clinical research

 

B.  Discuss the impact of a clinical practice problem on the patient or patients and the organization it affects.

1.  Identify each of the following PICO components of the clinical practice problem:

•   P: patient, population, or problem

•   I: intervention

•   C: comparison

•   O: outcome

2.  Develop an evidence-based practice (EBP) question based on the clinical practice problem discussed in part B and the PICO components identified in part B1.

Note: Refer to the “Appendix B: Question Development Tool” web link for information on the creation of an EBP question.

C.  Select a research-based article that answers your EBP question from part B2 to conduct an evidence appraisal.

Note: The article you select should not be more than five years old.

1.  Discuss the background or introduction (i.e., the purpose) of the research-based article.

2.  Describe the research methodology used in the research-based article.

3.  Identify the level of evidence for the research-based article using the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model.

Note: Refer to the “Appendix E: Research Evidence Appraisal Tool” web link for information on how to level a research-based article.

4.  Summarize how the researcher analyzed the data in the research-based article.

5.  Summarize the ethical considerations of the research-based article. If none are present, explain why.

6.  Identify the quality rating of the research-based article according to the JHNEBP model.

Note: Refer to the “Appendix E: Research Evidence Appraisal Tool” web link for information on how to establish the quality rating.

7.  Analyze the results or conclusions of the research-based article.

a.  Explain how the article helps answer your EBP question.

D.  Select a non-research-based article from a peer-reviewed journal that helps to answer your EBP question from part B2 to conduct an evidence appraisal.

Note: The article you select should not be more than five years old.

1.  Discuss the background or introduction (i.e., the purpose) of the non-research-based article.

2.  Describe the type of evidence (e.g., case study, quality improvement project, clinical practice guideline) used in the non-research-based article.

3.  Identify the level of evidence in the non-research-based article using the JHNEBP model.

Note: Refer to the “Appendix F: Non-Research Evidence Appraisal Tool” web link for information on how to level the non-research-based article.

4.  Identify the quality rating of the non-research-based article according to the JHNEBP model.

5.  Discuss how the author’s recommendations in the non-research-based article help answer your EBP question.

E.  Recommend a practice change that addresses your EBP question using both the research-based and non-research-based articles you selected for part C and part D.

1.  Explain how you would involve three key stakeholders in supporting the practice change recommendation.

2.  Discuss one specific barrier you may encounter when implementing the practice change recommendation. 

3.  Identify one strategy that could be used to overcome the barrier discussed in part E2.

4.  Identify one outcome (the O component in PICO) from your EBP question that can be used to measure the recommended practice change.

F.  Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.

G.  Demonstrate professional communication in the content and presentation of your submission.

File RestrictionsFile name may contain only letters, numbers, spaces, and these symbols: ! – _ . * ‘ ( )
File size limit: 200 MB
File types allowed: doc, docx, rtf, xls, xlsx, ppt, pptx, odt, pdf, txt, qt, mov, mpg, avi, mp3, wav, mp4, wma, flv, asf, mpeg, wmv, m4v, svg, tif, tiff, jpeg, jpg, gif, png, zip, rar, tar, 7z 

Researchevidence based practice

F
Nonresearch Evidence

Appraisal Tool

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Johns Hopkins Nursing Evidence-Based Practice Nonresearch Evidence Appraisal Tool292

Evidence level and quality rating:
____________

Article title: Number:

Author(s): Publication date:

Journal:

Setting: Sample

(composition and size):

Does this evidence address my EBP
question?

❑ Yes ❑ No
Do not proceed with appraisal of this evidence.

❑ Clinical Practice Guidelines LEVEL IV
Systematically developed recommendations from nationally recognized experts based on research
evidence or expert consensus panel

❑ Consensus or Position Statement LEVEL IV
Systematically developed recommendations, based on research and nationally recognized expert
opinion, that guide members of a professional organization in decision-making for an issue of
concern

■■ Are the types of evidence included identified?

❑ Yes ❑ No

■■ Were appropriate stakeholders involved in the development of
recommendations?

❑ Yes ❑ No

■■ Are groups to which recommendations apply and do not apply
clearly stated?

❑ Yes ❑ No

■■ Have potential biases been eliminated? ❑ Yes ❑ No

■■ Does each recommendation have an identified level of evidence
stated?

