Week 3 Humanistic TheoriesThe good life is a process, not a sta.docx

Week 3: Humanistic Theories
The good life is a process, not a state of being. It is a direction,
not a destination.
—Carl Rogers
Humanistic theories can empower clients to find meaning within
their lives. While people subjectively consider their insights,
emotions, and actions, how might you objectively employ
interventions in both a genuine and approachable manner?
Being a humanistic/existential counselor requires that you enter
into the phenomenological world of your clients, which means
that you gain a true understanding of the way they have
perceived the experiences in their lives. By demonstrating this
understanding, you provide genuine empathy. Feelings of
empathy can evoke an environment where mutual trust is
understood, thus allowing you to partner with clients in their
journeys to acquire a deeper understanding of themselves.
This week, you will review person-centered theory, observe the
application of this approach by watching a media
demonstration, and apply the person-centered approach to one
of the case studies used in this course.
Learning Objectives
Students will:
· Identify theorists, timeframes, and major constructs of
individual theories
· Analyze techniques/interventions associated with individual
theories
· Evaluate theories in relation to cases
Learning Resources
Required Readings
Hazler, R. (2016). Person-centered theory. In D. Capuzzi & M.
D. Stauffer (Eds.), Counseling and psychotherapy: Theories and
interventions (6th ed., pp. 169–194). Alexandria, VA: American
Counseling Association.

Document: Psychoanalytic Case Conceptualization Example
(Word document)
Document: Case Studies (Word document)
Required Media
Psychotherapy.net (Producer). (2008c). Person-centered
expressive arts therapy [Video file]. Mill Valley, CA: Author.
Discussion: Person-Centered Counseling: Case
Conceptualization
For this Discussion, you will write a case conceptualization just
as you did last week, but this time as though you were a person-
centered counselor. A case conceptualization is a report that is
written by a counselor to explain presenting problems, establish
goals, plan interventions, and identify expected outcomes.
As you review this week's Learning Resources and media file,
note techniques and interventions, and consider the role of a
person-centered counselor in planning treatment. Further,
reflect on person-centered therapy with respect to developing
your own theoretical orientation. In what ways do you find that
person-centered therapy resonates with your own point of view?
To Prepare:
· Review the person-centered expressive arts therapy video from
this week's Learning Resources. Take note of language and
techniques used by the counselor that are specific to this theory.
· Review the Psychoanalytic Case Conceptualization Example
found in this week’s Learning Resources and use this document
to prepare your initial Discussion post.
· Select one of the four case studies presented in this week’s
Learning Resources, and answer the following points as if you
were a person-centered counselor. Use your Learning Resources

and the notes you took on language and technique from the
person-centered expressive arts therapy video to support your
conceptualization and integrate examples from the case to
support your post. Include the following:
· Presenting Problem
· Treatment Goals
· Identification and explanation of at least two techniques and
interventions
· Expected Outcome
By Day 3
Post your person-centered conceptualization.
Be sure to support your main post with specific references to
the Learning Resources using proper APA format and citations.
Your response posts may be more conversational and less
formal.
Read your colleagues' postings.
By Day 5
Respond to at least two of your colleagues' posts and explain
whether you believe the proposed case conceptualization is the
most beneficial for the case selected and why.
Your responses may be more informal than your main post.
Return to this Discussion in a few days to read the responses to
your initial posting. Note what you have learned and/or any
insights that you have gained as a result of your colleagues'
comments.
Submission and Grading Information
Grading Criteria
To access your rubric:
Week 3 Discussion Rubric
Post by Day 3 and Respond by Day 5
To participate in this Discussion:
Week 3 Discussion

Week in Review
This week, you analyzed person-centered theory and the way
that environment can impact human development.
Next week, you will explore existential and Gestalt theories,
which focus on awareness and responsibility to make choices,
and you will apply these theories to a case.
I did my case study on Dale
Week 3: Humanistic Theories
The good life is a process, not a state of being. It is a direction,
not a destination.
—Carl Rogers
Humanistic theories can empower clients to find meaning within
their lives. While people subjectively consider their insights,
emotions, and actions, how might you objectively employ
interventions in both a genuine and approachable manner?
Being a humanistic/existential counselor requires that you enter
into the phenomenological world of your clients, which means
that you gain a true understanding of the way they have
perceived the experiences in their lives. By demonstrating this
understanding, you provide genuine empathy. Feelings of
empathy can evoke an environment where mutual trust is
understood, thus allowing you to partner with clients in their
journeys to acquire a deeper understanding of themselves.
This week, you will review person-centered theory, observe the
application of this approach by watching a media
demonstration, and apply the person-centered approach to one
of the case studies used in this course.
Learning Objectives
Students will:
· Identify theorists, timeframes, and major constructs of
individual theories
· Analyze techniques/interventions associated with individual
theories

· Evaluate theories in relation to cases
Learning Resources
Required Readings
Hazler, R. (2016). Person-centered theory. In D. Capuzzi & M.
D. Stauffer (Eds.), Counseling and psychotherapy: Theories and
interventions (6th ed., pp. 169–194). Alexandria, VA: American
Counseling Association.
Document: Psychoanalytic Case Conceptualization Example
(Word document)
Document: Case Studies (Word document)
Required Media
Psychotherapy.net (Producer). (2008c). Person-centered
expressive arts therapy [Video file]. Mill Valley, CA: Author.
Discussion: Person-Centered Counseling: Case
Conceptualization
For this Discussion, you will write a case conceptualization just
as you did last week, but this time as though you were a person-
centered counselor. A case conceptualization is a report that is
written by a counselor to explain presenting problems, establish
goals, plan interventions, and identify expected outcomes.
As you review this week's Learning Resources and media file,
note techniques and interventions, and consider the role of a
person-centered counselor in planning treatment. Further,
reflect on person-centered therapy with respect to developing
your own theoretical orientation. In what ways do you find that
person-centered therapy resonates with your own point of view?
To Prepare:
· Review the person-centered expressive arts therapy video from

this week's Learning Resources. Take note of language and
techniques used by the counselor that are specific to this theory.
· Review the Psychoanalytic Case Conceptualization Example
found in this week’s Learning Resources and use this document
to prepare your initial Discussion post.
· Select one of the four case studies presented in this week’s
Learning Resources, and answer the following points as if you
were a person-centered counselor. Use your Learning Resources
and the notes you took on language and technique from the
person-centered expressive arts therapy video to support your
conceptualization and integrate examples from the case to
support your post. Include the following:
· Presenting Problem
· Treatment Goals
· Identification and explanation of at least two techniques and
interventions
· Expected Outcome
By Day 3
Post your person-centered conceptualization.
Be sure to support your main post with specific references to
the Learning Resources using proper APA format and citations.
Your response posts may be more conversational and less
formal.
Read your colleagues' postings.
By Day 5
Respond to at least two of your colleagues' posts and explain
whether you believe the proposed case conceptualization is the
most beneficial for the case selected and why.
Your responses may be more informal than your main post.
Return to this Discussion in a few days to read the responses to
your initial posting. Note what you have learned and/or any
insights that you have gained as a result of your colleagues'
comments.
Submission and Grading Information
Grading Criteria

To access your rubric:
Week 3 Discussion Rubric
Post by Day 3 and Respond by Day 5
Dale
Dale is a 52-year-old White man who works as a prison guard in
Arizona and was referred to counseling because he has had
multiple verbal and physical altercations at work with inmates.
In the past month, Dale has been involved in two physical
altercations with prisoners, both of which were caused by Dale
calling prisoners by racist names. Based on his work behavior,
his supervisor referred him to counseling as a condition of his
continued employment. Dale does not want to be in counseling,
as he does not think that he needs to change anything, but he
has attended the first session in order to maintain his
employment.
Dale was a police officer for 18 years and was terminated from
the police force due to racial profiling and his inability to work
collaboratively with his minority colleagues. After termination,
he served as a bouncer at a local bar for 4 years but quit to
pursue a job with higher income and medical benefits for his
painful rheumatoid arthritis. Dale has worked in the prison
system for 2½ years.
Dale has been married twice. He was married to his first wife
for 6 years and had one son from that marriage who is currently
21 years old. His son was raised primarily by his ex-wife, and
Dale saw him on holidays and for 2 weeks during the summer.
Dale no longer has contact with his son. Dale broke contact
after his son brought home a Latina girlfriend; Dale states that
the “Mexicans and Blacks are taking over his country but won’t
take over his family.” Dale describes his ex-wife as a “lying
whore” who he believes had multiple affairs during the marriage
while he worked long hours as a police officer. He says she
denies these accusations, but Dale says that “you can’t really
trust women.” He also thinks she did a “terrible job” raising
their son, and he described his son as a “big baby.”

Dale has been married to his second wife, Anne, for 3 years.
Anne works as a clerk at a grocery store in their small town.
Anne does not have any children. Dale describes Anne as
politically and socially “ignorant” and “very religious.” He says
he trusts Anne because of her religious beliefs and that she is
afraid to go to hell for sinning. Dale states that it is Anne’s
religious beliefs that allow him to trust her not to be like most
women who have affairs, spend their husband’s money, and lie a
lot. He states she “knows her place” as his “property” and
doesn’t disagree with him. Dale was raised by his mother in a
rural community where he was the eldest of four children; his
views mirror those of his father, a man who worked as a laborer
to support his family.
Dale states that he seeks out people who oppose his views so
that he can try to convince them that the U.S.A. is a country for
White, English speaking people only. When asked about this
view, Dale shares that he grew up in extreme poverty and that
“the lazy Blacks and Mexicans” got services and support while
he had to “pull myself up by the bootstraps” to get to the middle
class. Dale did not adopt extreme anger about these views until
he started working in the prison, where many of the inmates are
Black Americans and/or Hispanic Americans.
video
http://www.psychotherapy.net.ezp.waldenulibrary.org/stream/w
aldenu/video?vid=086
By Susan B. Stillwell, DNP, RN, CNE,
Ellen Fineout-Overholt, PhD, RN,
FNAP, FAAN, Bernadette Mazurek
Melnyk, PhD, RN, CPNP/PMHNP,
FNAP, FAAN, and Kathleen M.

