is cofunded by the National Library of Medicine and the Agency for Healthcare Research and Quality, contract AHRQ-07-10045, and by grant T15-LM07065 from the National Library of Medicine.

  • Competing interests None.

  • Ethics approval The Yale Human Investigations Committee approved our study under exemption status. The survey instrument did not collect any personally identifiable information.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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