Identifying and Building a Clinical Question for Research and Evidence-Based Practice

Blank page in a notebook for identifying clinical questions

Identifying Clinical Questions (c)negativespace.com

This post is the first of two parts for crafting an efficient search strategy for research studies and for evidence-based practice (EBP) projects. In this post, I’ll provide 4 steps to get you halfway to writing a search strategy. I’ll show you how to identify a clinical question and your knowledge needs, build a four-part clinical question, and identify the key terms that will be used in your search strategy plan.

In the next post, we’ll build on this information and I’ll show you how to systematically frame your questions.  I’ll give you search strategy formulas and tips to craft a search strategy that will offer you the best chance at finding the relevant and valid evidence you need to answer those questions, in the most time-efficient manner possible. 

First Step: Identify a Clinical Question

Clinical questions are everywhere – you run into these every day, but unless you are intentionally looking for the problems or uncertainties of practice that might be solved with published evidence, you might miss them. Clinical questions may arise from personal observations and experience, reflective practice, and what Titler and colleagues (2001) called knowledge-focused triggers or problem-focused (i.e., practice) triggers

Knowledge-focused triggers are based on new research or evidence, national or organizational standards or guidelines, philosophies of care, or organizational data (Titler et al., 2001). Other knowledge-focused triggers include innovations in practice that might have been learned from what one might have read about in a journal article, heard about at a conference, observed a colleague use, or from information shared within a group. 

Problem-focused triggers or practice triggers are based on data specific to the organization, such as risk management or quality improvement data, internal or external benchmarking data, cost outcomes and other financial data, or through identification of a clinical problem (Titler et al., 2001). 

Clinical problems are found in your practice through observations of a phenomenon or a clinical problem related to the patients, staff, and environment (Whitney & Roncoli, 1986). For example, questions can come from your assessment of a patient or patient population, observations of the way staff interact with patients or with each other, use of new procedures or technologies, etc.

Issues related to patient care encounters often bring up an awareness of the need to ask clinical questions. These issues include the interpretation of clinical findings from the patient history or physical assessment data, the best treatments to offer patients, the patient’s experience of their health situation and/or the meaning of the experience to the patient, and how to prevent disease (Straus et al., 2005). Issues related to self-improvement often arise out of caring for patients, too (Straus et al., 2005).

Your clinical experience is another trigger for clinical questions. Again, your assessments can trigger a question — that piece of the nursing process is analogous to problem identification in the research process (Whitney & Roncoli, 1986). What about your ideas about clinical practice? Have you not come up with a possible solution to at least one clinical problem you’ve encountered, at least once in your practice? Your ideas can be researched to see if others have had the same thoughts – if so, you might be able to implement that researcher’s solution; if not, your idea could be the basis of a pilot study or EBP project. 

Johnston and Fineout-Overholt (2005) encouraged nurses to reflect on their clinical practice. The ability to self-identify gaps in your knowledge base is a benefit of reflective practice. Adequate and intentional reflection time can lead the nurse toward specific and relevant questions from which to create a search strategy. “Most questions arising from practice can be formulated in terms of a relationship among the patient, some ‘intervention,’ and one or more specific outcomes of interest” (p. 98).

Clinical problems or uncertainties in patient care are opportunities for problem-solving that can be turned into clinical questions for research studies or for EBP projects. 

Step Two: Identify Your Knowledge Needs

Once you’ve identified a clinical question, you need to find out what is known and unknown about the phenomenon of interest – you have to identify your knowledge needs. What I mean by identifying your knowledge needs is that you need to decide what information you need to have before you hone in on a specific clinical question. Do you need some general information about a topic? The Who, What, Where, When, How, and Why first? Or do you have the fundamentals and now want to search the literature for a precise answer?

You might remember that I have differentiated background questions and foreground questions in the post on the 6As of Evidence-Based Practice. So I won’t elaborate more on that topic, but remind you that:

Questions that are general knowledge (e.g., who gets heart disease, what causes heart disease, where is heart disease more prevalent, when do heart attacks occur, how is heart disease treated, why is heart disease different in women than in men) and thus foundational in nature are Background questions.  

Questions that are more specific to the clinical situation at hand are called Foreground questions and these are the questions we use to craft a search strategy to search the literature.

