ASKING THE
CLINICAL QUESTION
Raymund Christopher R. dela Peña, RN, RM, MAN
PhD in Nursing Student, SLU-SON
Clinical Faculty, UNP-CN
Steps of Evidence-based
Practice
1. Ask the clinical question
2. Collect the most relevant and best evidence
3. Critically appraise the evidence (scientific
merit, clinical relevance)
4. Integrate all evidence with clinical expertise,
patient preferences and values in making a
practice decision or change (implementation
potential)
5. Evaluate the practice decision or change
Formulating a
Well Built Clinical
Question
Efficiency is Key
Finding the right information in the
most efficient manner is key to
successfully practicing evidence-
based decision making.
Knowing what key components to
use in your search strategy will help
you develop that efficiency.
These key components of interest are:
The PICO process is a
technique used in
evidence based practice
to frame and answer a
clinical question. The
PICO framework is also
used to develop
literature search
strategies.
Patient (problem or population)
The first step in developing a
well-built question
Describe either the patient's
chief complaint or generalize
the patient's condition to a
larger population.
When identifying the P in PICO
it is helpful to ask:
How you would describe the patient to a
colleague?
What are the important characteristics of this
patient?
- Primary Problem
- Patient's main concern or chief complaint
- Disease or health status
- Age, Race, Sex, Previous ailments, current
medications
The P phrase could be
more detailed if the
added information
influences the results
you expect to find.
Problem
[Disease], e.g., “panic disorder”
[Behavior], e.g., “oppositional behaviors”
[Symptom], e.g., “leg cramps”
Population
[Age], e.g., “40-year- old”
[Gender], e.g., “male”
[Treatment Status], e.g., “delayed treatment”
[Physical Condition], e.g., “healthy”
[Medical History], e.g., “with prior attacks”
[Treatment & Drug], e.g., “taking hormone replacement
therapy”
[Disease], e.g., “nonvalvular atrial fibrillation”
[Symptom], e.g., “chronic cough”
P
Example: For
persons entering a
health care
facility……
Intervention
What main
intervention are
you considering?
What do you
want to do with
this patient? What
is the main
alternative being
considered?
It is important to identify what
you plan to do for that patient.
This may include the use of a
specific diagnostic test,
treatment, adjunctive therapy,
medication or the
recommendation to the patient
to use a product or procedure.
I
Example: For persons
entering a health care
facility, is hand rubbing
with a waterless,
alcohol based
solution…..
Comparison
is the third phase of the well-
built question, which is the main
alternative you are considering. It
should be specific and limited to
one alternative choice in order to
facilitate an effective
computerized search.
What you want to compare the
intervention against
- no intervention/traditional
intervention
- Alternative intervention
C
For persons entering a health
care facility, is hand rubbing
with a waterless, alcohol
based solution, as effective
as standard hand washing
with antiseptic soap…..
Outcome
The final aspect of the PICO question. It
specifies the result(s) of what you plan to
accomplish, improve or affect and should
be measurable. Outcomes may consist of:
relieving or eliminating specific symptoms
improving or maintaining function
enhancing aesthetics.
accuracy of diagnosis
improvement of health problem
Outcome
Define what is it that you are hoping to
achieve or avoid
Specific outcomes will yield better
search results and allow you to find the
studies that focus on the outcomes you
are searching for
O
Example: For persons entering a
health care facility, is hand
rubbing with a waterless, alcohol
based solution, as effective as
standard hand washing with
antiseptic soap for reducing hand
contamination?
In addition to identifying the PICO
components, it is important to clarify
the type of question you are asking.
The categories for types of questions
are:
Therapy/Prevention
Diagnosis
Etiology
Prognosis
Meaning
Question Template for PICO
Therapy
- Questions of treatment in order to
achieve some outcome. May include
effectiveness of drugs, surgical
intervention, change in diet, counselling,
etc.
Selection of treatments
or interventions that do
more good than harm
and that are worth the
effort and cost.
Example:
A 19 y/o Nigerian woman is brought to ER by her
mother with a 3-day history of nausea, vomiting
and headache. She is taking Acetaminophen 1 g
t.i.d for her headache. She is diagnosed with
Hepatitis B. Her mother asked you if she can
continue with Acetaminophen since she heard that
it can cause liver problems.
