The First Step: Ask; Fundamentals of Evidence-Based Nursing Practice

In this module, we will learn about identifying the problem, start the “Ask” process with developing an answerable clinical question, and learn about purpose statements and hypotheses.

Content includes:

• Identifying the problem
• Determining the Population, Intervention, Comparison, and Outcome (PICO)
• Asking a Research/Clinical Question (Based on PICO)
• Statements of Purpose
• Hypotheses

Objectives:

1. Describe the process of developing a research/practice problem.
2. Describe the components of a PICO.
3. Identify different types of PICOs.
4. Distinguish the function and form of statements of purpose.
5. Describe the function and characteristics of hypotheses.

Development of a Research/Practice Problem

Practice questions frequently arise from day-to-day problems that are encountered by providers (Dearholt & Dang, 2012). Often, these problems are very obvious. However, sometimes we need to back up and take a close look at the status quo to see underlying issues. The basis for any research project is indeed the underlying problem or issue. A good problem statement or paragraph is a declaration of what it is that is problematic or what it is that we do not know much about (a gap in knowledge) (Polit & Beck, 2018).

The process of defining the practice/clinical problem begins by seeking answers to clinical concerns. This is the first step in the EBP process: To ask. We start by asking some broad questions to help guide the process of developing our practice problem.

• Is there evidence that the current treatment works?
• Does the current practice help the patient?
• Why are we doing the current practice?
• Should we be doing the current practice this way?
• Is there a way to do this current practice more efficiently?
• Is there a more cost-effective method to do this practice?

Problem Statements:

For our EBP Project, we will need to ask these broad questions and then develop our problem that exists. This establishes the “background” of the issue we want to know more about.

For example, if we are choosing a clinical question based on wanting to know if adjunct music therapy helps decrease postoperative pain levels than just pharmaceuticals alone, we might consider the underlying problems of:

• Postoperative pain is not adequately managed in greater than 80% of patients in the US, although rates vary depending on such factors as type of surgery performed, analgesic/anesthetic intervention used, and time elapsed after surgery (Gan, 2017).
• Poorly controlled acute postoperative pain is associated with increased morbidity, functional and quality-of-life impairment, delayed recovery time, prolonged duration of opioid use, and higher health-care costs (Gan, 2017).
• Multimodal analgesic techniques are widely used but new evidence is disappointing (Rawal, 2016).

In the above examples, we are establishing that poorly managed postoperative pain is a problem. Thus, looking at evidence about adjunctive music therapy may help to address how we might manage pain more effectively. These are our problem statements. This would be our introduction section on the EBP poster. For the sake of our EBP poster, you do not need to list these on the poster references. A heads up: The sources used to help develop our research/clinical program should not be the same resources that we use to answer our upcoming clinical question. In essence, we will be conducting two literature reviews: One, to establish the underlying problem; and, two: To find published research that helps to answer our developed clinical question.

Knowledge to application link.

Here is the introduction to the article titled, “The relationships among pain, depression, and physical activity in patients with heart failure” (Haedtke et al, 2017). You can read that the underlying problem is multifocal: 67% of patient with heart failure (HF) experience pain, depression is a comorbidity that affects 22% to 42% of HF patients, and that little attention has been paid to this relationship in patients with HF. The researchers have established the need for further research and why further research is needed.

 

 

Here is another example of how the clinical problem is addressed in an EBP poster that wants to appraise existing evidence related to dressing choice for decubitus ulcers.

 

When trying to communicate clinical problems, there are two main sources (Titler et al., 1994, 2001):

• Problem-focused triggers: These are identified by staff during routine monitoring of quality, risk, adverse events, financial, or benchmarking data.
• Knowledge-focused triggers: There are identified through reading published evidence or learning new information at conferences or other professional meetings.

Sources of Evidence-Based Clinical Problems:

Hot Tip! When stating the problem, the underlying issue needs to be explained rather than listing symptoms of the problem. For example, “Forty percent of patients discharged post total knee replacement complain that they were not able to manage their pain,” instead of “Patients with total knee replacement were not satisfied after discharge.”

