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Evidence based practice
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RML Rendezvous - Evidence Based Nursing

  1. 1. Janet G Schnall, MS, AHIP Library Liaison to the UW School of Nursing Health Sciences Libraries Affiliate Instructor, UW School of Nursing University of Washington, Seattle, WA [email_address] Teaching Evidence-Based Practice Resources to Nurses and Nursing Students
  2. 2. Objectives <ul><li>Describe how to teach web resources to nurses and nursing students to use for evidence-based nursing practice </li></ul><ul><li>Highlight importance of EBNP to improve patient care </li></ul><ul><li>Identify evidence-based nursing resources on the web </li></ul><ul><li>Describe strategies to find evidence on the web for EBNP </li></ul>
  3. 3. What is evidence-based practice? <ul><li>Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. </li></ul><ul><li>The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. </li></ul><ul><li>Sackett DL et al. Evidence based medicine: what it is and what it isn't. </li></ul><ul><li>BMJ 1996 Jan 13; 312 (7023): 71-2. </li></ul>
  4. 4. Evidence-Based Practice
  5. 5. What is evidence-based nursing practice? <ul><li>&quot;Evidence-based nursing (EBN) means using the best available evidence from research, along with patient preferences and clinical experience, when making nursing decisions.&quot; </li></ul><ul><li>Cullum N. Users' guides to the nursing literature: an introduction. </li></ul><ul><li>Evid Based Nurs 2000 Jul;3(3):71-2. doi:10.1136/ebn.3.3.71 </li></ul>
  6. 6. Why do nurses need to do EBP? <ul><li>Results in better patient outcomes </li></ul><ul><ul><li>Failure to use evidence results in lower quality, less effective, more expensive care </li></ul></ul><ul><ul><li>Berwick DM . Disseminating innovations in health care. JAMA 2003 Apr 16;289(15):1969-75 </li></ul></ul><ul><li>Keeps practice current and relevant </li></ul><ul><li>Increases confidence in decision making </li></ul><ul><li>Experience greater autonomy in practice </li></ul><ul><li>Increases level of job satisfaction </li></ul>
  7. 7. Barriers to Nurses using EBP <ul><li>Lack of TIME </li></ul><ul><li>Lack of value of research in practice </li></ul><ul><li>Lack of understanding of electronic databases to find evidence </li></ul><ul><li>Lack of computer skills </li></ul><ul><li>Lack of EBP mentors at point of care </li></ul><ul><li>Difficulty understanding research articles </li></ul><ul><ul><li>Pravikoff DS, Tanner AB, Pierce ST. Readiness of U.S. nurses for </li></ul></ul><ul><ul><li>evidence-based practice. Amer J Nurs 2005 Sep;105(9): 40-52. </li></ul></ul>
  8. 8. 5 (7) Steps for EBN Practice <ul><li>1. Convert your information into an answerable question ( PICO ) </li></ul><ul><li>2. Search the literature for the best available evidence </li></ul><ul><li>3. Critically appraise the evidence for validity and usefulness </li></ul><ul><li>4. Apply the findings to your clinical practice along with clinical expertise and patient’s perspective to plan care </li></ul><ul><li>5. Evaluate the outcomes of your practice decisions or changes based on evidence. </li></ul>
  9. 9. 2 Additional Steps for EBP=7 Steps <ul><li>Step 0: Cultivate a spirit of inquiry </li></ul><ul><li>Step 6: Disseminate EBP results </li></ul><ul><li>Melnyk BM, Fineout-Overholt E, Stillwell SB, Williamson KM. Evidence-based practice: step by step: the seven steps of evidence-based practice. Am J Nurs 2010 Jan;110(1):51-3. PMID: 20032669. </li></ul>
  10. 10. What makes good evidence? <ul><li>Based on scientific research </li></ul><ul><li>RCT </li></ul><ul><li>Systematic review </li></ul><ul><li>Meta-analysis </li></ul><ul><li>Clinical guidelines </li></ul><ul><li>Opinion </li></ul><ul><li>Consensus </li></ul><ul><li>Because it’s been done this way for 100 years </li></ul>Good Shoddy
  11. 11. See’s Chocolates Slide adapted from Edward G. Miner Library, University of Rochester School of Medicine and Dentistry Chocolate Decadence Pyramid
  12. 12. Lots of Evidence Pyramids!
