Running head: PICO PAPER

PICO Paper
Sara Towers
Ferris State University

PICO PAPER

2
Abstract

Nurses use evidence-based research to support their decision-making and to improve the
quality and safety of patient care. This paper describes the process of gathering appropriate
information about a problem and uses it to ensure the best possible patient care outcome.
There are three articles that have been reviewed to determine if they are creditable resources
or not to support the question to a problem that has been identified.

PICO PAPER

3
PICO Paper

Nursing research supports the decisions made to provide quality and safe patient
care. According to Nieswiadomy (2012, p.5), nurses have become more independent in
making decisions about the care of clients, which has brought about a greater need for
accountability. Nursing research is defined as the systematic, objective process of
analyzing phenomena of importance to nursing (Nieswiadomy 2012, p. 3). The purpose of
this paper is to identify how the use of nursing research supports decision making within the
nursing profession.
Clinical Question
Over the ten years as a psychiatric nurse, I have seen an ongoing problem with the
patients having an increased weight gain. The question that will be addressed is should
there be regular scheduled exercise during inpatient hospitalization compared to no regular
exercise to reduce weight gain among psychiatric patients? Many patients have stated that
they always gain weight during inpatient hospitalizations related to lack of exercise,
medications and change of regular meal plans.
Within the nursing practice, evidence-based nursing practice requires that nurses
write clinical questions (Nieswiadomy, 2012, p. 282). The process that is best used in order
to develop an appropriate research question is using the acronym PICO. PICO is defined as
P-patient problem or population, I-intervention, C-comparison, O-outcome and T may be
used for time to achieve the outcome. Using these guidelines will support in the evidencedbased decision making process.

PICO PAPER

Looking at the studies that have been done will be helpful to understand how
important regular exercise promotes health wellness which will improve the quality and
safety for the mental health population. According to Shrivastava (2010, p.54), medications
have been found to be associated with substantial weight-gain which is troublesome as it
increases an individuals risk of diabetes and cardiovascular disease. Research suggests
that individuals with severe mental illness have significantly worse health outcomes and
premature mortality than the general population (Shrivastava, 2010, p.56). Following a
healthy meal plan and exercise will be beneficial for weight management and the prevention
of health risks related to weight gain.
Methodology
The method used to search for evidence to answer the PICO question was to do
several searches in a variety of databases such as CINAHL, PUBMED, and Cochrane
Review. Once the database was available keywords such as psychiatric hospital and weight
gain, exercise, and obesity were used to continue with the search. Specifying article types
such as clinical trials or reviews, publication data within five years or ten years helped to
narrow the search to identify the most relevant articles. The following are the results that
were found:

CINAHL: 16 total-25% relevant results

PUBMED: 36 total-10% relevant results
Cochrane: 9 total-1% relevant results

The articles were review to determine if they were appropriate nursing research.

It is

important for nurses to use credible resources in order to validate the knowledge being

PICO PAPER

applied. There are many ways to determine if the source is credible or not such as if the
author is a nurse, how recent the source is, and what the authors purpose is.
When reviewing an article, another factor to determine is the level of evidence that is
being used. An effective way to determine credible information is by the use of the levels of
evidence, ranging from least reliable and trustworthy to most reliable and trustworthy (Chitty &
Black 2011, p.245). According to Armola(2009, p.70), strength of the evidence has been the
focus of attention because not all research studies are equal in quality. Levels of evidence or
grading systems to rank research studies and other forms of evidence have been developed to
offer practitioners a reliable hierarchy to determine the strongest evidence (Armola et al, 2009,
p.70).
It is important for nurses to use nursing research within their scope of practice
because it promotes evidence-based nursing practice. According to Nieswiadomy, Nursing
research is the evidence that exists to achieve the best patient outcomes (2012, p.5). When
using research to answer a question to a problem, it is best to look at the studies that have
already been completed that focuses on the question asked. It is in the patients best interest
to have supported interventions utilized for their safely and quality care.
Discussion of Literature
Article one
This article found in the Journal of Advanced Nursing is considered nursing research
because three of the four authors are nurses, who used eight references from nursing
journals. These journals are used to support evidence-based nursing practice (EBNP). I did
not see IRB approval. This study was approved by the relevant ethics committees and all

PICO PAPER

participants received an explanation of the study before providing written consent (Usher, Park,
Foster & Buettner, 2013, p.1543). Participants in this study were able to consent only if they
were showing no signs of symptoms of psychosis by health professionals before allowing them
to participate in this study.
This study was a randomized controlled trial representing a level of evidence C, related to
the inconsistent results. The purpose was not clearly identified however, the reason for this study
was because weight gain has reached epidemic proportions in the general population but people
with mental illness are at greater risk of weight gain, especially those taking second generation
antipsychoticmedications(Usher et al., 2012, p.1543). Limitations were identified and the
sample size consisted of 104 people who were over the age of 18. A lifestyle, education and
weight loss intervention undertaken in combination with motivational interviewing conducted
over 12 weeks did not result in significant weight loss( Usher et at., 2012, p.1546).
There is a threat to validity with this study because the participants were aware of the
study and that they were being observed. Selection bias would be concerned a threat related to
the selected organizations used to find the participants. It was noted within the article that the
results that were found did not have much difference and that additional research is needed to
understand how individual can better manage weight gain related to medications.
Article two
This article was found in the Journal of Psychosocial nursing. It was not written by a
nurse however, it was written for nurses. There were four references used for this integrative
review. Research and review articles published between 1998 and 2010 were reviewed (Weber,
2010). The purpose was easily identified, as using exercise as a psychiatric nursing intervention.

