PICO

Write  a PICO question based on a scenario you choose from the list of  scenarios attached below.  Use the templates in the EBP Step by Step 3  article to help create your questions. You may need to do a pre-search  to finding an intervention (the “I”) that has been studied and published  to solve the problem.

• Identify the PICO elements for each question. 
• Develop  a search strategy using at least 3 keywords from the P, I, and O parts  of your PICO, 1 synonym for one of the keywords, and 1 MeSH term for one  of your keywords. 
• Locate 4 articles that help answer your PICO question.  The articles must meet the following requirements:  
• must be primary source quantitative research articles.  
• No article can be older than 2016. 
• Obtain  pdfs of the four articles you selected from the ResU database.  If not  available for the ResU database, you may request access from  the ResU Library, or you can email me the citation for the article, and I  will attempt to locate a pdf of it. 
• On  a Word document, include your scenario; write your PICO question as a  sentence; identify the P, I, C, and O for each question; and list the  search terms (3 keywords, 1 synonym, 1 MeSH term) for each. You may use  the template attached here. See also the link to the MeSH terms website  below.
• Provide  a properly formatted APA reference page for your selected articles from  Step 4 of these instructions. See the link to the APA and Writing  LibGuide below.

2

Student Name:

PICO and Literature Search

NUR4440

Scenario: Non-Pharmacological Management of Dementia: On the neurology inpatient unit, there are increasing numbers of patients with dementia. Some of the symptoms noted in these patients include agitation, wandering and even screaming and violence. A nurse on the unit was recently injured by an elderly man who attacked and hit her while she was providing nursing care to him. Your task is to propose a plan that will address the non-pharmacological management of dementia on the unit and train the nurses to provide quality care to patients with dementia.

PICO Question: In adults with Alzheimer’s disease, what is the effect of animal-assisted therapy compared to usual care on the intensity of agitation?

P: adults with Alzheimer’s disease

I: animal-assisted therapy

C: usual care

O: intensity of agitation

3 Keywords: Alzheimer’s, animal-assisted therapy, agitation

1 Synonym: dementia

1 MeSH term: psychomotor agitation

References

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

Updated 8/29/2020 CJP

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.

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

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.

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

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.

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

PICO and Literature Search Scenarios

1

:

Delegation: A unit employs RNs, LPN’s and PCTs (patient care techs) to provide direct care. The unit has had an issue with appropriate delegation. The PCTs and LPNs report that they are being asked to perform more than their “fair share”, and things they should not do. The RN’s state that they are the only ones who do anything, and every time they ask the LPNs and PCTs to do anything they are told the PCTs and LPNs are not allowed to perform the task. The Unit manager recognizes that efforts to improve delegation need to be made. Your task is to research an intervention to enhance the quality and practice of delegation on this unit.

2:

Decreasing wait times in ER or patient flow time to move from ED: A manager of an Emergency Department is concerned that patient satisfaction scores have dropped significantly for the department. The primary complaint is long wait times. Internal tracking of patient flow has shown patients are waiting up to 7 hours for transfers to patient care areas, or to hospital units. Your task is to research an intervention to decrease wait times with improved flow to the care areas.

3:

New grad nurse retention: The manager of a medical surgical unit that is expanding needs to hire additional staff. Over the last 3 years 90% of the new graduates hired have quit within the first year of hire. The current RN staff is comprised of 8 nurses with greater than 10 yrs experience, 6 nurses with 5-10 yrs experience and 7 nurses with less than 5 yrs experience on the unit. Six new graduates are hired for the expansion. They will start 3 months before the new beds open. Your task is to research an intervention to enhance retention of the new graduates.

4:

Reducing medication errors: A medical surgical unit manager has had a significant increase in medication administration errors over the last two months. The errors involve many staff members and are occurring on all shifts. The budget does not allow for the purchase of new administration system. Your task is to research an intervention to decrease medication administration errors from the nursing staff within these parameters.

5:

Patient family centered care: The manager of a medical surgical unit has experienced a significant drop in patient satisfaction with the primary complaints being a lack of communication to patients and their family members. Your task is to research an intervention to increase patient-family centered care environment that would address this issue.

6:

Evidence-based practice: A hospital is seeking Magnet Hospital status. The managers of the units are charged with enhancing the incorporation of evidenced based practice on a unit level. Your task is to research an intervention to enhance the exposure to and application of evidence-based practice among nurses on the medical surgical unit.

7:

Enhancing teamwork across care provider levels: The manager of a medical surgical unit has observed, and had complaints about, lack of teamwork between the RN’s and the patient care techs (PCT’s). Your task is to research an intervention to enhance teamwork on the unit.

8:

Call light response time: The manager of a medical surgical unit that employs RN’s and patient care techs (PCT’s) has had a significant increase in call light response time and decrease in patient satisfaction related to the answering of call lights. Your task is to research an intervention that addresses the answering of call light in a timely, respectful manner.

9:

Decreasing the incidence of DVT’s in post-op orthopedic patients: Quality assurance reports for an orthopedic surgery unit identify an increase in the incidence of DVT’s over the last 6 months. The unit uses a standard prevention plan of Lovenox subQ and sequential compression devices (SCD’s) for all appropriate post-op patients. A recent survey found that 64% of the patients did not have SCD’s on while in bed and 32% did not receive Lovenox with the notation “refused”. Your task is to research an intervention to increase the use of SCD’s and decrease the number of refused Lovenox doses.

1