Yogis right. If we dont know where were going, we just might not get there. Stated positively, if we can learn to pose a specific question, we have hope of fining a specific answer. This topic is that basic and the most important in this text. This chapter spends considerable time on learning to pose questions, because a well-built question is essential to all the other steps of EBP. The whole process of EBP depends on a good question. Other texts on evidence-based practice place posing a question first (Sackett, Straus, Richardson, Rosenberg & Haynes, 2000, p. 13), and many write articles and whole chapters just about posing specific questions (Armstrong,1999; Gibbs, 1991, pp. 109-133; McKibbon, Richardson & Walker-Dilks, 1999; Richardson, 1998, Richardson, Wilson, Nishikawa, & Hayward, 1995).
Initially, problems caused by vague questions are discussed to show why practitioners need question wording skills. Then this chapter defines generally what it means to pose a specific question, first with reference to COPES concepts (Client Oriented Practical Evidence Search), then with reference to elements present in clear questions as stated in Table 3-1. This Table includes five types of practice questions (Effectiveness, Prevention, Assessment, Description, and Risk) and four features of a well-built question relative to each (Client Type and Problem, What You Might Do, Alternate Course of Action, What You Want to Accomplish). Do study Table 3-1 carefully to get the gist of this chapters organization. Its examples will clarify the question types and criteria for clarity.
For each of the five question types, this chapter will give background regarding real practice situations and will derive specific COPES questions regarding each one. As you read each situation, try to put yourself in the practitioners and clients positions. Practice posing your own clear answerable question from the case material, then read the example question to see how well you did relative to criteria for a specific question. Doing so will prepare you for the three exercises at the end of the chapter.
This chapters three exercises concern successively more complex questioning tasks. Exercise 3-A gives you practice classifying and posing specific questions from case material. Next, Exercise 3-B helps to practice posing questions regarding real clients even if you do not have your own clients. Exercise 3-B will guide you through the process of soliciting a question from a practitioner in any discipline, either by phone or by letter, and clarifying your question. Exercise 3-B can supply you with a question that you can work on in later chapters (e.g. searching for related evidence, evaluating that evidence, deciding what action to recommend). Exercise 3-C assumes that you are employed in an agency and have access to your own clients. This exercise guides you through posing a specific question from your own practice.
The Need to Pose Vital Questions and Example General Questions
Here are some reasons for learning how to pose specific questions about practice:
COPES questions are worthwhile questions. COPES questions come directly from practice. COPES questions have three general features. First, they are questions from daily practice, posed by practitioners, that really matter to the clients welfaretheyre Client Oriented (Here the word client refers to an individual, to a group of clients, or to a community). Generally speaking, COPES questions concern issues that are central to the welfare of the client and to those whose lives are affected by the client. For example, the accuracy and reliability of an assessment of a child to determine whether it is autistic would concern a matter of central importance to the child and to the childs parent. If the child is autistic, then an effort might be made specific to that childs problem, but first the assessment presents a central problem. Another concern of central importance to a client might be a young woman who experiences feelings of panic in social situations. This problem presents a real problem for her. She thinks her quality of life will improve dramatically if she can get the problem under control; so the answer to a related question regarding the efficacy of treatments for her problem would be client-oriented. Regarding still another question, the effectiveness of group treatment for men who have abused their wives would be of vital importance for obvious reasons to the men, to their wives, and to their probation and parole agent who conducts the group. Regarding gangs, knowing which factors most frequently precede Hmong boys joining gangs might help a community organizer and community leaders to design a gang prevention program for them. All of these questions are Client Oriented. They begin with a matter of importance to clients.