❑ Yes ❑ No

■■ Are recommendations clear? ❑ Yes ❑ No

Complete the corresponding quality rating section.

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F Nonresearch Evidence Appraisal Tool 293

❑ Literature review LEVEL V
Summary of selected published literature including scientific and nonscientific such as reports of
organizational experience and opinions of experts

❑ Integrative review LEVEL V
Summary of research evidence and theoretical literature; analyzes, compares themes, notes gaps
in the selected literature

■■ Is subject matter to be reviewed clearly stated? ❑ Yes ❑ No

■■ Is literature relevant and up-to-date (most sources are within the
past five years or classic)?

❑ Yes ❑ No

■■ Of the literature reviewed, is there a meaningful analysis of the
conclusions across the articles included in the review?

❑ Yes ❑ No

■■ Are gaps in the literature identified? ❑ Yes ❑ No

■■ Are recommendations made for future practice or study? ❑ Yes ❑ No

Complete the corresponding quality rating.

❑ Expert opinion LEVEL V
Opinion of one or more individuals based on clinical expertise

■■ Has the individual published or presented on the topic? ❑ Yes ❑ No

■■ Is the author’s opinion based on scientific evidence? ❑ Yes ❑ No

■■ Is the author’s opinion clearly stated? ❑ Yes ❑ No

■■ Are potential biases acknowledged? ❑ Yes ❑ No

Complete the corresponding quality rating.

Organizational Experience

❑ Quality improvement LEVEL V
Cyclical method to examine workflows, processes, or systems with a specific organization

❑ Financial evaluation LEVEL V
Economic evaluation that applies analytic techniques to identify, measure, and compare the cost
and outcomes of two or more alternative programs or interventions

❑ Program evaluation LEVEL V
Systematic assessment of the processes and/or outcomes of a program; can involve both
quaNtitative and quaLitative methods

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Johns Hopkins Nursing Evidence-Based Practice Nonresearch Evidence Appraisal Tool294

Setting Sample Composition/Size

■■ Was the aim of the project clearly stated? ❑ Yes ❑ No

■■ Was the method fully described? ❑ Yes ❑ No

■■ Were process or outcome measures identified? ❑ Yes ❑ No

■■ Were results fully described? ❑ Yes ❑ No

■■ Was interpretation clear and appropriate? ❑ Yes ❑ No

■■ Are components of cost/benefit or cost effectiveness analysis
described?

❑ Yes ❑ No ❑ N/A

Complete the corresponding quality rating.

❑ Case report LEVEL V
In-depth look at a person or group or another social unit

■■ Is the purpose of the case report clearly stated? ❑ Yes ❑ No

■■ Is the case report clearly presented? ❑ Yes ❑ No

■■ Are the findings of the case report supported by relevant
theory or research?

❑ Yes ❑ No

■■ Are the recommendations clearly stated and linked to the
findings?

❑ Yes ❑ No

Complete the corresponding quality rating.

Community standard, clinician experience, or consumer preference LEVEL V

❑ Community standard: Current practice for comparable settings in the community

❑ Clinician experience: Knowledge gained through practice experience

❑ Consumer preference: Knowledge gained through life experience

Information Source(s) Number of Sources

■■ Source of information has credible experience. ❑ Yes ❑ No

■■ Opinions are clearly stated. ❑ Yes ❑ No ❑ N/A

■■ Evidence obtained is consistent. ❑ Yes ❑ No ❑ N/A

Findings That Help You Answer the EBP Question

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F Nonresearch Evidence Appraisal Tool 295

Quality Rating for Clinical Practice Guidelines, Consensus, or Position Statements (Level IV)

A. High quality
Material officially sponsored by a professional, public, or private organization or a government
agency; documentation of a systematic literature search strategy; consistent results with
sufficient numbers of well-designed studies; criteria-based evaluation of overall scientific
strength and quality of included studies and definitive conclusions; national expertise clearly
evident; developed or revised within the past five years.

B. Good quality
Material officially sponsored by a professional, public, or private organization or a government
agency; reasonably thorough and appropriate systematic literature search strategy; reasonably
consistent results, sufficient numbers of well-designed studies; evaluation of strengths and
limitations of included studies with fairly definitive conclusions; national expertise clearly evident;
developed or revised within the past five years.

