Forming Focused Questions with PICO. A tutorial presented by the UNC Health Sciences Library

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1 1 Forming Focused Questions with PICO A tutorial presented by the UNC Health Sciences Library Objectives Learn what PICO is Learn why you should use PICO Learn when you should use PICO Practice using PICO What do the letters in PICO stand for? Patient or problem Intervention Comparison Outcome Why use PICO? Helps you form a focused question that will return relevant results Helps you retrieve a manageable amount of results Assists you in brainstorming keywords for your search Saves time! When use PICO? In academia In practice A case study: patient education You are a nurse working in a busy inpatient medical surgical unit. The patients on your unit are admitted for a wide variety of conditions: renal, GI, dermatologic, etc. All patients admitted that are chronic smokers are given brief counseling by an RN and a self-help brochure about smoking cessation, but no follow up counseling after that. You hear your coworkers complaining that they feel like they re wasting their time because they think the patients will resume smoking after discharge. You decide you want to find out if this minimal contact intervention works in the long term. Let s write out our PICO elements. Things to consider when choosing your patient/problem: What are the most important characteristics? Relevant demographic factors

2 2 The setting Now, write the patient of interest for the case study. Librarian s suggested answers for these activities are on page 5. To consider for your intervention What is the main intervention, treatment, diagnostic test, procedure, or exposure? Think of dosage, frequency, duration, and mode of delivery. Now, write the intervention of interest for the case study. To consider for your comparison Inactive control intervention: Placebo, standard care, no treatment Active control intervention: A different drug, dose, or kind of therapy Now, write the comparison of interest for the case study. To consider for your outcome Be specific and make it measurable It can be something objective or subjective Now, write the outcome of interest for the case study. Putting it together Among hospitalized chronic smokers, does a brief educational nursing intervention lead to long term smoking cessation [when compared with no intervention]? Choose a specialty Practice writing out PICO components and then forming a focused question about the case study of at least one of the specialties below. Choose one or several that interest you. Librarian s suggested answers for these activities are on pages 5-8. Cardiology Patients on coronary artery bypass graft (CABG) waiting lists often experience anxiety and depression and your nurse manager wants to know if it would be a good idea to reach out to these patients with presurgical home visits and follow-up calls from a specialist cardiac nurse. ICU You work in the Big City Hospital ICU. Your mechanically ventilated patients sometimes contract nosocomial pneumonia, which leads to costly complications. You want to know if raising the head of the bed lowers the chance of the patient contracting pneumonia compared to letting the patient lie flat on their back.

3 3 Infection Control In the past few years, your hospital has installed antibacterial foam dispensers on all the nursing units. You ve had nurses asking you if the foam is just as effective as washing their hands with water and soap. Labor & Delivery You re a new nurse on a labor and delivery unit. You ve noticed that most women give birth in the lithotomy position at the encouragement of their doctors. However, you re sure you heard in nursing school that other positions are less likely to lead to deliveries with forceps or a vacuum.. or did you? You want to find some literature to back up your claim. Med Surg Shift change on your busy med-surg unit can be frustrating for you and your coworkers. Report at the nursing station takes up to 30 minutes, by the end of which you re anxious to see your patients. You read something in a recent ANA newsletter about other hospitals switching to a bedside shift report, and you want to find out if staff liked that style of shift change better. NICU You re the nurse manager of a NICU unit. One concern of parents of infants receiving tube feedings is being able to successfully breastfeed their child upon discharge. One of your staff nurses asks if it would be helpful to give the infants cup feedings instead of tube feedings during their NICU stay. Nurse Educator It s the last semester of your BSN students time in school and they re excited.. and anxious! They ve been asking you if they should take the NCLEX right after they graduate or wait for a while after graduation so they can relax and study. Nurse Practitioner It s winter at your family practice, and you have a lot of patients coming in with runny noses and general malaise. Brenda, a 35 year old working mother in for a checkup states, I m so busy between work and home that I definitely don t have time to get sick! Can those vitamin C or zinc pills prevent colds? Oncology You work with patients with advanced cancer and have been taught to suggest pain diaries for your patients as a form of pain management. You ve been wondering for a while now if these diaries actually improve pain control or make pain worse by making patients more aware of their pain. PACU The main concern for most of your patients coming out of anesthesia in your PACU is pain. You want to explore nursing interventions you can use on top of medication administration to decrease pain. One coworker mentions trying to make the PACU feel less clinical by playing soft music to relax patients.