Second, COPES questions have Practical importance in several ways. In addition to their central importance to the client and to persons affected by the client, COPES questions have practical significance if they concern problems that arise frequently in everyday practice. For example, if a child protective service worker takes telephone intake duty for at least one day a week, and these telephone contacts generally require some assessment of risk, then asking a question about what types of clients present the greatest immediate risk for child abuse would have repeated practical significance. COPES questions also have practical significance if they concern the mission of the agency. For example, asking a question about how to match hard to place children with foster families most likely to meet the childs needs would be a question central to a foster care agency. A COPES question will also have practical significance if knowing the answer concerns something within the realm of possibility. For example, a school social worker searching for the answer to whether the Lovaas method will help an autistic child demonstrates a question that has no practical value if funds for the treatment are unavailable or if no one in the region can administer the treatment.
Third, COPES questions can guide an Evidence Search. In order to guide an evidence search, a question must be posed specifically enough to get an answer in an electronic search. The process of formulating a specific question begins with a somewhat vague general question and then proceeds to a well-built question. COPES questions generally fall into five types that all meet four criteria for answerability (See Table 3-1).
Before we move on to examples of the five types of general questions and how these questions can become worked into well-built, answerable ones, it might help to know that COPES questions are sometimes called POEMs in medicine (Slawson & Shaughnessy, 1997). POEMs concern Patient Oriented Evidence that Matters (have real importance worth investigating) (p. 947). Since many practitiones dont work in a medical setting, and they may call the persons whom they serve clients, the acronym POEM would not do generally.
Also as an aside before we move to posing five types of questions specifically, the term COPES was not my invention. To give due credit, I must tell you where the term came from. For many hours my search went on without success for an acronym for practitioners aside from medicine that would get the features of a good question, but one that would not be a POEM! One just would not come to mind, until I noticed two women doing crossword puzzles in their seats next to me during an airline flight. Between their comments about heroes of the soap operas and gum chewing, the women solved several complex crossword puzzles with incredible speed and efficiency. Their ability to discuss a TV episode and to simultaneously solve a puzzle showed incredible verbal fluency. I wondered if they would mind directing their fine minds to the POEM acronym problem; they did, and they solved it in ten less than ten minutes with: Client Oriented Practical Evidence Search (COPES) (Brown, Sept. 16, 1999).
Five COPES Question Types and Four Features of Well-Built Questions
Table 3-1 below gets the essence of this chapter. On the vertical left you will see the five question types. Across to the right next to each question type you will find the question worded from left to right in a way that includes all four elements of a well-built COPES question. Do study the table for several minutes to get the most of the examples that follow the table.
Table 3-1: Five COPES
Question Types and Four Corresponding Features of a Well-Built Question
Examples of General Questions and Related COPES Questions
Each of the ten situations below implies a COPES question or questions. Note how the situation is Client Oriented in that it concerns a matter of importance to the client. Notice how each question arose logically out of a practitioners concern for how to approach the problem in a Practical way using available resources and skills, and notice too that the accompanying well-built question is posed so specifically relative to four criteria that it can guide an Evidence Search.
Each situation came from practice in an assortment of agencies and client types. All of the questions used in this chapter concern real clients, real members of the helping professions, and real practice issues, though the situations are modified slightly to protect confidentiality. None in this book are real client names.
Please note also that the five questions each exemplify one of five types including the following: Effectiveness, Prevention, Risk, Assessment, and Description. In the situations below, each question type is defined first, then for each question type two situations will be given including a general question and a well-built or specific question. At each general question, you might want to practice posing your own COPES question before you read the example question. To do so, you might take a piece of paper and slide it down to cover the Related Well-Built Question and try to pose it yourself before looking at the example. Doing so will help you to prepare for Exercise 3-A.
Effectiveness Question: Definition by General Concept and Two Examples
Effectiveness Questions concern the direct effects of an intervention on clients who share a particular problem and who have been exposed to the intervention (treatment).
3.1 Example Effectiveness Question Regarding Long-Term Care for Residents
of a Nursing Home
Box 3-2 Example Effectiveness Question Regarding a Probation and Parole Agents Use of Cognitive Group Treatment
Prevention Question: Definition by General Concept and Two Examples
Prevention Questions concern the effectiveness of interventions (treatments) that intend to prevent the initial occurrence of a problem before it can happen.
