How to Ask an

Answerable/ Right
Question?

Ns. Gst. Kade Adi Widyas Pranata, S.Kep., M.S.

What we have known…..
• Evidence-based practice (EBP) solves clinical
problems by integrating the available BEST
EVIDENCE, EXPERT OPINIONS, and
PATIENT VALUES AND PREFERENCES.
• Implementing EBP result in:
 higher quality health care and superior
patient outcomes
 greater autonomy in practices and a higher
level of job satisfaction

(Melnyk et al., 2012)

Definition
• However, there’s no magic formula for what percentage of a
clinical decision should be based on evidence or patient
preferences or nurse expertise.
• The weight given to each of these three EBP components
varies according to the clinical situation.

For example:
• Evidence-based guidelines might indicate that a young child
with an ear infection receive amoxicillin and clavulanate (ex:
augmentin) if the infection hasn’t resolved with amoxicillin.
• However, if the child dislikes the taste and it’s likely that the
medication won’t be taken  patient preference and clinical
expertise should outweigh the best practice guideline and an
alternative antibiotic should be prescribed.
 The Seven Steps of EBP
• Step 0: Cultivate a spirit of inquiry
• Step 1: Ask clinical questions in PICOT format
• Step 2: Search for the best Evidence
• Step 3: Critically appraise the evidence.
• Step 4: Integrate the evidence with clinical
expertise and patient preferences and
values
• Step 5: Evaluate the outcomes of the practice
decisions or changes based on evidence
• Step 6: Disseminate EBP results
(Melnyk &Fineout-Overholt, Stillwell, Williamson, 2010)
Session Objectives

A. Distinguish background and foreground

questions
B. Recognize elements of an answerable
question (PICOT)
C. Differentiate between the various types of
questions
D. Constructs background and foreground
questions (PICOT) from the scenario
Step Zero:
Cultivate a spirit of inquiry
For example:
• In patients with endotracheal tubes, how does use of saline with
suctioning compared with suctioning without saline affect oxygen
saturation?
• In patients with head injury, how does elevating the head of the
bed 30 degrees compared with keeping a patient in a supine
position affect intracranial pressure?
• In postoperative surgical patients, how does the use of music
compared with no use of music affect the frequency of pain
medication administration?
• In patients with supraventricular tachycardia, how does
administering the β-blocker metoprolol (Lopressor, Toprol-XL)
compared with administering no medicine affect the frequency of
tachycardic episodes?
 Step 1:
Ask clinical questions in PICOT format
 Two Kinds of Clinical
Question

• Background question

• Foreground question  answerable

question
 Background Question
• Considerably broader and when answered, provide
general knowledge or information about a clinical
issue.
• Biologic, psychological and social aspects of human
illness.
 The starting place of the question
 What, where, when, why and how
 The outcome of interest
 Clinical diagnosis

Ex:
• How does the drug acetaminophen work to affect
fever?
• How do hemodynamic differ with positioning?
 Foreground Question
• Specific and relevant to the clinical issue.
• Those can be answerable from scientific
evidence about diagnosing, treating, or
assisting patients with understanding their
prognosis.
• Allows the use of the PICOT format  the
PICOT format provides an efficient
framework for searching electronic
databases, one designed to retrieve only
those articles relevant to the clinical question
 Formulating an Answerable
Foreground Question

Patient / Population
Intervention/ Exposure/ Issue of
interest
Comparison
Outcome
Time/ Type of question/ Type of
study
Patient / Population

• Who are the patients (with certain

disorder) of interest?

• Is there a particular age group,

gender, ethnicity, or population?
Intervention/ Exposure/ Issue of
interest

• What therapeutic, diagnostic, preventive or

other health care interventions are you
interested in knowing more about?

• What risk behaviour or factor are you

interested in knowing more about?

• What phenomenon are you interested in

knowing more about?
Comparison
• Is there a comparison to be evaluated
against the intervention?
 Placebo, no intervention, or absence
of risk factor?

• Only used if more than one

intervention or if no intervention is a
factor.
Outcome
• What is the desired outcome to be
evaluated?

• How will the patient or population be

affected, or not affected, by the
intervention?

