Running head: CLINICAL QUESTION
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PICO Clinical Question
Tiffini Schnur
Ferris State University
PICO Clinical Question
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Abstract
When nurses identify an area of improvement and perform research to attempt in
improving patient outcomes, this is called nursing research. The question that this author chose
to research is Chinese related techniques to relieve chemotherapy-induced nausea and vomiting.
The interventions researched includes progressive muscle relaxation, acupuncture, and Chinese
herbs. Each of these remedies revealed positive effects on the patients, but some more than
others.
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Introduction
Chemotherapy-induced nausea and vomiting is a pestering side effects for many cancer
patients. Reducing this side effect would lead to a better quality of life and allow the patient to
recover more effectively after treatment. Many medications are used to assist in this process, but
those also come with risks and may cause further side effects. Non-pharmaceutical interventions
to relieve this nausea and vomiting has been researched and positive results have been reported.
Clinical Question
Chemotherapy-induced nausea and vomiting (CINV) can lead to harmful effects to the
patient. Many times antiemetic medications are given before, during, and after treatment, but
they do not always work. Nursing researchers have researched non-pharmaceutical interventions
that can assist in relieving CINV. The PICO question that this author has chosen to research is:
Does non-pharmacological interventions (specifically Chinese medicine related techniques)
reduce chemotherapy-induced nausea compared to medications alone in patients post receiving
chemotherapy?
The acronym PICO stands for patient/population, intervention, comparison, and outcome
(Lansing Community College, 2014). In the question above, the patient/population is patients
who had recently received chemotherapy. The interventions are non-pharmacological
interventions, focusing on Chinese medicine related techniques. The comparison is between
patients receiving Chinese medicine techniques along with antiemetic medication versus
antiemetic medications alone. Lastly, the outcome would be reduced CINV.
By answering this question and determining additional ways to reduce CINV, it will lead
to improved patient quality and safety. When an individual experience prolonged nausea and
vomiting, they often become malnourished and dehydrated. This causes more medical problems,
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on top of the cancer diagnosis they already have. Dehydration can lead to electrolyte imbalances,
irregular heart rhythms, constipation, infection, renal failure, weakness, and many other adverse
effects (Mayo Clinic, 2014). Being malnourished and dehydrated does not allow the body to
optimally recover from the treatment regimen.
Methodology
When performing research to find answers to the PICO question, nursing research from
academic and peer reviewed articles was used. Online databases via Ferris State University’s
library were used. The databases included CINAHL, PubMed, and Crochane Reviews. Only
nursing research that was pertinent to the PICO question was evaluated.
Nursing research was chosen because it “provides the scientific basis for the practice of
the profession,” (American Associated of Colleges of Nursing, 2014). Nursing research provides
evidence-based practice findings to improve patient outcomes and meet patient’s goals. In
finding answers to the PICO question, the nurse can assist the patient in exploring nonpharmaceutical interventions to assist in relieving CINV when medications are lacking. As a
registered nurse providing bedside nursing patient care, nursing research is the most useful and
relevant.
When researching articles, the credibility must be questioned. One way to assess the
credibility is by identifying the level of evidence. The levels range from level I to level VII.
Level VII represents the lowest quality of evidence and is classified as an expert’s opinion. Level
I is the highest quality of evidence represents systemic reviews of the topic. Each article that
assisted in answering the PICO question was graded an acceptable level of evidence, and will be
discussed further in the next section.
Discussion of Literature
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To attempt in finding an answer to the PICO question, three references were evaluated.
Each article contains research that was performed. The data obtained from that research was
assessed and graded on level of evidence and applicability to nursing practice was identified.
Article One
The first article was “The effectiveness of progressive muscle relaxation training in
managing chemotherapy-induced nausea and vomiting in Chinese breast cancer patients: a
randomized controlled trial.” In this research trial there were 38 individuals in experimental
group, 33 individuals in control group, all of which have been diagnosed with breast cancer. The
Morrow Assessment of Nausea and Vomiting was used to evaluate level of nausea and vomiting
and was asked via questionnaire (2001). The groups are appropriate and ethical as the
experiment had minimal risks and the participants were aware of the study. Results revealed that
experimental subjects reported fewer times when they felt nauseas than the control subjects. The
difference was most significant in the first 4 days after chemotherapy (2001).
In critiquing this article, the purpose of this study was clear, and easy to identify as it was
in the title of the article. The literature was appropriately reviewed and it was published by the
Department of Nursing at Chinese University of Hong Kong. This article is level 2 evidence, as
is contained one or more randomized controlled trials. This study collected data that was ordinal
level of measurement because nausea/vomiting level were ranked.