Box 3.4: A Community Organizers Question Regarding Preventing Hmong Boys Joining Gangs
Risk/Prognosis Question: Definition by General Concept and Two Examples
Risk/Prognosis Questions concern the likelihood or probability that a particular type of client will experience undesirable consequences within a give interval of time.
Box 3.5: A Protective Service Workers Concern for Risk of Re-abuse In the Childs Home
Box 3.6: A Community Support Workers Question Regarding Risk for Suicide
Assessment Questions: Definition by General Concept and Two Examples
concern standardized measures or procedures to determine whether a client
has a particular problem or strength and whether a client has benefited
from an intervention (treatment).
3.7: A Protective Service Workers Question About Shaken Baby Syndrome
Box 3.8: A Hospital Social Workers Question Regarding How to Screen for Dementia
Description Questions: Definition by General Concept and Two Examples
most often concern surveys of client needs or client satisfaction, but
can include any kind of effort that involves observations of clients within
a sample and generalizations made from that sample. Description Questions
can include qualitative studies that often seek an in-depth understanding
for client experiences and perceptions.
3.9: A Youth Workers Question Regarding the Age When Racial Identity
* A possibly more important question might be an Effectiveness Question regarding the effects of programs designed to foster or to negate racial identity. We have not yet gotten to questions of value that underlie any COPES question.
3.10: A Special Needs Adoptions Workers Question Regarding Adjustment
of Children Placed With Homosexual Couples
*This question implies a particular direction for an answer. Truth seeking implies an open mindedness to all possible answers to the question. This let truth fall where it may approach to seeking the answers to questions will be discussed in depth in the next chapter.
Practitioners Pose Vague Questions
Note also in Table 3-1 how each question includes all four elements of a well-built question whose four elements appear in order from left to right. Note how, as you read the questions they state first the client type, then the course of action being considered, then, where appropriate, an alternate course of action, and finally the intended result. These eighty-four questions came from a pile of hundreds that have been collected over two decades. Not one question was well-built relative to twelve criteria for a specific question (Gibbs, 1991, pp. 109-133). Apparently, practitioners may have not learned to pose specific questions. All of the original practitioners questions in Table 3-1 had to be reworded to make them well built. Therefore, another worthwhile area for research concerns how best to teach practitioners to pose specific questions about their practice.
Questions Concern Effectiveness and Other Issues as Well
Note also that all of the questions in Table 3-1 are Effectiveness Questions. Practitioners should be encouraged to ask questions of greatest importance to their clients; so limiting my research students to Effectiveness Questions only, though defensible for practical reasons, artificially limited the task for practitioners. When given wider choices, practitioners will ask other types of questions. Our limited experience with an Evidence-Based Practice assignment over a three-year period (taught by Donald Mowry, Richard Ryberg and myself) has shown that Effectiveness Questions account for slightly over half of the questions posed by our fieldwork students in their Evidence-Based Practice exercise. The rest come from the remaining four question types. Here are the numbers and proportions for each type of question during the three-year period: Effectiveness (N=35; 53%), Prevention (N=4; 6%), Assessment (N=15; 22%), Description (N=5; 8%) and Risk/Prognosis (N=7; 11%). Though we have no data on a wider scale, these data imply that practitioners may, when given the choice, ask Effectiveness Questions for about half of their practice questions. Another area for research concerns the need for surveys to discover which question types concern practitioners most in different settings.
Questions Need to be Posed as Questions of Fact
Note also how all of the questions in Table 3-1 are ones of fact. All COPES questions meet criteria for being Questions of Fact, because they can be answered by making observations through a process of testing or verification, a process that we would most commonly call, doing a study. Questions of fact can be posed in if/then format. In contrast, Questions of Value assume some underlying belief about what is fair and worthwhile in the world. Usually questions of value contain the word should either stated or implied within them. Questions of value generally cannot be answered through a process of verification or by test; they rely for an answer on what is in your heart. Each of the questions in Table 3-1 were posed because a human service worker had answered affirmatively an underlying related question of value including these: Is it worthwhile to seek the answer to this question? Yes! Should we find out the answer to this question? Yes!