Williamson, PhD, RN
In the previous article in this series, our hypothetical nurse,
Rebecca R., with the help
of one of her hospital’s expert
evidence-based practice (EBP)
mentors, Carlos A., learned Step
1 of the EBP process—how to
formulate a clinical question.
The impetus behind her desire
to develop her question, as you
may re call in our case scenario,
was that Rebecca’s nurse man-
ager asked her to search for more
evidence to support her idea of
using a rapid response team to
decrease rates of in-hospital car-
diac arrests and unplanned ICU
admissions—both of which were
on the rise on Rebecca’s medical–
surgical unit. She learned of the
idea of a rapid response team
from a study she read on the sub-
ject in Critical Care Medicine.1
Here is the clinical question
Rebecca formulated: “In hospital-
ized adults (P), how does a rapid
response team (I) compared with
no rapid response team (C) affect
the number of cardiac arrests (O)
and unplanned admissions to the
ICU (O) during a three-month
period (T)? Her question, called
a PICOT question, contains

the following elements: patient
population (P), intervention of
interest (I), comparison interven-
tion of interest (C), outcome(s)
of interest (O), and time it takes
for the intervention to achieve
the outcome(s) (T). (To review
PICOT questions and how to
formulate them, see “Asking
the Clinical Question: A Key
Step in Evidence-Based Practice,”
March.)
This month Rebecca begins
Step 2 of the EBP process, search-
ing for the evidence. For an over-
view of this step, see How to
Search for Evidence to Answer
the Clinical Question.
THE BEST EVIDENCE TO ANSWER THE
CLINICAL QUESTION
In their next meeting, Carlos
and Rebecca discuss what type
of evidence will best answer her
clinical question. Carlos explains
that knowing the type of PICOT
question you’re asking (for
example, is it an intervention,
etiology, diagnosis, prognosis, or
meaning question?) will help you
determine the best type of study
design to search for. Rebecca’s
PICOT question is an interven-
tion question because it compares
two possible interventions—a

rapid response team versus no
rapid response team.
[email protected] AJN ▼ May 2010 ▼ Vol. 110, No. 5 41
Searching for the Evidence
Strategies to help you conduct a successful search.
This is the fourth article in a series from the Arizona State
University College of Nursing and Health Innovation’s Center
for the Advancement of Evidence-Based Practice. Evidence-
based practice (EBP) is a problem-solving approach to the
delivery of health care that integrates the best evidence from
studies and patient care data with clinician expertise and
patient preferences and values. When delivered in a context of
caring and in a supportive organizational culture, the
highest quality of care and best patient outcomes can be
achieved.
The purpose of this series is to give nurses the knowledge and
skills they need to implement EBP consistently, one
step at a time. Articles will appear every two months to allow
you time to incorporate information as you work toward
implementing EBP at your institution. Also, we’ve scheduled
“Chat with the Authors” calls every few months to provide
a direct line to the experts to help you resolve questions. See
details below.
Need Help with Evidence-Based Practice? Chat with
the Authors on May 5!
On May 5 at 1 pm EDT, join the “Chat with the Authors” call.
It’s your chance to get personal consultation from the
experts! Dial-in early! U.S. and Canada, dial 1-800-947-5134
(International, dial 001-574-941-6964). When prompted, enter
code 121028#.

Go to www.ajnonline.com and click on “Podcasts” and then
on “Conversations” to listen to our interview with Susan B.
Stillwell
and Ellen Fineout-Overholt.
http://www.ajnonline.com
42 AJN ▼ May 2010 ▼ Vol. 110, No. 5 ajnonline.com
Determine the level of evi-
dence. Research evidence, also
called external evidence, can be
viewed from a hierarchical per-
spective. The best external evi-
dence (that which provides the
most reliable information) is at
the top of the list and the least
reliable is at the bottom (see Hi-
erarchy of Evidence for Inter-
vention Studies2). The level and
quality of the evidence are impor-
tant to clinicians because they
give them the confidence they
need to make clinical decisions.
The research methodology that
provides the best evidence will
differ depending on the type of
clinical question asked. To answer
a question that includes an in-
tervention, such as Rebecca’s
question, a systematic review of
randomized, controlled trials or a
metaanalysis in which studies are

compared using statistical analy-
sis is the best study design.2-5 When
well designed and executed, these
studies provide the strongest evi-
dence, and therefore the most
confidence for clinical decision
making.
“What happens when there
isn’t a metaanalysis or systematic
review available?” Rebecca asks.
Carlos replies that the next-best
evidence would be Level II evi-
dence, the findings of a random-
ized, controlled trial. Carlos
reminds Rebecca that when de-
Cumulative Index to Nursing
and Allied Health Literature
The CDSR and DARE databases
contain systematic reviews and
metaanalyses of randomized,
controlled trials. The reviews
conducted by the Cochrane Col-
laboration are contained in the
CDSR, and abstracts of sys-
tematic reviews not conducted
by Cochrane are indexed in the
DARE. Cochrane reviews are
considered to have the strongest
level of evidence for intervention
questions because they have the
best study designs and are gener-
ally the most rigorous.

To find other types of evidence,
databases other than CDSR and
DARE must be searched. Because
the intervention—rapid response
team—is a multidisciplinary, in-
terprofessional initiative, evidence
to answer Rebecca’s question
may be found in medical as well
as in nursing and allied health
journals. Therefore, the PubMed
database, which contains medical
and life sciences literature, and
the CINAHL database, which
contains nursing and allied health
literature, should be searched.
Abstracts can be reviewed and
accessed free of charge in the
Cochrane Library and PubMed
databases (although a fee may be
required to obtain electronic cop-
ies of reviews or articles), but a
subscription is required to access
CINAHL.
SEARCHING STRATEGIES
Now that Rebecca and Carlos
have decided what databases to
search, they need to select the
keywords they’ll use to begin
their search.
Choose keywords from the
PICOT question. Rebecca and
Carlos identify the following
keywords from her PICOT ques-
tion: hospitalized adults, rapid

response team, cardiac arrests,
and ICU admissions. Lynne
ciding whether to use evidence
to support a practice change, it’s
important to consider both the
level and quality of the evidence
as well as the feasibility of imple-
menting the intervention.
WHERE TO FIND THE EVIDENCE
Rebecca and Carlos set up an
appointment with Lynne Z., the
hospital librarian, to learn how
to begin searching for the evi-
dence. Lynne tells Rebecca and
Carlos that no matter what type
of question is being asked, it’s wise
to search more than one database.
Because databases index different
journals, searching several data-
bases will reduce the possibility of
missing relevant literature.
Select relevant databases to
search. To find evidence to an-
swer Rebecca’s PICOT question,
Lynne recommends searching the
following databases:
•theCochraneDatabaseof
Systematic Reviews (CDSR)
and the Database of Abstracts
of Reviews of Effects (DARE),
which are found in the Co-

chrane Library and can be ac-
cessed through the Cochrane
Collaboration Web site (www.
cochrane.org)
•PubMed,whichincludes
MEDLINE (www.ncbi.nlm.
nih.gov/pubmed)
•CINAHL(www.ebscohost.
com/cinahl), an acronym for
How to Search for Evidence to Answer the Clinical Question
1. Identify the type of PICOT question.
2. Determine the level of evidence that best answers the
question.
3. Select relevant databases to search (such as the CDSR,
DARE, PubMed, CINAHL).
4. Use keywords from your PICOT question to search the
databases.
5. Streamline your search with the following strategies:
• Use database controlled vocabulary (such as “MeSH terms”).
• Combine searches by using the Boolean connector “AND.”
• Limit the final search by selecting defining parameters (such
as “humans” or
“English”).
http://www.cochrane.org
http://www.cochrane.org
http://www.ebscohost.com/cinahl
http://www.ebscohost.com/cinahl

the same search conducted at
different times will likely produce
different numbers of articles.)
Rebecca and Carlos want to
combine their searches because
they’re interested in finding
articles that contain all of the
keywords (hospitalized adults
AND rapid response team AND
cardiac arrests AND ICU admis-
sions). After they enter each key-
word into the selected database
and search it individually, they’ll
combine all the searches using
the Boolean connector “AND.”
There’s a chance, however, that
combining the searches may re-
sult in few or even no articles. For
example, the first time Rebecca
searched PubMed using its con-
trolled vocabulary for her PICOT
keywords, and then combined
the searches, the database came
up with only one article. She de-
cided to refocus her search, hoping
that including only the interven-
tion and outcomes keywords,
and not the patient population,
would produce articles relevant
to her clinical issue.
Place limits on the final com-
bined search to further narrow
the results. This strategy can

eliminate articles written in lan-
guages other than English or
those in which animals, and not
hu mans, are the subjects. Other
limits—such as age or sex of
subjects or type of article (such
as clinical trial, editorial, or
review)—are available; however,
placing too many limits on a
search may produce too few or
even no articles.
recommends that in cases when
a database has its own indexing
language, or controlled vocabu-
lary, the search be conducted
with these index terms. In this
way, the search will be the most
inclusive.
Use database controlled
vocabulary. For example, when
the keyword rapid response
team is entered into PubMed,
the PubMed database matches
it to the controlled vocabulary
term “Hospital Rapid Response
Team.” All articles that contain
the topic of hospital rapid re-
sponse teams can be found by
searching with this one index
term. Using controlled vocabu-
lary in a search saves time and
helps prevent the chance of miss-
ing evidence that could answer
the clinical question.

