Evidence-Based Practice in Nursing: Steps, PICOT and Levels of Evidence

Evidence-based practice (EBP) is one of the most-used phrases in nursing education and one of the most misunderstood. It does not mean "do whatever the latest study says," and it does not mean "do what we have always done." This guide explains what EBP actually is, the steps nurses follow, how to write a PICOT question, how to rank evidence, and where EBP shows up in the Post RN BSN curriculum published by the Pakistan Nursing & Midwifery Council (PNMC).

Published: 12 October 2026 | Last verified: 12 October 2026

POST RN BSN Nursing Resources is an independent educational website. It is not affiliated with PNMC, LUMHS or any other institution. This article is a study aid, not clinical guidance. Always follow your institution's policies and the advice of your supervisors.

Figure 1: Evidence-based practice brings together best research evidence, clinical expertise and patient values, and follows a repeating cycle of steps. Educational summary only; verify current requirements with PNMC and your institution.

What is evidence-based practice?

The most quoted starting point is the 1996 definition of evidence-based medicine by Sackett and colleagues in the BMJ: "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients." The same paper describes the practice as integrating individual clinical expertise with the best available external clinical evidence, and states that it is not restricted to randomised trials and meta-analyses.

Nursing education guides adapt this idea into three parts that must all be present:

Best available research evidence – findings from well-conducted studies and reviews, not just one article that supports a preference.
Clinical expertise – the nurse's own skill, experience and understanding of the clinical setting.
Patient values and preferences – what matters to the patient and family, including culture, beliefs and circumstances.

If one part is missing, it is not EBP. Research alone ignores the patient in front of you; experience alone can repeat outdated habits.

Evidence-based practice in nursing: three components and the five-step Ask, Acquire, Appraise, Apply, Assess cycle

Evidence-Based Practice in Nursing Overview - Figure 1.

The EBP process: from five steps to seven

Two step-by-step versions are widely taught. Many library guides use a simple five-step cycle (Ask, Acquire, Appraise, Apply, Assess). Melnyk and Fineout-Overholt's version, published in the American Journal of Nursing in 2010, has seven steps, beginning at "Step 0." The table below shows how they line up. The alignment in the middle column is our own simplification to help students study, not an official crosswalk.

Five-step cycle	Melnyk and Fineout-Overholt seven steps	What you actually do
(before Ask)	Step 0: Cultivate a spirit of inquiry	Notice routines and ask "why do we do it this way?"
Ask	Step 1: Ask clinical questions in PICOT format	Turn the problem into a searchable question.
Acquire	Step 2: Search for the best evidence	Search databases and guideline sources systematically.
Appraise	Step 3: Critically appraise the evidence	Judge quality, results and relevance to your patients.
Apply	Step 4: Integrate the evidence with clinical expertise and patient preferences/values	Decide what to do with this patient or in this unit.
Assess	Step 5: Evaluate outcomes of the practice decision or change	Check whether care actually improved.
(after Assess)	Step 6: Disseminate EBP results	Share what you learned with colleagues.

Writing a PICOT question

Step 1 is where most students struggle. A PICOT question has up to five parts:

Letter	Stands for	Illustrative example
P	Population / Patient / Problem	Adult patients on a medical ward
I	Intervention (or exposure, or test)	Structured hourly nursing rounds
C	Comparison (optional)	Routine care without structured rounds
O	Outcome	Number of patient falls
T	Time (optional)	Over three months

Example question: In adult patients on a medical ward (P), do structured hourly nursing rounds (I), compared with routine care (C), reduce the number of patient falls (O) over three months (T)?

Note: this example was written for teaching the format. We are not claiming what the research says about hourly rounds; answering the question would be the job of Steps 2 and 3.

Library guides also group clinical questions by type, which helps you pick the right kind of study later:

Treatment/intervention – does one therapy work better than another?
Diagnosis – how accurate is a test compared with the current standard?
Prognosis – what is likely to happen over time?
Etiology/harm – does a risk factor or exposure increase the chance of disease?

PICOT and Levels of Evidence for Nursing - Figure 2

Levels of evidence

Not all evidence carries equal weight. One widely used ranking in nursing texts is the Melnyk and Fineout-Overholt hierarchy, shown here from strongest to weakest as reproduced in a university library guide:

Level	Type of evidence
I	Systematic reviews and meta-analyses of randomised controlled trials (RCTs)
II	Randomised controlled trials
III	Non-randomised controlled trials (quasi-experimental studies)
IV	Case-control or cohort studies
V	Systematic reviews of qualitative or descriptive studies
VI	Qualitative or descriptive studies
VII	Opinions of authorities and/or reports of expert committees

Figure 2: The PICOT question format and the seven-level Melnyk hierarchy of evidence, ordered strongest to weakest for treatment questions. Other ranking systems exist; confirm the framework your course uses.

