AT THE MONTHLY staff meeting, Steve's nurse manager Janis is reviewing sternal wound infection metrics for the unit. Because cardiac surgical site infections have increased, she's discussing possible reasons and solutions. Recalling an article he'd read recently, Steve suggests using chlorhexidine bath wipes to reduce surgical site infections.
Janis says, “The wipes are just too expensive. We can't commit to purchasing the wipes when we aren't even sure they'd work.” Other staff members have heard conflicting information about chlorhexidine wipes and believe they're not recommended for cardiac patients.
Feeling strongly about the benefits of chlorhexidine wipes, Steve asks Janis to trial the product. She says that if he can produce literature supporting his argument, she'll consider purchasing the wipes for a trial. Steve hasn't done a literature search since he was in nursing school and isn't sure how to begin.
What's the optimum way to find the best evidence? This article will help nurses get started by forming a clinical or researchable question with an evidence-based practice framework: A well-constructed PICOT question helps find the best evidence available to influence practice.1 PICOT is an acronym for five key components to a clinical research question. (See PICOT, point by point.) The question should be formulated before starting a literature search.
Finding the best possible evidence requires nurses to formulate a clinical question systematically.2 First, they need to consider the two types of questions.
- Background questions are broad ones commonly answered in textbooks. These questions typically begin with what or when. For example, “What are the signs and symptoms of digoxin toxicity?” When answered, background questions enhance general knowledge. Background questions serve as a foundation for foreground questions.
- Foreground questions are specific to a clinical issue. When these questions are answered, they provide evidence for clinical decision making.1 For example, “In heart failure patients, how do weekly digoxin education sessions compared with monthly education sessions affect the incidence of digoxin toxicity?” According to Stillwell et al., foreground questions can help clinicians decide which of two interventions will improve patient outcomes more effectively.
Foreground questions can be addressed with the PICOT system, which covers these five components: patient population, intervention or issue of interest, comparison intervention or group, outcome, and time frame.3 In the case of the chlorhexidine bath wipes, cardiac surgery patients are the population (P), chlorhexidine bath wipes are the intervention (I), soap and water is the comparison intervention (C), sternal wound infection rates are the outcome (O), and the postoperative period is the time (T) taken for the intervention to achieve an outcome. One way of writing the clinical or researchable question is, “In cardiac surgery patients (P), how does the use of chlorhexidine bath wipes (I) compared with soap and water (C) affect sternal wound infection rates (O) postoperatively (T)?”
Shaping an inquiry
When formulating a PICOT question, nurses must make sure they're using the most appropriate template to frame the question. Melynk and Fineout-Overholt described five types of clinical questions that can be asked and suggested templates that can be used to frame the question.3 (See Question templates for asking PICOT questions.)
These are the five question types:
- Intervention (or issue of interest): used to determine which treatment leads to the best outcome. For example: In patients at risk for falls (P), how does hourly rounding (I) compared with rounding every 2 hours (C) affect the incidence of falls (O)?
- Prognosis or prediction: used to determine the clinical course over time and likely complications of a condition. For example: In patients who have a family history of heart disease (P), how does choosing to participate in a nutrition program (I) compared with not choosing to participate in a nutrition program (C) influence healthy food consumption (O) over 6 months (T)?
- Diagnosis or diagnostic test: used to determine which test is more accurate in diagnosing a condition. For example: In patients with suspected type 2 diabetes (P), is the A1C (I) compared with the fasting plasma glucose (C) more accurate in diagnosing type 2 diabetes (O)?
- Etiology: used to determine the greatest risk factors or causes of a condition. For example: Are children (P) who have sedentary lifestyles (I) compared with children without sedentary lifestyles (C) at higher risk of developing obesity (O) over a 6-month period (T)?
- Meaning: used to understand the significance of an experience for an individual, group, or community. For example, how do women (P) with postpartum depression (I) perceive their ability to function (O) during the postpartum period (T)?
Note that in the template proposed, time (T) and comparison (C) aren't always appropriate for every question, but population (P), intervention or issue of interest (I), and outcome (O) are always present.
The example given in the beginning of the article about chlorhexidine wipes used the intervention template. So how did that turn out? Upon researching his question, Steve was able to provide evidence for his nurse manager Janis about the effects of chlorhexidine wipes on sternal wound infection rates. The literature supported his position that cardiac surgery patients who'd been bathed with chlorhexidine wipes had better sternal wound infection rates when compared with patients who'd been bathed with only soap and water. As a result, Steve's nurse manager agreed to pilot the use of chlorhexidine wipes.
Clinical nurses routinely face scenarios in which they encounter more questions than answers: Questions about what works better, why things are done the way they are, or why unusual things happen. Engaging nurses to ask questions encourages ownership of their practice and empowers them to make positive changes in patient care.4 Framing questions in a PICOT format takes practice, and nurses should be encouraged to embrace this process.
1. Stillwell SB, Fineout-Overholt E, Melnyk BM, Williamson KM. Evidence-based practice, step by step: asking the clinical question: a key step in evidence-based practice. Am J Nurs
2. Melnyk BM, Fineout-Overholt E, Stillwell SB, Williamson KM. Evidence-based practice: step by step: the seven steps of evidence-based practice. Am J Nurs
3. Melnyk BM, Fineout-Overholt E. Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice
. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011.
4. Pangarakis S, Graner T. Engage nurses in EBP with the nursing clinical question process. Nurs Manage