  13. 13. Searching for Evidence Pyramid: Basic MetaSearch Engines ex. TRIP ex. Cochrane ex. DynaMed, Nursing Reference Center, NGC ex. MEDLINE/PubMed, CINAHL ex.Textbooks, UptoDate Systematic Reviews, Meta-Analyses Evidence Summaries, Evidence Guidelines Randomized Controlled Trials (RCTs), Cohort Studies, Qualitative Studies Background Information, Expert Opinion
  14. 14. Searching for Evidence Pyramid: Detailed healthlinks.washington.edu/ebp/ebptools.html Modified from University of Virginia Health Sciences Library
  15. 15. 5S and 6S Pyramids 5S Model
  16. 16. Read about 5S and 6S Models <ul><li>The 5S Model Haynes B. Of studies, syntheses, synopses, summaries, and systems: The &quot;5S&quot; evolution of information services for evidence-based healthcare decisions. ACP J Club 2006 Nov-Dec;145(3):A8. </li></ul><ul><li>The 6S Model DiCenso A, Bayley L, Haynes RB. Accessing pre-appraised evidence:fine-tuning the 5S model into a 6S model. Evid Based Nurs 2009 Oct;12(4):99-101. doi:10.1136/ebn.12.4.99-b </li></ul>
  17. 17. HealthLinks: DNP Toolkit healthlinks.washington.edu.offcampus.lib.washington.edu/nurse/dnp
  18. 18. HealthLinks: Basic Introduction to Evidence-Based Practice Resources healthlinks.washington.edu/hsl/classes/evidence
  19. 19. Create your own Evidence Pyramid www.ebmpyramid.org/home.php EBM Page Generator
  20. 20. EBN Resources Flow Chart <ul><li>Kendall S. Evidence-based resources simplified. Can Fam Physician 2008 Feb; 54(2):241-3. </li></ul>
  21. 21. Search for the Best Evidence to answer the Question
  22. 22. Search Databases Efficiently for Research Journal Articles <ul><li>MEDLINE </li></ul><ul><li>or PubMed pubmed.gov </li></ul><ul><li>CINAHL/CINAHL Plus </li></ul>
  23. 23. CINAHL or [CINAHL Plus] cinahl.com <ul><li>Cumulative Index to Nursing and Allied Health Literature </li></ul><ul><li>Provides coverage from 1982 [1937] to date, of nursing and 17 allied health disciplines literature </li></ul><ul><li>1700+ [3800+] journals indexed including virtually all English-language nursing journals </li></ul><ul><li>Can easily search for Research articles </li></ul>
  24. 24. CINAHL: enter search terms
  25. 25. CINAHL Limit Your Results Screen CINAHL Limit Your Results Screen
  26. 26. CINAHL Publication Type Limits <ul><li>Clinical trial </li></ul><ul><li>Critical path </li></ul><ul><li>Practice guidelines </li></ul><ul><li>Research </li></ul><ul><li>Standards </li></ul><ul><li>Systematic review </li></ul>
  27. 27. CINAHL Results link to full text
  28. 28. Abstracts
  29. 29. Full text article
  30. 30. Searching CINAHL Plus Help web page healthlinks.washington.edu/howto/cinahlplus
  31. 31. Search MEDLINE or PubMed <ul><li>PubMed includes MEDLINE (1940’s+) </li></ul><ul><li>Indexes 5,000 biomedical journals </li></ul><ul><li>Covers all aspects of biosciences and healthcare </li></ul><ul><li>75%-80% of citations have abstracts </li></ul><ul><li>Updated 5x/week </li></ul>
  32. 32. 2 MEDLINE/PubMed Strategies for Finding Evidence-Based Citations <ul><li>1. Use Limits: Publication Type of Article </li></ul><ul><ul><li>Randomized Controlled Trial </li></ul></ul><ul><ul><li>Meta-Analysis </li></ul></ul><ul><ul><li>Practice Guideline </li></ul></ul><ul><ul><li>Clinical Trial </li></ul></ul><ul><ul><li>Consensus Development Conference </li></ul></ul><ul><li>2. Use Clinical Queries section </li></ul>
  33. 33. MEDLINE Search Screen Randomized controlled trial Strategy #1: Limit to RCTs under Publication Type
  34. 34. MEDLINE Results MEDLINE Results link to full text link to full text
  35. 36. Strategy #2: Clinical Queries – Link on Advanced Search or Home page
  36. 37. healthlinks.washington.edu/howto/pubmed
