Igniting a Spirit of Inquiry

To fully implement evidence-based practice (EBP),nurses need to have both a spirit of inquiry and a culture that supports it. In our first article in this series (“Igniting a Spirit of Inquiry: An Essential Foundation for Evidence-Based Practice,” November 2009), we defined a spirit of inquiry as “an ongoing curiosity about the best evidence to guide clinical decision making.” A spirit of inquiry is the founda- tion of EBP, and once nurses pos- sess it, it’s easier to take the next step—to ask the clinical question.1

Formulating a clinical question in a systematic way makes it pos- sible to find an answer more quickly and efficiently, leading to improved processes and patient outcomes. In the last installment, we gave

an overview of the multistep EBP process (“The Seven Steps of Evidence-Based Practice,” Janu- ary). This month we’ll discuss step one, asking the clinical question. As a context for this discussion we’ll use the same

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

let’s call her Rebecca R., noted that patients on her medical– surgical unit had a high acuity level that may have led to an in- crease in cardiac arrests and in the

number of patients transferred to the ICU. Of the patients who had a cardiac arrest, four died. Rebecca shared with her nurse manager a recently published study on how the use of a rapid response team resulted in reduced in-hospital cardiac arrests and un- 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 She believed this could be a great idea for her hospital. Based on her nurse manager’s suggestion to search for more evi- dence to support the use of a rap- id response team, Rebecca’s spirit of inquiry led her to take the next step in the EBP process: asking

the clinical question. Let’s follow Rebecca as she meets with Car- los A., one of the expert EBP men- tors from the hospital’s EBP and research council, whose role is to assist point of care providers in enhancing their EBP knowledge and skills.

Types of clinical questions. Carlos explains to Rebecca 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 on well- formulated clinical questions that guide us to search for the most current literature. There are two types of clinical

questions: background questions and foreground questions.3-5 Fore- ground questions are specific and relevant to the clinical issue. Fore- ground questions must be asked in order to determine which of two interventions is the most ef- fective in improving patient out- comes. For example, “In adult patients undergoing surgery, how does guided imagery compared with music therapy affect anal- gesia use within the first 24 hours post-op?” is a specific, well- defined question that can only

guides her in formulating a fore- ground question using 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). When Rebecca asks why the PICOT question is so important, Carlos explains that it’s a consistent, systematic way to identify the components of a clinical issue. Using the PICOT format to structure the clinical question helps to clarify these components, which will guide the search for the evidence.6, 7 A well- built PICOT question increases the likelihood that the best evi- dence to inform practice will be found quickly and efficiently.5-8

To help Rebecca learn to for- mulate a PICOT question, Car- los uses the earlier example of a foreground question: “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 and when answered, provide general knowl- edge. For example, a background

question such as, “What therapies reduce postoperative pain?” can generally be answered by looking in a textbook. For more 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 that Rebecca has an understanding of foreground and background questions, 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

ajn@wolterskluwer.com 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 asks Rebecca to reflect

on the clinical situation on her

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 and Carlos revisit aspects of the clinical issue to see which may be- come components of the PICOT question: the high acuity of pa- tients on the unit, the number of

cardiac arrests, the unplanned ICU admissions, and the research article on rapid response teams. Once the issue is clarified, the PICOT question can be written.

with music therapy affect analge- sia use within the first 24 hours post-op?” In this example, “adult patients undergoing surgery” is the population (P), “guided imag- ery” is the intervention of interest (I), “music therapy” is the com- parison intervention of interest (C), “pain” is the outcome of in- terest (O), and “the first 24 hours 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 24 hours after sur- gery. Note that a comparison may not be pertinent in some PICOT questions, such as in “meaning questions,” which are designed to uncover the meaning 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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Because Rebecca’s issue of in- terest is the rapid response team— an intervention—Carlos provides her with an “intervention or ther- apy” template to use in formu- lating the PICOT question. (For other types of templates, see Tem- plates and Definitions for PICOT Questions.5, 6) Since the hospital doesn’t have a rapid response team and doesn’t have a plan for addressing acuity issues before a crisis occurs, the comparison, or (C) element, in the PICOT ques- tion is “no rapid response team.” “Cardiac arrests” 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 PICOT question: “In hospi- talized adults (P), how does a rapid response team (I) compared with no rapid response team (C)

clinical question that’s most ap- propriate for each scenario, and choose a template to guide you. Then formulate one PICOT ques- tion for each scenario. Suggested PICOT questions will 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.Melnyk BM, et al. Igniting a spirit of inquiry: an essential foundation for evidence-based practice. Am J Nurs 2009;109(11):49-52. 2.Dacey MJ, et al. The effect of a rapid response team on major clinical out- come measures in a community hos- pital. Crit Care Med 2007;35(9): 2076-82. 3.Fineout-Overholt E, Johnston L. Teaching EBP: asking searchable, an- swerable clinical questions.World- views Evid Based Nurs 2005;2(3): 157-60. 4.Nollan R, et al. Asking compelling clinical questions. In: Melnyk BM, Fineout-Overholt E, editors. Evidence- based practice in nursing and health- care: a guide to best practice. Philadelphia: Lippincott Williams and Wilkins; 2005. p. 25-38. 5. Straus SE. Evidence-based medicine:

how to practice and teach EBM. 3rd ed. Edinburgh; New York: 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: Wolters Kluwer Health/Lippincott Williams and Wilkins. 7.McKibbon KA, 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 the best 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) during a three-month period (T)?” Now that Rebecca has formu-

lated the clinical question, she’s ready for the next step in the EBP process, searching for the evi- dence. Carlos congratulates Rebecca on developing a search- able, answerable question and arranges to meet with her again to mentor her in helping her find the answer to her clinical ques- tion. The fourth article in this series, to be published in the May 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.