If the index terms matched
by the database aren’t relevant
to the searcher’s keyword, then
the keyword and its synonyms
should be used to search the data-
base. It’s helpful, though rare,
when a keyword and an index
term match perfectly. More
often, the searcher will need
to determine which of several
database index terms is closest in
meaning to the keyword.
Combine searches. Each key-
word in the PICOT question is
searched individually. However,
keyword searches can result in
a large number of articles. For
example, a CINAHL search of
cardiac arrest resulted in more
than 2,700 articles and a search
of rapid response team resulted in
100 articles. But combining the
searches using the Boolean con-
nector “AND” (for example, car
diac arrest AND rapid response
team) yielded a more manageable
12 articles that contained both
concepts and were more likely
to answer the clinical question.
(Note that databases index arti-
cles on a regular basis; therefore,
Hierarchy of Evidence for Intervention Studies2

Type of evidence Level of evidence Description
Systematic review or
metaanalysis
I A synthesis of evidence from all relevant random-
ized, controlled trials.
Randomized, con-
trolled trial
II An experiment in which subjects are randomized
to a treatment group or control group.
Controlled trial with-
out randomization
III An experiment in which subjects are nonrandomly
assigned to a treatment group or control group.
Case-control or
cohort study
IV Case-control study: a comparison of subjects with
a condition (case) with those who don’t have the
condition (control) to determine characteristics that
might predict the condition.
Cohort study: an observation of a group(s) (cohort[s])
to determine the development of an outcome(s)
such as a disease.
Systematic review of
qualitative or descrip-
tive studies

V A synthesis of evidence from qualitative or descrip-
tive studies to answer a clinical question.
Qualitative or de-
scriptive study
VI Qualitative study: gathers data on human behavior
to understand why and how decisions are made.
Descriptive study: provides background information
on the what, where, and when of a topic of
interest.
Opinion or con-
sensus
VII Authoritative opinion of expert committee.
may yield additional useful articles.
From the results page, Rebecca
enters rapid response team in the
search field and clicks “Search.”
This search produces over 300
articles (see Figure 6); however,
many of them still don’t appear
to be relevant to the clinical ques-
tion. Lynne reassures Rebecca
that eventually combining her
searches will help weed out the
irrelevant articles. (Because this
search produced so many more

articles than her MeSH term
search, which captured only the
most recent articles, Lynne sug-
gests that when Rebecca com-
bines her searches, she use the
results of her keyword rapid
response team search, not her
“Hospital Rapid Response Team”
search.
Rebecca continues to use the
MeSH database to search her
two remaining keywords. For
each one, she starts back on the
PubMed home page (click on the
PubMed.gov logo on any results
page to get to the home page).
Again, she enters cardiac
arrest on the MeSH database
screen. Of the three MeSH terms
provided she selects “heart
arrest,” which yields over 25,000
articles. Since the keyword ICU
admissions produces no MeSH
terms, Lynne advises Rebecca to
search with the keyword inten-
sive care units, which matches
perfectly with the MeSH term
“Intensive Care Units” and
yields more than 40,000 articles.
After searching her keyword
and appropriate MeSH terms,
Rebecca has a total of more than
60,000 articles.

Lynne reassures Rebecca that
she won’t need to read all 60,000
articles. She explains that the next
step, combining the searches,
will eliminate extraneous articles
and focus on the search results
specific to the clinical question.
Combining the searches by using
the Boolean connector “AND”
will produce a list of articles that
contain all three keywords Re-
becca searched.
To combine her searches,
Rebecca selects the “Advanced
Search” tab at the top of any
results page. Each of her searches
now appears on the Advanced
Search page in the “Search
History” box. Lynne reminds
Rebecca to clear the search field
at the top of the page of any key-
words from past searches before
combining the final group of
searches.
Rebecca clicks on the number
assigned to her rapid response
team keyword search and selects
AND from the pull-down “Op-
tions” menu. Lynne shows her
that the number assigned to her
keyword search now appears in
the search field at the top of the
page. Rebecca continues to select

her individual searches and, one
by one, their corresponding num-
bers appear in the field above (see
Figure 7). To run the combined
searches and view the results, Re-
becca selects the “Search” tab.
Her combined search pro-
duces 11 articles (see Figure 8), a
much more manageable number
to review for relevancy to the
clinical question than the more
than 60,000 articles produced by
the individual keyword and con-
trolled vocabulary searches.
Rebecca asks Lynne if she can
request the three free full-text
articles (see “Free Full Text (3)”
under “Filter your results” on the
upper right of the results page;
Figure 8). Lynne informs her that
she can ap ply any number of lim-
its to her search, including “Links
to free full text.” However, the
more limits applied, the narrower
the search, and evidence to an-
swer the clinical question may be
missed.
Lynne shows Rebecca where
“Limits” can be found on the
CONDUCTING THE SEARCH
Rebecca begins to search the
PubMed database for the evidence

to answer her PICOT question.
She and Carlos will be search-
ing the keywords rapid response
team, the intervention of inter-
est, and cardiac arrests and ICU
admissions, the outcomes of
interest. To follow along, access
the PubMed home page at www.
ncbi.nlm.nih.gov/pubmed. (Note
that because new articles are
added to the database regularly,
your search results may not match
those described here.)
Rebecca starts by using
PubMed’s Medical Subject Head-
ing (MeSH) database to search
for the intervention keyword,
rapid response team. From
the PubMed home page, she
clicks on “MeSH Database”
(see Figure 1). On the MeSH
database screen, she types rapid
response team in the search field
and clicks “Go” (see Figure 2).
Rapid response team is a direct
match to the one MeSH term
provided—“Hospital Rapid
Response Team” (see Figure 3).
Rebecca selects this term by click-
ing the box next to it and then
selects “Search Box with AND”
from the pull-down menu. “‘Hos-
pital Rapid Response Team’
[Mesh]” appears in the search
box on the next screen (see Fig-

ure 4); Rebecca clicks on “Search
PubMed.” Her search is per-
formed and results in 19 articles
(see Figure 5). She notes that most
but not all articles appear to be
relevant to the clinical question,
and that they date back only to
2009 because the MeSH term
“Hospital Rapid Response Team”
was recently introduced.
Before Rebecca continues with
her MeSH database searches,
Lynne suggests that she use rapid
response team in a separate search
because the search will be broader
than a MeSH term search and
http://www.ncbi.nlm.nih.gov/pubmed
http://www.ncbi.nlm.nih.gov/pubmed
Figure 1. Select “MeSH Database” on the PubMed home page.
Figure 2. Type rapid response team in
the search field and click “Go.”
Figure 4. Click on “Search PubMed.”
Figure 3. Select the
MeSH term “Hospital
Rapid Response Team,”
then select “Search Box
with AND” from the

pull-down menu.
Figure 5. The “Hospital Rapid Response
Team” search yields 19 articles.
top of the Advanced Search page
(Figure 7). She suggests that Re-
becca consider limiting the ages
of her population to further re-
duce her results. If she eliminates
the pediatric population, for
example, the number of articles
produced by her search should
decrease. But Rebecca thinks that
any articles that include children
may be of interest to the nurses
on the pediatric unit, so she de-
cides to limit her search to only
“Humans” and “English” (Fig-
ure 9). Applying these limits to
Rebecca’s final combined search
reduces the re sults from 11 ar-
ticles to 10.
Rebecca asks Lynne if any of
the articles retrieved in the search
are metaanalyses, which she re-
members is the best study design
to answer her clinical question.
Lynne responds that a quick
way to find out is by going back

to the Limits page and selecting
“Meta-Analysis” (see Figure 9).
Although this didn’t produce
any results, limiting the search to
“Randomized Controlled Trial”
resulted in one article.
As Rebecca’s session in search-
ing PubMed concludes, Lynne
explains to Carlos and Rebecca
that searching is a skill that im-
proves with practice. Moreover,
each database may have its own
controlled vocabulary and limits.
In any search, Lynne emphasizes
the importance of
•searchingatleasttwodata-
bases
•searchingonekeywordata
time
•usingthedatabase’scontrolled
vocabulary when available
•combiningthesearchestoyield
articles that are manageable in
number and relate specifically
to the PICOT question
•applying“Humans”and“Eng-
lish” limits to the final search
Rebecca is excited to practice
her searching skills to find the

answer to her clinical question.
She and Carlos set up a time
to search the Cochrane and
CINAHL databases. Carlos
reminds Rebecca that although
considering the level of evidence
when making a clinical decision
is important, it’s not the only fac-
tor. The decision should also be
based on the quality of the evi-
dence, the feasibility of imple-
menting a change in the hospital,
and a consideration of the patients’
values and preferences.
In the next article in this series,
to be published in the July issue
of AJN, Rebecca gathers all the
articles relevant to her PICOT
question and meets with Carlos
to learn how to critically appraise
the evidence. You’re invited to
Figure 6. Type rapid response team in
the search field and click “Search”; this
search results in more than 300 articles.
Figure 7. Combine the individual searches.
Practice Mentorship Program at Ar izona
State University in Phoenix, where Ellen
Fineout-Overholt is clinical professor
and director of the Center for the Ad-
vancement of Evidence-Based Practice,