Most problem statements have the following components:

1. Problem identification: What is wrong with the current situation or action?
2. Background: What is the nature of the problem or the context of the situation? (this helps to establish the why)
3. Scope of the problem: How many people are affected? Is this a small problem? Big problem? Potential to grow quickly to a large problem? Has been increasing/decreasing recently?
4. Consequences of the problem: If we do nothing or leave as the status quo, what is the cost of not fixing the issue?
5. Knowledge gaps: What information about the problem is lacking? We need to know what we do not know.
6. Proposed solution: How will the information or evidence contribute to the solution of the problem?

If you are stumped on a topic, ask faculty, RNs at local facilities, colleagues, and key stakeholders at local facilities for some ideas! There is usually “something” that the nursing field is concerned about or has questions about.

Components of a PICO Question

After we have asked ourselves some background questions, we need to develop a foreground (focused) question. A thoughtful development of a well-structured foreground clinical/practice question is important because the question drives the strategies that you will use to search for the published evidence. The question needs to be very specific, non-ambiguous, and measurable in order to find the relevant evidence needed and also increased the likelihood that you will find what you are looking for.

In developing your clinical/practice question, there is a helpful format to utilize to establish the key component. This format includes the Patient/Population, Intervention/Influence/Exposure, Comparison, and Outcome (PICO) (Richardson, Wilson, Nishikawa, & Hayward, 1995).

Let’s dive into each component to better understand.

Patient, population, or problem: We want to describe the patient, the population, or the problem. Get specific. We will want to know exactly who we are wanting to know about. Consider age, gender, setting of the patient (e.g. postoperative), and/or symptoms.

Intervention: The intervention is the action or, in other words, the treatment, process of care, education given, or assessment approaches. We will come back to this in more depth, but for now remember that the intervention is also called the “Independent Variable”.

Comparison: Here we are comparing with other interventions. A comparison can be standard of care that already exists, current practice, an opposite intervention/action, or a different intervention/action.

Outcome: What is that that we are looking at for a result or consequence of the intervention? The outcome needs to have a metric for actually measuring results. The outcome can include quality of life, patient satisfaction, cost impacts, or treatment results. The outcome is also called the “Dependent Variable”.

The PICO question is a critical aspect of the EBP project to guide the problem identification and create components that can be used to shape the literature search.  

Let’s watch a nice YouTube video, “PICO: A Model for Evidence-Based Research”:

“PICO: A Model for Evidence Based Research” by Binghamton University Libraries. Licensed CCY BY.

Great! Okay, let’s move on and discuss the various types of PICOs.

Types of PICOs

Before we start developing our clinical question, let’s go over the various types of PICOs and the clinical question that can result from the components. There are various types of PICOs but we are concerned with the therapy/treatment/intervention format of PICO for our EBP posters. 

Let’s take a look at the various types of PICOs:

The first step in developing a research or clinical practice question is developing your PICO. Well, we’ve done that above. You will select each component of your PICO and then turn that into your question. Making the EBP question as specific as possible really helps to identify specific terms and narrow the search, which will result in reducing the time it times searching for relevant evidence.

Once you have your pertinent clinical question, you will use the components to begin your search in published literature for articles that help to answer your question. In class, we will practice with various situations to develop PICOs and clinical questions.

Statements of Purpose

Many articles have the researcher’s statement of purpose (sometimes referred to as “aim”, “goal”, or “objective”) for their research project. This helps to identify what the overarching direction of inquiry may be. You do not need a statement of purpose/aim/goal/objective for your EBP poster. However, knowing what a statement of purpose is will help you when appraising articles to help answer your clinical question.

Knowledge to application link. This statement of purpose identifies the intervention (I) of interest, as well as the outcome (O) that was being measured.

The following statement of purpose was written as an aim. The population (P) was identified as patients with HF, the interventions (I) included physical activity/exercise, and the outcomes (O) included pain, depression, total activity time, and sitting time as correlated with the interventions.