C. Low quality or major flaw
Material not sponsored by an official organization or agency; undefined, poorly defined, or
limited literature search strategy; no evaluation of strengths and limitations of included studies;
insufficient evidence with inconsistent results; conclusions cannot be drawn; not revised within
the past five years.

Quality Rating for Organizational Experience (Level V)

A. High quality
Clear aims and objectives; consistent results across multiple settings; formal quality improvement
or financial evaluation methods used; definitive conclusions; consistent recommendations with
thorough reference to scientific evidence.

B. Good quality
Clear aims and objectives; formal quality improvement or financial evaluation methods used;
consistent results in a single setting; reasonably consistent recommendations with some
reference to scientific evidence.

C. Low quality or major flaws
Unclear or missing aims and objectives; inconsistent results; poorly defined quality;
improvement/financial analysis method; recommendations cannot be made.

Quality Rating for Case Report, Integrative Review, Literature Review, Expert Opinion, Community
Standard, Clinician Experience, Consumer Preference (Level V)

A. High quality
Expertise is clearly evident, draws definitive conclusions, and provides scientific rationale;
thought leader in the field.

B. Good quality
Expertise appears to be credible, draws fairly definitive conclusions, and provides logical
argument for opinions.

C. Low quality or major flaws
Expertise is not discernable or is dubious; conclusions cannot be drawn.

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E
Research Evidence

Appraisal Tool

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AN: 1625431 ; Debora Dang, Sandra L. Dearholt.; Johns Hopkins Nursing Evidence-Based Practice Third Edition: Model and Guidelines
Account: ns017578.main.eds

Johns Hopkins Nursing Evidence-Based Practice Research Evidence Appraisal Tool282

Evidence level and quality rating:
_________________

Article title: Number:

Author(s): Publication date:

Journal:

Setting: Sample

(composition and size):

Does this evidence address my EBP
question?

❑ Yes ❑ No
Do not proceed with appraisal of this evidence.

Is this study:

■■ QuaNtitative (collection, analysis, and reporting of numerical data)

Measurable data (how many; how much; or how often) used to formulate facts, uncover patterns
in research, and generalize results from a larger sample population; provides observed effects of a
program, problem, or condition, measured precisely, rather than through researcher interpretation of
data. Common methods are surveys, face-to-face structured interviews, observations, and reviews of
records or documents. Statistical tests are used in data analysis.

Go to Section I: QuaNtitative

■■ QuaLitative (collection, analysis, and reporting of narrative data)

Rich narrative documents are used for uncovering themes; describes a problem or condition from
the point of view of those experiencing it. Common methods are focus groups, individual interviews
(unstructured or semistructured), and participation/observations. Sample sizes are small and are
determined when data saturation is achieved. Data saturation is reached when the researcher
identifies that no new themes emerge and redundancy is occurring. Synthesis is used in data
analysis. Often a starting point for studies when little research exists; may use results to design
empirical studies. The researcher describes, analyzes, and interprets reports, descriptions, and
observations from participants.

Go to

Section II: QuaLitative

■■ Mixed methods (results reported both numerically and narratively)

Both quaNtitative and quaLitative methods are used in the study design. Using both approaches,
in combination, provides a better understanding of research problems than using either approach
alone. Sample sizes vary based on methods used. Data collection involves collecting and analyzing
both quaNtitative and quaLitative data in a single study or series of studies. Interpretation is continual
and can influence stages in the research process.

Go to Section I for QuaNtitative components and Section II for QuaLitative components

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E Research Evidence Appraisal Tool 283

Section I: QuaNtitative

Level of Evidence (Study Design)

A. Is this a report of a single research study?
■

❑ Yes

■
❑ No

Go to B.

1. Was there manipulation of an independent
variable?

❑ Yes ❑ No

2. Was there a control group? ❑ Yes ❑ No

3. Were study participants randomly assigned to the
intervention and control groups? ❑ Yes ❑ No

If Yes to questions 1, 2, and 3, this is a randomized
controlled trial (RCT) or experimental study.

If Yes to questions 1 and 2 and No to question 3, or
Yes to question 1 and No to questions 2 and 3, this
is quasi-experimental (some degree of investigator
control, some manipulation of an independent
variable, lacks random assignment to groups, and
may have a control group).

If No to questions 1, 2, and 3, this is nonexperimental
(no manipulation of independent variable; can be
descriptive, comparative, or correlational; often uses
secondary data).

