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Cross-Cultural Dyads In The Psychotherapy Room, Sebastian Del Corral Winder, Katrina Spontak, Mixalis Poulakis Dec 2023

Cross-Cultural Dyads In The Psychotherapy Room, Sebastian Del Corral Winder, Katrina Spontak, Mixalis Poulakis

Midwest Social Sciences Journal

Therapeutic outcome is often impacted by the psychotherapeutic relationship throughout treatment. These outcomes are mediated by the client’s belief in the psychotherapist’s trust, comfort, and competency while navigating mental health concerns. Cultural differences can impact a client’s perspective on all three factors and thus impact the psychotherapeutic relationship and success of treatment. The Accent Prestige Theory has noted that individuals who speak English with a Latin American Spanish accent are perceived as less competent, friendly, and trustworthy by White individuals in the United States. While this theory has been examined in select contexts, there is no previous work related to …


Dental Fear, Anxiety, And Phobia – Behavioral Management And Implications For Dentists, Nadya Tsetsova Avramova Apr 2023

Dental Fear, Anxiety, And Phobia – Behavioral Management And Implications For Dentists, Nadya Tsetsova Avramova

Journal of Mind and Medical Sciences

Clinical management of patients with dental fear, anxiety, and phobia could be a major challenge to daily practice of dental professionals. The aim of the current review was to expand the modern consideration with respect to these issues, and therefore to discuss basic approaches and psychological techniques for management of oral health behaviors that should be employed in dentistry. This paper presents detailed description of the characteristics of dentist-patient therapeutic relationship as well as the most used techniques to cope with dental fear, anxiety, and phobia - relaxation techniques, cognitive-behavioral therapy (CBT), hypnosis and melotherapy. We can still argue that …


Implementation Of Post Falls Huddles In Skilled Nursing Facility, Princess Lomax May 2020

Implementation Of Post Falls Huddles In Skilled Nursing Facility, Princess Lomax

Evidence-Based Practice Project Reports

The purpose of this paper is to discuss the quality improvement project, implementation of the post fall huddle in a long-term care facility. Falls are the most common problem in adults 65 years and older. Falls in this population can have devastating effects, often leading to significant changes in morbidity or death. Adults in long term care settings have an increased risk of falling and having a subsequent fall due to an acute illness, weakness, or confusion (CDC, 2015). At the skilled facility, there has been a significant increase in hospitalizations due to injuries sustained from falls. To address this …


A Positive Framed Message To Improve Cpap Compliance For Patients With Osa, Frances Clark May 2020

A Positive Framed Message To Improve Cpap Compliance For Patients With Osa, Frances Clark

Evidence-Based Practice Project Reports

Obstructive sleep apnea (OSA) affects 24% of the US population (DiNapoli, 2014). Untreated OSA causes many diseases, affects one’s quality of life, and increases mortality (Pengo et al., 2018). Continuous positive airway pressure (CPAP) is the lifelong treatment for OSA; yet 30%-80% of OSA patients are CPAP noncompliant within one year. The purpose of this EBP project was to determine if implementing a positive frame message intervention would improve CPAP compliance for newly diagnosed OSA patients. Based on the evidence, implementation of behavioral interventions, such as a positive framed message, was effective in improving CPAP compliance (Pengo et al., 2018). …


A Multifactorial Intervention To Reduce Weight Bias In Healthcare Providers, Rose M. Flinchum May 2020

A Multifactorial Intervention To Reduce Weight Bias In Healthcare Providers, Rose M. Flinchum

Evidence-Based Practice Project Reports

No abstract provided.


What's All The Buzzy About? Using Cryotherapy And Vibration For Pain During Vaccinations In Children, Marta L. Byma May 2020

What's All The Buzzy About? Using Cryotherapy And Vibration For Pain During Vaccinations In Children, Marta L. Byma

Evidence-Based Practice Project Reports

Vaccinations are the most common painful needle procedure, with an estimated 12 billion injections given per year (CDC, 2019). The usual method for administration of vaccinations is through needle puncture, which is often painful. Children often report receiving a shot as one of the most feared and painful experiences (McMurtry et al., 2015). The purpose of this evidence-based practice (EBP) project was to improve patient experiences by decreasing the pain that is associated with vaccinations through the use of a nonpharmacological method for comfort via the Buzzy® device. After thorough analysis and synthesis of the literature, the Buzzy® device that …