Drawing a Distinction Between a Question of
Another related lesson here concerns the fact/value distinction. Confusing questions of value with questions of fact can lead to unnecessary and unproductive argument. One of the biggest problems in practice arises when we confuse Questions of Fact with Questions of Value. For example, assume that you have a great deal of your efforts tied up in an anger management program, and you value the program immensely because it concerns a matter of importance to you. You are concerned about violence among young people. You believe that such violence must stop. You believe in your heart that the young should treat each other with respect and kindness and that they should learn to manage their anger. Assume further that another practitioner asks the following question of fact related to your anger management program: If delinquent adolescents in an inpatient facility receive anger management group therapy as opposed to no such therapy, then will the former have lower anger (State Anger Scale scores)? You might become incensed and hurt that someone would pose such a question. You might say, "Dont you care about the problem of violence among adolescents? How could you ask such a question? Your response would then demonstrate confusing a Question of Value with a Question of Fact. The practioner posing the Question of Fact regarding effectiveness might share your values entirely, but still want to know if in fact the anger management program achieves its objective. Questions of Value determine which Questions of Fact we try to answer. On the other hand, Questions of Fact seek an answer to a specific question through a process of guessing and testing. This book cannot tell you which Questions of Fact to pose. This lies in your heart and in your professions value base.
Questions Need to Be Posed So They Do Not Imply an Answer
One more lesson about posing questions: All questions need to be posed so they dont imply what the answer is expected to be. Question wording should imply an objective search for an answer. For example, does this question imply an objective search for an answer: If hard to place children are adopted into homes of homosexual couples, as opposed to heterosexual couples, then among the former, how much lower will their interpersonal adjustment scores be? Such a question implies that it must be lower. To be worth our effort, we need COPES questions that are well-built, that are posed as questions of fact, and that are fair and objectively worded.
the questions below will serve as a model for Effectiveness Questions.
You may not want to read other than those that pertain to a particular
practice area, but they are included here to demonstrate the incredible
diversity of important questions that can arise from practitioners.
Some Final Suggestions Regarding Soliciting Questions from Practitioners
These suggestions may make doing this chapters exercises easier. These suggestions concern how to approach a practitioner for a question. Because learning how to pose questions regarding practice does not constitute a standard part of education for practice, doing the exercises below will present a challenge. Many practitioners have never seriously thought to pose specific questions about the effectiveness of their methods, nor seriously wondered if there might be a more accurate way to evaluate risk, nor wondered about the inter-rater agreement of persons doing independent assessments. My students report that some practitioners are struck dumb by the almost unworldly event of being asked to help pose a question. They look at the questioner with the stare of a walleyed pike. Be prepared to encounter a blank look or a puzzled tone of voice when soliciting questions from practitioners. Sometimes practitioners assume that if they help you to pose a question, then they are committing themselves to doing a study, and all the inconvenience and time that entails. It may help to assure them that you are only planning a search for the current best evidence and may plan, but not execute, a study.
to solicit your question. It will probably help greatly if you review
the concepts in this chapter so that you can clarify for others what a
COPES question is, what the five question types may be, and which four
elements of a question you need to state. Some practitioners, on the other
hand, open the flood gates when asked. They spew out many vague questions
in rapid succession, mixing questions of value and questions of fact,
all in a jumble, and when asked for clarification they insert still more
questions and elements of questions. Such gushy cooperation can induce
paralysis in a questioners mind as effectively can a walleyed look.
To counter the open flood-gate problem, try to focus on a single topic
of importance; listen carefully and reflect feelings as questions of value
come forward; try to solicit COPES questions that include all elements
of a well-built question.
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