Writing a PICO question is often easier than deciding what the question should actually be about. PICO provides a structure for asking an evidence question, but that structure depends on having a clearly defined problem in practice.

A practice problem is an observable or measurable gap between current care and a safer, more effective, evidence-informed, or otherwise desirable state. It explains what is happening, who is affected, where the gap occurs, and why it deserves attention.

Evidence-based practice models place problem identification near the beginning of the process because the quality of the evidence question depends heavily on how well the problem has been defined (Bissett et al., 2025; Iowa Model Collaborative et al., 2017). Advanced nursing competencies similarly emphasize systematic decision-making, evidence synthesis, and translation of evidence into practice (American Association of Colleges of Nursing [AACN], 2026).

PICO provides the structure for the inquiry. The practice problem determines what needs to be investigated.

A Topic Is Not Yet a Practice Problem

“Hypertension,” “falls,” “medication adherence,” and “emergency department utilization” are topics. They identify areas of interest without describing what is actually going wrong.

A student interested in hypertension might discover that patients with newly elevated blood pressure readings frequently leave a primary care clinic without timely reassessment. Another setting might have problems with inaccurate measurement, medication follow-up, or access to home monitoring. Each represents a different practice problem and would lead to a different evidence search.

The distinction continues through project development:

Term	Purpose	Example
Topic	Identifies a broad area	Hypertension
Practice problem	Defines the gap	Follow-up after newly elevated blood pressure is inconsistent
PICO question	Structures the evidence inquiry	In adults with newly elevated blood pressure, how does a structured follow-up process compared with usual care affect timely reassessment?
Project aim	States what the local project intends to accomplish	Increase timely reassessment during the implementation period

The literature may change the intervention, outcome, population, or project aim. Defining the problem before settling on the solution keeps that possibility open.

Practice Problems Usually Come From Patterns

Many useful practice problems emerge from ordinary clinical work. Quality data may remain below target. Patients may repeatedly encounter the same barrier. Clinicians may approach similar situations differently. A workaround may become routine, or a new guideline may reveal that current practice no longer reflects available evidence.

The Iowa Model identifies clinical problems, quality data, safety concerns, and process issues as potential triggers for evidence-based practice work (Iowa Model Collaborative et al., 2017).

Clinical observation is often where the process starts, but one difficult encounter is not enough to establish a recurring practice problem. A stronger case develops when the same concern appears across patients, clinicians, shifts, or data sources.

Support may come from chart review, quality dashboards, incident reports, patient feedback, benchmark comparisons, workflow observations, or agreement among clinicians who recognize the same pattern. The important step is moving from “this was frustrating” to evidence that the problem extends beyond a single case.

Define the Gap Before Choosing the Intervention

A useful practice problem describes the current state without assuming the solution.

Suppose fewer than half of eligible patients complete recommended follow-up within seven days. That gap can be described and measured before deciding whether the appropriate response is nurse outreach, scheduling before discharge, text messaging, care navigation, an electronic reminder, or another approach.

The same distinction applies when education is proposed immediately. “We need more staff education” already assumes what should change. “Required reassessment is frequently missed after a meaningful change in patient condition” describes the actual gap.

Once the problem is clear, the literature and local assessment can help determine whether education, workflow redesign, a protocol, an electronic prompt, or another intervention has sufficient support.

A useful test is to remove the intervention from the project idea. If a meaningful and measurable problem remains, the underlying practice gap is usually becoming clearer.

Local Data and Published Evidence Serve Different Purposes

A practice problem should eventually be supported by evidence that it exists.

Local evidence may come from chart audits, quality dashboards, infection rates, readmissions, appointment data, patient complaints, incident reports, staff feedback, or workflow observations. These sources establish what is happening within the setting where change is being considered.

Published research, professional guidelines, benchmarking data, and national reports answer a different set of questions. They help establish what is already known about the problem, how similar problems have been studied, and which interventions have been evaluated elsewhere.

Students developing an early PICO question may not yet have access to local organizational data. Published evidence can still support an initial inquiry. Local data become increasingly important as the idea develops into an actual practice-change project because evidence translation depends on understanding the environment in which implementation will occur (White et al., 2024).

A nationally important issue may not represent a meaningful local gap. A locally significant problem may also receive relatively little attention in national literature. Good project development requires recognizing that difference.