Bernadette Mazurek Melnyk is dean and
distinguished foundation professor of
nursing, and Kathleen M. Williamson is
associate director of the Center for the
Advancement of Evidence-Based Prac-
tice. Contact author: Susan B. Stillwell,
[email protected]
REFERENCES
1. Dacey MJ, et al. The effect of a rapid
response team on major clin ical out-
come measures in a community hos-
pital. Crit Care Med 2007;35(9):
2076-82.
2. Melnyk BM, Fineout-Overholt E.
Making the case for evidence-based
practice. In: Melnyk BM, Fineout-
Overholt E, editors. Evidence-based
practice in nursing and healthcare: a
guide to best practice. 1st ed. Phila-
delphia: Lippincott Williams and
Wilkins; 2005. p. 3-24.
3. DiCenso A, et al. Introduction to
evidence-based nursing. In: DiCenso A,
et al., editors. Evidence-based nurs ing:
a guide to clinical practice. St. Louis:
Elsevier Mosby; 2005. p. 3-19.
4. Gibson F, Glenny A. Critical appraisal
of quantitative studies: is the quality
of the study good enough for you to
use the findings? In: Craig JV, Smyth
RL, editors. The evidence-based
practice manual for nurses. 2nd ed.

Edinburgh; New York: Churchill Liv-
ingstone Elsevier; 2007. p. 95-122.
5. Fineout-Overholt E, et al. Finding
relevant evidence. In: Melnyk BM,
Fineout-Overholt E, editors. Evidence-
based practice in nursing and health-
care: a guide to best practice. 1st ed.
Philadelphia: Lippincott Williams
and Wilkins; 2005. p. 39-69.
this meeting to learn, along with
Rebecca, how to select “keeper”
studies that, when synthesized,
will help determine if a practice
change should be implemented at
her hospital. ▼
Susan B. Stillwell is clinical associate
professor and program coordinator of
the Nurse Educator Evidence-Based
Solution
s to Our “Practice Creating a PICOT Question”
Exercise
Did your questions come close to these?
Scenario 1: A meaning question.
How do family caregivers (P) with relatives receiving hospice

care
(I) perceive the loss of their relative (O) during end of life (T)?
Scenario 2: An intervention or therapy question.
In patients with dementia who are agitated (P), how does baby
doll therapy (I) compared with risperidone (or antipsychotic
drug
therapy) (C) affect behavior outbursts (O) within one month
(T)?
Figure 8. The final results.
Figure 9. Using limits to narrow the search.
D
o you ever wonder why
nurses engage in practices
that aren’t supported by
evidence, while not implementing

practices substantiated by a lot
of evidence? In the past, nurses
changed hospitalized patients’ IV
dressings daily, even though no
solid evidence supported this prac-
tice. When clinical trials finally
explored how often to change IV
dressings, results indicated that
daily changes led to higher rates
of phlebitis than did less frequent
changes.1 In many hospital EDs
across the country, children with
asthma are treated with albuterol
delivered with a nebulizer, even
though substantial evidence shows
that when albuterol is delivered
with a metered-dose inhaler plus
a spacer, children spend less time
in the ED and have fewer adverse
effects.2 Nurses even disrupt
patients’ sleep, which is important
for restorative healing, to docu-
ment blood pressure and pulse
rate because it’s hospital policy to

take vital signs every two or four
hours, even though no evidence
supports that doing so improves
the identification of potential
complications. In fact, clinicians
often follow outdated policies and
procedures without questioning
their current relevance or accu-
racy, or the evidence for them.
When a spirit of inquiry—an
ongoing curiosity about the best
evidence to guide clinical decision
making—and a culture that sup-
ports it are lacking, clinicians are
unlikely to embrace evidence-based
practice (EBP). Every day, nurses
across the care continuum perform
a multitude of interventions (for
example, administering medica-
tion, positioning, suctioning)
that should stimulate questions
about the evidence supporting
their use. When a nurse possesses

a spirit of inquiry within a sup-
portive EBP culture, she or he
can routinely ask questions about
clinical practice while care is being
delivered. For example, in patients
with endotracheal tubes, how
does use of saline with suctioning
compared with suctioning without
saline affect oxygen saturation?
[email protected] AJN � November 2009 � Vol. 109, No. 11 49
By Bernadette Mazurek Melnyk, PhD,
RN, CPNP/PMHNP, FNAP, FAAN,
Ellen Fineout-Overholt, PhD, RN,
FNAP, FAAN, Susan B. Stillwell, DNP,
RN, CNE, and Kathleen M.
Williamson, PhD, RN
Igniting a Spirit of Inquiry: An Essential Foundation for
Evidence-Based Practice

How nurses can build the knowledge and skills they need to
implement EBP.
Every day, nurses perform interventions (for
example, administering medication, positioning,
suctioning) that should stimulate questions
about the evidence supporting their use.
This is the first article in a new series from the Arizona State
University College of Nursing and Health Innovation’s
Center for the Advancement of Evidence-Based Practice.
Evidence-based practice (EBP) is a problem-solving approach
to the delivery of health care that integrates the best evidence
from studies and patient care data with clinician
expertise and patient preferences and values. When delivered in
a context of caring and in a supportive organiza-
tional culture, the highest quality of care and best patient
outcomes can be achieved.
The purpose of this new series is to give nurses the knowledge
and skills they need to implement EBP consistently,
one step at a time. Articles will appear every two months to

allow you time to incorporate information as you work
toward implementing EBP at your institution. Also, we’ll
schedule “Ask the Authors” call-ins every few months to
provide
a direct line to the experts to help you resolve questions. Details
about how to participate in the calls will be published
with January’s Evidence-Based Practice: Step by Step.
50 AJN � November 2009 � Vol. 109, No. 11 ajnonline.com
In patients with head injury, how
does elevating the head of the bed
compared with keeping a patient
in a supine position affect intracra-
nial pressure? In postoperative
surgical patients, how does the
use of music compared with no use
of music affect the frequency of
pain medication administration?
The Institute of Medicine has
set a goal that by 2020, 90% of
all health care decisions in the

United States will be evidence
based,3 but the majority of nurses
are still not consistently imple-
menting EBP in their clinical set-
tings.4 To foster outcomes-driven
health care in which decisions
are based on evidence, providers
and health care systems need a
To accelerate the use of EBP
by nurses and other health care
providers, some insurers have
instituted pay-for-performance
programs that offer clinicians
incentives to follow evidence-
based guidelines. And Medicare
no longer reimburses hospitals
for treating preventable hospital-
acquired injuries or infections
(such as falls, pressure ulcers, or
ventilator-associated pneumonia).
Although these measures should
improve the overall quality of care
in our hospitals, it’s well known
that extrinsic motivators are

typically not more successful in
facilitating a change in behavior
than intrinsic motivators. There-
fore, for EBP to accelerate and
comprehensive approach to ensure
that their results are measured.5
Without EBP, patients don’t receive
the highest quality of care, health
outcomes are seriously jeopar-
dized, and health care costs soar.6
Findings from recent studies also
indicate that when nurses and
other health care providers engage
in EBP, they experience greater
autonomy in their practices and a
higher level of job satisfaction.7 At
a time when this country is facing
the most serious nursing shortage
in its history, empowering nurses
to routinely engage in EBP may
lead to less turnover and lower
vacancy rates, in addition to im-

proving the quality of health care
and patient outcomes.
Figure 1. The EBP Paradigm: the merging of science and art.
EBP within a context of caring and an EBP culture results in the
highest quality of health
care and patient outcomes. © Melnyk and Fineout-Overholt,
2003.
EBP Organizational Culture
Research evidence
and evidence-based
theories
High-quality
patient
outcomes
Clinical decision
making
Patient

preferences
and values
Clinical expertise (for example,
evidence from patient assessment
as well as use of health care
resources)
Context of Caring
[email protected] AJN � November 2009 � Vol. 109, No. 11 51
with amoxicillin. However, if the
child dislikes the taste and it’s
likely that the medication won’t
be taken, patient preference should
outweigh the best practice guide-
line and an alternative antibiotic
should be prescribed.
Although EBP may be re-
ferred to as evidence-based medi-

cine, evidence-based nursing, or
evidence-based physical therapy
within various disciplines, we
advocate referring to all of these
as evidence-based practice, in
order to stimulate transdiscipli-
nary evidence-based care and
avoid the specialized terminology
that can isolate the various health
professions.
When nurses implement EBP
within a context of caring and a
supportive organizational cul-
ture, the highest quality of care
is delivered and the best patient,
provider, and system outcomes are
achieved (see Figure 1).10 Despite
outcomes being substantially
better when patients receive
evidence-based care, nurses and
other health care providers often
cite barriers that prevent its deliv-
ery, including10, 11

• inadequate EBP knowledge
and skills.
• a lack of EBP mentors to
work with providers at the
point of care.
• inadequate resources and
support from higher admin-
istration.
• insufficient time, especially
when there are demanding
patient caseloads and staffing
shortages.
Conversely, a number of factors
facilitate the implementation of
EBP, including8, 12, 13
• EBP knowledge and skills.
• belief in the value of EBP and
the ability to implement it.