The Effect Of The Implementation Of A Quarterly Triad Tool In The Pain Clinic Setting On The Assessment And Mitigation Of Risks In Patients On Chronic Opioid Therapy, Caroline Asava May 2019

The Effect Of The Implementation Of A Quarterly Triad Tool In The Pain Clinic Setting On The Assessment And Mitigation Of Risks In Patients On Chronic Opioid Therapy, Caroline Asava

Evidence-Based Practice Project Reports

The concurrent use of opioids and benzodiazepines (BZDs poses a formidable challenge for clinicians who manage chronic pain. While the escalating use of opioid analgesics for the treatment of chronic pain and the concomitant rise in opioid-related abuse and misuse are widely recognized trends, the contribution of combination use of BZDs, alcohol, and/or other sedative agents to opioid-related morbidity and mortality is underappreciated, even when these agents are used appropriately. Patients with chronic pain who use opioid analgesics along with BZDs have a defined increase in rates of adverse events, overdose, and death, warranting close monitoring. To improve patient outcomes, …


Implementation Of An Advance Care Planning Protocol To Increase Advance Directive Completion Rates, Christine Engle May 2019

Implementation Of An Advance Care Planning Protocol To Increase Advance Directive Completion Rates, Christine Engle

Evidence-Based Practice Project Reports

Advanced directives (AD) allow an individual to retain autonomy in end-of-life decisions and can prevent unnecessary costs and treatments associated with aggressive life-prolonging measures. As of 2017, only an estimated 36.7% of the United States adult population had a form of advance directive documented (Yadav et al., 2017). The purpose of this evidence-based project was to determine if implementation of an advanced care planning (ACP) protocol would increase ACP discussions, AD completion, and result in a modification in stage of change or behavior. The Transtheoretical Model (TTM) and Stetler Model of evidence-based practice were used as the framework to guide …


Use Of Smartphone Application To Facilitate Weight Loss And Promote Accountability In Obese And Overweight Patients, Angela M. Turner May 2019

Use Of Smartphone Application To Facilitate Weight Loss And Promote Accountability In Obese And Overweight Patients, Angela M. Turner

Evidence-Based Practice Project Reports

In 2015, the U.S. Department of Health and Human Services published a National Health and Nutrition Survey (NHANES) on obesity from 2011 through 2014. From the survey, it was determined that the prevalence of obesity in the U.S. was 36% in adults and 17% in young adults/children (Ogden et al., 2015). Lifestyle modifications including moderation of caloric intake and increased exercise have been shown to be effective for both prevention and treatment of obesity. The purpose of this evidence-based practice (EBP) project involved the design, administration, and evaluation of a technology-assisted weight loss intervention to address the health problem of …


The Risk Of Bleeding And Encephalopathy In Surgical Patients With Liver Cirrhosis, Petrișor Banu, Salvatore Settineri, Emanuele Maria Merlo, Maria Rosaria Anna Muscatello, Nicolae Bacalbașa, Carolina Negrei, Bianca Gălățeanu, Octav Ghinghină, Ioana Păunica, Cristian Bălălău Apr 2019

The Risk Of Bleeding And Encephalopathy In Surgical Patients With Liver Cirrhosis, Petrișor Banu, Salvatore Settineri, Emanuele Maria Merlo, Maria Rosaria Anna Muscatello, Nicolae Bacalbașa, Carolina Negrei, Bianca Gălățeanu, Octav Ghinghină, Ioana Păunica, Cristian Bălălău

Journal of Mind and Medical Sciences

Liver cirrhosis is a disease with an increasing incidence. Surgical procedures in patients with cirrhosis are also increasing, due to a longer life expectancy in these patients and also to the improvement of therapeutic and diagnostic resources.