Narrow the Problem to Something You Can Influence

Some healthcare problems are too broad for a focused student project without further refinement. Housing instability, medication prices, clinician shortages, rural healthcare access, health disparities, and emergency department crowding involve forces extending across multiple organizations, policies, and social systems.

The task is to identify a part of the larger issue that can realistically be examined or changed within the available setting.

National hypertension prevalence cannot be changed through one DNP project. Inconsistent follow-up after newly elevated blood pressure readings in one clinic may be manageable. Emergency department crowding cannot be solved through one departmental intervention, while a specific delay within one portion of patient flow may be measurable and modifiable.

Narrowing the problem also helps prevent a project from becoming overloaded with screening, education, referrals, staff training, electronic changes, follow-up processes, and multiple long-term outcomes at the same time.

A focused project can address one meaningful part of a larger healthcare problem and still produce useful evidence about practice.

Define the Population, Setting, and Consequence

A practice problem becomes more useful when it identifies who is affected and where the gap occurs.

“Older adults” may be too broad if the problem concerns hospitalized older adults receiving medications associated with increased fall risk. “Emergency department patients” may be unnecessarily broad if a transition problem predominantly affects patients with complex follow-up needs.

The population should be specific enough to describe the problem meaningfully while remaining broad enough to locate relevant evidence. Preliminary searching can help show how similar populations have been defined in published research (Bissett et al., 2025).

Setting also affects applicability. An intervention developed in long-term care may require substantial adaptation before implementation in primary care or an emergency department. The Johns Hopkins evidence-based practice approach considers population and setting during question development for this reason (Bissett et al., 2025).

The gap also needs a meaningful consequence. Problems may affect safety, access, delay, patient experience, clinical outcomes, workflow, utilization, cost, or another dimension of healthcare quality. That consequence often points toward the outcome that will eventually appear in the PICO question.

Check the Problem Before Building the PICO

Before finalizing the evidence question, the practice problem should be clear enough to answer several practical questions:

Question	What should be clear
What is happening now?	The current practice, process, or outcome
Who is affected?	A reasonably defined population
Where does it occur?	The relevant setting
Why is it a problem?	A meaningful consequence
What suggests the gap exists?	Data, benchmarks, repeated observations, stakeholder input, or published evidence
Is part of it modifiable?	A process or practice that can realistically be influenced
Can change be measured?	An outcome or process capable of showing what happened
Is the scope manageable?	A problem that can be investigated within the available setting and timeframe

Difficulty answering several of these questions usually means the idea is still closer to a topic than a defined practice problem.

A preliminary literature search can help refine the wording before the PICO is finalized. It may reveal how researchers define the population, which terminology appears in the literature, and whether the proposed intervention or outcome has been studied in the way initially expected (Bissett et al., 2025).

Once the problem is sufficiently clear, the PICO components become easier to identify. The population comes from who is experiencing the gap. The intervention comes from the approach supported by the evidence and under consideration. The comparison reflects current practice or another appropriate alternative. The outcome connects with the consequence the project is intended to improve.

The Writing a Strong PICO Question guide covers those components in greater detail.

The broader evidence-based practice pathway then continues through literature searching, critical appraisal, evidence synthesis, implementation, and evaluation. The question may continue to evolve as the evidence and local understanding improve (Bissett et al., 2025; White et al., 2024).

A useful PICO question begins with a practice gap defined well enough that the evidence has something specific to answer.

References

American Association of Colleges of Nursing. (2026). The Essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/0/PDFs/Publications/Essentials-2026.pdf

Bissett, K., Ascenzi, J., & Whalen, M. (2025). Johns Hopkins evidence-based practice for nurses and healthcare professionals: Model and guidelines (5th ed.). Sigma Theta Tau International.

Iowa Model Collaborative, Buckwalter, K. C., Cullen, L., Hanrahan, K., Kleiber, C., McCarthy, A. M., Rakel, B., Steelman, V., Tripp-Reimer, T., & Tucker, S. (2017). Iowa Model of evidence-based practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175–182. https://doi.org/10.1111/wvn.12223

White, K. M., Dudley-Brown, S., & Terhaar, M. F. (Eds.). (2024). Translation of evidence into nursing and healthcare (4th ed.). Springer Publishing Company.