nusg research

Pico research

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, 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.

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 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

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 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.

60 AJN � March 2010 � Vol. 110, No. 3 ajnonline.com

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.

ajn@wolterskluwer.com AJN � March 2010 � Vol. 110, No. 3 61

PICOand Literature Search Assignment

PICO questions are used by researchers to focus research questions and develop an efficient literature search strategy. You will create 3 PICO questions and a search strategy for each to find research studies that help answer one of your PICO questions.

PICO Questions

· Write 3 PICO questions
related to nursing
. Use the PICO templates in the EBP Step by Step 3 article to help create your questions.

· Identify the PICO elements for each question.

Search Strategy and Execution

· Develop a search strategy using at least 3 keywords, 1 synonym, and 1 MeSH term for your PICO questions.

· Using any
one
of your three PICO questions and the search strategy for it, locate 4 articles that help answer it.

· Your articles must be primary source quantitative research articles.

· The population studied, issues/intervention of interest, and outcomes measured in the article should match the P, I, and C of your PICO question.

· No article can be older than 2015.

· Obtain pdfs the four articles you selected.

Submitting Your Results

· On a Word document, write each PICO question with elements identified and the search terms for each.

· Highlight the PICO question for which you selected articles.

· Provide APA references for your selected articles.

· See the example at the end of this document for suggested formatting. You may use it as a template.

· Name each document as follows:

· Lastname PICO

· Lastname article 1

· Lastname article 2

·

Lastname article 3

· Lastname article 4

· Write all five documents in (Word document and pdfs of the articles)

PICO Questions and Literature Search Rubric

Grading Criterion

Pts

Mastery

4

Proficient

3

Developing

2

Beginning

1 or 0

1. Elements of requirements included (3 foreground questions; 3 background questions; PICO Identification for each of the 3 questions; at least 3 keywords, 1 synonym, and 1 MeSH term for each of the 3 questions) = 33 elements total

33 elements included

32 elements included

31 elements included

30 (1 pt) or 29 or fewer (0 pts) elements included

2. All 3 PICOT questions are nursing related

All 3 questions are nursing related

2 questions are nursing related

1 question is nursing related

No questions are nursing related (0 pts)

3. All parts of the PICO are correctly identified = 12 elements

11 to 12 elements are correctly identified

9 to 10 elements are correctly identified

7 to 8 elements are correctly identified

6 (1 pt) or 5 or fewer (0 pts) elements are correctly identified

4. Articles are primary source quantitative research reports.

All 4 are primary source reports

3 are primary source reports

2 are primary source reports

1 (1 pt) or 0 (0 pts) are primary source reports

5. All articles help answer the same PICO question

All 4 help answer the same PICO question

3 help answer the same PICO question

2 help answer the same PICO question

1 (1 pt) or 0 (0 pts) help answer the same PICO question

6. Article citations provided in APA format (see example on next page)

0 to 1 unique APA elements are incorrect

2 to 3 unique APA elements are incorrect

4 to 5 unique APA elements are incorrect

6 (1 pt) or 7 or more (0 pts) unique APA elements are incorrect

7. Articles are no older than 2015

All 4 are no older than 2015

3 are no older than 2015

2 are no older than 2015

1 (1 pt) or 0 (0 pts) are no older than 2015

8. Pdfs of all articles are provided (all or nothing)

Yes

No (0 pts)

Total points / 8 = X.XX = conversion to 100 points

QUESTION 1

Background question:

Does animal therapy help Alzheimer’s patients calm down during sundowning?

Foreground question:

In nursing home residents with Alzheimer’s disease, what is the effect of animal-assisted therapy compared to usual care on the intensity of agitation?

P:

nursing home residents with Alzheimer’s disease

I:

animal-assisted therapy

C:

usual care

O:

intensity of agitation

Keywords:

animal-assisted therapy, Alzheimer’s disease, sundowning, nursing home residents

Synonyms:

dementia, agitation

MeSH terms:

animal assisted therapy, Alzheimer disease, psychomotor agitation, nursing homes

QUESTION 2

Background question:

Foreground question:

P:
I:
C:
O:

Keywords:
Synonyms:
MeSH terms:

QUESTION 3

Background question:

Foreground question:

P:
I:
C:

O:

Keywords:
Synonyms:
MeSH terms:

ARTICLE CITATIONS (must be double spaced, no extra line spacing between citations, Times New Roman 12 pt font, hanging indent, in alpha order, and correctly formatted for scholarly articles in a journal for full points for APA)

Majic, T., Gutzmann, H., Heinz, A., Lang, U. E., & Rapp, M. A. (2013). Animal-assisted therapy and agitation and depression in nursing home residents with dementia: A matched case-control trial. American Journal of Geriatric Psychiatry, 21(11), 1052-1059.

https://doi.org/10.1016/j.jagp.2013.03.004

Nordgren, L., & Engström, G. (2014). Effects of dog-assisted intervention on behavioural and psychological symptoms of dementia. Nursing Older People, 26(3), 31-38.

https://doi.org/10.7748/nop2014.03.26.3.31.e517

Olsen, C., Pedersen, I., Bergland, A., Enders‐Slegers, M., Patil, G., & Ihlebæk, C. (2016). Effect of animal-assisted interventions on depression, agitation and quality of life in nursing home residents suffering from cognitive impairment or dementia: A cluster randomized controlled trial. International Journal of Geriatric Psychiatry, 31(12), 1312-1321.

https://doi.org/10.1002/gps.4436

Swall, A., Ebbeskog, B., Lundh Hagelin, C., & Fagerberg, I. (2017). Stepping out of the shadows of Alzheimer’s disease: A study of older people with Alzheimer’s disease caring for a therapy dog. International Journal of Studies on Health & Well-Being, 12(1), 124-127.

https://doi.org/10.1080/17482631.2017.1347013