evidence- based practice

To fully implement evidence- based practice (EBP), nurses need to have both

a spirit of inquiry and a culture that supports it. Inour first article in this series (“Igniting a Spirit of Inquiry:AnEssential Foundation for Evidence-Based Practice,” November 2009),we defined a spirit of inquiry as “an ongoing curiosity about the best evidence toguide clinical decisionmaking.” A spirit of inquiry is the founda- tionof EBP, andonce nurses pos- sess it, it’s easier to take the next step—toask the clinical question.1

Formulating a clinical question in a systematicwaymakes it pos- sible to find an answermore quickly and efficiently, leading to improved processes and patient outcomes. In the last installment,wegave

an overviewof themultistepEBP process (“The Seven Steps of Evidence-Based Practice,” Janu- ary). Thismonthwe’ll discuss step one, asking the clinical question. As a context for this discussionwe’ll use the same

scenariowe used in the previous articles (see Case Scenario for EBP: Rapid Response Teams). In this scenario, a staff nurse,

let’s call herRebeccaR., noted that patients on hermedical– surgical unit had a high acuity level thatmay have led to an in- crease in cardiac arrests and in the

number of patients transferred to the ICU.Of thepatientswho had a cardiac arrest, four died. Rebecca sharedwith her nurse manager a recently published study onhow the use of a rapid response teamresulted in reduced in-hospital cardiac arrests andun- planned admissions to the critical

Asking the Clinical Question: A Key Step in Evidence-Based Practice

A successful search strategy starts with a well-formulated question.

This is the third article in a series from the Arizona State University College of Nursing and Health Innovation’s Center for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. When delivered in a context of caring and in a supportive organizational culture, the highest quality of care and best patient outcomes can be achieved.

The purpose of this series is to give nurses the knowledge and skills they need to implement EBP consistently, one step at a time. Articles will appear every two months to allow you time to incorporate information as you work toward implementing EBP at your institution. Also, we’ve scheduled “Ask the Authors” call-ins every few months to provide a direct line to the experts to help you resolve questions. Details about how to participate in the next call will be pub- lished with May’s Evidence-Based Practice, Step by Step.

Case Scenario for EBP: Rapid Response Teams

You’re a staff nurse on a busy medical–surgical unit. Overthe past three months, you’ve noticed that the patients on your unit seem to have a higher acuity level than usual, with at least three cardiac arrests per month, and of those patients who arrested, four died. Today, you saw a report about a recently published study in Critical Care Medicine on the use of rapid response teams to decrease rates of in-hospital car- diac arrests and unplanned ICU admissions. The study found a significant decrease in both outcomes after implementation of a rapid response team led by physician assistants with spe- cialized skills.2 You’re so impressed with these findings that you bring the report to your nurse manager, believing that a rapid response team would be a great idea for your hospital. The nurse manager is excited that you have come to her with these findings and encourages you to search for more evidence to support this practice and for research on whether rapid re- sponse teams are valid and reliable.

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care unit.2 Shebelieved this could be a great idea for her hospital. Based onher nursemanager’s suggestion to search formore evi- dence to support theuseof a rap- id response team,Rebecca’s spirit of inquiry ledher to take thenext step in the EBPprocess: asking

the clinical question. Let’s follow Rebecca as shemeetswithCar- losA., oneof the expertEBPmen- tors from the hospital’s EBP and research council, whose role is to assist point of care providers in enhancing their EBPknowledge and skills.

Types of clinical questions. Carlos explains toRebecca that finding evidence to improve pa- tient outcomes and support a practice change depends upon how the question is formulated. Clinical practice that’s informed by evidence is based onwell- formulated clinical questions that guide us to search for the most current literature. There are two types of clinical

questions: backgroundquestions and foregroundquestions.3-5 Fore- ground questions are specific and relevant to the clinical issue. Fore- groundquestionsmust be asked in order to determinewhich of two interventions is themost ef- fective in improving patient out- comes. For example, “In adult patients undergoing surgery, how does guided imagery compared withmusic therapy affect anal- gesia usewithin the first 24hours post-op?” is a specific,well- defined question that can only

guides her in formulating a fore- groundquestionusing PICOT format. PICOT is an acronym for the

elements of the clinical question: patient population (P), interven- tion or issue of interest (I), com- parison intervention or issue of interest (C), outcome(s) of inter- est (O), and time it takes for the intervention to achieve the out- come(s) (T).WhenRebecca asks why the PICOTquestion is so important, Carlos explains that it’s a consistent, systematicway to identify the components of a clinical issue. Using the PICOT format to structure the clinical question helps to clarify these components,whichwill guide the search for the evidence.6, 7 Awell- built PICOTquestion increases the likelihood that the best evi- dence to informpracticewill be foundquickly and efficiently.5-8

To helpRebecca learn to for- mulate a PICOTquestion,Car- los uses the earlier example of a foregroundquestion: “In adult patients undergoing surgery, how does guided imagery compared

be answered by searching the current literature for studies comparing these two interven- tions.