Two cautions for exams and for real practice:

Higher is not always "better for your question." Treatment questions are best answered by trials, but a question about patients' experience of illness is best answered by qualitative research. Other level systems also exist, such as the Johns Hopkins model, which uses five levels, so always follow the framework your course teaches.
A hierarchy is a decision aid, not a substitute for judgement. A poorly done RCT can be less trustworthy than a well-done cohort study.

Quick appraisal prompts

When you reach Step 3, these general questions help you read a study critically (they are common-sense prompts, not an official checklist):

Was the question clear and the study design suited to it?
Who took part, and are they similar to your patients?
Were the groups compared fairly, and were outcomes measured properly?
How large and how precise were the results?
Can this be done safely and realistically in your setting, and would your patients accept it?

Reading results with confidence depends on basic statistics and study-design knowledge. Our guide to epidemiology basics for nursing students explains study designs and common measures that you will meet while appraising evidence.

EBP, nursing research and quality improvement

Students often mix these up. In simple terms, nursing research produces new knowledge by carrying out a study, while EBP finds, judges and uses existing knowledge to improve care. If you want to carry out your own study, see our guide on how to write a nursing research proposal.

What nurses are expected to be able to do

In 2014, a team led by Bernadette Melnyk (Ohio State University College of Nursing) with Lynn Gallagher-Ford, Lisa English Long and Ellen Fineout-Overholt published 24 EBP competencies in Worldviews on Evidence-Based Nursing: 13 for registered nurses and 11 for advanced practice nurses. The RN competencies include questioning clinical practices to improve the quality of care, critically appraising published research and tracking outcomes data. The advanced practice competencies focus on leading teams and sustaining an EBP culture. These are US-developed competencies and are not a Pakistani regulatory standard, but they are a useful picture of what "doing EBP" looks like at the bedside.

Where EBP appears in the PNMC Post RN BSN curriculum

The PNMC curriculum for the two-year Post RN BSN programme (the document is titled "Curriculum Post RN BSN (02 Years Degree Program)" and was issued under the earlier name Pakistan Nursing Council) does not contain a course with the exact title "Evidence-Based Practice." However, several courses connect directly to it:

Code	Course title (as listed by PNMC)	Year / Semester	Credits
SC 622	Introduction to Biostatistics	Year 1, Semester 2	2
SC 623	Epidemiology	Year 1, Semester 2	2
SC 632	Introduction to Nursing Research	Year 2, Semester 1	3
NU 641	Research/Evidence based Elective project	Year 2, Semester 2	4

The document's preface also says the emphasis is "moving from task orientation and skills to competency based incorporating evidence based practice," and one course (NU 612, Advance Concepts in Nursing I) lists applying the nursing process with support from evidence-based nursing in its unit objectives. A footnote on NU 641 says each student must write an individual project or research report in the final year.

Important: this is PNMC's general programme curriculum. It must not be read as the exact syllabus of any one university. For the historical LUMHS subject list, see our article on LUMHS Post RN BSN nursing subjects, and confirm current course content with your own institution.

Practical study tips

Memorise one framework and name it. In an exam, say which steps you are using (five-step or Melnyk's seven) rather than mixing them.
Practise PICOT on real ward problems. Write three PICOT questions from your own clinical area and check that each has a population, an intervention and a measurable outcome.
Link each study design to a question type. Treatment questions point to trials; risk and harm questions to cohort or case-control studies; experience questions to qualitative research.
Always include the patient. If an answer describes evidence but not patient values and clinical expertise, it is incomplete.

Frequently asked questions

Is evidence-based practice the same as nursing research?

No. Research creates new evidence through studies. EBP is the process of finding, appraising and applying existing evidence together with clinical expertise and patient preferences.

Does EBP ignore clinical experience?

No. In the Sackett definition and in nursing guides, clinical expertise is one of the three essential parts alongside research evidence and patient values.

Do randomised controlled trials always rank first?

For treatment questions, systematic reviews of trials and RCTs rank highest in the Melnyk hierarchy. For other kinds of questions, such as patients' experiences, other designs are more suitable. Sackett and colleagues also state that EBM is not restricted to randomised trials and meta-analyses.

Is there a separate "Evidence-Based Practice" course in Post RN BSN?

In the PNMC curriculum we reviewed, no course carries that exact title, but research and evidence-related content appears in Introduction to Nursing Research and in the Research/Evidence based Elective project. We could not verify the course lists of individual universities.

What is the difference between the five-step and seven-step models?

The seven-step model adds a "Step 0" (spirit of inquiry) and a final step (disseminating results). The core idea is the same: ask, search, appraise, apply and evaluate. Use the version your teacher or exam board specifies.