A Key Step in Evidence-Based Practice Stillwell
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 Advancement of Evidence-Based Practice, Bernadette 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 Practice.
Contact author: Susan B. Stillwell, [email protected]
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 published with May’s Evidence-Based Practice, Step by Step.
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 foundation of EBP, and once nurses possess 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 possible 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,” January). 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 increase 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 unplanned admissions to the critical 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 evidence to support the use of a rapid 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 Carlos A., one of the expert EBP mentors 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 patient 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 Foreground questions are specific and relevant to the clinical issue. Foreground questions must be asked in order to determine which of two interventions is the most effective in improving patient outcomes.
For example, “In adult patients undergoing surgery, how does guided imagery compared with music therapy affect analgesia use within the first 24 hours post-op?” is a specific, well-defined question that can only be answered by searching the current literature for studies comparing these two interventions.
Background questions are considerably broader and when answered, provide general knowledge. For example, a background question such as, “What therapies reduce postoperative pain?” can generally be answered by looking in a textbook. For more information 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 guides her in formulating a foreground question using PICOT format. Ask the question in PICOT format. Now that Rebecca has an understanding of foreground and background questions, Carlos guides her in formulating a foreground question using PICOT format.
TABLE. Comparison of Background and Foreground Questions 4-6
PICOT is an acronym for the elements of the clinical question: patient population (P), intervention or issue of interest (I), comparison intervention or issue of interest (C), outcome(s) of interest (O), and time it takes for the intervention to achieve the outcome(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 evidence to
inform practice will be found quickly and efficiently.5-8