Background questions are considerably broader andwhen answered, provide general knowl- edge. For example, a background

question suchas, “What therapies reduce postoperative pain?” can generally be answeredby looking in a textbook. Formore informa- tion on the two types of clinical questions, see Comparison of Background and Foreground Questions.4-6

Ask the question in PICOT format. Now thatRebecca has an understanding of foreground andbackgroundquestions,Carlos

Comparison of Background and Foreground Questions4-6

Question type Description Examples

Background question

A broad, basic-knowledge question commonly answered in textbooks. May begin with what or when.

1) What is the best method to pre- vent pressure ulcers?

2) What is sepsis? 3) When do the effects of

furosemide peak?

Foreground question

A specific question that, when answered, provides evidence for clin- ical decision making. A foreground question includes the following ele- ments: population (P), intervention or issue of interest (I), comparison inter- vention or issue of interest (C), out- come (O), and, when appropriate, time (T).

1) In mechanically ventilated pa- tients (P), how does a weaning protocol (I) compared with no weaning protocol (C) affect venti- lator days (O) during ICU length of stay (T)?

2) In hospitalized adults (P), how does hourly rounding (I) com- pared with no rounding (C) affect fall rates (O)?

The PICOT question is a consistent,

systematic way to identify the components

of a clinical issue.

By Susan B. Stillwell, DNP, RN, CNE, Ellen Fineout-Overholt, PhD, RN, FNAP, FAAN, Bernadette Mazurek Melnyk, PhD, RN,

CPNP/PMHNP, FNAP, FAAN, and Kathleen M. Williamson, PhD, RN

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also not always required. But population, intervention or issue of interest, and outcome are es- sential to developing any PICOT question. Carlos asksRebecca to reflect

on the clinical situation onher

unit in order to determine the unit’s current intervention for ad- dressing acuity. Reflection is a strategy to help clinicians extract critical components from the clin-

ical issue to use in formulating the clinical question.3 Rebecca andCarlos revisit aspects of the clinical issue to seewhichmaybe- come components of the PICOT question: the high acuity of pa- tients on the unit, the number of

cardiac arrests, the unplanned ICUadmissions, and the research article on rapid response teams. Once the issue is clarified, the PICOTquestion can bewritten.

withmusic therapy affect analge- sia usewithin the first 24 hours post-op?” In this example, “adult patients undergoing surgery” is thepopulation (P), “guided imag- ery” is the interventionof interest (I), “music therapy” is the com- parison intervention of interest (C), “pain” is the outcomeof in- terest (O), and“the first 24hours post-op” is the time it takes for the intervention to achieve the outcome (T). In this example, music therapy or guided imagery is expected to affect the amount of analgesia used by the patient within the first 24hours after sur- gery.Note that a comparisonmay not be pertinent in somePICOT questions, such as in “meaning questions,”which are designed to uncover themeaning of a particular experience.3, 6 Time is

Templates and Definitions for PICOT Questions5, 6

Question type Definition Template

Intervention or therapy

To determine which treatment leads to the best outcome

In _____________________ (P), how does ______________ (I) compared with ___________ (C) affect __________________ (O) within __________________ (T)?

Etiology To determine the greatest risk factors or causes of a condition

Are ______________________________ (P) who have ________________________ (I), compared with those without ________ (C), at ____ risk for ____________________ (O) over _____________________________ (T)?

Diagnosis or diagnostic test

To determine which test is more accurate and precise in diagnosing a condition

In ______________________________ (P), are/is ___________________________ (I) compared with ___________________ (C) more accurate in diagnosing _______ (O)?

Prognosis or prediction

To determine the clinical course over time and likely complications of a condition

In ___________________ (P), how does _____________ (I) compared with ________ (C), influence _____________ (O) over _________________ (T)?

Meaning To understand the meaning of an experience for a particular individual, group, or commu- nity

How do ______________ (P) with _________________ (I) perceive ______________ (O) during _______________ (T)?

A well-built PICOT question increases the

likelihood that the best evidence to inform

practice will be found.

