FORMULATING CLINICAL

QUESTIONS
Learning Objectives:
AT THE END OF THE LECTURE, THE LEARNERS WILL BE ABLE
TO:
1. Explain the components of a PICOT question:
population, issue or intervention of interest,
comparison of interest, outcome, and time for
intervention to achieve the outcome.
2. State the purpose of the PICOT format.
3. Distinguish the difference among clinical questions,
quality improvement questions, and research questions.
4. Differentiate background and foreground questions.
 INTRODUCTION
It is essential for clinical questions to be written
well for the rigor of the evidence-based practice
(EBP) process to be maintained. The search for
evidence depends on a well-written question.
This lecture provides you (students) with
strategies to develop skills in properly
formulating clinical questions to clarify the
clinical issue and to minimize the time spent
searching for relevant, valid evidence to answer
them.
CLINICAL INQUIRY AND UNCERTAINTY IN
GENERATING CLINICAL QUESTIONS
Clinical inquiry: A process in which clinicians gather data
together using narrowly defined clinical parameters; it allows
for an appraisal of the available choices of treatment for the
purpose of finding the most appropriate choice of action.
Components of Clinical inquiry in action:
1. Problem identification and
2. Clinical judgment across time about the particular transitions
of particular patient/family clinical situations.
Four aspects of clinical inquiry in action are:
1.) Making qualitative distinctions,
2.) Engaging in detective work,
3.) Recognizing changing relevance, and
4.) Developing clinical knowledge about specific patient
populations.
 Clinical inquiry must be cultivated in the work
environment. To foster clinical inquiry, one must
have a level of comfort with uncertainty.
• Uncertainty is the inability to predict what an
experience will mean or what outcome will occur
when encountering ambiguity.
 Although uncertainty may be uncomfortable,
uncertainty is imperative to good practice, and is a
means to inquiry and clinical reasoning needed for
developing focused foreground questions
 Two(2)types of questions clinicians might ask
1. Background Questions- are those that need to be answered as a foundation
for asking the searchable, answerable foreground question. These
questions ask for general information about a clinical issue.
Two components of background questions:
1) The starting place of the question (e.g., what, where, when, why, and
how)
2) The outcome of interest (e.g., the clinical diagnosis)
Examples of a background question:
> How does the drug acetaminophen work to affect fever? The answer to
this question can be found in a drug pharmacokinetics text.
> “How does hemodynamics differ with positioning?” The answer can be
found in textbooks as well.
Often, background questions are far broader in scope than foreground
questions. Clinicians often want to know the best method to prevent a
clinically undesirable outcome: “What is the best method to prevent
pressure ulcers during hospitalization?” This question will lead to a
foreground question, but background knowledge is necessary before the
foreground question can be asked.
2. Foreground questions - are those that can be answered from
scientific evidence about diagnosing, treating, or assisting
patients in understanding their prognosis or their health
experience.
- These questions focus on specific knowledge.
Examples of foreground questions:
> In children, how does acetaminophen affect fever within 30
minutes of administration compared with ibuprofen?
> In patients with acute respiratory distress syndrome, how
does the prone position compared with the supine position
affect heart rate, cardiac output, oxygen saturation, and blood
pressure after position change?
 Formatting Foreground Questions to Drive the
Search
Five (5) types of Foreground Questions:
1. Intervention questions that ask what intervention most effectively leads
to an outcome;
2. Prognosis/prediction questions that ask what indicators are most
predictive of or carry the most associated risk for an outcome;
3. Diagnosis questions that ask what mechanism or test most accurately
diagnoses an outcome;
4. Etiology questions that ask to what extent a factor, process, or condition is
highly associated with an outcome, usually undesirable;
5. Meaning questions that ask how an experience influences an outcome,
the scope of a phenomenon, or perhaps the influence of culture on
healthcare.
Whatever the reason for the question, the components of the question
need to be considered and formulated carefully using the proper format
to efficiently find relevant evidence to answer the question
 Posing the Question Using PICOT
• The purpose of the PICOT question is to guide the systematic search of
healthcare databases to find the best available evidence to answer the
question. Components of the question are the basis for the keywords used to
search databases such as CINAHL and MEDLINE to find the evidence to
answer the question.
• COMPONENTS:
P - patient population
I - intervention or issue of interest-may include but is not limited to any
exposure, treatment, diagnostic test, condition, predictor/prognostic factor,
an issue that the clinician is interested in, such as fibromyalgia or a new
diagnosis of cancer.
C – comparison - needs special consideration, because it is sometimes
appropriate to include in a question and not needed at other times. If the (I) is
an intervention, the comparison should be the usual standard of care.
O - outcome
T - time frame (T) is associated with the outcome
Not all of the components may be appropriate for a clinical question;
however, the essential components of a PICOT question include a P, I, and O
 Examples of PICOT Questions
• Intervetion question:
In disabled, older adult patients (P-opulation), how does the use of
level-access showers (I-ntervention) compared with bed bathing
(C-omparison) affect patient satisfaction with hygiene (O-utcome)?
The intervention of interest is level-access showers, and the
comparison is the usual care of bed bathing.
• Meaning question, the (I) is an issue of interest.
“How do parents (P-opulation) with children who have been newly
diagnosed with cancer (I-ssue) perceive their parent role(O-utcome)
within the first month after diagnosis (T-ime frame)?”
In this question, there is no appropriate comparison to the issue of
interest, and, therefore, C is not found in the question.
PICOT COMPONENTS:
“In family members who have a relative undergoing
cardiopulmonary resuscitation (P-opulation), how does presence
during the resuscitation (I-ntervention) compared with no presence
(C-omparison) affect family anxiety (O-utcome) during the
resuscitation period (T-ime frame)?”
• T-ime frame and C-omparison are not always
appropriate for every question; however,
P-opulation, I-ntervention, and O-utcome
must always be present.
Question templates for asking PICOT QUESTIONS
 SHORT DEFINITIONS OF DIFFERENT TYPES OF
QUESTIONS