  37. 38. CINAHL vs MEDLINE <ul><li>CINAHL </li></ul><ul><li>Coverage: 1982+ </li></ul><ul><li>Indexes 1700 journals </li></ul><ul><li>Focuses on nursing and allied health literature </li></ul><ul><li>CINAHL Thesaurus with more nursing terms </li></ul><ul><li>Has peer-reviewed limit </li></ul><ul><li>Includes cited references at end of many refs </li></ul><ul><li>MEDLINE </li></ul><ul><li>Coverage: late 1940’s+ </li></ul><ul><li>Indexes 5000 journals </li></ul><ul><li>Focuses on biomedical literature </li></ul><ul><li>Uses MeSH as its controlled vocabulary </li></ul><ul><li>No peer-reviewed limit </li></ul><ul><li>No cited references </li></ul>
  38. 39. Locating E-Journals <ul><li>Check with your library for access to </li></ul><ul><li>full-text e-journals </li></ul><ul><li>Use HEAL-WA for WA State nurses </li></ul><ul><ul><li>Includes CINAHL and MEDLINE full-text </li></ul></ul><ul><ul><li>A-Z Journals: 2,600 full-text journals </li></ul></ul><ul><li>UW Affiliates : use the Proxy service to access full-text ejournals from off-campus </li></ul>
  39. 40. HEAL-WA Health Electronic Resource for Washington heal-wa.org <ul><li>Began: January 2009 </li></ul><ul><li>Website: offers online access to a collection of health information resources </li></ul><ul><li>Who has access? selected health care providers in Washington YES, NURSES ! </li></ul><ul><li>Funded by: license fees </li></ul><ul><li>Mission: provide evidence-based information to support patient care </li></ul>
  40. 41. What is included in HEAL-WA? <ul><li>Resources: electronic databases, online texts, and e-journals </li></ul><ul><li>Includes information resources specific to nurses, such as CINAHL and the Nursing Reference Center </li></ul><ul><li>Other excellent resources: MEDLINE , DynaMed, Cochrane, Natural Standard </li></ul><ul><li>Gives practitioners access to timely, </li></ul><ul><li>evidence-based answers to patient care Q’s </li></ul>
  41. 42. h heal-wa.org
  42. 43. HEAL-WA Toolkit: Registered Nurse
  43. 44. HEAL-WA Toolkit: ARNP
  44. 45. HEAL-WA Journals A-Z 2,600 full-text health-related journals
  45. 46. Open Access and Free Journal Sites <ul><li>BioMed Central biomedcentral.com </li></ul><ul><ul><li>Independent publishing house providing immediate free access to peer-reviewed biomedical research </li></ul></ul><ul><ul><li>Includes BMC Nursing, etc. </li></ul></ul><ul><li>PubMed Central pubmedcentral.gov </li></ul><ul><ul><li>National Library of Medicine's free digital archive of biomedical and life sciences journal literature </li></ul></ul><ul><li>Free Medical Journals freemedicaljournals.com </li></ul><ul><li>Highwire Press highwire.stanford.edu </li></ul><ul><ul><li>Provides full-text to over 1,000 peer-reviewed scientific, medical and social science journals. </li></ul></ul>
  46. 47. Search Clinical Practice Guideline Resources <ul><li>National Guideline Clearinghouse </li></ul><ul><li>Nursing Reference Center </li></ul><ul><li>MEDLINE/PubMed </li></ul><ul><li>CINAHL/CINAHL Plus </li></ul><ul><li>Advanced Google or Google Scholar </li></ul>
  47. 48. Clinical Practice Guidelines <ul><li>Systematically developed statements of appropriate care designed to assist the practitioner and patient make decisions about appropriate health care for specific clinical circumstances </li></ul><ul><li>Usually based on the most current available research if from reputable, authoritative organizations </li></ul><ul><li>Developed using widely varying standards </li></ul><ul><ul><li>Cost may be considered as well as health outcomes or politics </li></ul></ul>
  48. 49. National Guideline Clearinghouse guideline.gov <ul><li>Initiative of the Agency for Healthcare Research and Quality (AHRQ) </li></ul><ul><li>Database of clinical practice guidelines and related documents </li></ul><ul><li>Free </li></ul><ul><li>Updated weekly </li></ul><ul><li>Voluntary participation </li></ul>
  49. 51. Guideline Comparison
  50. 52. Guideline Summary