• a culture that supports EBP and
provides the necessary tools to
sustain evidence-based care (for
example, access to computer
databases at the point of care
and time to search for evidence).
• EBP mentors (advanced prac-
tice clinicians with expertise in
EBP and organizational and
individual behavior-change
strategies) who work directly
with clinicians at the point of
care in implementing EBP.
Once nurses gain EBP knowl-
edge and skills, they realize it’s
not only feasible within the con-
text of their practice setting, but
that it reignites their passion for
thrive in the U.S. health care sys-
tem, nurses must have
• a never-ending spirit of inquiry
and consistently question cur-

rent clinical practices.
• strong beliefs in the value of
EBP.
• knowledge of and skills in EBP
along with the confidence to
use it.
• a commitment to deliver the
highest quality evidence-based
care to patients and their fam-
ilies.
In addition, health care institu-
tions must sustain a culture that
embraces EBP, including providing
clinicians the support and tools
they need to engage in evidence-
based care.
EBP is a problem-solving ap-
proach to the delivery of health
care that integrates the best evi-
dence from well-designed studies

and patient care data, and com-
bines it with patient preferences
and values and nurse expertise.8, 9
However, there’s no magic for-
mula 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 exam-
ple, evidence-based guidelines
might indicate that a young child
with an ear infection receive amox-
icillin and clavulanate (Augmentin)
if the infection hasn’t resolved
Questions that Spark a Spirit of Inquiry
• Who can I seek out to assist me in enhancing my evidence-
based practice
(EBP) knowledge and skills and serve as my EBP mentor?
• Which of my practices are currently evidence based and which
don’t have

any evidence to support them?
• When is the best time to question my current clinical practices
and with whom?
• Where can I find the best evidence to answer my clinical
questions?
• Why am I doing what I do with my patients?
• How can I become more skilled in EBP and mentor others to
implement
evidence-based care?
Strategies for Building a Spirit of Inquiry
Write “WHY?” on a poster and place it in the staff lounge
orrestroom to inspire questions from nurses about why they’re
engaging in certain practices with their patients. Gather the
responses
in an answer box. After one month, take the responses and
arrange
them according to common themes. Address the themes in a
staff
meeting.
Review and answer the Questions that Spark a Spirit of Inquiry.
Create a poster with these questions and post them where your

colleagues will see them. Think about these clinical questions
when caring for your patients.
52 AJN � November 2009 � Vol. 109, No. 11 ajnonline.com
We’ll use this case in each column
to focus on successive steps of the
EBP process. In the meantime,
we encourage you to answer the
Questions that Spark a Spirit
of Inquiry and implement two
Strategies for Building a Spirit
of Inquiry in order to start your
own EBP journey and begin build-
ing a spirit of inquiry with your
colleagues at work. �
Bernadette Mazurek Melnyk is dean and
nursing at Arizona State University in
Phoenix, where Ellen Fineout-Overholt
is clinical professor and director of the

Center for the Advancement of Evidence-
Based Practice, Susan B. Stillwell is clinical
associate professor and program coordi-
nator of the Nurse Educator Evidence-
Based Practice Mentorship Program, and
Kathleen M. Williamson is associate direc-
tor of the Center for the Advancement
of Evidence-Based Practice. Contact
author: Bernadette Mazurek Melnyk,
[email protected]
REFERENCES
1.Gantz NM, et al. Effects of dressing
type and change interval on intra-
venous therapy complication rates.
Diagn Microbiol Infect Dis 1984;2(4):
325-32.
2.Cates CJ, et al. Holding chambers
(spacers) versus nebulisers for beta-
agonist treatment of acute asthma.
Cochrane Database Syst Rev 2006(2):
CD000052.
3. Olsen L, et al. The learning health-

care system: workshop summary.
Washington, DC: National Academies
Press; 2007. http://www.nap.edu/
catalog.php?record_id=11903.
4. Pravikoff DS, et al. Evidence-based
practice readiness study supported by
academy nursing informatics expert
panel. Nurs Outlook 2005;53(1):
49-50.
5. Piper K. Results-driven health care:
the five steps to higher quality, lower
costs. Washington, DC: Health
Results Group LLC; 2008.
6. Health Research Institute, Pricewater-
houseCoopers. What works: healing
the healthcare staffing shortage. Dal-
las: PricewaterhouseCoopers; 2007.
http://www.pwc.com/us/en/healthcare/
publications/what-works-healing-
the-healthcare-staffing-shortage.
jhtml.

7. Maljanian R, et al. Evidence-based
nursing practice, Part 2: building skills
through research roundtables. J Nurs
Adm 2002;32(2):85-90.
8. Melnyk BM, et al. The evidence-based
practice beliefs and implementation
scales: psychometric properties of two
new instruments. Worldviews Evid
Based Nurs 2008;5(4):208-16.
9. Sackett DL, et al. Evidence-based
medicine: how to practice and teach
EBM. 2nd ed. Edinburgh; New York:
Churchill Livingstone; 2000.
10. Melnyk BM, Fineout-Overholt E.
Evidence-based practice in nursing and
healthcare: a guide to best practice.
Philadelphia: Lippincott Williams and
Wilkins; 2005.
11. Melnyk BM. Strategies for overcoming
barriers in implementing evidence-
based practice. Pediatr Nurs 2002;

28(2):159-61.
12. French B. Contextual factors influenc-
ing research use in nursing. Worldviews
Evid Based Nurs 2005;2(4):172-83.
13. Melnyk BM. The evidence-based
practice mentor: a promising strategy
for implementing and sustaining EBP
in healthcare systems. Worldviews
Evid Based Nurs 2007;4(3):123-5.
14. Dacey MJ, et al. The effect of a rapid
response team on major clinical out-
come measures in a community hos-
2076-82.
their roles and assists them in
delivering a higher quality of care
with improved patient outcomes.
We use the term Step Zero to refer
to the continual cultivation of a
spirit of inquiry as an essential

foundation for EBP, and we rec-
ommend the routine use of a
standard set of questions in prac-
tice (see Questions that Spark a
Spirit of Inquiry) and the use of
the strategies in Strategies for
Building a Spirit of Inquiry.
Remember, EBP starts with a
spirit of inquiry (Step Zero). As
you embark on this wonderful
journey to promote the highest
quality of care and the best out-
comes for your patients, reflect
upon Step Zero, the EBP para-
digm, and how you practice care.
The Case Scenario for EBP: Rapid
Response Teams will provide a
context for learning EBP through-
out the next several columns.
Case Scenario for EBP: Rapid Response Teams
You’re a staff nurse on a busy medical–surgical unit. Overthe
past three months, you’ve noticed that the patients on

your unit seem to have a higher acuity level than usual, with
at least three cardiac arrests per month, and of those patients
who arrested, four died. Today you saw a report about a
recently published study in Critical Care Medicine on the use
of rapid response teams to decrease rates of in-hospital car-
diac arrests and unplanned ICU admissions. The study found
a significant decrease in both outcomes after implementation
of a rapid response team led by physician assistants with spe-
cialized skills.14 You’re so impressed with these findings that
you bring the report to your nurse manager, believing that a
rapid response team would be a great idea for your hospital.
The nurse manager is excited that you’ve come to her with
these findings and encourages you to search for more evi-
dence to support this practice and for research on whether
rapid response teams are valid and reliable.
Step Zero refers to the continual cultivation
of a spirit of inquiry.
T
o fully implement evidence-

based practice (EBP),
nurses need to have both
a spirit of inquiry and a culture
that supports it. Inour first article
in this series (“Igniting a Spirit of
Inquiry:AnEssential Foundation
for Evidence-Based Practice,”
November 2009),we defined a
spirit of inquiry as “an ongoing
curiosity about the best evidence
toguide clinical decisionmaking.”
A spirit of inquiry is the founda-
tionof EBP, andonce nurses pos-
sess it, it’s easier to take the next
step—toask the clinical question.1
Formulating a clinical question
in a systematicwaymakes it pos-
sible to find an answermore
quickly and efficiently, leading to
improved processes and patient
outcomes.
In the last installment,wegave

an overviewof themultistepEBP
process (“The Seven Steps of
Evidence-Based Practice,” Janu-
ary). Thismonthwe’ll discuss
step one, asking the clinical
question. As a context for this
discussionwe’ll use the same
scenariowe used in the previous
articles (see Case Scenario for
EBP: Rapid Response Teams).
In this scenario, a staff nurse,
let’s call herRebeccaR., noted
that patients on hermedical–
surgical unit had a high acuity
level thatmay have led to an in-
crease in cardiac arrests and in the
number of patients transferred
to the ICU.Of thepatientswho
had a cardiac arrest, four died.
Rebecca sharedwith her nurse
manager a recently published
study onhow the use of a rapid

response teamresulted in reduced
in-hospital cardiac arrests andun-
planned admissions to the critical
Asking the Clinical Question: A Key Step in
Evidence-Based Practice
A successful search strategy starts with a well-formulated
question.
This is the third article in a series from the Arizona State
University College of Nursing and Health Innovation’s Center
for the Advancement of Evidence-Based Practice. Evidence-
based practice (EBP) is a problem-solving approach to the
delivery of health care that integrates the best evidence from
studies and patient care data with clinician expertise and
patient preferences and values. When delivered in a context of
caring and in a supportive organizational culture, the
highest quality of care and best patient outcomes can be
achieved.
The purpose of this series is to give nurses the knowledge and
skills they need to implement EBP consistently, one
step at a time. Articles will appear every two months to allow
you time to incorporate information as you work toward

implementing EBP at your institution. Also, we’ve scheduled
“Ask the Authors” call-ins every few months to provide a
direct line to the experts to help you resolve questions. Details
about how to participate in the next call will be pub-
lished with May’s Evidence-Based Practice, Step by Step.
Case Scenario for EBP: Rapid Response Teams
You’re a staff nurse on a busy medical–surgical unit. Overthe
past three months, you’ve noticed that the patients on
your unit seem to have a higher acuity level than usual, with
at least three cardiac arrests per month, and of those patients
who arrested, four died. Today, you saw a report about a
recently published study in Critical Care Medicine on the use
of rapid response teams to decrease rates of in-hospital car-
diac arrests and unplanned ICU admissions. The study found
a significant decrease in both outcomes after implementation
of a rapid response team led by physician assistants with spe-
cialized skills.2 You’re so impressed with these findings that
you bring the report to your nurse manager, believing that a
rapid response team would be a great idea for your hospital.
The nurse manager is excited that you have come to her with
these findings and encourages you to search for more evidence
to support this practice and for research on whether rapid re-
sponse teams are valid and reliable.