In Nigerian female adolescent with hepatitis ,(P)
what is the effect of Acetamenophen (I) on liver
function (O) compared with Ibuprofen? (C)
For patients who underwent surgery
(P), what is the effect in postoperative
pain (O), when post-operative patients
use music therapy (I), as compared to
post-operative patients who do not use
music (C)?
P – Postoperative patients
I – Use of music therapy
C – No music
O – Reduction of postoperative pain
How Problem-based Learning (I) compared
with traditional lecture-based learning (C)
affects the critical thinking skills (O) of
nursing students (P)
P – Nursing students
I – Problem-based Learning
C – Compared with Lecture-base Learning
O – promotes better critical thinking (better
clinical judgment, less clinical error,
improved patient outcome)
For infants diagnosed with bronchiolitis
(P), will incorporating hypertonic saline
solution on nebulization (I) compared to
not incorporating (C) affect the relief of
signs and symptoms (O)?
P - infants diagnosed with bronchiolitis
I - incorporating hypertonic saline solution
on nebulization
C -not incorporating saline to
nebulization
O - relief of signs and symptoms
Etiology
Identification of
causes or risk
factors for
disease
Example:
A 40 y/o woman comes to the clinic with BP
130/90. When you discuss the findings with her,
she asks you about her chance of having a heart
attack. Given the discussions about
hypertension parameters, what is the best
evidence?
Are 30-50 y/o women (P) who have high blood
pressure (I) at increased risk for an acute MI (O)
compared to women without high blood
pressure. (C)
Diagnosis
Selection and interpretation of diagnostic
tests, inorder to confirm or exclude a
diagnosis, based on considering their
precision, accuracy, acceptability,
expense, safety, etc
Example:
Alison, 2 y/o was seen at the ER due to vomiting and
fever. Urine was collected in a bag, then sent to the lab
for microscopy and culture. The WBC was high so
antibiotic was started. In the follow-up checkup, the
culture results showed mixed growth. It is not clear if
Alison is with UTI or whether the urine sample was
contaminated
In children who are not toilet trained suspected of
UTI(P), what is the risk of culture contamination (O)
when urine is obtained by clean catch (I), as compared
with urine obtained by suprapubic aspiration directly
from the bladder (C)
Prevention
identifying risks factors
that if adjusted can help
to reduce the change of
developing the disease
Example
A group of elderly in the Health center asked
you to talk about the importance for people
of their age to get an annual flu shot. You
want to be well prepared on answer their
questions
For patients 65 years and older (P) does the
use of an influenza vaccine(I) reduce the
risk of pneumonia (O) compared with
patients who did not receive the vaccine (C)
Prognosis
Estimation of a
patient's likely clinical
course over time and
anticipation of likely
complications of
disease
Prognosis
You are a coordinator of a local support group for
smokers and planned a joint session for patients
and nurses on smoking cessation. There were 3
participants who had their second myocardial
infarction in the last 6 years. You expect questions
about smoking and subsequent heart attacks.
Does smoking status: smokers (I) vs non-
smokers(C) influence infarction rate (O) in pts
who had experienced an acute MI (P)?
Meaning
You are caring for a 35 y/o admitted patient
after a vehicular accident and who was
diagnosed with fibromyalgia 5 years ago. She
complains of fatigue and the patient becomes
concerned. She wants to make sure that her
diagnosis is taken seriously.
How do women (P) diagnosed with
fibromylagia (I) perceive (O) others’ perception
of their physical limitations (C)?
Other PICO examples
Do children have fewer site reactions when flue
vaccine is administered with a ½-inch or a ¼-inch
needle?
Is a visual analogue scale more accurate in
assessing dyspnea than asking the patients if they
are short of breath
Do distracters in clinic waiting rooms reduce the
dissatisfaction of long waiting time
What is the most effective teaching strategy to
educate clinical staff on EBP
Is a surgical 2-minute hand wash as effective as a
4-minute hand wash
Thank you
very much
for listening!