• Risk of disease, accuracy of diagnosis,

rate of occurrence of adverse outcome...
Time/ Type of question/ Type
of study
• Time takes for the intervention to achieve the
outcome

• Types of question
 Intervention/therapy, etiology/risk factor,
diagnosis/diagnosis test (measurement),
prognosis/prediction, meaning

• Type of study
 Research design that can answer the PICO
 Foreground Question
Example:
 Which is more effective in reducing
fevers in children, acetaminophen or
ibuprofen?
 Which is more effective to increase
oxygen saturation in patients with ARDS,
prone or supine positioning?
 “In adult patients undergoing surgery,
how does guided imagery compared with
music therapy affect analgesia use within
the first 24 hours post-op?”
 Why Should We Ask an
Answerable Question?
• Increasing complexity of patient’s
illness.
• An overwhelming amount of
information.
• Rare time to search evidence.
• To guide the right searching strategies.
Why Should We Ask an
Answerable Question?
 Scenario
• You are a staff nurse who has been asked to join an
infection control committee in the hospital to address
the issue of hand washing in light of the recent influenza
outbreak in neighboring communities.
• The committee has decided that all persons entering
the hospital must wash their hands, but committee
members disagree on how best to implement this
recommendation.
• Some committee members believe that antiseptic soap
must be used, and others believe that a waterless,
alcohol-based solution would be preferable. You offer to
seek out studies that could help the committee to make
a final decision.
Example from: DiCenso A, Guyatt G, Ciliska D. (2005). Evidence-Based Nursing:
A Guide to Clinical Practice. St. Louis, MO: Mosby.
 Background Question

• Is a waterless, alcohol-based solution an

effective agent for hand washing?

• Kenapa antiseptic soap dapat membunuh

kuman yang menempel pada tangan?
atau
• Apa kandungan dalam antiseptic soap yang
dapat membunuh kuman yang menempel
pada tangan?
 Foreground Question
P : persons entering a health care facility
I : hand rubbing with a waterless, alcohol-based solution
C : standard hand washing with antiseptic soap
O : Incidence of influenza/ hand contamination

Foreground question:
For persons entering a health care facility, is hand
rubbing with a waterless, alcohol-based solution, as
effective as standard hand washing with antiseptic soap
for reducing incidence of influenza or hand
contamination?

How about T?
 Foreground Question
• Note that a COMPARISON may not be
pertinent in some PICOT questions, such as in
“meaning questions,” which are designed to
uncover the meaning of a particular experience.

• TIME is also not always required.

• But POPULATION (P), INTERVENTION or

ISSUE OF INTEREST (I), and OUTCOME (O)
are essential to developing any PICOT
question.
Types of Question (T of PICOT)
• Quantitative question
 To interpret patient assessment date,
determine the cause of the patient
problem …
 Etiology, diagnosis/test, therapy,
prevention, and prognosis.

• Qualitative question
 To determine meaning, provide insight
and scope to a phenomenon, to
appreciate a patient’s experience…
 Quantitative Question
• Interventions (or Treatment, Prevention,
Therapy)
 Determining the effect of different
interventions on improving patient function or
avoid adverse events.
Example:
• In African-American female adolescents with
hepatitis, what is the effect of acetaminophen
on liver function compared with ibuprofen?
• Does the use of an influenza vaccine reduce
the risk of pneumonia in 65-year-old patients?
 Quantitative Question
• Interventions (or Treatment, Prevention,
Therapy)
 In African-American female adolescents with
hepatitis, what is the effect of acetaminophen
on liver function compared with ibuprofen?
P : African-American female adolescents with
hepatitis
I : Acetaminophen
C : Ibuprofen
O : Liver function
T : Intervention (or Treatment, Prevention, Therapy)
 Quantitative Question
• Interventions (or Treatment, Prevention,
Therapy)
 Does the use of an influenza vaccine reduce
the risk of pneumonia in 65-year-old
patients?
P : 65-year-old-patients or elderly
I : Influenza vaccine
C : -
O : The risk of pneumonia
T : Intervention (or Treatment, Prevention,
Therapy)
Quantitative Question
• Harm (or Causation, Etiology, Risk Factor)
 Ascertaining the effects of potentially harmful
agents on patient function, morbidity, and
mortality

Example:
• Are 30 to 50- year-old women who have high
blood pressure at increased risk for an acute
myocardial infarction?
• Jika dibandingkan dengan memiliki berat
badan berlebih, apakah kurang berolahraga
lebih beresiko menyebabkan terjadinya
benigna prostat hyperplasia (BPH) pada lansia
laki-laki?
Quantitative Question
• Harm (or Causation, Etiology, Risk Factor)
 Are 30 to 50- year-old women who have
high blood pressure at increased risk for
an acute myocardial infarction?

P : 30-50 year-old women

I : High blood pressure or hypertension
C : -
O : Risk for acute myocardial infarction
T : Harm (or Causation, Etiology, Risk Factor)
Quantitative Question
• Harm (or Causation, Etiology, Risk Factor)
 Jika dibandingkan dengan memiliki berat
badan berlebih, apakah kurang
berolahraga lebih beresiko menyebabkan
terjadinya benign prostatic hyperplasia
(BPH) pada lansia laki-laki?