PICO PAPER

According to Weber (2010, p.35), this article reviews the use of exercise as a therapeutic and
adjunctive intervention in the prevention of weight gain, obesity, and metabolic consequences in
multiple populations with psychiatric illnesses. The level of evidence of this article is level C.
After reviewing this article, it was demonstrated the information would be helpful in the
psychiatric setting as a nursing intervention to promote quality and safety for the best patient
outcomes. It was found that psychiatric nurses are taking the first steps in incorporating exercise
into their recommendations and interventions in populations with psychiatric illnesses, but a long
journey remains to make a significant difference in clients' lives(Weber,2010,p.36). According
to the Scope and Standards of Practice, the registered nurse implements activities to enhance the
quality of nursing practices (2010, p.52).
Article three
The third article was found in the Journal of Psychiatric and Mental Health Nursing and
one of the three authors is a nurse. There was only one article used from a nursing journal,
however, the rest were related to psychiatry. According to Iglesias-Garcia (2010,p.850), this is a
randomized controlled study to test the preliminary effectiveness of a structured educational
program in reducing weight, in a subject population of overweight and obese patients with
chronic stable schizophrenia, who were taking antipsychotics. C is the level of evidence used for
this study. The participants consisted of 15 outpatients who were all taking antipsychotics
medications and having a DSM-IV diagnosis of schizophrenia. I did not see IRB however;
the participants were informed about the study and provided written consent before
participating.
This study used a conceptual framework demonstrated by the information related to past
studies on this topic. Purposive sampling was used for the participants because they were

PICO PAPER

selected subjects considered to be representatives of the population (Nieswiadomy, 2012,

p.87). This may be seen as a threat to validity because of the researches selection bias, by
only choosing those who fit certain criteria to be involved with this study. History could also
be a factor if a participant showed signs of increased side effects and need to have
medication changes or was unable to complete the study. Interval level of measure is used
because the results can be ranked and placed into categories. Results of the study were
clearly identified, and it was noted that further studies to test the effectiveness of nonpharmacological interventions for weight control may be useful.
Significance to Nursing
The findings from these articles can be integrated into practice to improve quality
and safety of psychiatric patients by formulating recommendations to improve nursing
practice or outcomes (Scope and Standards of Practice, 2010, p.52). By recognizing the
risk for increase weight gain, incorporating exercise and healthy behaviors may decrease the
risk for further health problems. It is important as nurses to uphold high quality standards to
deliver the best patient care and outcomes possible. Utilizing current evidence-based
research will increase knowledge to support the nursing profession.
According to QSEN(2008), the definition of safety is to minimize risk of harm to
patients and providers through both system effectiveness and individual performance.
Nursing research will support the decision-making process to improve safety within the
nursing profession. Nurses are responsible for developing sound clinical judgment and are
accountable for their decisions and nursing practice that arise from those decisions(Chitty
& Black,2011,p.189).

PICO PAPER

Although the PICO question was related to inpatient hospitalization, it was evident
through the research that the problem with increased weight gain does not occur only in the
hospital setting but, outside as well related to medications. After reviewing the evidencebased research, it did show that with the increase of exercise and healthy personal habits the
psychiatric population will decrease the risks that are involved with weight gain such as
diabetes and heart disease. These articles will be helpful educating both patients and
coworkers in achieving high quality and safety for positive outcomes with those with mental
illnesses.

References

PICO PAPER

10

American Nurses Association [ANA] (2010). Nursing: Scope and Standards of Practice (2nd
Ed.). Silver Spring, Maryland: Author
Armola, R. R., Bourgault, A. M., Halm, M. A., Board, R. M., Bucher, L., Harrington, L.,
Medina, J. (2009). AACN Levels of Evidence: Whats New? Critical Care Nurse,
29(4), 7073. doi:10.4037/ccn2009969
Chitty, K.K., & Black, B.P. (2011). Professional nursing: Concepts and Challenges (6th ed.)
Maryland Heights.MO: Saunders Elsevier.
Iglesias-Garica, C., Tomil-Iglesias, A. and Alonso-Villa, M. J. (2010), Pilot study of the
efficacy of an educational programme to reduce weight, on overweight and obese
patients with chronic stable schizophrenia. Journal of Psychiatric and Mental Health
Nursing, 17: 849851. doi: 10.1111/j.1365-2850.2010.01590.x
Nieswiadomy, R. M. (2012). Foundations of nursing research (6th ed.). Boston: Pearson.
Patient Safety and Quality. (2008, April 1).
Shrivastava, A., & Johnston, M. E. (2010). Weight-Gain in Psychiatric Treatment: Risks,
Implications, and Strategies for Prevention and Management. Mens Sana Monographs,
8(1), 5368. doi:10.4103/0973-1229.58819
Usher, K., Park, T., Foster, K., & Buettner, P. (2013). A randomized controlled trial undertaken to
test a nurse-led weight management and exercise intervention designed for people with
serious mental illness who take second generation antipsychotics. Journal of Advanced
Nursing, 69(7), 15391548. doi:10.1111/jan.12012
Weber, M. (2010). The Importance of Exercise for Individuals with Chronic Mental Illness.
Journal of Psychosocial Nursing & Mental Health Services, 48(10), 3540.

PICO PAPER

11