Digestive hemorrhage in the cirrhotic patient requires emergency medical intervention (intensive therapy, endoscopic or even surgical approaches), being at the same time a factor that precipitates episodes of encephalopathy, i.e. the conventional complication of cirrhosis. Hepatic encephalopathy represents one of the most severe clinical events of cirrhosis, being associated with high morbidity and mortality. The causes of hepatic encephalopathy are briefly presented in …


Meditation As An Intervention To Help College Students Cope With Stress, Marissa Bottos Apr 2019

Meditation As An Intervention To Help College Students Cope With Stress, Marissa Bottos

Evidence-Based Practice Project Reports

According to the American College Health Association (ACHA) (2017), in a survey of 31,463 students, 31.7% stated that stress negatively impacts their academic performance (lower grades, dropped course, etc.). Additionally, 45.1% of the students stated they have more than average stress levels. The purpose of this evidence-based practice (EBP) project was to determine if mindfulness meditation was effective in helping college students cope with stress. Based on current evidence, Jon Kabat-Zinn’s online application for mindfulness meditation is supported as an effective way to help college students cope with stress (Regehr et al. 2013; Yusufov et al. 2018; Cavanagh et al. …


The Effects Of Stress Mindset Interventions On University Students' Health And Functioning, Abigail Fate Apr 2019

The Effects Of Stress Mindset Interventions On University Students' Health And Functioning, Abigail Fate

Undergraduate Honors Papers

In modern society, the overwhelming cultural narrative proclaims that stress is detrimental to health and should be limited and avoided at all costs. However, recent research has demonstrated that it is one’s stress mindset, rather than their stress level, that determines the psychological and physiological outcomes. Mindsets are lenses that simplify and order the world, and have been proven to influence daily behavioral and physiological responses to create cascading effects. Recent research has demonstrated that one’s mindset about stress is the demining factor in health, performance, and productivity in response to stressful conditions, and that these mindsets can be manipulated …


Personality Dimensions And Attributional Styles In Individuals With And Without Gender Dysphoria, Siamak Khodarahimi, Hassan Ali Veiskarami, Maria Mercedes Ovejero Bruna Oct 2018

Personality Dimensions And Attributional Styles In Individuals With And Without Gender Dysphoria, Siamak Khodarahimi, Hassan Ali Veiskarami, Maria Mercedes Ovejero Bruna

Journal of Mind and Medical Sciences

This research investigates personality dimensions and attributional styles among individuals with and without gender dysphoria in relationship to gender, educational level, and ethnicity. Participants were 60 men and women with and without gender dysphoria. A demographic sheet and two inventories were used. Results showed that patients with gender dysphoria had significantly higher neuroticism and lower agreeableness compared with individuals without gender dysphoria. No significance differences in extraversion, openness to experience, and conscientiousness (based on the “big five” personality model) were found between those with and without gender dysphoria. Also, individuals without gender dysphoria had higher positive attributional styles compared to …


Combating Workplace Violence: An Evidence Based Initiative, Diana L. Giordano May 2017

Combating Workplace Violence: An Evidence Based Initiative, Diana L. Giordano

Evidence-Based Practice Project Reports

Patient/visitor violence against healthcare (HC) employees is a type of workplace violence (WPV) and considered a dangerous hazard within HC occupations (Bureau of Labor Statistics, 2015). Lack of recognition of the true incidence and underreporting of WPV may contribute to a false sense of security within a HC facility (HCF). Therefore, fully addressing the problem may be met with administrative resistance, resulting in poor employee perceptions of support and commitment for a zero-violence environment. A retrospective analysis was conducted on the HCF’s online incident reports, security request calls, and data from a previously deployed WPV employee survey. The emergency department …


The Effect Of Routine Adult Phq-2 Depression Screen And Scheduled Follow-Up Protocol In The Primary Care Setting, Alex F. Bikowski Apr 2017

The Effect Of Routine Adult Phq-2 Depression Screen And Scheduled Follow-Up Protocol In The Primary Care Setting, Alex F. Bikowski

Evidence-Based Practice Project Reports

Healthy People has projected depression to be the primary cause of disability by 2020; therefore routine depression screening has been prioritized as a national healthcare initiative. The purpose of this Evidence-Based Practice (EBP) project is to demonstrate that routine implementation of the 2-item Patient Health Questionnaire (PHQ-2) depression screener, along with a scheduled follow-up protocol for adults in the primary care setting, can improve current mental health practices regarding the identification of depression by clinicians. The evidence supports use of the PHQ-2 for routine adult depression screening, as long as a scheduled follow-up protocol is available for positive screens. This …


Improving Lgbt Cultural Competence In Senior Nursing Students, Hallie Orgel Apr 2017

