EBP Competency is Primary for All Nursing Graduates

In the evolving landscape of nursing education and practice, there is growing discussion about how well nurses and nursing students achieve the competence required to deliver evidence-based care through the evidenced-based practice (EBP) process. Given that 24 EBP competencies have been around for over a decade (Melnyk et al, 2014; Beckett et al., 2025), it is understandable that all graduates of any nursing program would be expected to be competent in operationalizing the EBP process, no matter their educational level. The 10 basic competencies match expectations for Bachelor of Science in Nursing (BSN) graduates, with an additional 14 advanced competencies for Master of Science in Nursing (MSN), Doctor of Nursing Practice (DNP), and PhD graduates to demonstrate at the completion of their programs. Benner’s novice to expert theory (1983) offers a variance across nursing program graduates, with the range of competence extending from BSN graduates achieving advanced beginner to DNP graduates as experts in EBP. This article will describe the core value of ensuring nurses ask an answerable clinical question as a foundational step to effectively navigate the steps of EBP.

Step 0 of the EBP process is establishing a spirit of inquiry that results in identification of clinical problems with data that provide scope and understanding of the problem within the context of the organization, whether it is community health, primary care, or the acute care setting (Melnyk & Fineout-Overholt, 2023; Milner et al., 2024). From this description of the clinical problem comes the identified gaps about how to resolve the problem (i.e., what we don’t know). Before proceeding to Step 1, it is essential to ask a background question to gain a preliminary understanding of what is known about the clinical problem.  Using the Population, Intervention, and Outcome format, a background question asks, In this population (P), what are the best practices (I) to reduce the outcome (O).  When developing the background question, nurses would gather a high-level overview of what has been studied that impacts the outcomes associated with the clinical problem.  The purpose of this step is to build foundational knowledge, clarify key concepts, and generally understand how the problem has been previously studied. What is learned through the background search directly informs the formulation of a focused foreground clinical question in Step 1, which is then appropriately constructed to guide a systematic, unbiased search for evidence using the Population, Intervention or Issue, Comparison, Outcome, and Time (PICOT) method.

Given that the nature of EBP is that each step builds on the one prior and given that the EBP process has been part of AACN’s expectations of nurses for over 20 years, it is surprising that there is a lack of competence in asking the clinical question (Milner et al., 2024b). Furthermore, evidence indicates that there are more research questions asked for DNP projects than clinical questions (Milner et al, 2023, Milner et al., 2024b). How the nursing profession addresses these gaps in DNP-prepared clinical scholars’ and other nurses’ competency to ask clinical questions is critical for sustainable improvement in evidence-based care. That said, there have been varied responses to these gaps. Some scholars have recommended using other formats than the PICOT method to construct the foreground question that reflects the clinical problem or forego the foreground question (e.g., PURPOSE, PPCO), particularly within the context of point-of-care EBP projects as well as DNP and other student projects. While these approaches may be useful for articulating a project’s intent, we argue that their use represents a conceptual misunderstanding of the distinct purpose served by a structured clinical question. Specifically, the PICOT method helps describe the clinical problem, including the outcome that needs to change, in a way that is designed to guide a systematic and unbiased search of the evidence to determine what is known about what can be done in practice to impact that clinical problem. In contrast, alternative formats, such as PPCO or PURPOSE, primarily emphasize the development of clinical problem description or a project purpose statement.  These methods may not adequately support systematic literature searching. Treating all formats that are used to describe a clinical problem as functionally equivalent and assuming they serve the same aim risks undermining the rigor of the EBP process by disrupting its sequential progression from clinical inquiry, in which a well-constructed clinical question is the foundational step, to evidence searching, appraisal, and application.

Properly used, these formats can support the steps in the EBP process that best match their function.  PPCO functions as a broad, background‑type framework that when used early to understand the clinical problem supports description of the Problem, the Population it affects, the potential Changes needed, and the target Outcomes. Once these elements are described, the knowledge can inform development of the PICOT foreground question (Waldrup et al., 2024). PURPOSE clarifies the scope of a project, the outcomes, users, team, setting, and effort required for the project (Cullen et al., 2023). Both frameworks support the EBP process, but do not lead to a foreground question that guides a systematic, unbiased search. Note that the goal of the search is to identify what has been shown to work (e.g., intervention, process, strategy), ideally rigorous research studies, to achieve the desired outcome.