❑ LEVEL I

❑ LEVEL II

❑ LEVEL III

Study Findings That Help Answer the EBP Question

Complete the Appraisal of QuaNtitative Research Studies section.

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Johns Hopkins Nursing Evidence-Based Practice Research Evidence Appraisal Tool284

B. Is this a summary of multiple sources of
research evidence?

❑ Yes

Continue

❑ No

Go to Appendix F

1. Does it employ a comprehensive search
strategy and rigorous appraisal method?

If this study includes research,
nonresearch, and experiential
evidence, it is an integrative review. See
Appendix F.

❑ Yes ❑ No

Go to Appendix F

2. For systematic reviews and systematic
reviews with meta-analysis (see
descriptions below):

a. Are all studies included RCTs?

b. Are the studies a combination of
RCTs and quasi-experimental, or
quasi-experimental only?

c. Are the studies a combination
of RCTs, quasi-experimental,
and nonexperimental, or non-
experimental only?

A systematic review employs a search strategy
and a rigorous appraisal method, but does not
generate an effect size.

A meta-analysis, or systematic review with
meta-analysis, combines and analyzes results
from studies to generate a new statistic: the
effect size.

❑ Level I

❑■Level II

❑■Level III

Study Findings That Help Answer the EBP Question

Complete the Appraisal of Systematic Review (With or Without a Meta-Analysis) section.

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E Research Evidence Appraisal Tool 285

Appraisal of QuaNtitative Research Studies

Does the researcher identify what is known and not known about the
problem and how the study will address any gaps in knowledge?

❑ Yes ❑ No

Was the purpose of the study clearly presented? ❑ Yes ❑ No

Was the literature review current (most sources within the past five
years or a seminal study)?

❑ Yes ❑ No

Was sample size sufficient based on study design and rationale? ❑ Yes ❑ No

If there is a control group:

■■ Were the characteristics and/or demographics similar in both the
control and intervention groups?

❑ Yes ❑ No ❑ N/A

■■ If multiple settings were used, were the settings similar? ❑ Yes ❑ No ❑ N/A

■■ Were all groups equally treated except for the intervention
group(s)?

❑ Yes ❑ No ❑ N/A

Are data collection methods described clearly? ❑ Yes ❑ No

Were the instruments reliable (Cronbach’s α [alpha] > 0.70)? ❑ Yes ❑ No ❑ N/A

Was instrument validity discussed? ❑ Yes ❑ No ❑ N/A

If surveys or questionnaires were used, was the response rate > 25%? ❑ Yes ❑ No ❑ N/A

Were the results presented clearly? ❑ Yes ❑ No

If tables were presented, was the narrative consistent with the table
content?

❑ Yes ❑ No ❑ N/A

Were study limitations identified and addressed? ❑ Yes ❑ No

Were conclusions based on results? ❑ Yes ❑ No

Go to Quality Rating for QuaNtitative Studies section

Appraisal of Systematic Review (With or Without Meta-Analysis)

Were the variables of interest clearly identified? ❑ Yes ❑ No

Was the search comprehensive and reproducible?

■■ Key search terms stated ❑ Yes ❑ No

■■ Multiple databases searched and identified ❑ Yes ❑ No

■■ Inclusion and exclusion criteria stated ❑ Yes ❑ No

Was there a flow diagram that included the number of studies
eliminated at each level of review?

❑ Yes ❑ No

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Johns Hopkins Nursing Evidence-Based Practice Research Evidence Appraisal Tool286

Were details of included studies presented (design, sample, methods,
results, outcomes, strengths, and limitations?

❑ Yes ❑ No

Were methods for appraising the strength of evidence (level and quality)
described?

❑ Yes ❑ No

Were conclusions based on results? ❑ Yes ❑ No

■■ Results were interpreted. ❑ Yes ❑ No

■■ Conclusions flowed logically from the interpretation and systematic
review question.

❑ Yes ❑ No

Did the systematic review include a section addressing limitations and
how they were addressed?

❑ Yes ❑ No

Quality Rating for QuaNtitative Studies

Complete quality rating for quaNtitative studies section.

Circle the appropriate quality rating below

A High quality: Consistent, generalizable results; sufficient sample size for the study design; adequate
control; definitive conclusions; consistent recommendations based on comprehensive literature
review that includes thorough reference to scientific evidence.