58 AJN � March 2010 � Vol. 110, No. 3 ajnonline.com
care unit.2 Shebelieved this could
be a great idea for her hospital.
Based onher nursemanager’s
suggestion to search formore evi-
dence to support theuseof a rap-
id response team,Rebecca’s spirit
of inquiry ledher to take thenext
step in the EBPprocess: asking
the clinical question. Let’s follow
Rebecca as shemeetswithCar-
losA., oneof the expertEBPmen-
tors from the hospital’s EBP and
research council, whose role is to
assist point of care providers in
enhancing their EBPknowledge
and skills.
Types of clinical questions.
Carlos explains toRebecca that

finding evidence to improve pa-
tient outcomes and support a
practice change depends upon
how the question is formulated.
Clinical practice that’s informed
by evidence is based onwell-
formulated clinical questions
that guide us to search for the
most current literature.
There are two types of clinical
questions: backgroundquestions
and foregroundquestions.3-5 Fore-
ground questions are specific and
relevant to the clinical issue. Fore-
groundquestionsmust be asked
in order to determinewhich of
two interventions is themost ef-
fective in improving patient out-
comes. For example, “In adult
patients undergoing surgery, how
does guided imagery compared
withmusic therapy affect anal-
gesia usewithin the first 24hours
post-op?” is a specific,well-

defined question that can only
guides her in formulating a fore-
groundquestionusing PICOT
format.
PICOT is an acronym for the
elements of the clinical question:
patient population (P), interven-
tion or issue of interest (I), com-
parison intervention or issue of
interest (C), outcome(s) of inter-
est (O), and time it takes for the
intervention to achieve the out-
come(s) (T).WhenRebecca asks
why the PICOTquestion is so
important, Carlos explains that
it’s a consistent, systematicway
to identify the components of a
clinical issue. Using the PICOT
format to structure the clinical
question helps to clarify these
components,whichwill guide the
search for the evidence.6, 7 Awell-
built PICOTquestion increases

the likelihood that the best evi-
dence to informpracticewill be
foundquickly and efficiently.5-8
To helpRebecca learn to for-
mulate a PICOTquestion,Car-
los uses the earlier example of a
foregroundquestion: “In adult
patients undergoing surgery, how
does guided imagery compared
be answered by searching the
current literature for studies
comparing these two interven-
tions.
Background questions are
considerably broader andwhen
answered, provide general knowl-
edge. For example, a background
question suchas, “What therapies
reduce postoperative pain?” can
generally be answeredby looking
in a textbook. Formore informa-

tion on the two types of clinical
questions, see Comparison of
Background and Foreground
Questions.4-6
Ask the question in PICOT
format. Now thatRebecca has
an understanding of foreground
andbackgroundquestions,Carlos
Comparison of Background and Foreground Questions4-6
Question type Description Examples
Background
question
A broad, basic-knowledge question
commonly answered in textbooks.
May begin with what or when.
1) What is the best method to pre-
vent pressure ulcers?
2) What is sepsis?

3) When do the effects of
furosemide peak?
Foreground
question
A specific question that, when
answered, provides evidence for clin-
ical decision making. A foreground
question includes the following ele-
ments: population (P), intervention or
issue of interest (I), comparison inter-
vention or issue of interest (C), out-
come (O), and, when appropriate,
time (T).
1) In mechanically ventilated pa-
tients (P), how does a weaning
protocol (I) compared with no
weaning protocol (C) affect venti-
lator days (O) during ICU length
of stay (T)?
2) In hospitalized adults (P), how

does hourly rounding (I) com-
pared with no rounding (C) affect
fall rates (O)?
The PICOT question is a consistent,
systematic way to identify the components
of a clinical issue.
By Susan B. Stillwell, DNP, RN, CNE, Ellen Fineout-Overholt,
PhD,
RN, FNAP, FAAN, Bernadette Mazurek Melnyk, PhD, RN,
CPNP/PMHNP, FNAP, FAAN, and Kathleen M. Williamson,
PhD, RN
[email protected] AJN � March 2010 � Vol. 110, No. 3 59
also not always required. But
population, intervention or issue
of interest, and outcome are es-
sential to developing any PICOT

question.
Carlos asksRebecca to reflect
on the clinical situation onher
unit in order to determine the
unit’s current intervention for ad-
dressing acuity. Reflection is a
strategy to help clinicians extract
critical components from the clin-
ical issue to use in formulating
the clinical question.3 Rebecca
andCarlos revisit aspects of the
clinical issue to seewhichmaybe-
come components of the PICOT
question: the high acuity of pa-
tients on the unit, the number of
cardiac arrests, the unplanned
ICUadmissions, and the research
article on rapid response teams.
Once the issue is clarified, the
PICOTquestion can bewritten.

withmusic therapy affect analge-
sia usewithin the first 24 hours
post-op?” In this example, “adult
patients undergoing surgery” is
thepopulation (P), “guided imag-
ery” is the interventionof interest
(I), “music therapy” is the com-
parison intervention of interest
(C), “pain” is the outcomeof in-
terest (O), and“the first 24hours
post-op” is the time it takes for
the intervention to achieve the
outcome (T). In this example,
music therapy or guided imagery
is expected to affect the amount
of analgesia used by the patient
within the first 24hours after sur-
gery.Note that a comparisonmay
not be pertinent in somePICOT
questions, such as in “meaning
questions,”which are designed
to uncover themeaning of a
particular experience.3, 6 Time is
Templates and Definitions for PICOT Questions5, 6

Question type Definition Template
Intervention or
therapy
To determine which treatment leads to the
best outcome
In _____________________ (P),
how does ______________ (I)
compared with ___________ (C)
affect __________________ (O)
within __________________ (T)?
Etiology To determine the greatest risk factors or
causes of a condition
Are ______________________________ (P)
who have ________________________ (I),
compared with those without ________ (C),
at ____ risk for ____________________ (O)
over _____________________________ (T)?
Diagnosis or

diagnostic test
To determine which test is more accurate and
precise in diagnosing a condition
In ______________________________ (P),
are/is ___________________________ (I)
compared with ___________________ (C)
more accurate in diagnosing _______ (O)?
Prognosis or
prediction
To determine the clinical course over time
and likely complications of a condition
In ___________________ (P),
how does _____________ (I)
compared with ________ (C),
influence _____________ (O)
over _________________ (T)?
Meaning To understand the meaning of an experience
for a particular individual, group, or commu-
nity

How do ______________ (P)
with _________________ (I)
perceive ______________ (O)
during _______________ (T)?
A well-built PICOT question increases the
likelihood that the best evidence to inform
practice will be found.
60 AJN � March 2010 � Vol. 110, No. 3 ajnonline.com
BecauseRebecca’s issue of in-
terest is the rapid response team—
an intervention—Carlos provides
herwith an“interventionor ther-
apy” template to use in formu-
lating the PICOTquestion. (For
other types of templates, see Tem-
plates and Definitions for PICOT
Questions.5, 6) Since the hospital

doesn’t have a rapid response
teamanddoesn’t have a plan for
addressing acuity issues before a
crisis occurs, the comparison, or
(C) element, in the PICOTques-
tion is “no rapid response team.”
“Cardiacarrests”and“unplanned
admissions to the ICU”are the
outcomes in the question.Other
potential outcomes of interest to
the hospital could be “lengths of
stay” or “deaths.”
Rebecca proposes the follow-
ing PICOTquestion: “In hospi-
talized adults (P), howdoes a
rapid response team (I) compared
with no rapid response team (C)
clinical question that’smost ap-
propriate for each scenario, and
choose a template to guide you.
Then formulate onePICOTques-
tion for each scenario. Suggested
PICOTquestionswill be pro-

vided in the next column. �
Susan B. Stillwell is clinical associate
professor and program coordinator of
the Nurse Educator Evidence-Based
Practice Mentorship Program at Arizona
State University in Phoenix, where Ellen
Fineout-Overholt is clinical professor and
director of the Center for the Advance-
ment of Evidence-Based Practice, Ber-
nadette Mazurek Melnyk is dean and
nursing, and Kathleen M. Williamson is
associate director of the Center for the
Advancement of Evidence-Based Prac-
tice. Contact author: Susan B. Stillwell,
[email protected]
REFERENCES
1.MelnykBM, et al. Igniting a spirit of
inquiry: an essential foundation for
evidence-based practice. Am J Nurs
2009;109(11):49-52.
2.DaceyMJ, et al. The effect of a rapid
response teamonmajor clinical out-
comemeasures in a community hos-

