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LANGKAH-LANGKAH EBN

REMILDA A.V

REVIEW

Essensi Pelayanan Suatu Profesi:


Problem

identification
Problem solving

History

Nursing research began to focus on clinical issues in the


mid 80s (Stevens & Cassidy, 1999).
The National Institute for Nursing Research (NINR) (
http://www.nih.gov/ninr/) was formed in 1986, greatly
increasing the visibility and funding opportunities for
nursing research.
Many new journals emphasize nursing research
In recent years the International Society for Nursing
Research, Sigma Theta Tau, has greatly increased its
capacity to support and disseminate nursing
scholarships (http://www.nursingsociety.org/)
McMaster University in Ontario, Canada has developed
extensive resources in teaching and implementing
evidence-based practice in nursing and other disciplines
(http://www.fhs.mcmaster.ca/ceb/acts/ebcp.htm)

Evidence Based Nursing

Proses dimana pengambilan keputusan


keperawatan didasarkan pada hasilhasil penelitian yang terbaik, keahlian
klinik, dan harapan serta nilai-nilai
yang ada pada pasien (University of
Minesota, 2001).
Tujuan praktek EBN adalah penggunaan
riset-riset keperawatan yang valid ke
dalam praktek keperawatan sehari-hari
(research utilization)

Evidence Based Nursing (EBN)?

Evidence Based Nursing is the process by which nurses


make clinical decisions using the best available research
evidence, their clinical expertise and patient preferences.
Three areas of research competence are:

interpreting and using research,


evaluating practice, and
conducting research.

These three competencies are important to EBN.


To carry out EBN the following factors must be
considered:

sufficient research must have been published on the


specific topic
the nurse must have skill in accessing and critically
analyzing research
the nurse's practice must allow her/him to implement
changes based on EBN

Proses praktek EBN

Sama dengan proses praktek Evidence Based


Medicine.
mengidentifikasi permasalahan dalam
bidang keperawatan
melakukan pelacakan untuk mencari
penelitian yang dapat digunakan untuk
menjawab permasalahan
melakukan evaluasi dan telaah bukti ilmiah
mengidentifikasi intervensi yang paling baik
berdasar pada hasil penelitian, keahlian
klinik dan harapan pasien
Melakukan evaluasi hasil guna penerapan
dalam praktek

Lima langkah praktek EBN

(1) Mengajukan pertanyaan klinik yang dapat


dijawab (asking answerable question),
(2) Melakukan pelacakan pustaka untuk
menjawab pertanyaan klinik,
(3) Melakukan telaah kritis terhadap bukti
ilmiah,
(4) Melakukan integrasi antara bukti ilmiah
yang valid, keahlian klinik, dan nilai serta
harapan yang ada pada pasien
(5) Melakukan evaluasi hasil guna penerapan
bukti ilmiah di dalam praktek (Sackett, 2000).

Evidence-based Nursing Practice


Solves problems encountered by
nurses by carrying out four steps:
1.

2.
3.

4.

Clearly identify the issue or problem


based on accurate analysis of current
nursing knowledge and practice
Search the literature for relevant
research
Evaluate the research evidence using
established criteria regarding scientific
merit
Choose interventions and justify the
selection with the most valid evidence

STEP 1
MENGAJUKAN PERMASALAHAN KLINIK

Old paradigms in learning

Much learning complete at the end of


formal training
Intuition very powerful
Dominated by knowledge from
experience
Professionals on top

IK IK Syndrome

I Know I Know
To be certain means to close our
minds to learning

New paradigms in learning

Knowing what you dont know (not feeling


bad about it) and knowing how to find out
(or help others to...)
Longlife learner
Learning by questioning
Turning problems into questions and to find,
appraise, store, and act on experience and
evidence to solve them
Complementing experience with knowledge
from research
Professionals on tap

Mengajukan permasalahan
klinik

Permasalahan klinik dapat muncul dari


aspek paparan faktor risiko, tindakan
prevensi, tindakan diagnosis, terapi
atau intervensi dan prognosis.
Pertanyaan klinik yang diajukan
sebaiknya spesifik.
Pertanyaan klinik yang baik
(foreground question) akan membantu
proses pelacakan pustaka yang efektif.

Komponen Pertanyaan Klinik

P (populasi/ population/ patient),


I (intervensi/ eksposur/ intervention),
C (comparison)
O (outcome).

