Practice Question

John Hopkins nursing ebp Practice Question Phase

The John Hopkins Nursing Evidence Based Practice Model includes six steps in its practice question phase. They are listed below.

Recruit the interprofessional team
Define the problem
Develop and refine the EBP question
Identify the stakeholders
Determine the responsibility for project leadership
Schedule the team meetings

Step 1: Recruit the interprofessional team

The John Hopkins Nursing Evidence Based Practice Model encourages the use of interdisciplinary teams to examine clinical practice questions. This team may consist of nurses, physicians, pharmacists, physical therapists, or other professionals. Having a variety of perspectives at the table will make it easier to understand who the stakeholders are involved in the clinical practice you are hoping to change.

Step 2: Define the Problem

Problems in nursing practice typically fall into one of three categories: clinical, managerial, or educational.

Clinical

A clinical problem is one that pertains to patient care.

Examples:

Does the lack of homan sign indicate the presence a deep vein thrombosis?
Is a warm or cool compress better for relieving pain from an insect sting?

Managerial

A managerial problem pertains to staffing and financial concerns in nursing practice.

Examples:

What is the best way to promote retention in nursing?
Do 12 hour shifts contribute to nurse fatigue?

educational

An educational problem relates to learning for nurses or patients.

Examples:

What is the best way to provide patient education about COPD?
Do nurses learn better from classroom instruction than online courses?

Evidence-based practice problems can also be defined as having problem-focused or knowledge-focused triggers.

Problem-Focused Triggers

These include quality, risk, adverse events or other issues identified by staff during the normal course of their work.
Example problem-focused triggers include: an uptick in the number of catheter-associated infections on a nursing unit, a mislabeling of a patient's blood sample, or a patient fall.

Knowledge-Focused Triggers

These triggers are related to new evidence in the medical and nursing literature.
Example knowledge-focused triggers include: new guidelines for the care of patients with sepsis, studies on factors related to nursing job satisfaction for millenials, or a new standards published by an accrediting body that the organization reports to.

Restate the problem!

Many people assume they know the solution to their identified problems, but for evidence-based practice, it is important to realize that there may be more than one solution to a problem. Therefore, taking the time to rework your question so that it doesn't contain a solution within it is important. For example: "Does adding more nurses per shift reduce nursing burnout?" might better be stated "What are ways to reduce nursing burnout?" because it does not presuppose a solution to the practice problem you have identified.

Step 3: Develop and refine the EBP question

Foreground vs. Background questions

Your clinical question will either be a foreground or a background question.
What's the difference?

Background Clinical Questions:
These are questions asked to gain general knowledge about a disorder, disease, test, or treatment.

These types of questions typically ask who, what, where, when, how & why.

EXAMPLE: What causes tinnitus?
How do I treat tinnitus?

Foreground Clinical Questions:
These are more specific questions and are asked to inform on clinical decisions.

These questions are usually more complex than background questions, and are categorized into a major type.

Read more below to learn about the types of foreground questions.

PICO QUESTIONS

In the practice of evidence-based nursing, the most common way of framing a clinical question is called "PICO". The PICO format helps you to define specific, answerable question that will lead to relevant results when you search the medical literature.

"P" stands for patient or population

Who is your patient?
(Disease or Health status, age, race, sex)

"I" stands for intervention

What do you plan to do for the patient?
(Specific tests, therapies, medications)

"C" stands for Comparison

What is the alternative to your plan?
(ie. No treatment, different treatment, etc.)

"O" stands for outcome

What outcome do you seek?
(Less symptoms, no symptoms, full health, etc.)

Here are some tutorials to help you understand the PICO model and how to use it to create your clinical question.

PICO questions are foreground questions.
They are asked to inform clinical decision-making.

Major types of foreground clinical questions

Therapy
Etiology
Diagnosis
Prevention or Prognosis

CLINICAL QUESTION TEMPLATES

These fill-in-the-blank templates can help you formulate a good foreground question.

THERAPY
In ___________ , what is the effect of ________________on _______________ compared with _______________?

ETIOLOGY
Are ______________ who have _______________ at ______________ risk for/of ____________ compared with _____________ with/without ______________?

DIAGNOSIS OR DIAGNOSTIC TEST
Are (Is) ________________ more accurate in diagnosing _______________ compared with __________?

PREVENTION
For ___________ does the use of _________________ reduce the future risk of ____________ compared with ______________?

PROGNOSIS
Does ____________ influence ______________ in patients who have _____________?

MEANING
How do _______________ diagnosed with _______________ perceive __________________?

Source: Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.

EXAMPLES OF PICO CLINICAL QUESTIONS

(P) Patient	(I) Intervention	(C) Comparison	(O) Outcome
In patients with acute bronchitis	do antibiotics	none	reduce sputum production, cough or days off?
In patients requiring wound care	does tap water	compared to normal saline	reduce the incidence of infection?

John Hopkins EBP Question Development tool

The John Hopkins Nursing Evidence-Based Practice Model provides a Question Development Tool to provide you guidance with navigating the above steps in creating an answerable clinical question. It can be downloaded here.

Step 4: Identify the stakeholders

A stakeholder is a person or group of people who have an interest in an activity or decision made by an organization. In healthcare, these can be people who carry out the process under review or people who are affected by a change in practice. Some examples of stakeholders include patients, nurses, physicians, and the purchasing department.

Identifying your stakeholders early in the EBP process is important because stakeholder buy-in is important for the success of the practice change implementation.

How do you identify stakeholders for your project?

The John Hopkins Nursing Evidence Based Practice Model provides a Stakeholder Analysis Tool.
The tools4dev Stakeholder Analysis Matrix Template provides an easy-to-use visual way of organizing how your stakeholders interact with your project.
And here is a short video by the Primes, explaining what stake is and how to motivate stakeholders to make a change.

Step 5: Determine the responsibility for project leadership

Choosing an appropriate leader is important for the project's success. The leader should have experience in evidence-based practice and working with multidisciplinary teams.

Step 6: Schedule the team meetings

The project leader will handle scheduling of the EBP team meetings at a time that is amenable to most team members. At Ellis, scheduling of conference rooms is handled through Microsoft Outlook. You can contact the Helpdesk at 518.243.4445 for assistance with using Outlook to schedule meetings.