P : Lansia lak-laki
I : Kurang berolahraga
C : Berat badan berlebih
O : Resiko benign prostatic hyperplasia
T : Harm (or Causation, Etiology, Risk Factor)
Quantitative Question
• Diagnosis (or Test/Assessment)
 Establishing the power of a diagnostic tool to
differentiate between persons with and
persons without a target condition or disease.

Example:
• Are serial 12-lead ECGs more accurate in
diagnosing an infarct in patient with acute
myocardial infarction compared with one
initial 12-lead ECGs?
• Apakah CT-scan lebih akurat dalam
mendiagnosis neoplastic dibandingkan
dengan MRI pada pada pasien neoplasma
intracranial?
Quantitative Question
• Diagnosis (or Test/Assessment)
 Are serial 12-lead ECGs more accurate in
diagnosing an infarct in patient with acute
myocardial infarction compared with one
initial 12-lead ECGs?

P : Patient acute myocardial infarction

I : Serial 12-lead ECGs
C : One-initial 12-lead ECGs
O : Infarct
T : Diagnosis (or Test/ Assessment)
Quantitative Question
• Diagnosis (or Test/Assessment)
 Apakah CT-scan lebih akurat dalam
mendiagnosis neoplastic dibandingkan
dengan MRI pada pada pasien neoplasma
intracranial?

P : Pasien neoplasma intracranial

I : CT-scan
C : MRI
O : Neoplastic
T : Diagnosis (or Test/ Assessment)
Quantitative Question
• Prognosis
 Estimating the future course of a patient’s
disease or condition

Example:
• Does smoking status influence death and
infarction rate in patients who have
experience an acute myocardial infarction?
• Apakah thrombocytopenia status lebih
memperburuk fase penyembuhan luka jika
dibandingkan dengan leukopenia status
pada pasien pasca laparotomy?
Quantitative Question
• Prognosis
 Does smoking status influence death
and infarction rate in patients who have
experience an acute myocardial
infarction?

P : Patients with experience an acute myocardial

infarction
I : Smoking status
C : -
O : Death and infarction
T : Prognosis
Quantitative Question
• Prognosis
 Apakah thrombocytopenia status lebih
memperburuk fase penyembuhan luka
jika dibandingkan dengan leukopenia
status pada pasien pasca laparotomy?

P : Pasien pasca laparotomy

I : Thrombocytopenia status
C : Leukopenia status
O : Fase penyembuhan luka
T : Prognosis
Qualitative Question
• Meaning
 Describing, exploring, and explaining
phenomena being studied (focus on process
rather than outcome)

Example:
• How do women diagnosed with fibromyalgia
perceive others’ perceptions of their physical
limitations?
• Bagaimana pengalaman orang tua dengan
retardasi mental merawat anak dengan autism
yang terus menerus mengalami kecemasan
ketika kontak dengan lingkungan sosial?
Qualitative Question
• Meaning
 How do women diagnosed with
fibromyalgia perceive others’ perceptions
of their physical limitations?

P : Women
I : Fibromyalgia Status
C : -
O : Other’s perceptions of their physical
limitations
T : Meaning
Qualitative Question
• Meaning
 How do women diagnosed with fibromyalgia
perceive others’ perceptions of their physical
limitations? Atau
 How do fibromyalgia status influence women
perceive others’ perceptions of their physical
limitations?

P Population and : Women

their problem
I Phenomena of : Fibromyalgia status
Interest
Co Context : Other’s perceptions of their
physical limitations
Qualitative Question
• Meaning
 Bagaimana pengalaman orang tua dengan
retardasi mental merawat anak dengan
autism yang terus menerus mengalami
kecemasan ketika kontak dengan lingkungan
sosial?

P : Orang tua dengan retardasi mental

I : Pengalaman merawat anak dengan autism
C : -
O : Kecemasan kontak dengan lingkungan sosial
T : Meaning
Qualitative Question
• Meaning
 Bagaimana pengalaman orang tua dengan
retardasi mental merawat anak dengan
autism yang terus menerus mengalami
kecemasan ketika kontak dengan lingkungan
sosial?