2076-82.
3.Fineout-Overholt E, JohnstonL.
TeachingEBP: asking searchable, an-
swerable clinical questions. World-
views Evid Based Nurs 2005;2(3):
157-60.
4.NollanR, et al. Asking compelling
clinical questions. In:MelnykBM,
Fineout-Overholt E, editors. Evidence-
based practice in nursing and health-
care: a guide to best practice.
Philadelphia: LippincottWilliams
andWilkins; 2005. p. 25-38.
5.Straus SE. Evidence-based medicine:
how to practice and teach EBM. 3rd
ed. Edinburgh;NewYork: Elsevier/
Churchill Livingstone; 2005.
6.Fineout-Overholt E, Stillwell SB.Ask-
ing 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:

WoltersKluwerHealth/Lippincott
Williams andWilkins.
7.McKibbonKA,Marks S. Posing clini-
cal questions: framing the question
for scientific inquiry. AACN Clin
Issues 2001;12(4):477-81.
8.Fineout-Overholt E, et al. Teaching
EBP: getting to the gold: how to search
for thebest evidence. Worldviews Evid
Based Nurs 2005;2(4):207-11.
affect the number of cardiac ar-
rests (O) and unplanned admis-
sions to the ICU (O) duringa
three-month period (T)?”
Now thatRebecca has formu-
lated the clinical question, she’s
ready for thenext step in theEBP
process, searching for the evi-
dence. Carlos congratulates
Rebecca ondeveloping a search-
able, answerable question and
arranges tomeetwith her again
tomentor her in helping her find

the answer to her clinical ques-
tion. The fourth article in this
series, tobepublished in theMay
issue of AJN, will focus on strat-
egies for searching the literature
to find the evidence to answer
the clinical question.
Now that you’ve learned to
formulate a successful clinical
question, try this exercise: after
reading the two clinical scenarios
in Practice Creating a PICOT
Question, select the type of
Practice Creating a PICOT Question
Scenario 1: You’re a recent graduate with two years’ experi-
ence in an acute care setting. You’ve taken a position as a
home health care nurse and you have several adult patients
with various medical conditions. However, you’ve recently
been assigned to care for hospice patients. You don’t have
experience in this area, and you haven’t experienced a loved
one at the end of life who’s received hospice care. You notice
that some of the family members or caregivers of patients in
hospice care are withdrawn. You’re wondering what the fam-

ily caregivers are going through, so that you might better un-
derstand the situation and provide quality care.
Scenario 2: You’re a new graduate who’s accepted a position
on a gerontology unit. A number of the patients have demen-
tia and are showing aggressive behavior. You recall a clinical
experience you had as a first-year nursing student in a long-
term care unit and remember seeing many of the patients in
a specialty unit for dementia walking around holding baby
dolls. You’re wondering if giving baby dolls to your patients
with dementia would be helpful.
What type of PICOT question would you create for each of
these scenarios? Select the appropriate templates and formu-
late your questions.
[email protected] AJN � March 2010 � Vol. 110, No. 3 61
Evidence Based Library and Information Practice 2011, 6.2
75

Evidence Based Library and Information Practice
Commentary
Formulating the Evidence Based Practice Question: A Review
of the Frameworks
Karen Sue Davies
Assistant Professor, School of Information Studies
University of Wisconsin–Milwaukee
Milwaukee, Wisconsin, United States of America
Email: [email protected]
Received: 17 Jan. 2011 Accepted: 04 Apr. 2011
2011 Davies. This is an Open Access article distributed under
the terms of the Creative Commons-Attribution-
Noncommercial-Share Alike License 2.5 Canada
(http://creativecommons.org/licenses/by-nc-sa/2.5/ca/

), which
permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly
attributed, not used for commercial purposes, and, if
transformed, the resulting work is redistributed under the
same or similar license to this one.
Introduction
Questions are the driving force behind
evidence based practice (EBP) (Eldredge,
2000). If there were no questions, EBP would
be unnecessary. Evidence based practice
questions focus on practical real-world
problems and issues. The more urgent the
question, the greater the need to place it in an
EBP context.
One of the most challenging aspects of EBP is
to actually identify the answerable question.
This ability to identify the question is
fundamental to then locating relevant

information to answer the question. An
unstructured collection of keywords can
retrieve irrelevant literature, which wastes
time and effort eliminating inappropriate
information. Successfully retrieving relevant
information begins with a clearly defined,
well-structured question. A standardized
format or framework for asking questions
helps focus on the key elements. Question
generation also enables a period of reflection.
Is this the information I am really looking for?
Why I am looking for this information? Is
there another option to pursue first?
This paper introduces the first published
framework, PICO (Richardson, Wilson,
Nishikawa and Hayward, 1995) and some of
its later variations including ECLIPSE
(Wildridge and Bell, 2002) and SPICE (Booth,
2004). Sample library and information science
(LIS) questions are provided to illustrate the
use of these frameworks to answer questions
in disciplines other than medicine.

Booth (2006) published a broad overview of
developing answerable research questions
which also considered whether variations to
the original PICO framework were justifiable
and worthwhile. This paper will expand on
that work.
mailto:[email protected]�
76
Question Frameworks in Practice
PICO
The concept of PICO was introduced in 1995

by Richardson et al. to break down clinical
questions into searchable keywords. This
mnemonic helps address these questions:
P - Patient or Problem: Who is the patient?
What are the most important characteristics of
the patient? What is the primary problem,
disease, or co-existing condition?
I – Intervention: What is the main intervention
being considered?
C – Comparison: What is the main comparison
intervention?
O - Outcome: What are the anticipated
measures, improvements, or affects?
Medical Scenario and Question: An
overweight woman in her forties has never
travelled by airplane before. She is planning
an anniversary holiday with her husband
including several long flights. She is
concerned about the risk of deep vein
thrombosis. She would like to know if
compression stockings are effective in
preventing this condition or whether a few
exercises during the flight would be enough.
P – Patient / Problem: Female, middle-aged,

overweight
I – Intervention: Compression stockings
C – Comparison: In-flight exercises
O – Outcome: Prevent deep vein thrombosis
The PICO framework and its variations were
developed to answer health-related questions.
With a slight modification, this framework can
structure questions related to LIS. The P in
PICO refers to patient, but substituting
population for patient provides a question
format for all areas of librarianship. The
population may be children, teens, seniors,
those from a specific ethnic group, those with
a common goal (e.g., job-seekers), or those
with a common interest (such as a gardening
club). The intervention is the new concept
being considered, such as longer opening
hours, a reading club, after-school activity,
resources in a particular language, or the
introduction of wi-fi.
LIS Scenario and Question: Art history
master’s students submit theses with more
bibliography errors than those from students

of other faculties. The Dean of art history
raised this issue with the head librarian. The
head librarian suggested that database
training could help.
P – Population: Art History master’s students
I – Intervention: database searching training
C – Comparison: students with no training or
students from other Faculties
O – Outcome: Improved bibliographic quality
Table 1 illustrates the different components
introduced in several PICO framework
variations. Fineout-Overholt and Johnson
(2005) considered the questioning behavior of
nurses. They suggested a five-component
scheme for evidence based practice questions
using the acronym PICOT, with T
representing timeframe. This refers to one or
more time-related variables such as the length
of time the treatment should be prescribed or
the point at which the outcome is measured. A
PICOT question in the LIS field is: In a
specialist library, does posting the monthly
library bulletin on the Website instead of only
having printed newsletters available result in

increased usage of the library and the new
resources mentioned in the bulletin? In this
question, the timeframe refers to a month.
Petticrew and Roberts (2005) suggested
PICOC as an alternative ending to PICOT,
with C representing context. For example,
what is the context for intervention delivery?
In LIS, context could be a public library,
academic library, or health library.
A variation similar to PICOT is PICOTT. In
this instance, neither T relates to timeframe.
The Ts refer to the type of question and the
best type of study design to answer that
particular question (Schardt, Adams, Owens,
Keitz, and Fontelo, 2007). An example LIS
question is: In a specialist library, does instant
messaging or e-mail messaging result in the
greatest customer satisfaction with a virtual
reference service? This type of question is user
analysis, and a relevant type of study design is

77

a questionnaire. The PICOTT framework may
be too restrictive when searching. If you are
searching for effective Websites then
transaction log analysis would be a reasonable
type of study design. By limiting to that study
type you would miss user observation studies,
focus groups, and controlled experiments.
These frameworks should focus the search

strategy, while not excluding potentially
useful and relevant information.
Specifically developed for building and
adapting oncology guidelines is PIPOH
(ADAPTE Collaboration, 2009). The second P
refers to professionals (to whom the guideline
will be targeted) and H stands for health care

setting and context (in which the adapted
guideline will be used). An example of this in
the LIS setting would be:
What is appropriate training for fieldwork
students working on the library’s issue or

circulation desk?
P – Population: Library users
I – Intervention: Training
P – Professionals: Fieldwork students
O – Outcome:
S – Setting: Issue or circulation desk
Dawes et al. (2007) developed PECODR and
undertook a pilot study to determine whether
this structure existed in medical journal
abstracts. E refers to exposure, replacing
Table 1
Components of the Different PICO-based Frameworks
Pa
ti
en
t /
P
op

ul
at
io
n
In
te
rv
en
tio
n
C
om
pa
ri
so
n
O

ut
co
m
e
T
im
ef
ra
m
e
C
on
te
xt
T
yp

e
of
Q
ue
st
io
n
T
yp
e
of
S
tu
d
y
D

es
ig
n
Pr
of
es
si
on
al
s
H
ea
lt
h
C
ar

e
Se
tt
in
g
E
xp
os
ur
e
D
ur
at
io
n
R

es
ul
ts
E
nv
ir
on
m
en
t
St
ak
eh
ol
d
er

s
Si
tu
at
io
n
Richardson et
al., 1995
Fineout-
Overholt &
Johnson, 2005
Petticrew &
Roberts, 2005
Schardt et al.,