4 4 Pediatrics You work in a pediatrician s office and give patients their routine vaccinations. The younger children are often fearful of needles, and some of the RNs use toys to distract the patients. You want to know if this technique actually has an effect on the children's pain response. Psychiatry You work on an inpatient psychiatric unit. One of your patients with chronic schizophrenia, Joe, normally mumbles to himself, but will occasionally speak to others when residents play games together. Noticing this, you say to a coworker that maybe social skills group training sessions would bring out Joe s conversational skills. Your coworker shakes her head and says I don t think so. Joe is in and out of this hospital, he s a lost cause. Public Health You coordinate health education programs and have been holding seminars for low-income teenagers about STI prevention. You ve been found that they re hesitant to open up to you during classes to ask you questions. You re wondering if recruiting peer educators closer to their age will encourage them to actively participate and get more satisfaction out of the classes. Pulmonary On your pulmonary unit, many of your COPD patients receive injections of heparin to prevent pulmonary emboli, and patients find the bruises associated with heparin injections unsightly. You ve had nursing students shadowing you lately, so you ve been particularly concerned with injection technique. You want to find out if the duration of injection has any effect on the extent of bruising. School Nursing You re a school nurse at a school in a low-income area. One aspect of your job is counseling pregnant teens with the aim of enabling them to complete high school. You ve even been conducting home visits on top of your normal in-school meetings as part of their preparation-for-motherhood counseling. You want sources to back up the effectiveness of these home visits. Wound Care A diabetic patient from a nursing home has recently been admitted with a stage III pressure ulcers on his heels. The unit nurses have called you in for a wound consult. You have to choose between standard moist wound therapy and using a wound vac. Thank you for using the! Credits: This tutorial was created by Lisa Philpotts, RN, BSN, UNC HSL Instructional Assistant. You may contact her at lphilpot@ .unc.edu

5 5 Questions or comments? We welcome your feedback! o Contact Julia Shaw-Kokot at jsk@med.unc.edu References and Further Reading Chapter 5: Defining the review question and developing criteria for including studies. (2009). In J. Higgins, & S. Green (Eds.), Cochrane handbook for systemic reviews of interventions (5.0.1 ed.,) The Cochrane Collaboration. Flemming, K. (1998) Asking answerable questions. Evidence-Based Nursing. 1(2), Formulating EBP questions. (2009). In N.A. Schmidt, & J.M. Brown (Eds.), Evidence-based practice for nurses: Appraisal and application of research (pp ) Sudbury, Mass. : Jones and Bartlett Publishers, c2009. Making the most of existing knowledge. (2004). In P. Crookes, & S. Davies (Eds.), Research into practice: Essential skills for reading and applying research in nursing and health care (pp ) Edinburgh; New York : Bailliere Tindall, McKibbon, K.A., & Marks, S. (2001). Posing clinical questions: Framing the question for scientific inquiry. AACN Clinical Issues: Advanced Practice in Acute & Critical Care, 12(4), Planning a literature search. (2006). In K. Gerrish, & A. Lacey (Eds.), The research process in nursing (pp ) Oxford; Malden, MA: Blackwell Pub., Stone, P.W. (2002). Popping the (PICO) question in research and evidence-based practice. Applied Nursing Research, 15(3), Suggested Answers to Exercises A case study: patient education P: Hospitalized chronic smokers. Note: Synonyms for any of these terms are acceptable. For instance, you may have typed "inpatient chronic smokers" and that would also be a correct answer. Keep this in mind as you continue the tutorial. I: A brief, one-time educational nursing intervention C: No treatment O: Long term smoking cessation, as reported by the patient. Note: To make your outcome measurable, you may choose to define what "long term" is. Ex: 1 year post intervention Cardiology P: patients on CABG waiting lists I: program consisting of presurgical home visit and follow-up calls form a specialist cardiac nurse C: no intervention O: decreased patient anxiety and depression