Improving Lgbt Cultural Competence In Senior Nursing Students, Hallie Orgel

Evidence-Based Practice Project Reports

LGBT (lesbian, gay, bisexual, transgender) health care is considered a national priority by The Institute of Medicine (IOM, 2011) and HealthyPeople 2020 (2013). The shortage of LGBT culturally competent health care providers is a top contributor to the oppression and discrimination affecting LGBT health (2013). The purpose of the evidence-based practice (EBP) project was to improve the cultural competence of nursing students by improving their knowledge, attitudes, and skills in working with the LBGT population. A multi-method intervention was provided to seniors in a baccalaureate program. The project took place at a private Midwestern university and utilized a pretest/post-test design. …


An Evidence Based Guide To A Safe Intraoperative Approach Of Avoiding Iatrogenic Lesions During Difficult Laparoscopic Cholecystectomies, Cosmin Alec Moldovan, Roxana M. Duncea, Florin Dan Ungureanu, Vladimir Belis Mar 2017

An Evidence Based Guide To A Safe Intraoperative Approach Of Avoiding Iatrogenic Lesions During Difficult Laparoscopic Cholecystectomies, Cosmin Alec Moldovan, Roxana M. Duncea, Florin Dan Ungureanu, Vladimir Belis

Journal of Mind and Medical Sciences

Introduction: Although there are many sources for iatrogenic lesions during laparoscopic cholecystectomy, only a few stand out as being one of the most difficult to predict due to their nature of being very hard to diagnose before surgery. Materials and Methods: a short guide of cases with an evidence-based approach to avoid laparoscopic iatrogenic lesions. Results: these cases have been classified and presented into 3 main groups: cases with abnormal arterial layout, cases with heavy alteration of the normal anatomy, and cases with anomalies of the main biliary pathway. Conclusions: while not a complete guide covering …


The Effects Of Continuing Education On Nurse Knowledge Of Safe Haven Laws In Illinois, Lindsay Thiemkey Gordon May 2016

The Effects Of Continuing Education On Nurse Knowledge Of Safe Haven Laws In Illinois, Lindsay Thiemkey Gordon

Evidence-Based Practice Project Reports

Illegal and often fatal infant abandonment is a pervasive public health crisis. Safe Haven Laws (SHLs) help to prevent illegal infant abandonment by allowing specific professionals, including nurses, to accept unharmed newborns within statutorily defined parameters. SHLs have existed for nearly two decades, yet many healthcare workers are not knowledgeable about these laws: this implies that initial efforts to educate healthcare workers about SHLs have been ineffective. Continuing education supports lifelong learning which is a basic tenet of nursing practice. The purpose of this evidence-based practice (EBP) project was to teach nurses about SHLs through evidence-based continuing education. Literature firmly …


Implementation Of A Nursing Workload Tool To Reduce Nurse Burnout, Nicole K. Greives Apr 2016

Implementation Of A Nursing Workload Tool To Reduce Nurse Burnout, Nicole K. Greives

Evidence-Based Practice Project Reports

Nursing burnout and workload is a complicated issue with far-reaching effects. Nursing burnout and inappropriate nursing workload have been linked to increased risk of urinary tract infection, respiratory infections, decreased patient satisfaction, decreased quality and safety of care, and increased mortality. The purpose of the project was to decrease nursing burnout on a Medical Progressive Care Unit (MPCU) by moving patients with high workloads and medical instability to a higher level of care. Within this project, Rosabeth Kanter’s Theory of Structural Power was used for the theoretical framework, and the Stetler Model guided the implementation. The intervention consisted of a …


The Effect Of Standardized Patient Encounters On Undergraduate Nursing Student Empathy And Self-Efficacy In Therapeutic Communication, Alana M. Urness Apr 2016

The Effect Of Standardized Patient Encounters On Undergraduate Nursing Student Empathy And Self-Efficacy In Therapeutic Communication, Alana M. Urness

Evidence-Based Practice Project Reports

Therapeutic communication between the nurse and patient is an essential component of optimal nursing care. Current evidence supports the use of standardized patient (SP) encounters to assist students in learning therapeutic communication skills. In addition to offering students an opportunity to practice in an environment free of clinical consequence, SP encounters have been shown to increase clinical knowledge and skill, improve diagnostic reasoning, and improve communication skills and interviewing skills. The purpose of this evidence-based practice project was to assess the effect of SP encounters on undergraduate nursing student empathy and self-efficacy related to therapeutic communication. Secondary outcomes included participant …