Once you have the answers to your background questions, it’s time to write a specific clinical question. Foreground questions are devised to find out specific information needed to make precise clinical decisions. 

Step Three: Write a Well-Built Clinical Question

“Well-built” foreground questions have at least four intentionally phrased components (Richardson, 1998; Richardson et al., 1995; Straus et al., 2005), are well thought-out, and contain the essential elements needed to mount a successful search. You may have been introduced to the mnemonic “PICOT” in your research or EBP classes. 

Foreground questions are more efficient because they include targeted components that are more likely to find research findings relevant to the problem at hand; they create an “answerable question” (Sackett et al., 1997). The use of the PICO(TS) format structures the question and helps you identify those major or key search terms. Identifying key terms will assist you in finding the answers you need more quickly than a haphazard stab at throwing terms into a literature or research database search box. 

The components included in a foreground question are captured in the mnemonic PICO(TS) or PECO(TS):

  • Patient population of interest or Problem of interest
  • Intervention (i.e., a test, drug, treatment) or Issue of interest or Exposure
  • Comparison of interest (i.e., counter-intervention, placebo, standard care)
  • Outcome of interest (e.g., what are the expectations or consequences of the intervention?)

PICO example: In adult patients with arthritis (P), does treatment with acupuncture (I) decrease the amount of pain (O) as compared to standard medical therapy? (C)

These four components (PICO or PECO) are the basic form for a targeted search of the literature. The addition of a time frame and pointed search strategy may further help to precisely identify the articles relevant to your clinical question. 

  • Timeframe (usually linked to the outcome)
  • Search strategy (i.e., study design)

Timeframe is not always identified nor appropriate for every type of question. It is usually connected to the outcome of interest.

Search strategy will limit your results to a specific study design in which you are likely to find the answers to your PICO question.  Again, this additional search term may limit your results to the point that other relevant studies will be excluded from your search results. So you might add in this search term at first and see what you get – if this term narrows the search too much, then take it out and do the search again. This is an extra step but one that would be a good idea to add to your thought process about searching the literature!

PICOTS example: In adult patients with arthritis (P), does treatment with acupuncture (I) decrease the amount of pain (O) during flare-ups (T) as compared to standard medical therapy? (C) Randomized controlled trials (S)

Step Four: Determine the Key Terms

Once you’ve identified your foreground clinical question, you want to identify the key terms in your PICO question for use in your search strategy. Key terms are the major variables of your clinical question that you can now readily pick out of your PICO question. 

From the previous PICO example: In adult patients with arthritis (P), does treatment with acupuncture (I) decrease the amount of pain (O) during flare-ups (T) as compared to standard medical therapy? (C) Randomized controlled trials (S)

What are the key terms in that PICOTS statement? Wait, don’t look ahead – try to figure it out first. 

Okay. Now that you’ve had some time, I’ll tell you my answer!

Key terms of the PICOTS statement are bolded:  In adult patients with arthritis (P), does treatment with acupuncture (I) decrease the amount of pain (O) during flare-ups (T) as compared to standard medical therapy? (C) Randomized controlled trials (S).

The comparator you don’t always have to identify if you are comparing something to the gold standard or standard of care (SOC), but it doesn’t hurt to be clear because studies don’t always compare a new intervention to the SOC. It also doesn’t necessarily need to be a key term. 

Now that you have your key terms identified, we’ll craft a search strategy — in the next post, so stay tuned! 

References

Johnston, L., & Fineout-Overholt, E. (2005). Teaching EBP: ‘Getting from zero to one.’ Moving from recognizing and admitting uncertainties to asking searchable, answerable questions. Worldviews On Evidence-Based Nursing, 2(2), 98-102.

Richardson, W. S. (1998). Ask, and ye shall retrieve. Evidence-Based Medicine, 3(4), 100-101.

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

Sackett, D. L., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (1997). Evidence-based medicine: How to practice and teach EBM. London, UK: Churchill Livingstone.

Straus, S. E., Richardson, W. S., Glasziou, P., & Haynes, R. B. (2005). Evidence-based medicine: How to practice and teach EBM (3rd ed.). Edinburgh, Scotland: Elsevier Churchill Livingstone. 

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

Whitney, F. W., & Roncoli, M. (1986). Turning clinical problems into research. Heart & Lung, 15(1), 57-59.

4TH EDITION OF EVIDENCE-BASED MEDICINE