Start at the Beginning

Nurses must be able to describe the clinical problem using data that come from practice (Hays et al., 2024). This seeds the information needed to form the clinical question in Step 1. Given that the DNP degree is the pinnacle clinical degree in nursing, it is reasonable to expect that these graduates would be able to competently describe clinical problems using practice data, as well as mentor others in the same. Milner and colleagues (2023) demonstrated that across the country, DNP projects fell short of this goal. Without a data-driven description of the clinical problem, it is hard to craft a clinical question. The opposite is true when the data clearly demonstrate the clinical problem by describing the current practice and the outcome (the C and O in the PICOT method). After identifying these, a background search can give insight into which interventions have been studied and are published in the literature. This exploration of the literature helps shape the question with a better understanding of what can help improve the outcome.

Asking Questions Using the PICOT Method and Why It Matters

The PICOT method is the foundation of Step 1 in the EBP process: formulating a focused, searchable clinical question (Bermudez, 2021; Cleary-Holdforth et al., 2021; Gallagher Ford & Melnyk, 2019; Fineout-Overholt & Johnson, 2023; Fineout-Overholt, 2015; McClinton, 2022). This method was designed to generate answerable questions that support systematic literature searching. Each element in the PICOT method contributes to search term selection and clarity, helping clinicians avoid vague or biased searches. The PICOT method enables nursing students and practicing nurses to ask precise, unbiased questions like: "In the emergency department (P), how does use of skilled team for blood culture collection (I) compared with no skilled team (C) affect blood culture contamination rates (O) while in the emergency department (T)?" The keywords from this question are directly translated into the search strategy, leading to discovery of synonyms and subject headings in indexed databases that broaden the yield.  The PICOT method supports intentional search strategies that require priority searching for Outcome and Intervention/Issue, with the expectation that these will be found in all studies retrieved. Systematic searching begins with searching the essential O and I terms, followed by the C term and finally, the P term as needed.  Often when all PICOT terms are entered into the search at one time, the yield is narrow and results in few, or even zero, hits (see more in Fineout-Overholt et al., 2024).

The 2024 national study by Milner et al. affirms the centrality of the PICOT method in the DNP curriculum and in actual project development. The research team found that while DNP students struggle with using the PICOT method correctly, it remains a key tool for framing clinical questions. Ninety-four percent of DNP project authors incorrectly used the PICOT method or asked research questions, and six percent of DNP project authors asked the clinical question using the PICOT method properly (Milner et al., 2024). Errors in using the PICOT method often led to biased searches or premature identification of the project purpose, skipping essential EBP steps like evidence synthesis and appraisal. Focusing on competence using the PICOT method is key to supporting evidence-based decision making.

Critics of the PICOT method have described its use as leading to a kind of “shiny object syndrome,” (Cullen & Fowler, 2025; Tucker et al., 2023), positing that students latch onto an intervention prematurely without sufficient grounding in evidence. This perception reflects a misapplication of the PICOT method versus a flaw in the method itself, which leads back to how nursing students at all levels are being taught and which competencies are evaluated across their programs of study and at graduation. Establishing competency with the EBP process and using the PICOT method requires that the intervention (I) in a clinical question should never be guessed or selected based on convenience or personal preference. Rather, competency focuses on determining the intervention after conducting a thorough background search of the literature to identify which interventions have been studied in relation to the identified outcome. This is essential to ensuring that the intervention under consideration is relevant, feasible, and rooted in existing evidence. The same type of discovery about what has been studied, published, and measured is true for the outcome of interest (O) as well.