Differential Involvement Of Hippocampal Angiotensin 1 Receptors In Learning And Memory Processes In Bulbectomized Rats, Roman Tashev, Margarita Ivanova, Stiliana Belcheva, Iren Belcheva Mar 2016

Differential Involvement Of Hippocampal Angiotensin 1 Receptors In Learning And Memory Processes In Bulbectomized Rats, Roman Tashev, Margarita Ivanova, Stiliana Belcheva, Iren Belcheva

Journal of Mind and Medical Sciences

There is conflicting evidence regarding the effect of AT1 receptor antagonists on learning and memory processes. The effects of angiotensin II and losartan administration into CA1 hippocampal area on the avoidance performance in olfactory bulbectomized (OBX) rats using active avoidance (shuttle box) test and passive avoidance (step through) test were investigated. Rats were microinjected unilaterally through implanted guide cannulas into the CA1 area of the dorsal hippocampus and the drugs were administered separately, 5 minutes before each training session. The microinjections of losartan into the left, but not the right CA1 hippocampal area improved the acquisition and retention of active …


The Effect Of Education On Compassion Fatigue As Experienced By Staff Nurses, Kathryn L. Zehr Apr 2015

The Effect Of Education On Compassion Fatigue As Experienced By Staff Nurses, Kathryn L. Zehr

Evidence-Based Practice Project Reports

Historically, nursing has been perceived as a highly rewarding profession. Yet, due to the increasing complexity of today’s healthcare, nurses are faced with greater challenges in their work environments. Registered nurses who work in tertiary care settings are exposed to disturbing patient situations including trauma, death, abuse, or chronic disease. Joinson (1992) described this experience as compassion fatigue and symptoms include headaches, short attention span, or fatigue. A review of literature has identified that nurses should be educated about risk factors and coping strategies to combat compassion fatigue. Guided by the Model for Evidence-Based Practice Change and Jean Watson’s Theory …


Implementation Of An Advance Directive Protocol In A Primary Care Setting, Gloria Dillman Apr 2015

Implementation Of An Advance Directive Protocol In A Primary Care Setting, Gloria Dillman

Evidence-Based Practice Project Reports

Despite the passage of the Patient Self-Determination Act in 1992, only 15% of the United States population has completed an advance directive (AD). This statistic will be exaggerated with the future growth of older adults in the year 2030, at which time this portion of the population is expected to double to 72.1 million people. Without an AD, patients lose their autonomy and may be subjected to costly, life prolonging treatments that they would never choose for themselves. The unnecessary costs and unwanted treatment are preventable with an AD, and primary care providers are in a prime position to initiate …


The Effect Of An Antenatal Breastfeeding Intervention On Breastfeeding Self-Efficacy And Intention Among Inner City Adolescents, Jamie El Harit Apr 2015

The Effect Of An Antenatal Breastfeeding Intervention On Breastfeeding Self-Efficacy And Intention Among Inner City Adolescents, Jamie El Harit

Evidence-Based Practice Project Reports

According to Healthy People 2020, infants who are breastfed have improved nutritional, immunological, developmental, and social outcomes (USDHHS, 2014). Despite the benefits of breastfeeding and the focused international efforts to increase levels of breastfeeding, adolescents remain largely unaware and continue to have among the lowest levels of breastfeeding initiation (CDC, 2013; Spear, 2006). The purpose of this EBP project was to reduce the disparities of breastfeeding initiation by increasing breastfeeding self-efficacy and intention in an inner city specialty high school. Synthesis of the evidence demonstrated that needs-based, repeated antenatal education delivered by a lactation expert including breastfeeding peer counselor supports …


The Effect Of Patient Education On Anxiety Levels In Patients Receiving Chemotherapy For The First Time, Sarah Garcia May 2014

The Effect Of Patient Education On Anxiety Levels In Patients Receiving Chemotherapy For The First Time, Sarah Garcia

Evidence-Based Practice Project Reports

Cancer affects approximately 1.5 million people every year throughout the United States.Comprehensive care that includes psychosocial aspects is important to help patients effectively adapt to their diagnosis and treatment plan. Improper prevention and management of anxiety can lead to poor psychosocial outcomes, dissatisfaction with care, and decreased adherence to treatment. Current evidence suggests that education is effective at helping reduce anxiety in patients receiving chemotherapy for the first time. The purpose of this evidenced based practice project was to determine if nurse-led patient education regarding chemotherapy side effects, side-effect management, and orientation to the infusion center was effective at decreasing …


