NURS 8211 _Appendix B_ Question Development Tool

What is the problem?
Mercy Hospital’s adult inpatient units report elevated patient fall rates, with incident reports suggesting that understaffed nursing shifts contribute to lapses in fall prevention protocols. Nurse feedback and QI audits highlight increased workloads, inadequate monitoring, and delayed response times: NURS 8211 _Appendix B_ Question Development Tool.
What are the data and sources of information that validate the problem?
☒Safety and risk management concerns: Inadequate staffing increases fall risk and safety violations. ☒Data: Internal fall reports and HCAHPS scores                                                                       ☒Financial information: Increased costs due to fall-related injuries                                           ☒Lack of evidence for current practice:  No standardized policy exists                                      ☒Quality indicators:  National benchmarks, such as NDNQI, not met                                       ☒Practice observations:  Overburdened nursing staff                                                                 ☒Other: Nurse complains citing workload as a burnout factor
Why is the problem important and relevant? What would happen if it were not addressed?
When fall rates are high in inpatient units, patient safety is directly at stake as there are high chances of experiencing severe fractures, injuries to the head, and long-term immobility. These complications often go hand-in-hand with prolonged hospital stays, slower recoveries, and increased readmission rates, straining healthcare resources and increasing operational costs. Moreover, high rates of falls may adversely affect the quality indicators of the hospital and lead to fines from regulatory agencies (Turner et al., 2022). In addition to financial consequences, frequent safety events may affect the reputation and eliminate trust of the population toward the hospital, and lead to burnout and staff turnover caused by moral distress and workloads.
What is the current practice?
Nurse-patient ratios vary from 1:4 to 1:5 based on shift availability. No hospital-wide mandate exists for consistent ratios aligned with best practices, and unit managers often struggle to fill staffing gaps.
Is this a background question to establish the state of the evidence on a topic (with no comparison group) or a foreground question to compare specific interventions?
☒Background	☐ Foreground
What are the PICO components?
P (patient, population, or problem): Adult inpatients at Mercy Hospital I (intervention): Nurse-to-patient ratio above 1:6 C (comparison with other interventions if foreground question): O (outcomes): Patient fall rate within 30-day stay
Initial EBP question:
In adult inpatient units at Mercy Hospital (P), how does maintaining a ratio above 1:6 (I) affect inpatient fall rates over a 30-day hospital stay (O)?

 

List possible search terms for each part of the PICO question:
PICO Element	Possible Search Terms
P	Patient falls, inpatient safety, nurse workload, fall prevention, and hospital falls,
I	Nurse staffing ratios, nurse-patient ratio, and nursing hours per patient day
C
O	Quality of care, nurse workload, and fall prevention
What are preliminary inclusion and exclusion criteria (e.g., date, population, setting, other)?
Inclusion: English peer-reviewed articles less than five years old, adult inpatient settings, nurse staffing/fall prevention outcomes.		Exclusion: Pediatric or intensive care unit settings, long-term care, articles more than 5 years old, non-English sources
What evidence needs to be reviewed? (Check all that apply)
☒Peer-reviewed publications (from databases such as PubMed, CINAHL, and Embase) ☒Standards (regulatory, professional, community) ☒Clinical Practice Guidelines ☒Organizational data (e.g., quality improvement or financial data, local clinical expertise, patient/family preferences) ☒Evidence-based professional organization position statements ☒Consensus studies (e.g., commissioned reports from the National Academy of Medicine, professional organizations, and philanthropic foundations) ☐Other
Revised EBP question:
In adult inpatient units at Mercy Hospital, how does a nurse-to-patient ratio of above 1:6 affect fall rates during hospitalization?
What are measures that indicate if the EBP project is successful? (Measures may be structure, process, and/or outcome)
The main indicators of measuring the effectiveness of the evidence-based practice project are the fall rates per 30 patient days as they directly show positive changes in patient safety. Workload and satisfaction as reported by the nurses will be observed to determine the sufficiency of the staffing pattern and general team morale. The stay length of the patients will also be monitored, since the length of stay in hospitals is associated with decreased falls. Further, the financial burden of fall-related complications will also be evaluated to determine the economic value of enhanced nurse-to-patient ratios.

Reference

Turner, K., Staggs, V. S., Potter, C., Cramer, E., Shorr, R. I., & Mion, L. C. (2022). Fall prevention practices and implementation strategies. Journal of Patient Safety, 18(1), 236–242. https://doi.org/10.1097/pts.0000000000000758

See Chapter 11, Lessons from Practice, for examples of completed tools.

Directions for Use of the Question Development Tool

Purpose: This form guides the EBP team to develop an answerable EBP question. It is meant to be fluid and dynamic as the team engages in the PICO question development process. As the team becomes

familiar with the evidence base for the topic of interest, they revisit, revise, and/or refine the question, search terms, search strategy, and sources of evidence.