B Good quality: Reasonably consistent results; sufficient sample size for the study design; some
control, and fairly definitive conclusions; reasonably consistent recommendations based on fairly
comprehensive literature review that includes some reference to scientific evidence.

C Low quality or major flaws: Little evidence with inconsistent results; insufficient sample size for the
study design; conclusions cannot be drawn.

Section II: QuaLitative

Level of Evidence (Study Design)

A. Is this a report of a single quaLitative research study? ❑ Yes

Level
III

❑ No

Go to Section
II. B

Study Findings That Help Answer the EBP Question

Complete the Appraisal of Single QuaLitative Research Study section.

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E Research Evidence Appraisal Tool 287

Appraisal of a Single QuaLitative Research Study

Was there a clearly identifiable and articulated:

■■ Purpose? ❑ Yes ❑ No

■■ Research question? ❑ Yes ❑ No

■■ Justification for method(s) used? ❑ Yes ❑ No

■■ Phenomenon that is the focus of the research? ❑ Yes ❑ No

Were study sample participants representative? ❑ Yes ❑ No

Did they have knowledge of or experience with the research area? ❑ Yes ❑ No

Were participant characteristics described? ❑ Yes ❑ No

Was sampling adequate, as evidenced by achieving saturation of data? ❑ Yes ❑ No

Data analysis:

■■ Was a verification process used in every step by checking and
confirming with participants the trustworthiness of analysis and
interpretation?

❑ Yes ❑ No

■■ Was there a description of how data were analyzed (i.e., method), by
computer or manually?

❑ Yes ❑ No

Do findings support the narrative data (quotes)? ❑ Yes ❑ No

Do findings flow from research question to data collected to analysis
undertaken?

❑ Yes ❑ No

Are conclusions clearly explained? ❑ Yes ❑ No

Go to Quality Rating for QuaLitative Studies section.

B. For summaries of multiple quaLitative research studies (meta-synthesis),
was a comprehensive search strategy and rigorous appraisal method used?

❑ Yes

Level
III

❑ No Go to
Appendix F.

Study Findings That Help Answer the EBP Question

Complete the Appraisal of Meta-Synthesis Studies section.

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Johns Hopkins Nursing Evidence-Based Practice Research Evidence Appraisal Tool288

Appraisal of Meta-Synthesis Studies

Were the search strategy and criteria for selecting primary studies clearly
defined?

❑ Yes ❑ No

Were findings appropriate and convincing? ❑ Yes ❑ No

Was a description of methods used to:

■■ Compare findings from each study? ❑ Yes ❑ No
■■ Interpret data? ❑ Yes ❑ No

Did synthesis reflect:

■■ New insights? ❑ Yes ❑ No
■■ Discovery of essential features of phenomena? ❑ Yes ❑ No
■■ A fuller understanding of the phenomena? ❑ Yes ❑ No

Was sufficient data presented to support the interpretations? ❑ Yes ❑ No

Complete Quality Rating for QuaLtitative Studies section.

Quality Rating for QuaLitative Studies

Circle the appropriate quality rating below

No commonly agreed-on principles exist for judging the quality of quaLitative studies. It is a subjective
process based on the extent to which study data contributes to synthesis and how much information
is known about the researchers’ efforts to meet the appraisal criteria.

For meta-synthesis, there is preliminary agreement that quality assessments should be made before synthesis to screen out poor-quality
studies1.

A/B High/Good quality is used for single studies and meta-syntheses)2.

The report discusses efforts to enhance or evaluate the quality of the data and the overall inquiry in
sufficient detail; and it describes the specific techniques used to enhance the quality of the inquiry.
Evidence of some or all of the following is found in the report:

■■ Transparency: Describes how information was documented to justify decisions, how data were
reviewed by others, and how themes and categories were formulated.

■■ Diligence: Reads and rereads data to check interpretations; seeks opportunity to find multiple
sources to corroborate evidence.

■■ Verification: The process of checking, confirming, and ensuring methodologic coherence.

■■ Self-reflection and self-scrutiny: Being continuously aware of how a researcher’s experiences,
background, or prejudices might shape and bias analysis and interpretations.

■■ Participant-driven inquiry: Participants shape the scope and breadth of questions; analysis and
interpretation give voice to those who participated.

■■ Insightful interpretation: Data and knowledge are linked in meaningful ways to relevant literature.