6 6 For patients on CABG waiting lists, does an intervention program consisting of presurgical home visits and follow-up calls from a specialist cardiac nurse lead to decreased patient anxiety and depression [when compared with no intervention]? ICU P: mechanically ventilated ICU patients; I: semi-fowlers position C: supine position O: lower incidence of nosocomila pneumonia In mechanically ventilated ICU patients, does positioning the patient in semi-fowlers result in a lower incidence of nosocomial pneumonia when compared to the supine position? Infection Control P: hospital nurses I: using antibacterial foam C: hand washing with soap and water O: decreased bacteria count In hospital nurses, does antibacterial foam decrease bacteria count on hands as much as hand washing with soap and water? Labor & Delivery P: laboring women deliving in a hospital I: positions other than the lithotomy position C: lithotomy position O: decreased incidence of assisted deliveries In laboring women delivering in the hospital, do positions other than lithotomy position lead to a decreased incidence of assisted deliveries? Med Surg P: Staff med-surg nurses I: implementation of bedside shift reports C: shift change reports at the nurses station/standard practice O: greater satisfaction with care Among staff nurses on a medical-surgical unit, do implementing bedside shift reports lead to greater satisfaction with care when compared to traditional shift change reports at the nurses station? NICU P: Infants in the NICU I: Cup feeding throughout the hospital stay C: tube feedings throughout the hospital stay O: greater reported success with breastfeeding post-discharge In infants in the NICU, will cup feeding throughout the hospital stay lead to greater success with breastfeeding postdischarge when compared to tube feedings?

7 7 Nurse Educator P: BSN students I: Sitting for the NCLEX within 2 months of graduation C: Sitting for the NCLEX after 2 months from graduation O: Higher pass rates Among BSN students, does taking the NCLEX within 2 months of graduating result in a higher pass rates when compared to sitting for the exam later? Nurse Practitioner P: adult females I: taking daily vitamin C or sinc supplements C: no intervention O: incidence of the common cold In adult females, will daily vitamin C or zinc supplements reduce the incidence of the common cold when compared with no intervention? Oncology P: patients with advanced cancer I: keeping a pain journal C: no intervention O: lower reported pain scores In patients with advanced cancer, does keeping a pain journal result in lower reported pain scores when compared to no intervention? PACU P: PACU patients I: soft music as an adjunct to standard care C: standard care alone O: lower reported pain scores In PACU patients, will playing soft music in the PACU as an adjunct to standard care result in lower reported pain scores when compared to standard care alone? Pediatrics P: young children I: distraction techniques during immunization C: no intervention O: lower pain scores rated by the Faces pain scale In young children, do distraction techniques during immunization administration using toys result in lower pain scores when compared to no intervention? Psychiatry P: Inpatient chronic schizophrenia patients

8 8 I: social skills group training sessions C: standard care I: increased conversational skills as evidenced by greater number of interactions with peers In inpatient chronic schizophrenia patients, do social skills group training sessions increase conversational skills when compared to standard care? Public Health P: low-income adolescents I: a peer-led STI prevention class C: a nurse-led STI prevention class O: greater client participation and satisfaction In low-income adolescents, will a peer-led STI prevention class result in greater participation and client satisfaction when compared to a nurse led class? Pulmonary P: COPD patients recieving prophylactic heparin I: heparin injection duration of thirty seconds C: heparin injection duration of ten seconds O: decreased circumference of bruising In COPD patients receiving prophylactic heparin, will a heparin injection duration of thirty seconds lead to a decreased circumference of bruising when compared to an injection duration ten seconds? School Nursing P: pregnant high-school adolescents I: nurse home visits adjunct to in school interventions C: in school interventions alone O: decreased drop out rate In pregnant high-school adolescents, do nurse home visits adjunct to in school interventions decrease drop out rate when compared with in school interventions alone? Wound Care P: elderly diabetic with stage III foot ulcers I: negative pressure wound therapy C: standard moist wound therapy O: improved wound healing as measured by pressure ulcer grading system guidelines In elderly diabetic patients with stage III foot ulcers, does negative pressure wound therapy lead to improved wound healing when compared to standard moist wound therapy?