Developing and refining a clinical question

Developing and refining a clinical question: A consumer’s perspective Practicing nurses, as well as students, are challenged to keep their practice up to date by searching for, retrieving, and critiquing research articles that apply to practice issues that are encountered in their clinical setting (see Chapter 20). Practitioners strive to use the current best evidence from research when making clinical and health care decisions. As research consumers, you are not conducting research studies; however, your search for information from clinical practice is converted into focused, structured clinical questions that are the foundation of evidence-based practice and quality improvement projects. Clinical questions often arise from clinical situations for which there are no ready answers. You have probably had the experience of asking, “What is the most effective treatment for . . . ?” or “Why do we still do it this way?”

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Using similar criteria related to framing a research question, focused clinical questions form a basis for searching the literature to identify supporting evidence from research. Clinical questions have four components:

• Population

• Intervention

• Comparison

• Outcome

These components, known as PICO, provide an effective format for helping nurses develop searchable clinical questions. Box 2.2 presents each component of the clinical question. BOX 2.2

C o m p o n e n t s o f a C l i n i c a l Q u e s t i o n U s i n g t h e P I C O F o r m a t Population: The individual patient or group of patients with a particular condition or health care problem (e.g., adolescents age 13–18 with type 1 insulin-dependent diabetes)

Intervention: The particular aspect of health care that is of interest to the nurse or the health team (e.g., a therapeutic [inhaler or nebulizer for treatment of asthma], a preventive [pneumonia vaccine], a diagnostic [measurement of blood pressure], or an organizational [implementation of a bar coding system to reduce medication errors] intervention)

Comparison intervention: Standard care or no intervention (e.g., antibiotic in comparison to ibuprofen for children with otitis media); a comparison of two treatment settings (e.g., rehabilitation center vs. home care)

Outcome: More effective outcome (e.g., improved glycemic control, decreased hospitalizations, decreased medication errors)

The significance of the clinical question becomes obvious as research evidence from the literature is critically appraised. Research evidence is used together with clinical expertise and the patient’s perspective to confirm, develop, or revise nursing standards, protocols, and policies that are used to plan and implement patient care (Cullum, 2000; Sackett et al., 2000; Thompson et al., 2004). Issues or questions can arise from multiple clinical and managerial situations. Using the example of catheter acquired urinary tract infections (CAUTIs), a team of staff nurses working on a medical unit in an acute care setting were reviewing their unit’s quarterly quality improvement data and observed that the number of CAUTIs had increased by 25% over the past 3 months. The nursing staff reviewed the unit’s standard of care and noted that although nurses were able to discontinue an indwelling catheter, according to a set of criteria and without a physician order, catheters were remaining in place for what they thought was too long and potentially contributing to an increase in the prevalence of CAUTIs. To focus the nursing staff’s search of the literature, they developed the following question: Does the use of daily nurse-led catheter rounds in hospitalized older adults with indwelling urinary catheters lead to a decrease in CAUTIs? Sometimes it is helpful for nurses who develop clinical questions from a quality improvement perspective to consider three elements as they frame their focused question: (1) the situation, (2) the intervention, and (3) the outcome.

• The situation is the patient or problem being addressed. This can be a single patient or a group of patients with a particular health problem (e.g., hospitalized adults with indwelling urinary catheters).

• The intervention is the dimension of health care interest, and often asks whether a particular intervention is a useful treatment (e.g., daily nurse-led catheter rounds).

• The outcome addresses the effect of the treatment (e.g., intervention) for this patient or patient population in terms of quality and cost (e.g., decreased CAUTIs). It essentially answers whether the intervention makes a difference for the patient population.

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The individual parts of the question are vital pieces of information to remember when it comes to searching for evidence in the literature. One of the easiest ways to do this is to use a table, as illustrated in Table 2.6. Examples of clinical questions are highlighted in Box 2.3. Chapter 3 provides examples of how to effectively search the literature to find answers to questions posed by researchers and research consumers. BOX 2.3

E x a m p l e s o f C l i n i c a l Q u e s t i o n s • Does using a Discharge Bundle combined with Teachback Methodology reduce pediatric

readmissions? (Shermont et al., 2016)

• What is the most effective IV insulin practice guideline for cardiac surgery patients? (Westbrook et al., 2016)

• Does using a structured content and electronic nursing handover reduce patient clinical management errors? (Johnson et al., 2016)

• What is the impact of nursing teamwork on nurse-sensitive quality indicators? (Rahn, 2016)

• Do PCMH access and care coordination measures reflect the contributions of all team members? (Annis et al., 2016)

• Is a patient-family-staff partnership video the most effective approach for preventing falls in hospitalized patients? (Silkworth et al., 2016)

• What is the impact of prompt nutrition care on patient outcomes and health care costs? (Meehan et al., 2016)

PCMH, Patient-centered medical home.

  E V I D E N C E – B A S E D P R A C T I C E T I P You should be formulating clinical questions that arise from your clinical practice. Once you have developed a focused clinical question using the PICO format, you will search the literature for the best available evidence to answer your clinical question.

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