CCH-Asking Searchable, Answerable Questions

Asking Searchable, Answerable Questions Finding the right information amidst an overwhelming amount of information in a timely way is imperative. The first step to accomplish this goal is to formulate the clinical issue into a searchable, answerable question. It is important to distinguish between the two types of questions that clinicians might ask—background questions and foreground questions.

 Background questions are those that need to be answered as a foundation for asking the searchable, answerable foreground question . Background questions are described as those that ask for general information about a clinical issue.

 This type of question usually has two components: the starting place of the question (e.g., what, where, when, why, and how) and the outcome of interest (e.g., the clinical diagnosis). 

An example of a background question is: How does the drug acetaminophen work to affect fever? 

{Acetaminophen is an analgesic and antipyretic drug that has almost no anti inflammatory effects. Its mechanism of action is unknown, but it is thought to act centrally through inhibition of the enzymes cyclooxygenase (COX) type 3 (constitutive) and COX-2b (inducible)}

The answer to this question can be found in a drug pharmacokinetics text. Another example of a background question is: How does hemodynamics differ with positioning? This answer can be found in textbooks, as well. Often, background questions are far broader in scope than foreground questions. Clinicians often want to know the best method to prevent a clinically undesirable outcome. For example, What is the best method to prevent pressure ulcers during hospitalization? This question will lead to a foreground question, but background knowledge is necessary before the foreground question can be asked. In this example, the clinician must know what methods of pressure ulcer prevention are being used. Generally, this information comes from knowledge of what is being used in clinicians’ practices and what viable alternatives are available to improve patient outcomes or it may come from descriptive research, such as survey research. Once the methods most supported are identified, clinicians can formulate the foreground question and ask, between the two most effective methods of pressure ulcer prevention, which one will work best in my population? If a clinician does not realize that the question at hand is a background question, time may be lost in searching for an answer in the wrong haystack (e.g., electronic evidence databases versus a textbook). Foreground questions are those that can be answered from scientific evidence about diagnosing, treating, or assisting patients in understanding their prognosis. These questions focus on specific knowledge. In the first two background question examples, the subsequent foreground questions could be: In children, how does acetaminophen compared to ibuprofen affect fever? and In patients with acute respiratory distress syndrome, how does the prone position compared to the supine position affect hemodynamic readings? The first question builds on the background knowledge of how acetaminophen works but can be answered only by a study that compares the two listed medications. The second question requires the knowledge of how positioning changes hemodynamics (i.e., the background question), but the two types of positioning must be compared in a specific population of patients to answer it. 

The foreground question generated from the third background question example could be: In patients at risk for pressure ulcers, how do pressure mattresses compared to pressure overlays affect the incidence of pressure ulcers? The answer provided by the evidence would indicate whether pressure mattresses or overlays are more effective in preventing pressure ulcers. The most effective method will become the standard of care. Recognizing the difference between the two types of questions is the challenge. 

 a novice may need to ask primarily background questions.

 As one gains experience, the background knowledge grows, and the focus changes to foreground questions.

 Although background questions are essential and must be asked, it is the foreground questions that are the searchable, answerable questions

Clinical Inquiry and Uncertainty in Generating Clinical Questions

Where clinical questions come from (i.e., their origin) is an important consideration. On a daily basis, most clinicians encounter situations for which they do not have all the information they need (i.e., uncertainty) to care for their patients as they would like (Ely et al., 2002; Scott et al., 2008). The role of uncertainty is to spawn clinical inquiry. Clinical inquiry can be defined as a process in which clinicians gather data together using narrowly defined clinical parameters to Melnyk_Chap02.indd 28 3/3/2010 12:47:08 PM Asking Compelling, Clinical Questions chapter 2 29 appraise the available choices of treatment for the purpose of finding the most appropriate choice of action (Horowitz, Singer, Makuch, et al., 1996). Clinical inquiry must be cultivated in the work environment. To foster clinical inquiry, a level of comfort must be had with uncertainty. Scott et al. (2008) define uncertainty as the inability to predict what an experience will mean or what outcome will occur. Lindstrom and Rosyik (2003) state that uncertainty is a sequela of ambiguity. Clinicians live in a rather ambiguous world. What works for one patient may not work for another patient. The latest product on the market claims that it is the solution to wound healing, but is it? Collaborating partners in caring for complex patients have “their” way of providing care. Formulating clinical questions in a structured, specific way, such as with PICOT formatting (discussed later in this chapter), assists the clinician in finding the right evidence to answer those questions and to decrease uncertainty. This approach to asking clinical questions facilitates a well-constructed search. Schardt et al. (2007) found that that using PICOT templates improved clinicians’ skills to search PubMed for answers to burning clinical questions. These successes then foster further clinical inquiry. Clinical circumstances, such as interpretation of patient assessment data (e.g., clinical findings from a physical examination or laboratory data), a desire to determine the most likely cause of the patient’s problem among the many it could be (i.e., differential diagnosis), or simply wanting to improve one’s clinical skills in a specific area, can prompt five types of questions. These five types of foreground questions are (a) intervention questions that ask what intervention most effectively leads to an outcome; (b) prognosis/prediction questions that ask what indicators are most predictive of or carry the most associated risk for an outcome; (c) diagnosis questions that ask what mechanism or test most accurately diagnoses an outcome; (d) etiology questions that ask to what extent a factor, process, or condition is highly associated with an outcome, usually an undesirable outcome; or (e) meaning questions that ask how an experience influences an outcome, the scope of a phenomenon, or perhaps the influence of culture on healthcare. Whatever the reason for the question, the components of the question need to be considered and formulated carefully to efficiently find relevant evidence to answer the question.

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