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BecauseRebecca’s issue of in- terest is the rapid response team— an intervention—Carlos provides herwith an“interventionor ther- apy” template to use in formu- lating the PICOTquestion. (For other types of templates, see Tem- plates and Definitions for PICOT Questions.5, 6) Since the hospital doesn’t have a rapid response teamanddoesn’t have a plan for addressing acuity issues before a crisis occurs, the comparison, or (C) element, in the PICOTques- tion is “no rapid response team.” “Cardiacarrests”and“unplanned admissions to the ICU”are the outcomes in the question.Other potential outcomes of interest to the hospital could be “lengths of stay” or “deaths.” Rebecca proposes the follow-

ing PICOTquestion: “In hospi- talized adults (P), howdoes a rapid response team (I) compared with no rapid response team (C)

clinical question that’smost ap- propriate for each scenario, and choose a template to guide you. Then formulate onePICOTques- tion for each scenario. Suggested PICOTquestionswill be pro- vided in the next column. �

Susan B. Stillwell is clinical associate professor and program coordinator of the Nurse Educator Evidence-Based Practice Mentorship Program at Arizona State University in Phoenix, where Ellen Fineout-Overholt is clinical professor and director of the Center for the Advance- ment of Evidence-Based Practice, Ber- nadette Mazurek Melnyk is dean and distinguished foundation professor of nursing, and Kathleen M. Williamson is associate director of the Center for the Advancement of Evidence-Based Prac- tice. Contact author: Susan B. Stillwell, sstillwell@asu.edu.

REFERENCES 1.MelnykBM, et al. Igniting a spirit of inquiry: an essential foundation for evidence-based practice. Am J Nurs 2009;109(11):49-52. 2.DaceyMJ, et al. The effect of a rapid response teamonmajor clinical out- comemeasures in a community hos- pital. Crit Care Med 2007;35(9): 2076-82. 3.Fineout-Overholt E, JohnstonL. TeachingEBP: asking searchable, an- swerable clinical questions. World- views Evid Based Nurs 2005;2(3): 157-60. 4.NollanR, et al. Asking compelling clinical questions. In:MelnykBM, Fineout-Overholt E, editors. Evidence- based practice in nursing and health- care: a guide to best practice. Philadelphia: LippincottWilliams andWilkins; 2005. p. 25-38. 5.Straus SE. Evidence-based medicine:

how to practice and teach EBM. 3rd ed. Edinburgh;NewYork: Elsevier/ Churchill Livingstone; 2005. 6.Fineout-Overholt E, Stillwell SB.Ask- ing compelling questions. In:Melnyk BM, Fineout-Overholt E, editors. Evidence-based practice in nursing and healthcare: a guide to best practice [forthcoming]. 2nd ed. Philadelphia: WoltersKluwerHealth/Lippincott Williams andWilkins. 7.McKibbonKA,Marks S. Posing clini- cal questions: framing the question for scientific inquiry. AACN Clin Issues 2001;12(4):477-81. 8.Fineout-Overholt E, et al. Teaching EBP: getting to the gold: how to search for thebest evidence. Worldviews Evid Based Nurs 2005;2(4):207-11.

affect the number of cardiac ar- rests (O) and unplanned admis- sions to the ICU (O) duringa three-month period (T)?” Now thatRebecca has formu-

lated the clinical question, she’s ready for thenext step in theEBP process, searching for the evi- dence. Carlos congratulates Rebecca ondeveloping a search- able, answerable question and arranges tomeetwith her again tomentor her in helping her find the answer to her clinical ques- tion. The fourth article in this series, tobepublished in theMay issue of AJN, will focus on strat- egies for searching the literature to find the evidence to answer the clinical question. Now that you’ve learned to

formulate a successful clinical question, try this exercise: after reading the two clinical scenarios in Practice Creating a PICOT Question, select the type of

Practice Creating a PICOT Question Scenario 1: You’re a recent graduate with two years’ experi- ence in an acute care setting. You’ve taken a position as a home health care nurse and you have several adult patients with various medical conditions. However, you’ve recently been assigned to care for hospice patients. You don’t have experience in this area, and you haven’t experienced a loved one at the end of life who’s received hospice care. You notice that some of the family members or caregivers of patients in hospice care are withdrawn. You’re wondering what the fam- ily caregivers are going through, so that you might better un- derstand the situation and provide quality care.

Scenario 2: You’re a new graduate who’s accepted a position on a gerontology unit. A number of the patients have demen- tia and are showing aggressive behavior. You recall a clinical experience you had as a first-year nursing student in a long- term care unit and remember seeing many of the patients in a specialty unit for dementia walking around holding baby dolls. You’re wondering if giving baby dolls to your patients with dementia would be helpful.

What type of PICOT question would you create for each of these scenarios? Select the appropriate templates and formu- late your questions.

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