In the articles above, the authors made it easy and included their statements of purpose within the abstract at the beginning of the article. Most articles do not feature this ease, and you will need to read the introduction or methodology section of the article to find the statement of purpose, much like within article 3.1.

In qualitative studies, the statement of purpose usually indicates the nature of the inquiry, the key concept, the key phenomenon, and the population.

Function and Characteristics of Hypotheses.

A hypothesis (plural: hypotheses) is a statement of predicted outcome. Meaning, it is an educated and formulated guess as to how the intervention (independent variable – more on that soon!) impacts the outcome (dependent variable). It is not always a cause and effect. Sometimes there can be just a simple association or correlation. We will come back to that in a few modules.

In your PICO statement, you can think of the “I” as the independent variable and the “O” as the dependent variable. Variables will begin making more sense as we go. But for now, remember this:

Independent Variable (IV): This is a measure that can be manipulated by the researcher. Perhaps it is a medication, an educational program, or a survey. The independent variable enacts change (or not) onto the independent variable. 

Dependent Variable (DV): This is the result of the independent variable. This is the variable that we utilize statistical analyses to measure. For instance, if we are intervening with a blood pressure medication (our IV), then our DV would be the measurement of the actual blood pressure.

Most of the time, a hypothesis results from a well-worded research question. Here is an example:

Research Question: “Does sexual abuse in childhood affect the development of irritable bowel syndrome in women?”

Research Hypothesis: Women (P) who were sexually abused in childhood (I) have a higher incidence of irritable bowel syndrome (O) than women who were not abused (C).

You may note in that hypothesis that there is a predicted direction of outcome. One thing leads to something.

But, why do we need a hypothesis? First, they help to promote critical thinking. Second, it gives the researcher a way to
measure a relationship. Suppose we conducted a study guided only by a research question. Take the above question, for example. Without a hypothesis, the researcher is seemingly prepared to accept any result (Polit & Beck, 2021). The problem with that is that it is almost always possible to explain something superficially after the fact, even if the findings are inconclusive. A hypothesis reduces the possibility that spurious results will be misconstrued (Polit & Beck, 2021).

Knowledge to application link.

 

Not all research articles will list a hypothesis. This makes it more difficult to critically appraise the results. That is not to say that the results would be invalidated, but it should ignite a spirit of further inquiry as to if the results are valid.

Types of Hypotheses

Understanding the different types of hypotheses is crucial for conducting robust research. Here are the main types:

Null Hypothesis (H₀):

Purpose: The null hypothesis states that there is no effect, relationship, or difference between variables. It serves as a baseline that researchers seek to refute.

Example: “There is no significant difference in blood pressure levels between patients who receive a low-sodium diet and those who do not.”

Alternative Hypothesis (H₁ or Ha) (this is the same as the plain ol’ hypothesis):

Purpose: The alternative hypothesis posits that there is an effect, relationship, or difference between variables. It is what the researcher aims to support through the study.

Example: “Patients who receive a low-sodium diet will have significantly lower blood pressure levels compared to those who do not.”

Directional Hypothesis:

Purpose: A directional hypothesis specifies the direction of the expected relationship or difference between variables.

Example: “Nurse-led education programs will lead to a decrease in patient anxiety levels.”

Non-Directional Hypothesis:

Purpose: A non-directional hypothesis predicts a relationship or difference between variables but does not specify the direction.

Example: “There is a difference in anxiety levels between patients who receive nurse-led education programs and those who do not.”

Complex Hypothesis:

Purpose: A complex hypothesis predicts the relationship between multiple independent and/or dependent variables.

Example: “The implementation of a nurse-led education program and regular physical exercise will lead to lower anxiety and depression levels among patients.”

Simple Hypothesis:

Purpose: A simple hypothesis predicts the relationship between a single independent variable and a single dependent variable.

Example: “Increased hand hygiene practices reduce the incidence of hospital-acquired infections.”

An important concept to remember, is that a hypothesis can tick more than one box (ex: it can be an alternative and simple hypothesis at the same time).