P Population and : Orang tua dengan retardasi

their problem mental
I Phenomena of : Pengalaman merawat anak
Interest dengan autism
Co Context : Kecemasan kontak dengan
lingkungan sosial
Strength of PICOT
• A consistent, systematic way to identify the
components of a clinical issue  structure the
clinical question  guide the search for the
evidence
• A well-built PICOT question increases the
likelihood that the best evidence to inform
practice will be found quickly and efficiently

Limits of PICOT
• This model works best for Therapy/ Treatment &
Diagnosis questions, however, PICOT is a
model, not a rigid structure
References
• Craig, J. V., & Smyth, R. L. (Eds.). (2007). The evidence-based practice
manual for nurses. Edinburgh: Churchill Livingstone.
• DiCenso, A., Guyatt, G., & Ciliska, D. (Eds.). (2005). Evidence-based
nursing :a guide to clinical practice. St. Louis, MO: Elsevier Mosby.
• Fineout-Overholt E, Stillwell SB. Asking compelling questions. In: Melnyk
BM, Fineout-Overholt E, editors. Evidence-based practice in nursing and
healthcare: a guide to best practice [forthcoming]. 2nd ed. Philadelphia:
Wolters Kluwer Health/Lippincott Williams and Wilkins.
• Melnyk, B.M., & Fineout-Overholt, E. (2014). Evidence-based Practice in
Nursing and Healthcare: A Guide to Best Practice. 3rd ed., Philadelphia:
Lippincott, Williams & Wilkins
• Nollan R, et al. Asking compelling clinical questions. In: Melnyk BM,
Fineout-Overholt E, editors. Evidence based practice in nursing and
healthcare: a guide to best practice. Philadelphia: Lippincott Williams and
Wilkins; 2005. p. 25-38.
• Straus SE. Evidence-based medicine: how to practice and teach EBM. 3rd
ed. Edinburgh; New York: Elsevier/ Churchill Livingstone; 2005.
Sesi Diskusi
 Foreground Question
In adult patients undergoing surgery, how does
guided imagery compared with music therapy affect
analgesia use within the first 24 hours post-op?

Jelaskan komponen PICOT Format dari pertanyaan!

P?
I?
C?
O?
T?
 Foreground Question

In adult patients undergoing surgery, how

does guided imagery compared with music
therapy affect analgesia use within the first
24 hours post-op?

P  adult patients undergoing surgery

I  guided imagery
C  music therapy
O  pain or analgesia use
T  the first 24 hours post-op/ intervention
 Background Question

• Apakah medical-surgical unit?

• Apakah cardiac arrest?
• Apakah rapid-response team?
• dll
 Foreground Question
P : acute care hospitals/ medical-surgical patient
I : rapid response team
C : not having a response team
O : number of cardiac arrests
T : three-month period/ intervention/

“In acute care hospitals (patient/ population), how does

having a rapid response team (intervention)
compared with not having a response team
(comparison) affect the number of cardiac arrests
(outcome) during a three-month period (time)?”
Scenario
• You are a school nurse at a large high school
in your community. You have just completed a
day of information sessions on the harmful
effects of smoking and have offered to meet
with students who are interested in quitting
smoking. The next day you are visited in your
office by an 18-year-old girl who has smoked
half a pack of cigarettes a day for the past
year. She has tried unsuccessfully to quit
smoking. She asks you whether “the patch
(nicotine) and e-cigarettes” works.
 Background Question

• Apakah harmful effects of smoking?

• Apakah the patch (nicotine)?
• Apakah e-cigarettes?
• dll
Foreground Question
Foreground Question
Penugasan
 Tugas
Bentuk dan Format Tugas:
 Makalah tentang scenario kasus EBP lengkap dengan
background and foreground question untuk semua
jenis pertanyaan (quantitative dan qualitative)
 Jumlah scenario lengkap dengan background dan
foreground question adalah 10 buah

Metode penugasan:
 Kelas masih dibagi menjadi 6 kelompok untuk
mengerjakan tugas berikut. Kelompok berhak tidak
mencantumkan nama mahasiswa yang tidak
terlibat dalam pengerjaan tugas.
 Segala bentuk plagiarism seperti Copy Paste tugas
dari kelompok ataupun kelas lain tidak
diperkenankan. Jika terbukti melanggar, otomatis
nilai kelompok akan langsung 0.
 Tugas
Waktu pengumpulan dan format pengiriman tugas:
 Tugas dikumpulkan selambat-lambatnya satu minggu
sejak tugas diberikan ke alamat email
ebp.itekesbali@gmail.com
 Pada saat pengiriman tugas, format penulisan pada
SUBJEK EMAIL adalah sebagai berikut:
Nama Mata Kuliah_Prodi & Kelas_Nama
Kelompok_Jenis Tugas
 Contoh:
EBP_Anestesiologi Alih Jenjang Kelas A_Kelompok
1_Makalah Scenario Background dan Foreground
Question