National Nursing Practice Network P - I - C - O The first step in using EBP is to ask pertinent questions regarding patient care. What is the best way to….. How can we…… Why are we doing it this way? Formulating the question and tracking down the information to answer the question can seem overwhelming to both the novice and expert nurse. Formulating a question that is searchable is often the hardest step. There are two basic types of questions: background questions and foreground questions. NNPN, 2009

Two Types of Questions Background questions Foreground questions General information Biological, psychological, or sociological aspects of illness Found in textbooks or general websites When do complications of Acute Pancreatitis usually occur? How does Morphine work to decrease pain? What is Ehlers Danlos syndrome? Foreground questions Specific questions answered by research Found in Databases/Research Journals Which is better for reducing pain in adults-Morphine or Demerol? Many of our questions can be answered by looking at general textbook information. Many of these questions relate to what we learned in our physiology or biology classes. We encounter diseases and syndromes in our school age children that we may not be familiar with. There are many sources of information on the etiology of these conditions. We consider these to be background questions, we just need background information to fill our knowledge gaps and to be a source of information for staff and parents. Foreground questions are those questions that are better answered by research. These questions are not answered well in textbooks because information to answer these questions changes quickly. New research may reverse old idea which is why we can’t “do things the way we have always done them.” NNPN, 2009

P-I-C-O Model for Clinical Statement/Question Patient, Population, or Problem Intervention or Treatment Comparison Intervention or Treatment Outcome Type of question Type of study One method to guide us in our quest to answer the “foreground” questions is the PICO method. This is a systematic thought process that guides us to be sure we are developing a question that can be answered in a “searchable” way. The PICO format can be used to create a purpose statement or can be used to develop a searchable question. Either format is fine. It is best to use the format that is the least confusing to the staff. Some people prefer the question format thinking it focuses the literature search while others like the purpose statement format thinking it keeps the staff focused on the overall EBP project. University of Illinois at Chicago. (2003). Evidence based medicine. Finding the best clinical literature. Accessed March 30, 2004 from http://www.uic.edu/depts/lib/lhsp/resources/pico.shtml NNPN, 2009

Building the Statement/Question Using P.I.C.O. Patient, Population, or Problem I Intervention or Treatment C Comparison Intervention or Treatment O Outcome Tips for Building How would I describe a group of patients similar to mine? Which main intervention am I considering? What is the main alternative to compare with the intervention? What can I hope to accomplish? Example Patients with Type 2 diabetes who need to change exercise behavior Behavior Change Behavior Modification Behavior Therapy Conventional Therapy Usual Care Exercise Behavior Blood Glucose Control Weight Reduction NNPN, 2009

Building the Statement/Question Using P.I.C.O. Patient, Population, or Problem I Intervention or Treatment C Comparison Intervention or Treatment O Outcome Tips for Building How would I describe a group of patients similar to mine? Which main intervention am I considering? What is the main alternative to compare with the intervention? What can I hope to accomplish? Example Hospitalized patients who have a family pet that they are close to (e.g., for patients with longer stays) Family pet visiting – dogs and cats No visiting of family pets Decreased stress Decreased anxiety Patient and family satisfaction NNPN, 2009

Example of PICO Purpose Statement The purpose of the EBP project is to implement an evidence-based family pet visitation program for hospitalized patients to improve patient and family satisfaction with care delivery and to decrease anxiety associated with hospitalization. NNPN, 2009

Example of PICO Question Unformed practice question: Why do we use ammonia snaps? Question formed using PICO: Do ammonia snaps (intervention) reduce syncope (outcome) in post-op surgical patients (patient population) upon standing? What does the evidence say? Clarifying the question helps define the search for evidence. UIHC Institute, 2007 NNPN, 2009

PICO Example P = patient falls on your psychiatry unit I = fall risk assessment C = pre/post comparison O = improve identification of patients at risk for falling and improve identification of interventions for fall risk factors This is an example of a practice issue flushed out using PICO. NNPN, 2009 UIHC Institute, 2007

Sample Purpose Statement The purpose of this project is to develop an evidence-based fall risk assessment for patients on the medical-psychiatry inpatient unit to improve nursing knowledge, use, and documentation of appropriate interventions. A pre/post comparison will be done using current practice for comparison. Once the PICO is complete, a clear purpose statement can be developed using the PICO components. NNPN, 2009 UIHC Institute, 2007

Using the PICO Method A well formulated PICO statement or question gives direction to find answers more quickly: Helps direct evidence search to best resources Helps focus reading Assists with developing appropriate implementation and evaluation plans Focuses attention on identified learning needs Keeps the team focused Creating a well formulated PICO question or statement can be challenging. It takes time, thought and practice to get it “right.” But if you make this your first step in using EBP, your search for evidence will be much more focused—resulting in saved time and better outcomes. Modified from: McKibbons & Marks, (2001). Posing Clinical Questions: Framing the Question for Scientific Inquiry. AACN Clinical Issues, 12(4), 477-481. NNPN, 2009