Hot Tip! When reading research articles, it is important to have a good idea of what type of hypothesis the researcher utilized. The hypotheses are not always written in an article, but as you get better with reading articles, you can usually glean what prediction the research had made prior to data collection. When you read the article, does the researcher discuss the results as to how they relate to the hypothesis? Was the prediction supported in their statistical analysis?

EBP Poster Application! At this point, you will develop (or have developed) your PICO and clinical question. Don’t forget that you will need a reasonable and ethical comparison. Perhaps take a look at existing studies to see what comparisons have already been made with the intervention that you have in mind. Important to remember, is that you are not trying to predict with a hypothesis! You are simply answering, “What is the difference that this intervention is making?” with evidence that already exists. It could be that you find evidence that the intervention you are investigating is not  helpful and not improving patient outcomes. That’s okay! We need to know what does not work in clinical practice in order to ask more questions about what does work.

EBP Poster Application! Continue to work on the Introduction section of your poster. Again, going back to the beginning of this module, ask the following: 

• Is there evidence that the current treatment works?
• Does the current practice help the patient?
• Why are we doing the current practice?
• Should we be doing the current practice this way?
• Is there a way to do this current practice more efficiently?
• Is there a more cost-effective method to do this practice?

And then, further develop the problem and background through finding existing literature to help answer the following questions:

• Problem identification: What is wrong with the current situation or action?
• Background: What is the nature of the problem or the context of the situation? (this helps to establish the why)
• Scope of the problem: How many people are affected? Is this a small problem? Big problem? Potential to grow quickly to a large problem? Has been increasing/decreasing recently?
• Consequences of the problem: If we do nothing or leave as the status quo, what is the cost of not fixing the issue?
• Knowledge gaps: What information about the problem is lacking? We need to know what we do not know.
• Proposed solution: How will the information or evidence contribute to the solution of the problem?

With the previous example of pain in the pediatric population, here is an example of an Introduction section from a past student poster:

References & Attribution

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“Light bulb doodle” by rawpixel licensed CC0.

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“Orange flame” by rawpixel licensed CC0.

Chen, P., Nunez-Smith, M., Bernheim, S… (2010). Professional experiences of international medical graduates practicing primary care in the United States. Journal of General Internal Medicine, 25(9), 947-53.

Dearholt, S.L., & Dang, D. (2012). Johns Hopkins nursing evidence-based practice: Model and guidelines (2nd Ed.). Indianapolis, IN: Sigma Theta Tau International. 

Gan, T. (2017). Poorly controlled postoperative pain: Prevalence, consequences, and prevention. Journal of Pain Research, 10, 2287-2298.

Genc, A., Can, G., Aydiner, A. (2012). The efficiency of the acupressure in prevention of the chemotherapy-induced nausea and vomiting. Support Care Cancer, 21, 253-261.

Haedtke, C., Smith, M., VanBuren, J., Kein, D., Turvey, C. (2017). The relationships among pain, depression, and physical activity in patients with heart failure. Journal of Cardiovascular Nursing, 32(5), E21-E25.

Pankong, O., Pothiban, L., Sucamvang, K., Khampolsiri, T. (2018). A randomized controlled trial of enhancing positive aspects of caregiving in Thai dementia caregivers for dementia. Pacific Rim Internal Journal of Nursing Res, 22(2), 131-143.

Polit, D. & Beck, C. (2021). Lippincott CoursePoint Enhanced for Polit’s Essentials of Nursing Research (10th ed.). Wolters Kluwer Health.

Rawal, N. (2016). Current issues in postoperative pain management. European Journal of Anaesthesiology, 33, 160-171.

Richardson, W.W., Wilson, M.C., Nishikawa, J., & Hayward, R.S. (1995). The well-built clinical question: A key to evidence-based decisions. American College of Physicians, 123(3), A12-A13.

Titler, M. G., Kleiber, C., Steelman, V.J. Rakel, B. A. Budreau, G., Everett,…Goode, C.J. (2001). The Iowa model of evidence-based practice to promote quality care. Critical Care Nursing Clinics of North America, 13(4), 497-509.