The Use Of Stress Reduction Techniques In Nursing Education, Jennifer S. Bauer May 2014

The Use Of Stress Reduction Techniques In Nursing Education, Jennifer S. Bauer

Evidence-Based Practice Project Reports

Stress is a complex phenomenon that has significant effects on students which may disturb their physiological, psychological, and spiritual health and well-being. Nursing students have been identified to be at high risk for stress during their education. Stress can arise from new clinical experiences, academic load, and personal stressors (Jones & Johnston, 2006). This increase in stress can lead to the student’s inability to assimilate and learn within the classroom and clinical settings. A review of the literature provided evidence that reported a positive relationship between guided imagery and a decrease in stress and anxiety. This evidence-based practice (EBP) project …


Is Their Foundation Solid Enough To Build On: An Investigation Into The Information-Seeking Skills And Self-Efficacy Levels Of New Nursing Students, Kimberly J. Whalen, Patricia J. Mileham May 2014

Is Their Foundation Solid Enough To Build On: An Investigation Into The Information-Seeking Skills And Self-Efficacy Levels Of New Nursing Students, Kimberly J. Whalen, Patricia J. Mileham

Library Faculty Presentations

Researchers at a mid-sized, Midwest, faith-based university used a quasi-experimental non-equivalent control group pretest posttest design to gather data from newly enrolled nursing students in a baccalaureate, masters and doctorate in nursing practice program. Literature regarding confidence levels, self-efficacy and information literacy skills was reviewed. Specific tools to assess confidence and self-efficacy of information literacy skills were explored. The 28-item Information Literacy Self-Efficacy Scale (ILSES) developed in 2006 by Serap Kurbanoglu was used in fall 2012, spring 2013 and fall 2013 to gather data from over 200 newly enrolled nursing students. Analysis of self-reported information literacy skills and self-efficacy levels …


Five-Course Meal Infused With Information Skills And Resources, Kimberly J. Whalen, Suzanne E. Zentz Jan 2014

Five-Course Meal Infused With Information Skills And Resources, Kimberly J. Whalen, Suzanne E. Zentz

Library Faculty Publications

No abstract provided.


Teaching Information Literacy Skills To Undergraduate Nursing Students: A Collaborative Approach, Suzanne E. Zentz, Kimberly J. Whalen Nov 2013

Teaching Information Literacy Skills To Undergraduate Nursing Students: A Collaborative Approach, Suzanne E. Zentz, Kimberly J. Whalen

Nursing and Health Professions Faculty Presentations

Background An expectation of baccalaureate nursing education is to prepare nurses to implement evidenced-based practice (EBP). This expectation extends far beyond a basic understanding of the research process. BSN prepared nurses must be able to effectively and efficiently identify, analyze, and synthesize evidence (AACN, 2008). The acquisition of information literacy skills is foundational to the development of EBP. Implementation The study took place at a College of Nursing within a mid-sized, faith-based university located in the Midwest. Historically, students enrolled in their senior level undergraduate nursing research/EBP course underwent one library instruction session with the nursing librarian to reinforce search …


Using A Research Log And Reflective Writing To Improve Ebp And Information Literacy Skills Of Bsn Students, Suzanne E. Zentz, Kimberly J. Whalen Jul 2013

Using A Research Log And Reflective Writing To Improve Ebp And Information Literacy Skills Of Bsn Students, Suzanne E. Zentz, Kimberly J. Whalen

Library Faculty Presentations

Background Baccalaureate nursing educators must prepare nurses to implement evidence-based practice (EBP). BSN nurses must be able to effectively identify, analyze, and synthesize evidence (AACN, 2008). In a nursing research course, students conducted group projects which required searching for the best evidence. Project evaluations revealed that students were not searching systematically. To facilitate EBP and information literacy skill development, a collaboration between the College of Nursing and Library Services emerged.

Targeted Learning Outcomes 1. Formulate a strategic search using databases and Internet resources 2. Evaluate and select the ‘best available’ evidence 3. Document systematic search (keywords, subject headings, limiters, and …