• Intervention: Questions addressing the treatment of an illness

or disability.
• Etiology: Questions that address the causes or origin of disease,
the factors that produce or predispose toward a certain disease
or disorder.
• Diagnosis: Questions addressing the act or process of
identifying or determining the nature and cause of a disease or
injury through evaluation.
• Prognosis/Prediction: Questions addressing the prediction of
the course of a disease.
• Meaning: Questions addressing how one experiences a
phenomenon.
 Sample Questions
• Intervention: In elderly patients in acute care facilities (P), how do
fall prevention programs with risk assessment (I) compared to fall
prevention programs without risk assessment (C) affect fall rates
(O) within one quarter after intervention (T)?
• Etiology: Are 50- to 60-year-old women (P) who have family
history of obesity (I) compared with those without family history
of obesity (C) at increased risk for increased body mass index
(BMI) (O) during the first 3 years after hysterectomy or
menopause (T)?
• Diagnosis: In middle-aged males with suspected myocardial
infarction (P), are serial 12-lead electrocardiograms (ECGs) (I)
compared to one initial 12-lead ECG (C) more accurate in
diagnosing an acute myocardial infarction (O)?
• Prognosis/Prediction: (1) For patients 65 years and older (P),
how does receiving the influenza vaccine (I) compared with
not receiving the vaccine (C) influence the risk of developing
pneumonia (O) during flu season (T)?
(2) In patients who have experienced an acute myocardial
infarction (P), how does being a smoker (I) compared to being
a nonsmoker (C) influence death and infarction rates (O)
during the first 5 years after the myocardial infarction (T)?
• Meaning: How do parents (P) of toddlers with a new
diagnosis of a terminal disease (I) perceive their parenting
role (O) during the first 3 months after diagnosis (T)?
MCQ:
1. The purpose of PICOT questions is?
a. to generate new knowledge/external evidence
b. to guide the systematic search for evidence to determine the best intervention
to affect the outcome.
c. to identify and fix the processes leading to a problem that is internal to the
clinical setting
2. What is the Intervention in the clinical question: “In elderly patients in acute
care facilities, how do fall prevention programs with risk assessment compared to
fall prevention programs without risk assessment affect fall rates within one
quarter after intervention?”
a. fall prevention programs with risk assessment
b. affect fall rates
c. within one quarter after intervention
d. compared to fall prevention programs without risk assessment
3. Questions addressing the act or process of identifying or determining the nature
and cause of a disease or injury through evaluation is?
a. meaning
b. intervention
c. diagnosis