What is the problem?

Describe and specify the problem that needs to be addressed. What led the team to question this practice? Validate the problem statement with staff who experience it day to day. The interprofessional team needs to work through the problem definition process together to probe the problem description, reflect, gather information, observe current practice, and listen to clinicians’ perspectives.

This team deliberation ensures the problem statement defines the actual problem rather than a solution and guides the type of measure(s) they will use to determine if the intervention results in improvements once implemented.

What are the data and sources of information that validate the problem?

Confirm the problem with concrete, rather than anecdotal, information. Concrete information exists in the form of staff or patient safety concerns, data demonstrating unsatisfactory process or outcome measures, financial reports, identification of the lack of evidence for current practice, or unsatisfactory quality indicators. Formal information or observations may demonstrate variations within the practice setting or variations within the community. These elements are not mutually exclusive, and the problem may be evidenced in multiple areas.

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

Establishing a sense of importance and urgency for a practice problem can help build support for the EBP project and on-board other stakeholders. Emphasize why the problem must be addressed and the potential consequences of not doing so. This is the place to establish your “burning platform” for practice change.

What is the current practice?

Define the current practice as it relates to the problem by identifying the gap or performance issue. Think about current policies and procedures as well as adherence to these guidelines.

What is commonly considered acceptable among the staff related to their daily practice? Do policy and practice align? What do you see?

Is this a background question to establish the evidence on a topic (with no comparison group) or a foreground question to compare specific interventions?

Select if you are intending to write a background or foreground question. Background questions are broad and produce a wide range of evidence to establish best practices when the team has little knowledge, experience, or expertise in the area of interest. Background questions do not include a “comparison” group.

Foreground questions are focused, with the specific comparison of two or more ideas or interventions. Foreground questions often flow from an initial background question and evidence review.

What are the PICO components?

Complete each section. Definitions of each PICO element are included below.

P (patient, population, problem): This may include characteristics such as age, sex, setting, ethnicity, condition, disease, type of patient, or community.

I (intervention): This can be a best practice statement or include a specific treatment, medication, education, diagnostic test, or care practice.

C (comparison): Not applicable for background questions. For foreground questions, comparisons are typically with current practice or an intervention identified in the evidence.

O (outcomes): structure, process, or outcome measures that indicate the success of evidence translation. More than one measure can be listed; examples include structure (e.g., adequacy of resources, space, people, training), process (e.g., care coordination, adherence to protocols for care, performance), or outcomes (e.g., satisfaction scores or retention, fall rates, rates of disease in a population).

Initial EBP Question:

Combine each element of the PICO to create an answerable EBP question. The initial question is refined throughout the PET process.

List possible search terms for each part of the PICO question:

Select concepts from each PICO component to identify search terms. Mapping search terms to each component aids the evidence search; ensure terms are neither too broad nor too narrow. Brainstorm common synonyms for each concept. Be sure to consider alternate spellings or terms used in different countries (e.g., “ward” vs. “unit”) as well as brand names of specific interventions.

It may be appropriate to leave some of the rows blank (e.g., the O in PICO) to avoid building solutions into the search itself (e.g., words like “reduction” will only provide evidence that exhibited reductions in the outcome of interest and may miss evidence with no change or even an increase).

What are preliminary inclusion and exclusion criteria (e.g., publication date, population, and setting)?

As a team, list the initial characteristics you want to include or exclude from your evidence search (for example you may want to include student nurses but do not want to include post-licensure nurses). This will help to ensure the team has a mutual understanding of the scope of the project. The group should revisit the list throughout the process to provide further clarifications and refine evidence search results.

What evidence needs to be reviewed?

Select the types of evidence you intend to gather based on the PICO and initial EBP question. This will guide you to the appropriate sources to begin the search.

Revised EBP question:

Often the question that you start with will not be the final EBP question. Needed revisions to the EBP question may not be evident until after the initial evidence review; examples include a revision to the background question

or a change from a background to a foreground question. Additionally, preliminary reviews of the evidence may indicate a need to focus or broaden the question, update terminology, and/or consider additional measures of success.

What are measures that indicate if the EBP project is successful? (Measures maybe structure, process, and/or outcome)

It is essential to consider a measurement plan from the onset of an EBP project. As a team, reflect on how you will determine project success. Success can be captured in many ways, and measures can include:

• The structure measures that describe the physical or organizational environment (e.g., nurse-patio ratios)
• Outcome measures that occur after a project (e.g., number of safety events)
• Process measures that are gathered throughout to track progress toward the goals (e.g., use of a new tool or protocol)

 

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