C Lower-quality studies contribute little to the overall review of findings and have few, if any, of the
features listed for High/Good quality.

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E Research Evidence Appraisal Tool 289

Section III: Mixed Methods

Level of Evidence (Study Design)

You will need to appraise both the quaNtitative and quaLitative
parts of the study independently, before appraising the study in its
entirety.

1. Evaluate the quaNtitative portion of the study using Section I.
Insert here the level of evidence and overall quality for this part:

2. Evaluate the quaLitative part of the study using Section II. Insert
here the level of evidence and overall quality for this part:

3. To determine the level of evidence, circle the appropriate study
design:

(a) Explanatory sequential designs collect quaNtitative data
first, followed by the quaLitative data; and their purpose
is to explain quaNtitative results using quaLitative
findings. The level is determined based on the level of the
quaNtitative part.

(b) Exploratory sequential designs collect quaLitative data
first, followed by the quaNtitative data; and their purpose
is to explain quaLitative findings using the quaNtitative
results. The level is determined based on the level of the
quaLitative part, and it is always Level III.

(c) Convergent parallel designs collect the quaLitative and
quaNtitative data concurrently for the purpose of providing
a more complete understanding of a phenomenon by
merging both datasets. These designs are Level III.

(d) Multiphasic designs collect quaLitative and quaNtitative
data over more than one phase, with each phase informing
the next phase. These designs are Level III.

Level __

Level __

Quality __

Quality __

Study Findings That Help Answer the EBP Question

Use the Appraisal of Mixed Methods Studies section.

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Johns Hopkins Nursing Evidence-Based Practice Research Evidence Appraisal Tool290

Appraisal of Mixed Methods Studies3

Was the mixed-methods research design relevant to address the
quaNtitative and quaLitative research questions (or objectives)?

❑ Yes ❑ No ❑ N/A

Was the research design relevant to address the quaNtitative and
quaLitative aspects of the mixed-methods question (or objective)?

❑ Yes ❑ No ❑ N/A

For convergent parallel designs, was the integration of quaNtitative
and quaLitative data (or results) relevant to address the research
question or objective?

❑ Yes ❑ No ❑ N/A

For convergent parallel designs, were the limitations associated
with the integration (for example, the divergence of quaLitative and
quaNtitative data or results) sufficiently addressed?

❑ Yes ❑ No ❑ N/A

Quality Rating for Mixed-Methods Studies

Circle the appropriate quality rating below

A High quality: Contains high-quality quaNtitative and quaLitative study components; highly relevant
study design; relevant integration of data or results; and careful consideration of the limitations of
the chosen approach.

B Good quality: Contains good-quality quaNtitative and quaLitative study components; relevant study
design; moderately relevant integration of data or results; and some discussion of limitations of
integration.

C Low quality or major flaws: Contains low quality quaNtitative and quaLitative study components;
study design not relevant to research questions or objectives; poorly integrated data or results; and
no consideration of limits of integration.

1 https://www.york.ac.uk/crd/SysRev/!SSL!/WebHelp/6_4_ASSESSMENT_OF_QUALITATIVE_RESEARCH.htm

2 Adapted from Polit & Beck (2017).

3 National Collaborating Centre for Methods and Tools. (2015). Appraising Qualitative, Quantitative, and Mixed Methods Studies included
in Mixed Studies Reviews: The MMAT. Hamilton, ON: McMaster University. (Updated 20 July, 2015) Retrieved from http://www.nccmt.ca/
resources/search/232

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B
Question Development Tool

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AN: 1625431 ; Debora Dang, Sandra L. Dearholt.; Johns Hopkins Nursing Evidence-Based Practice Third Edition: Model and Guidelines
Account: ns017578.main.eds

268 Johns Hopkins Nursing Evidence-Based Practice Question Development Tool

1. What is the problem?

2. Why is the problem important and relevant? What would happen if it were not addressed?

3. What is the current practice?

4. How was the problem identified? (Check all that apply.)

❑ Safety and risk-management
concerns

❑ Quality concerns (efficiency,
effectiveness, timeliness, equity,
patient-centeredness)

❑ Unsatisfactory patient, staff, or
organizational outcomes

❑ Variations in practice within the
setting

❑ Variations in practice compared to community
standard

❑ Current practice that has not been validated

❑ Financial concerns

5.

What are the PICO components?