For students, the process of selecting the “I” should be collaborative, involving faculty and clinical mentors who are familiar with both the problem and the body of evidence (i.e., existing research), which ensures it is evidence informed. During the background search, students learning the EBP process must familiarize themselves with the literature to determine what has been studied, in what populations, and under what conditions. Only then can they craft a well-formulated, focused clinical question using the PICOT method. Engaging the EBP process with rigor that involves using the PICOT method in this way avoids the very problem some scholars raise and ensures students are building on a foundation of evidence and clinical reality, not chasing shiny, unsupported interventions.

Establishing Rigor with the Current EBP Process

Describing the clinical problem in terms that are clear and data driven is agreed upon by most scholars (Step 0 of the EBP process; Melnyk & Fineout-Overholt, 2023; Milner et al., 2024a). Writing a clinical question using PICOT method (Step 1), systematically searching the literature (Step 2), gathering a relevant body of evidence (Step 2), completing the four-phases of critical appraisal (Step 3), and determining implementation strategies (Step 4) dovetail with tools, like PURPOSE (i.e., Population, Users, Responsible team, Problem, Outcomes, Setting, and Effort; Cullen et al., 2023), that help with writing a purpose statement for a quality improvement or practice change project (Cullen & Fowler, 2025). These tools help articulate what the project will do, for whom, where, and with what intended outcome. This comes later in the EBP process and does not preclude a precise clinical question, systematic evidence searching, and synthesized body of evidence. Tools like PURPOSE can be important for project planning, implementation, and evaluation of project processes and impact. These types of statements typically are written after the clinical problem has been identified, the clinical question has been asked, and the answer the literature can offer has been synthesized. Skipping Step 1, writing the clinical question using the PICOT method risks moving forward with non-evidence-based solutions.

Why Introduce Something New Before Achieving Competency in the Current EBP Process?

Competency #2 states “describes clinical problems using internal evidence” and Competency # 3 (Melnyk, et al., 2017) requires “participat[ing] in the formulation of clinical questions using PICOT format” (p. 47). These are basic competencies expected of all nurses.  Milner and colleagues (2024) noted that the challenge lies not in the PICOT method itself, but in a lack of faculty and mentor training in writing clinical questions using this method. Competency in writing clinical questions using the PICOT method and then searching using the clinical question as a framework were not taught in programs from which most nursing faculty graduated, given the average age is 55.6 (AACN 2024). Abandoning using the PICOT method to write the clinical question in favor of other formats (e.g., PPCO, PURPOSE) confuses two distinct steps in the EBP process. To help simplify the use of these types of tools, the PPCO method, the PICOT method, and the PURPOSE method have utility in the EBP process, but at different points within it:

• The PPCO is a tool to accurately describe the clinical problem that could lead to the background question.
• The PICOT method is a tool for developing a searchable foreground question grounded in clinical inquiry.
• The PURPOSE is a tool for articulating a project aim, once evidence has been appraised and synthesized.

Replacing PICOT short-circuits the critical thinking and evidence appraisal processes that are at the heart of EBP.

The Real Solution: Keep Helpful Tools, Provide Better Support

Rather than discarding the PICOT method, or any other helpful tool that supports the EBP process, the nursing profession and organizations must invest in helping faculty, mentors, and students better understand its role and how to apply it with greater confidence and precision. Guaranteeing competency in the EBP process ensures that student projects are truly grounded in the best available evidence and that their resulting interventions are more likely to yield sustainably improved outcomes. This same competency facilitates interprofessional communication, including the clinical question that underpinned the search for the evidence that drove the practice change, with the mutual goal of improving outcomes.

EBP begins with inquiry that leads to a well-formed question. Without using the PICOT method, there is a risk of asking the wrong questions or worse, implementing interventions that are not evidence-based. Let’s use the tools we have for ensuring rigor and competency with the EBP process where they belong. Engaging PPCO for clinical problem discovery, PICOT to describe the problem in a foreground searchable, answerable question that guides a systematic search for evidence that matters, and PURPOSE to support a clear and concise project goal statement after the synthesis of evidence gets EBP work off on the right foot at the beginning of the journey, guiding us to sustainable outcomes that make a difference.

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