  51. 53. Searching for Practice Guidelines in: <ul><li>MEDLINE/PubMed </li></ul><ul><li>CINAHL </li></ul>Limit to Practice Guidelines under Publication Type <ul><ul><li>Limit to Practice Guideline </li></ul></ul>In MEDLINE , under Pub Type : In PubMed, under Type of Article:
  52. 54. Search for Evidence Summaries <ul><li>DynaMed </li></ul><ul><ul><li>Evidence-based clinical resource providing summaries of 3,500+ diseases and conditions </li></ul></ul><ul><li>Nursing Reference Center </li></ul><ul><ul><li>Comprehensive point-of-care resource for nurses, including Evidence-based Care Sheets </li></ul></ul><ul><li>Evidence-Based Nursing </li></ul><ul><ul><li>Quarterly journal that assesses clinical relevance of research studies from international journals </li></ul></ul>
  53. 55. DynaMed <ul><li>Provides summaries of the best evidence for over 3,500 clinical topics </li></ul><ul><li>Can quickly browse and find key recommendations </li></ul><ul><li>Updated daily </li></ul><ul><li>Monitors content of over 500 journals and systematic review databases </li></ul><ul><li>Available for PDA and mobile devices </li></ul>
  54. 57. DynaMed: Treatment Overview Level 1 evidence
  55. 58. DynaMed Treatment, detailed Level 1 evidence Full-text
  56. 59. DynaMed: Reviews and Guidelines
  57. 60. Levels and Grades of Evidence REPROLINE, Johns Hopkins University www.reproline.jhu.edu
  58. 61. Nursing Reference Center <ul><li>Evidence-based Care Sheets </li></ul><ul><ul><li>Evidence-based summaries on key topics incorporating the best available evidence through vigorous systematic surveillance </li></ul></ul><ul><li>Diseases & Conditions </li></ul><ul><li>Quick Lessons </li></ul><ul><li>Drug information </li></ul><ul><li>Skills & Procedures </li></ul><ul><li>Practice Guidelines </li></ul><ul><li>Patient Education materials </li></ul><ul><li>CE modules </li></ul>
  59. 62. Nursing Reference Center: Basic Search
  60. 64. Nursing Reference Center Evidence-Based Care Sheet April 2009
  61. 65. Evidence-Based Nursing <ul><li>Surveys a wide range of international medical journals applying strict criteria for the quality and validity of research </li></ul><ul><li>Practicing clinicians assess the clinical relevance of the best studies </li></ul><ul><li>Key details of these essential studies are presented in a succinct, informative abstract with an expert commentary on its clinical application </li></ul>
  62. 66. Evidence-Based Nursing review
  63. 68. Additional Point of Care Evidence-Based Resources for Nursing: [have some level of evidence-based information] <ul><li>Clini-eguide Nursing Advisor www.clineguide.com/nursing-standards-care-plan.aspx </li></ul><ul><li>Lippincott’s Nursing Procedures & Skills www.healthstream.com/Lippincott/ </li></ul><ul><li>Mosby’s Nursing Consult www.nursingconsult.com </li></ul><ul><li>Mosby’s Nursing Skills mosbysnursingskills.com </li></ul><ul><li>UptoDate uptodate.com </li></ul>
  64. 69. Essential Nursing Resources from ICIRN icirn.org
  65. 70. Search for Evidence in Natural Medicines and Herbal Resources <ul><li>Natural Medicines Comprehensive Database </li></ul><ul><ul><li>naturaldatabase.com </li></ul></ul><ul><li>Natural Standard naturalstandard.com </li></ul><ul><ul><li>high quality, evidence-based information about complementary and alternative therapies </li></ul></ul><ul><ul><li>Also available partially through </li></ul></ul><ul><ul><li>MedlinePlus: Drugs, Herbs, and Supplements </li></ul></ul><ul><ul><li>www.nlm.nih.gov/medlineplus/druginformation.html </li></ul></ul>
  66. 71. Natural Medicines Comprehensive Database
  67. 72. Natural Standard Professional reading level 12 th grade reading level Patient handout 5 th grade Aloe
  68. 73. Natural Standard Professional Monograph
  69. 74. Aloe Natural Standard
  70. 76. Use a Meta-Search Engine to find evidence sites Allows you to search multiple other search engines simultaneously and combine the results
