Discussion Post :research question/problem u
Explain the importance of a research question/problem. Create a clinical research question related to a clinical experience you have encountered at work/school. Use the PICOT format to create your question. Select a topic/area of interest to you as this will be your topic you will use for the remaining semester to develop a research protocol.TOPIC OF MY INTEREST WOULD BE SUBSTANCE ABUSE.
Requirements for this post:
Read the PICOT article attached
Word count: Max 500 words
APA format
T
o 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, its easier to take the next
steptoask 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). Thismonthwell discuss
step one, asking the clinical
question. As a context for this
discussionwell use the same
scenariowe used in the previous
articles (see Case Scenario for
EBP: Rapid Response Teams).
In this scenario, a staff nurse,
lets 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 Innovations 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, weve 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 Mays Evidence-Based Practice, Step by Step.
Case Scenario for EBP: Rapid Response Teams
Youre a staff nurse on a busy medicalsurgical unit. Overthe past three months, youve 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 Youre 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.
58 AJN March 2010 Vol. 110, No. 3 ajnonline.com
care unit.2 Shebelieved this could
be a great idea for her hospital.
Based onher nursemanagers
suggestion to search formore evi-
dence to support theuseof a rap-
id response team,Rebeccas spirit
of inquiry ledher to take thenext
step in the EBPprocess: asking
the clinical question. Lets follow
Rebecca as shemeetswithCar-
losA., oneof the expertEBPmen-
tors from the hospitals 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 thats 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
its 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
[emailprotected] AJN March 2010 Vol. 110, No. 3 59
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
units 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), andthe 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.
60 AJN March 2010 Vol. 110, No. 3 ajnonline.com
BecauseRebeccas issue of in-
terest is the rapid response team
an interventionCarlos provides
herwith aninterventionor 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
doesnt have a rapid response
teamanddoesnt 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.
Cardiacarrestsandunplanned
admissions to the ICUare 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 thatsmost 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,
[emailprotected]
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, shes
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 youve 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: Youre a recent graduate with two years experi-
ence in an acute care setting. Youve taken a position as a
home health care nurse and you have several adult patients
with various medical conditions. However, youve recently
been assigned to care for hospice patients. You dont have
experience in this area, and you havent experienced a loved
one at the end of life whos received hospice care. You notice
that some of the family members or caregivers of patients in
hospice care are withdrawn. Youre wondering what the fam-
ily caregivers are going through, so that you might better un-
derstand the situation and provide quality care.
Scenario 2: Youre a new graduate whos 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. Youre 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.
[emailprotected] AJN March 2010 Vol. 110, No. 3 61