2007
ADAPTE
Collaboration,
2009
Dawes et al.,
2007
Schlosser &
O'Neil-Pirozzi,
2006
DiCenso,
Guyatt, &
Ciliska, 2005

78
intervention to allow the inclusion of different
study types such as case control studies and
cohort studies. The D stands for duration,
either the length of time of the exposure or
until the outcome is assessed. The R refers to
results. Here is a sample LIS question:
Does teaching database searching skills to
postgraduate students in a hands-on
workshop compared to a lecture result in
effective skills to utilize throughout two or
more years of study? Duration would be the
length of the postgraduate course (2+ years),
and results could be defined as effective
searching skills.
Schlosser and O'Neil-Pirozzi (2006) proposed
PESICO which applied to the field of fluency
disorders and speech language pathology. E

refers to the environment or the context in
which the problem occurs, and S stands for
stakeholders. Stakeholders are an important
consideration in certain library settings.
LIS Scenario and Question: Each year, library
staff accompany new university students on
an introductory library tour. The tour is time-
consuming and may not be appropriate for
new students who have much information to
absorb in their first few days. Library staff and
student instructors suggested that staff post a
virtual library tour on the Website. It can be
accessed at a time and place to suit the
student, and may improve their
understanding of library services.
P – Population: New university students
E – Environment: Library
S – Stakeholders: Library staff and student
instructors
I – Intervention: Virtual library tour
C – Comparison: Physical library tour
O – Outcome: Improved understanding of
library services

Many of the adapted PICO frameworks
introduce terms worth consideration
depending on the subject, area, topic, or
question. The elements which are additions to
the original PICO framework could serve as
filters to be reviewed after gathering the initial
PICO search results. They can help determine
the relevance of initial search results. For
example, consider filtering on context when
determining if the results from a rural public
library service are directly applicable to a large
endowed university library.
DiCenso, Guyatt, and Ciliska (2005) suggested
that questions which can best be answered
with qualitative information require just two
components. Such questions may focus on the
meaning of an experience or problem.
P – Population: The characteristics of
individuals, families, groups, or communities
S – Situation: An understanding of the
condition, experiences, circumstances, or
situation

This framework focuses on these two key
elements of the question. An LIS example is:
In a public library, should all library staff who
have face-to-face, telephone, or e-mail contact
with users attend a customer awareness
course?
P - Population: Library staff with user contact
S - Situation: Customer awareness course
ECLIPSE
PICO and its variations were all developed to
answer clinical questions. Within the medical
field there are other types of questions which
need to be answered. ECLIPSE was
developed to address questions from the
health policy and management area
(Wildridge and Bell, 2002).
E – Expectation: Why does the user want the
information?
C - Client Group: For whom is the service
intended?
L – Location: Where is the service physically
sited?

I – Impact: What is the service change being
evaluated? What would represent success?
How is this measured? This component is
similar to outcomes of the PICO framework.
P – Professionals: Who provides or improves
the service?
SE – Service: What type of service is under
consideration?
79
LIS Scenario and Question: There have been
user complaints about the current Interlibrary
Loan (ILL) service. What alternatives might
improve customer satisfaction?
E – Expectation: Improve customer satisfaction
C - Client group: Library users who request
ILLs

L – Location: Library
I – Impact: Improve the ILL service
P – Professionals: ILL staff
SE – Service: ILL
SPICE
The previous frameworks can all be adapted
to answer LIS questions. One framework,
SPICE, was developed specifically to answer
questions in this field (Booth, 2004):
S – Setting: What is the context for the
question? The research evidence should reflect
the context or the research findings may not be
transferable.
P – Perspective: Who are the users, potential
users, or stakeholders of the service?
I – Intervention: What is being done for the
users, potential users, or stakeholders?
C – Comparison: What are the alternatives?
An alternative might maintain the status quo
and change nothing.
E – Evaluation: What measurement will
determine the intervention’s success? In other
words, what is the result?

The SPICE framework specifically includes
stakeholders under P for perspective and is
therefore similar to the PESICO framework.
LIS Question: In presentations to library
benefactors, does the use of outcome-based
library service evaluations improve their
perceptions of the importance and value of
library services?
S – Setting: Library presentation to funders
P – Perspective: Library benefactors
I – Intervention: Outcome-based evaluations
of library services
C – Comparison: Other evaluations
E – Evaluation: Improved perception of the
importance and value of library services
Some of these additional concepts are related.
Context, environment, and setting have
similar connotations, and duration is similar to
timeframe. This suggests that the options for
constructing well-defined questions are not as
numerous as Table 1 suggests.

Combining comparable and related terms
would provide the following concepts:
P – Population or problem
I – Intervention or exposure
C – Comparison
O – Outcome
C – Context or environment or setting
P – Professionals
R – Research – incorporating type of question
and type of study design R – Results
S – Stakeholder or perspective or potential
users
T – Timeframe or duration
Conclusion
These frameworks are tools to guide the
search strategy formation. A minor adaption
to the medical question frameworks, usually
something as simple as changing patient to
population, enables the structuring of
questions from all the library and information
science domains.

Rather than consider all of these frameworks
as essentially different, it is useful to examine
the different elements: timeframe, duration,
context, (health care) setting, environment,
type of question, type of study design,
professionals, exposure, results, stakeholders,
and situation. These can be used
interchangeably when required. Maintaining
an awareness of the different options for
structuring searches broadens the potential
uses of the frameworks. Detailed knowledge
of the frameworks also enables the searcher to
refine strategies to suit each particular
situation rather than trying to fit a search
situation to a framework.

80
References
The ADAPTE Collaboration. (2009). The
ADAPTE process: Resource toolkit for
guideline adaption (version 2).
Retrieved from http://www.g-i-
n.net/document-store/adapte-
resource-toolkit-guideline-adaptation-
version-2
Booth, A. (2004). Formulating answerable
questions. In A. Booth & A. Brice
(Eds.), Evidence based practice for
information professionals: A handbook
(pp.61-70). London: Facet Publishing.
Booth, A. (2006). Clear and present questions:

Formulating questions for evidence
based practice. Library Hi Tech, 24(3),
355-68. doi:10.1108/07378830610692127
Dawes, M., Pluye, P., Shea, L., Grad, R.,
Greenberg, A., & Nie, J.Y. (2007). The
identification of clinically important
elements within medical journal
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exposure intervention, comparison,
outcome, duration and results
(PECODR). Informatics in Primary Care,
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DiCenso, A., Guyatt, G., & Ciliska, D. (2005).
Evidence-based nursing: A guide to
clinical practice. St Louis, MO: Elsevier
Mosby.

Eldredge, J. D. (2000). Evidence-based
librarianship: An overview. Bulletin of
the Medical Library Association, 88(4),
289-302.
Fineout-Overholt, E., & Johnson, L. (2005).
Teaching EBP: Asking searchable,
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Worldviews on Evidence-Based Nursing,
2(3), 157-60. doi: 10.1111/j.1741-
6787.2005.00032.x
Nollan, R., Fineout-Overholt, E., &
Stephenson, P. (2005). Asking
compelling clinical questions. In B. M.
Melnyk & E. Fineout-Overholt (Eds.).
Evidence-based practice in nursing and
healthcare: A guide to best practice
(pp.25-37). Philadelphia: Lippincott,
Williams & Wilkins.

Petticrew M., & Roberts, H. (2005). Systematic
reviews in the social sciences: A practical
guide. Malden, MA: Blackwell
Publishing.
Richardson, W. S., Wilson, M. C., Nishikawa,
J., & Hayward, R. S. A. (1995). The
well-built clinical question: A key to
evidence-based decisions. ACP Journal
Club, 123, A12-13.
Schardt, C., Adams, M. B., Owens, T., Keitz, S.,
& Fontelo, P. (2007). Utilization of the
PICO framework to improve
searching PubMed for clinical
questions. BMC Medical Informatics and
Decision Making, 7, 16.
doi:10.1186/1472-6947-7-16

Schlosser, R. W., & O'Neil-Pirozzi, T. (Spring,
2006). Problem formulation in
evidence-based practice and
systematic reviews. Contemporary
Issues in Communication Sciences and
Disorders, 33, 5-10.
Wildridge, V., & Bell, L. (2002). How CLIP
became ECLIPSE: A mnemonic to
assist in searching for health
policy/management information.
Health Information and Libraries Journal,
19(2), 113-115. doi: 10.1046/j.1471-
1842.2002.00378.x
http://www.g-i-n.net/document-store/adapte-resource-toolkit-
guideline-adaptation-version-2�

http://dx.doi.org/10.1108/07378830610692127�/ Evidence
Based Library and Information Practice

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