  71. 77. Special Meta -Search Engines that find evidence sites TRIP tripdatabase.com SUMSearch 2 sumsearch.org SUMSearch
  72. 78. TRIP Database tripdatabase.com <ul><li>Metasearch engine </li></ul><ul><li>Performs a simple search of more than </li></ul><ul><li>75 databases </li></ul><ul><li>Finds evidence based resources </li></ul><ul><li>Searches Cochrane, National Guideline Clearinghouse, Bandolier , etc. </li></ul>
  73. 80. SUMSearch 2 sumsearch.org
  74. 81. Search for Systematic Reviews and Meta-Analyses Resources <ul><li>Cochrane Database of Systematic Reviews </li></ul><ul><li>MEDLINE or PubMed </li></ul><ul><li> Clinical Queries </li></ul><ul><li>CINAHL </li></ul>
  75. 82. Systematic review vs Meta-analysis <ul><li>Systematic review : </li></ul><ul><ul><li>a literature review of RCTs focused on a single question which tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question. </li></ul></ul><ul><ul><li>Uses explicit methods to identify, select and critically evaluate relevant research. </li></ul></ul><ul><li>Meta-analysis: </li></ul><ul><li>- systematic review combining results of several studies using quantitative statistics. </li></ul>
  76. 83. Cochrane Database of Systematic Reviews <ul><li>‘ Gold standard’ for high quality systematic reviews </li></ul><ul><li>Includes full-text reviews and protocols </li></ul><ul><li>Cochrane Abstracts available in CINAHL and MEDLINE/PubMed </li></ul>
  77. 84. Cochrane Search link to full text
  78. 85. Systematic Review Authors’ conclusions Antibiotics have a small treatment effect in patients with uncomplicated acute sinusitis in a primary care setting with symptoms for more than seven days. However, 80% of participants treated without antibiotics improve within two weeks. Clinicians need to weigh the small benefits of antibiotic treatment against the potential for adverse effects at both the individual and the general population level .
  79. 86. Finding Systematic Reviews and Meta-Analyses in CINAHL <ul><li>Limit search to Pub Type: Systematic Review </li></ul><ul><li>Search for Meta Analysis as a Subject Heading </li></ul>
  80. 87. Finding Systematic Reviews and Meta-Analyses in PubMed <ul><li>Use Clinical Queries: Systematic Reviews </li></ul><ul><li>Limit to Type of Article: Meta-Analysis </li></ul>Systematic reviews
  81. 88. Results for Systematic Reviews
  82. 89. Searching for Evidence Pyramid MetaSearch Engines ex. TRIP ex. Cochrane ex. DynaMed, Nursing Reference Center, NGC ex. MEDLINE/PubMed, CINAHL ex.Textbooks, UptoDate Systematic Reviews, Meta-Analyses Evidence Summaries, Evidence Guidelines Randomized Controlled Trials (RCTs), Cohort Studies, Qualitative Studies Background Information, Expert Opinion
  83. 90. So, you want to use Google? <ul><li>CINAHL results </li></ul><ul><li>150 articles </li></ul><ul><li>Top result: </li></ul><ul><li>Schatz M, Dombrowski MP. Clinical practice: asthma in pregnancy. NEJM 2009 Apr 30; 360(18):1862-9 </li></ul><ul><li>Google results </li></ul><ul><li>2, 530,00 hits </li></ul><ul><li>Top result: </li></ul><ul><li>Asthma in pregnancy. eMedicine Health . Last editorial review 10/24/2005 </li></ul>Search June 2009: asthma and pregnancy by Dolores Judkins, OHSU Library, Portland, OR
  84. 91. Navigating the Web Beyond Basic Google to Find Evidence? <ul><li>Google google.com </li></ul><ul><ul><li>Largest search engine: over 25 billion pages </li></ul></ul><ul><ul><li>Relevance ranking based on link analysis </li></ul></ul><ul><li>Google Advanced Search </li></ul><ul><li>www.google.com/advanced_search?hl=en </li></ul><ul><li>Google Scholar scholar.google.com </li></ul>
  85. 92. Searching Advanced Google for Guidelines Searching Advanced Google for Guidelines .gov, .edu pdf in title pressure ulcer prevention guidelines pressure ulcer prevention guidelines
