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IWU OCLS Tutorials: Evidence-Based Toolkit for Nursing - Question & PICO


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Identify the Problem


The most important step in Evidence-Based Nursing (EBN) is to correctly identify a problem through patient assessment or practice assessment, processes that require reflection by the nurse on clinical practice, in conjunction with a knowledge of the patient's present circumstances. The information below describes how to frame the question once the patient or practice assessment and the resulting problem identification have occurred.





PICO (Translating the Question into Searchable Parts)


Clinical and nursing practice questions can be broken down into the PICO(T) format, which breaks a question apart into searchable parts:

P – Patient, population, problem
I – Intervention or Exposure
C – Comparison 
O – Outcome 
T – Time (May not be available in every instance)


Example: A small, rural hospital's primary population has become elderly patients and the nurses are working together to update patient safety procedures. When they look at hospital records, they realize that falls are their number one risk factor among their patients. The question might be: what is the effectiveness of restraints in reducing the occurrence of falls in patients 65 and over? , which can be broken apart into descriptors, written in noun forms, such as:

  • P – elderly, inpatient, accidental falls
  • I – restraint, physical restraint
  • C – no restraint
  • O – to be determined once the literature has been found and in conjunction with an understanding of the patient’s specific situation and the underlying causes of sleep loss.
  • T– not applicable in this example



PICO Question Formats


Fill in the blanks with information from your clinical scenario:


In_______________, what is the effect of ________________on _______________ compared with _________________?


For ___________ does the use of _________________ reduce the future risk of ____________ compared with ______________?


Are (Is) ________________ more accurate in diagnosing _______________ compared with ____________?


Does ____________ influence ______________ in patients who have _____________?


Are ______________ who have _______________ at ______________ risk for/of ____________ compared with _____________


How do _______________ diagnosed with _______________ perceive __________________?



Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.




Background vs. Foreground


Background questions ask for general knowledge and do not normally arise from the need to make a clinical decision.

  • Background questions usually have two essential components:
    • A question root (who, what, when, etc.) with a verb
    • A disorder, treatment, test, or other aspect of healthcare
      • e.g. What causes obesity? When should children be introduced to sexual education?  Who is most susceptible to nursing burn out?


  • Background information can be found in: 
    • reference book entries
    • textbooks, chapters, appendices
    • drug monographs, guides to diagnostic tests


Foreground questions ask for specific knowledge to inform clinical decisions or actions.

  • ​Foreground questions usually have 3 or 4 essential components, from the PICO format:
    • ​Patient/population characteristics, problem
    • Interventions or Exposures 
    • Comparison
    • Outcome



Types of Questions


Clinical questions

Clinical questions typically fall into one of four main categories:

  • Etiology (or harm/risk factors): What causes the problem?
  • Diagnosis: Does this patient have this problem?
  • Therapy: What is the best treatment for this problem?
  • Prognosis: What will the outcome of the problem be?

* Knowing the type of clinical question is important later in the EBN process--once the nurse goes to look for studies that will answer his/her question.


Nursing Practice Questions

In nursing, many other questions about practice will also arise, with some of the questions resulting from the nursing principle of working with rather than on the patient. These questions can be quantitative or qualitative in nature. Examples include:

  • What other, validated instruments for measuring this condition or phenomenon (e.g. pain) exist and how do they compare to the one we currently use? 
  • Should a nurse deliver patient education on the patient's disease/condition near the beginning or the end of an appointment or consultation?
  • How do caregivers of patients with [x] cope with the burden of care and how can nurses assess the level of caregiver burden and/or support the caregivers?


Study Design (Clinical Questions)


Different types of clinical questions are best answered by different types of research studies. Understanding what types of studies are best suited for your question can improve your search for information to answer your question.

All types of clinical questions can be answered by systematic reviews or meta-analysis, when available. When these filtered resources are not available, look for unfiltered resources (individual studies), focusing on the study types appropriate to your question. The table below suggests study designs best suited to answer each type of clinical question.


The Suggested Research Designs refer to the resource types in the John Hopkins Nursing EBP: Levels of Evidence diagram in the next tab.


Type of Questions

Suggested Research Design(s)


All Clinical Questions

Systematic review, meta-analysis



Randomized controlled trial (RCT), meta-analysis

Also: cohort study, case-control study, case series



Randomized controlled trial (RCT), meta-analysis, cohort study

Also: case-control study, case series



Randomized controlled trial (RCT)

Also: cohort study



Randomized controlled trial (RCT), meta-analysis

Also: prospective study, cohort study, case-control study, case series



Cohort Study

Also: case-control study, case series



Qualitative study


Quality Improvement

Randomized controlled trial (RCT)

Also: qualitative study



Economic evaluation




The Literature Review Process


  1. Write down your topic in a way to identify the key concepts and issues that you want to address. You may find it helpful to structure the topic in a PICOT format (P = Patient, Population, I = Intervention, C = Comparison or Control, O = Outcomes T = Time). Although it is not necessary to use all elements of the PICO in the search strategy, this will help you frame the topic into a translatable framework. Use the PICO worksheet and the Search Building Worksheets below to help keep track of your research concepts and search terms. For more information on PICOT, see the PICOT section above. 
  2. Do some background research to see what's already been written about the topic. You may find it helpful to search books and journals through the library catalog, as well as databases that may be relevant to your topic.
  3. Narrow down the topic, if necessary. You may find that the original question is too broad. After you have done the background research, you will have a better idea of what specifically you are interested in.
  4. Decide on the scope and nature of your review. What types of research are you interested in? Are you prepared to do title and abstract screening? What are you hoping to address with your research?
  5. Create and execute your database searches. Searching is an iterative process, so you may need to test and refine before settling on your final search strategy. Your search strategy should use a combination of keywords and controlled vocabulary terms to represent each concept of your research topic. Combine your search concepts using AND, OR, or NOT to refine or broaden your search. For more information on combining search terms, see the Combining Search Terms to Locate Information section in the Databases & Searching Help tab in this guide.  
  6. Examine and evaluate your results to make sure that they could potentially answer your research question. This is the point to make changes before proceeding.
  7. Export and screen your results. Using a citation manager will allow you to remove duplicates when you screen. 
  8. Extrapolate the data and evidence to draw conclusions about your research topic. For more information see the Tools for Translation tab in this guide. 

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