P – (Patient, population, or problem)

I – (Intervention)

C – (Comparison with other interventions, if foreground question)

O – (Outcomes are qualitative or quantitative measures to determine the success of change)

6. Initial EBP question ❑ Background ❑ Foreground

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269B Question Development Tool

7.

List possible search terms, databases to search, and search strategies.

8. What evidence must be gathered? (Check all that apply.)

❑ Publications (e.g., EBSCOHost,
PubMed, CINAHL, Embase)

❑ Standards (regulatory, professional,
community)

❑ Guidelines

❑ Organizational data (e.g., QI, financial data, local
clinical expertise, patient/family preferences)

❑ Position statements

9. Revised EBP question

(Revisions in the EBP question may not be evident until after the initial evidence review;
the revision can be in the background question or a change from the background to a
foreground question.)

10. Outcome measurement plan

What will we
measure?

(Structure, process,
outcome measures)

How will we
measure it?

(Metrics
expressed as rate
or percent)

How often will
we measure it?

(Frequency)

Where will
we obtain
the data?

Who will
collect the
data?

To whom
will we
report the
data?

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270 Johns Hopkins Nursing Evidence-Based Practice Question Development Tool

Directions for Use of the Question Development Tool

Purpose

This form is used to develop an answerable EBP question and to guide the team
in the evidence search process. The question, search terms, search strategy, and
sources of evidence can be revised as the EBP team refines the EBP question.

What is the problem, and why is it important?

Indicate why the project was undertaken. What led the team to seek evidence?
Ensure that the problem statement defines the actual problem and does not in-
clude a solution. Whenever possible, quantify the extent of the problem. Validate
the final problem description with practicing staff. It is important for the inter-
professional team to take the time together to reflect, gather information, observe
current practice, listen to clinicians, visualize how the process can be different or
improved, and probe the problem description in order to develop a shared under-
standing of the problem.

What is the current practice?

Define the current practice as it relates to the problem. Think about current poli-
cies and procedures. Observe practices. What do you see?

How was the problem identified?

Check all the statements that apply.

What are the PICO components?

P (patient, population, problem) e.g., age, sex, setting, ethnicity, condition, disease,
type of patient, or population

I (intervention) e.g., treatment, medication, education, diagnostic test, or best
practice(s)

C (comparison with other interventions or current practice for foreground
questions; is not applicable for background questions, which identify best practice)

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B Question Development Tool 271

O (outcomes) stated in measurable terms; may be a structure, a process, or an
outcome measure based on the desired change (e.g., decrease in falls, decrease in
length of stay, increase in patient satisfaction)

Initial EBP question

A starting question (usually a background question) that is often refined and ad-
justed as the team searches through the literature:

■■ Background questions are broad and are used when the team has little
knowledge, experience, or expertise in the area of interest. Background
questions are often used to identify best practices.

■■ Foreground questions are focused, with specific comparisons of two or
more ideas or interventions. Foreground questions provide specific bodies
of evidence related to the EBP question. Foreground questions often flow
from an initial background question and literature review.

List possible search terms, databases to search, and search strategies.

Using PICO components and the initial EBP question, list search terms. Terms can
be added or adjusted throughout the evidence search. Document the search terms,
search strategy, and databases queried in sufficient detail for replication.

What evidence must be gathered?

Check the types of evidence the team will gather based on the PICO and initial
EBP question.

Revised EBP question

Often, the question that you start with may not be the final EBP question. Back-
ground questions can be refined or changed to a foreground question based on
the evidence review. Foreground questions are focused questions that include spe-
cific comparisons and produce a narrower range of evidence.

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272 Johns Hopkins Nursing Evidence-Based Practice Question Development Tool

Measurement plan

Measures can be added or changed as the review of the literature is completed
and the translation planning begins:

■■ A measure is an amount or a degree of something, such as number of falls
with injury. Each measure must be converted to a metric, which is calcu-
lated before and after implementing the change.

■■ Metrics let you know whether the change was successful. They have a
numerator and a denominator and are typically expressed as rates or
percent. For example, a metric for the measure falls-with-injury would be
the number of falls with injury (numerator) divided by 1,000 patient days
(denominator). Other examples of metrics include the number of direct
care RNs (numerator) on a unit divided by the total number of direct care
staff (denominator); the number of medication errors divided by 1,000
orders.

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