  86. 93. Advanced Google Results
  87. 94. Google Scholar scholar.google.com <ul><li>Searches for scholarly literature , including peer-reviewed papers, theses, books, abstracts and technical reports </li></ul><ul><li>Finds articles from academic publishers, professional societies, universities, etc. as well as scholarly articles on the web </li></ul><ul><li>&quot; Cited by&quot; link identifies # that have cited the original </li></ul><ul><li>Access to full text only available with subscription </li></ul><ul><li>Caution: Not a reliable sole source for searching scholarly literature </li></ul>
  88. 95. Google Scholar
  89. 96. Must Evaluate Web Resources: Evaluation Strategies <ul><li>Evaluate using Criteria for Evaluating Web Resources </li></ul><ul><li>Determine the type of site by analyzing Web Site Addresses </li></ul><ul><li>A User's Guide to Finding and Evaluating Health Information on the Web www.mlanet.org/resources/userguide.html </li></ul>
  90. 97. Criteria for Evaluating Web Sites healthlinks.washington.edu/howto/navigating/criteria.pdf <ul><li>Authority </li></ul><ul><li>Accuracy </li></ul><ul><li>Objectivity </li></ul><ul><li>Currency </li></ul><ul><li>Coverage </li></ul><ul><li>Design </li></ul>
  91. 98. Analyze the Website Address <ul><li>edu </li></ul><ul><li>org </li></ul><ul><li>com </li></ul><ul><li>gov </li></ul><ul><li>net </li></ul><ul><li>The URL (Uniform Resource Locator) includes the name of the host computer which can indicate the purpose of the web site. </li></ul>http :// www.cdc.gov / nip / child.htm sub directory name of host computer how information is transmitted filename
  92. 99. Resources <ul><li>Basic Introduction to Evidence-Based Practice (UW HSL) healthlinks.washington.edu/hsl/classes/evidence </li></ul><ul><li>Video (2009,60 min) based on Basic Intro to EBP Res healthlinks.washington.edu/hsl/classes/evidence/EBP_2009/EBP_2009.html </li></ul><ul><li>DNP Toolkit (UW HSL) healthlinks.washington.edu.offcampus.lib.washington.edu/nurse/dnp </li></ul><ul><li>Essential Nursing Resources (ICIRN) www.icirn.org/Homepage/Essential-Nursing-Resources/Essential-Nursing-Resources.aspx </li></ul><ul><li>Schnall Liaison page with links under Presentations </li></ul><ul><li>healthlinks.washington.edu/hsl/liaisons/schnall/ </li></ul>
  93. 100. Overview of EBP for Nurses Series full-text available FREE on AJN website: journals.lww.com/ajnonline/pages/collectiondetails.aspx?TopicalCollectionId=10 <ul><li>1: Fineout-Overholt E, Melnyk BM, Stillwell SB, Williamson KM. Evidence-based practice, step by step: critical appraisal of the evidence: part II: digging deeper--examining the &quot;keeper&quot; studies. Am J Nurs. 2010 Sep;110(9):41-8. PMID: 20736710. </li></ul><ul><li>2: Fineout-Overholt E, Melnyk BM, Stillwell SB, Williamson KM. Evidence-based practice step by step: Critical appraisal of the evidence: part I. Am J Nurs. 2010 Jul;110(7):47-52. PMID: 20574204. </li></ul><ul><li>3: Stillwell SB, Fineout-Overholt E, Melnyk BM, Williamson KM. Evidence-based practice, step by step: searching for the evidence. Am J Nurs. 2010 May;110(5):41-7. PMID: 20520115. </li></ul><ul><li>4: Stillwell SB, Fineout-Overholt E, Melnyk BM, Williamson KM. Evidence-based practice, step by step: asking the clinical question: a key step in evidence-based practice. Am J Nurs. 2010 Mar;110(3):58-61. PMID: 20179464. </li></ul><ul><li>5: Melnyk BM, Fineout-Overholt E, Stillwell SB, Williamson KM. Evidence-based practice: step by step: the seven steps of evidence-based practice. Am J Nurs. 2010 Jan;110(1):51-3. PMID: 20032669. </li></ul><ul><li>6: Melnyk BM, Fineout-Overholt E, Stillwell SB, Williamson KM. Evidence-based practice: step by step: igniting a spirit of inquiry: an essential foundation for evidence-based practice. Am J Nurs. 2009 Nov;109(11):49-52. PMID: 19858857. </li></ul>