Research Guides: Evidence-Based Practice for Nursing: Asking the Clinical Question

Identifying the Problem

Clinical questions arise from various cues, problems, and/or observations from patient care, nursing practice, or broader changes in healthcare knowledge and delivery. The most important step in Evidence-Based Nursing (EBN) is to correctly identify a problem through patient assessment or practice assessment, processes that require reflection by the nurse on clinical practice, in conjunction with a knowledge of the patient's present circumstances. The ability to identify the problem is the foundation for evidence-based nursing; if a nurse fails to identify a problem correctly, then all the evidence she/he locates and the resulting decision-making will be irrelevant (Haddock, 2005).

The information below describes how to frame the question once the patient or practice assessment and the resulting problem identification have occurred.

Background vs. Foreground

An early step in framing the clinical question is to determine the type of question: background or foreground. The type of question helps to determine the resource to access to answer the question.

Background questions ask for general knowledge about a condition or thing and do not normally arise from the need to make a clinical decision about a specific patient.
- Background questions usually have two essential components:
  - A question root (who, what, when, etc.) with a verb
  - A disorder, treatment, test, or other aspect of healthcare
  - e.g. What causes migraines? How often do women over 40 need a mammogram?
- Books are generally better resources for answering background questions.
Foreground questions ask for specific knowledge to inform clinical decisions or actions.
- Foreground questions usually have 3 or 4 essential components, from the PICO format (see PICO, under next section: Finding the Evidence):
  - Patient/population characteristics, problem
  - Interventions or Exposures
  - Comparison
  - Outcome
- Articles are typically more specific and current, making them better suited for foreground questions.

Types of Questions

Clinical questions

Clinical questions typically fall into one of four main categories:

Etiology (or harm/risk factors): What causes the problem?
Diagnosis: Does this patient have this problem?
Therapy: What is the best treatment for this problem?
Prognosis: What will the outcome of the problem be?

* Knowing the type of clinical question is important later in the EBN process--once the nurse goes to look for studies that will answer his/her question.

Nursing Practice Questions:

In nursing, many other questions about practice will also arise, with some of the questions resulting from the nursing principle of working with rather than on the patient. These questions can be quantitative or qualitative in nature. Examples include:

What other, validated instruments for measuring this condition or phenomenon (e.g. pain) exist and how do they compare to the one we currently use?
Should a nurse deliver patient education on the patient's disease/condition near the beginning or the end of an appointment or consultation?
How do caregivers of patients with [x] cope with the burden of care and how can nurses assess the level of caregiver burden and/or support the caregivers?

References

Jane Haddock. (2002). Reflective practice and decision-making related to research implementation. In Robert McSherry, Maxine Simmons, & Pamela Abbott (Eds.), Evidence-Informed Nursing: A Guide for Clinical Nurses (pp. 78–97). London: Routledge.