Note. This article is the second in a series on evidence-based practice. The series is a result of the feedback provided by chapters on the 2004 Chapter Annual Reporting Form: Evidence-Based Practice and Research. The feedback indicated that chapter members are interested in learning more about evidence-based practice and how to implement it. Visit the ONS Evidence-Based Practice Resource Area for more information.

1. Identify a clinical problem and ask a clinical question.
2. Find the evidence.
3. Critically appraise the evidence.
4. Summarize the evidence.
5. Apply the recommendation to practice.
6. Evaluate the practice change.

Identifying a clinical problem and asking a good clinical question are the first steps in the EBP process. When using the EBP process, work with colleagues who have expertise in the clinical topic of interest and allow adequate time to discuss and develop the question. A focused problem and well-developed question are essential for obtaining an efficient, productive search of the evidence.

1. Diagnosis: questions regarding the selection and interpretation of diagnostic tests (Example: Should a venogram dye study be performed on all patients with cancer undergoing chemotherapy who have central venous devices from which a nurse is unable to obtain a blood return?)
2. Prognosis: questions regarding the patient's likely clinical outcome (Example: Does a difference exist in response rate of IV heparin administration compared to subcutaneous low molecular-weight heparin in patients with lower extremity deep vein thrombosis?)
3. Therapy or intervention: questions regarding the selection of treatments or interventions that are most beneficial (Example: In patients with cancer who have chronic pain, what bowel regimen will be most effective in relieving constipation associated with the administration of opioid therapy for the relief of pain?)
4. Prevention: questions regarding screening and prevention methods to reduce the risk of disease or side effects of treatment (Example: Is ginger effective in preventing delayed chemotherapy-induced nausea and vomiting?)
5. Education: questions regarding best teaching strategies for colleagues, patients, or family members (Example: What is the most effective teaching strategy for educating patients and family members about interventions to reduce radiation therapy-related fatigue?)

Nurses encounter many clinical problems on a daily basis that can be queried to identify the evidence for best practice.

• Background questions provide general information about a clinical issue and often are the what, where, when, why, and how questions. Information for answering background questions frequently can be found in textbooks. (Example: How do corticosteroids work to reduce chemotherapy-induced nausea and vomiting? The answer would most likely be found in a pharmacology textbook.)
• Foreground questions are more specific and can be answered by searching the scientific evidence related to diagnosing, preventing, treating, or assisting patients to understand disease, treatment, and self-care management. The questions are focused on specific knowledge gaps or uncertainty and usually build on the basic knowledge found as a result of background questions. (Example: In patients receiving taxanes [e.g., docetaxel, paclitaxel], which are more effective in reducing treatment-related nausea and vomiting: corticosteroids [e.g., dexamethasone] or serotonin antagonists [e.g., ondansetron]?)

The EBP process focuses on asking foreground questions because they often are the questions that clinicians face in daily practice.

What Components Should Be Included in Good Clinical Questions?
A good clinical question addresses the problem of interest and provides a statement of the question that needs to be answered or a situation that needs a solution (ONS, 2004). The PICO Framework often is used to formulate clinical questions (Craig, 2002; ONS, 2004). The framework identifies and defines the essential components of a good clinical question.

• Patient population of interest or situation being addressed
• Intervention or phenomenon of interest
• Comparison intervention (if applicable)
• Outcome

The PICO acronym can be helpful in formulating clinical questions because it serves as a reminder of the key components. A table format can be used based on PICO in developing clinical questions (University of Alberta Library Services, 2005). The following table provides an example of using the PICO Framework to develop a clinical question.

A well-formulated clinical question will facilitate an efficient and productive search of the evidence and result in identifying a solution to the identified problem more quickly.

The best way to become more skilled at developing good clinical questions is to practice. Nurses are very good critical thinkers. As you care for patients on a daily basis, begin to take note of opportunities where you might be able to identify knowledge gaps or uncertainty about why you are providing a certain intervention or treatment or even whether other treatments or interventions may result in better patient outcomes. This is the first step in implementing the EBP process.

Stay tuned for more information on the EBP process. In the next issue, we will provide key points and tips about finding the evidence for a clinical question.