Article Two
The second article, “Evaluation of acupuncture for cancer symptoms in cancer institute in
Brazil,” (2012) was also beneficial to answering the PICO question. In this research 183 patients
whom were enrolled in outpatient acupuncture at the State of Sao Paulo Cancer Institute for
treatment of chronic pain, nausea, vomiting, and zerostomia due to cancer or cancer-related
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therapies. The participants ranked their nausea level on a scale from 0-10 (10 being the worst)
before and after acupuncture. Results showed initial (before acupuncture) the average score was
7.04 (p. 25). After acupuncture the average score was 2.56, showing a drastic improvement on
symptom intensity (p. 25)
This article is level 6 on the hierarchy of evidence. This study was observational with no
control group. The question statement was easy to identify and the results were clearly stated.
Using a ranking scale is appropriate, but may have caused some barriers because individuals may
interpret the scale differently. This data is also ordinal level of measurement, due to being based
on a ranking.
Article Three
The last article “Chinese medicinal herbs to treat the side-effects of chemotherapy in
breast cancer patients,” (2007) focused on Chinese herbs. The purpose of this research was to
determine if the use of Chinese medical herbs reduce toxicity-related conditions (ex:
nausea/vomiting) in patients receiving chemotherapy. Like the previous research, the results
were based on numerical ranking. Scores were analyzed after six weeks of treatment and there
was a 1.8% decrease in vomiting in patients receiving the herbal capsule (Zhang, Liu, Li, He,
Tripathy, 2007, p. 1).
The goal of the research was clear. The research consisted of 58 participants. Some
participants were given the Chinese herbs, while others were given placebo pills with starch.
This may lead to ethical issues because those receiving the placebo pills were unaware that it was
not the Chinese herbs. This is level 2 evidence. Participants were chosen via random selection
and there were no determinants as to who received placebo and who received the herbs. The data
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collected was nominal level of measurement because the number of vomiting episodes was the
determining factor.
Significance to Nursing
Nurses work closely along with patients before, during, and after receiving
chemotherapy. Managing side effects of chemotherapy can be one of the most difficult tasks.
There are many medications and anti-emetics available, but unfortunately, they do not work well
for everybody. By researching other interventions to relieve CINV, the nurse can explore these
options with the patients to improve their symptoms and quality of life. By performing research
and evaluating other research, nurses provide the best care because they are using evidencebased practice. Nurses have the skills to “use health research methods and processes, alone or in
partnership with scientists, to generate new knowledge for practice,” (QSEN Institute, 2014).
Evidence-based practice is the most respected set of standards and is supported by the
American Nurses Association Scope and Standards of Practice. “Evidence based practice is a
scholarly and systematic problem-solving paradigm that results in delivery of high-quality health
care,” (American Nurses Association, 2010, p. 16). Research is used to achieve the best patient
outcomes for individuals, groups, populations, and healthcare systems (p. 16).
Acupuncture and muscle relaxation therapy is a realistic therapy that patients in this area
have access to. The Chinese herbs may be less realistic. Identifying and learning nonpharmaceutical interventions to control symptoms is safer for the patient because medication side
effects and errors are no longer a risk. Educating the patients on these regimens may make a
huge difference in how well they recover after chemotherapy.
Conclusion
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The research has proven that Chinese related non-pharmacological remedies can assist in
relieving nausea and vomiting after receiving chemotherapy. By exploring these options with the
patients, it can lead to improved patient outcomes and increase patient safety. Nursing research
develops evidence-based care and allows the patient to have the highest quality of care to
improve their health and meet their goals.
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Reference:
American Association of Colleges of Nursing. (2014). Nursing research. Retrieved from
http://www.aacn.nche.edu/publications/position/nursing-research
American Nurses Association. (2010). Nursing: Scope and standards of practice. (2nd ed). Silver
Spring, MD: Nursesbooks.org.
D’Alessandro, E., de Brito, C., Cecatto, R., Saul, M., Atta, J. A., An Lin, C. (2012). Evaluation of
acupuncture for cancer symptoms in a cancer institute in Brazil. Acupunt Med. 31: 23-26. doi:
10.1136/acupmed-2012-010206
Lansing Community College. (2014). What is PICOT? Retrieved from
http://libguides.lcc.edu/content.php?pid=280891&sid=2313384
Mayo Clinic. (2014). Dehydration. Retrieved from http://www.mayoclinic.org/diseasesconditions/dehydration/basics/symptoms/con-20030056
Molassiotis A., Yung H..P, Yam B.M., Chan F.Y., Mok T.S. (2001). The effectiveness of progressive
muscle relaxation training in managing chemotherapy-induced nausea and vomiting in Chinese
breast cancer patients: a randomized controlled trial. Support Care Cancer. 10(3):237-46
QSEN Institute. (2014). Graduate KSAS: evidence-based practice. Retrieved from
http://qsen.org/competencies/graduate-ksas/#evidence-based_practice
Zhang, M., Liu, X., Li, J., He, L., Tripathy, D. (2007). Chinese medicinal herbs to treat the side-effects
of chemotherapy in breast cancer patients. DOI: 10.1002/14651858.CD004921.pub2