Contoh

Kasus anak dengan demam dan nyeri

Pertanyaan klinik dalam bidang terapi


adalah: apakah ibuprofen lebih efektif
dibanding parasetamol untuk mengatasi
nyeri dan demam pada anak-anak?.

Populasi: anak-anak,
Intervensi yang ditelaah adalah
ibuprofen,
Pembanding paracetamol or plasebo,
outcome yang dinilai adalah bebas
demam/ nyeri.

Contoh

Tn. B, 48 th, sebelumnya tidak mengeluhkan


sesuatu, ketika sedang kerja bakti mengeluh
nyeri dada bagian tengah. Nyeri hilang
setelah istirahat 2-3 menit. Setelah kejadian
tersebut Tn. B sering mengeluh nyeri dada
baik pada waktu melakukan kegiatan seperti
olah raga, maupun pada saat istirahat. Tn. B
adalah perokok, 1 bungkus setiap hari. Hasil
pemeriksaan EKG normal, TD 150/96
mmHg.

Pertanyaan Pasien

Apakah saya sakit?


Bukti apa yang menunjukkan bahwa
saya sakit?
Kalau sakit apa penyebabnya?
Apa yang akan dilakukan untuk
mengatasi sakit saya?

Pertanyaan Klinisi

Apkah keadaan Tn. B berbahaya?


Apakah perlu pengobatan lanjut atau
hanya dengan penjelasan saja?
Bagaimana dengan hasil EKG yang
normal?

Sejauhmana EKG bisa memastikan adanya


PJK?

Apakah berhenti merokok bisa


mengurangi Risiko penyakit?

STEP 2
MENCARI DAN MENEMUKAN BUKTI
ILMIAH TERBAIK

Menemukan Bukti Ilmiah

Tahapan paling penting dan mendasar


Menemukan hasil penelitian yang
valid dan reliable.
Hasil penelitian yang dipilih adalah
penelitian yang memiliki kualitas yang
baik, sesuai dengan hirarki bukti
ilmiah

Derajat Evidence
Derajat

Jenis Evidence

Ia

Meta-analisis dari RCT

Ib

RCT (uji klinis acak terkendali)

IIa

Uji klinik dengan pembanding,


tanpa randomisasi

IIb

Penelitian quasi-eksperimental

III

Penelitian deskriptif: studi komparasi,


studi korelasi, studi kasus
Laporan komisi ahli, opini, pengalaman
klinik ahli yang diakui

IV

REKOMENDASI
Tingkat

Rekomendasi

A (Evidence Memerlukan paling sedikit satu hasi


Levels Ia, Ib)RCT sebagai bagian utama kepustakaan
B (Evidence Memerlukan minimal hasil uji klinis
tanpa randomisasi
Levels IIa, IIb,
III)
C (Evidence Memerlukan bukti dari laporan
suatu
Level IV)
komite ahli atau opini atau
pengalaman klinik ahli yang diakui

Definitions

Research Utilization: Transfers research findings to nursing


practice: Carried out by individual nurses, groups of nurses
working together to solve problems, by interdisciplinary teams,
and by institutions and organizations seeking to make systemwide improvements in care outcomes
Literature review: Scholarly analysis of a body of research
about a specific issue or topic[1]
Integrative literature review: Integration of a body of
research findings (including theory, statistics) which concludes
by addressing issues for future research[1]
Systematic literature review: Comprehensive, unbiased
analysis of research findings on a specific topic which uses a
strict scientific design to select and assess various related
scientific studies[1]
Meta-analysis: Merged statistical results from a number of
related studies which combines various research studies with
the goal of discovering consistencies and differences between
studies[1]
Clinical Decision-making: drawing conclusions based on
EBN, clinical expertise, patient preference, and other factors
such as cost-benefit analysis, availability of alternatives, etc.

STEP 3
Telaah Kritis

TELAAH KRITIS

Telaah kritis dilakukan dengan mengajukan


3 pertanyaan utama, yaitu:

(1) apakah penelitian ini valid?


(2) apakah hasilnya penting?
(3) apakah penelitian yang valid dan penting ini
berguna bagi tatalaksana pasien-pasien saya?

Pertanyaan validitas dan akurasi suatu


artikel bertujuan untuk mempertimbangkan
apakah efek yang dilaporkan benar-benar
menunjukkan arah dan besar efek yang
sesungguhnya.

Evaluating quality of nursing


research
Evaluating Quality of the Research
Content

Description

Study Design

Random, blind, or repeated measures

Population

Brief description of larger population

Sample

Sample characteristics, randomization

Inclusions/Exclusion Criteria

Criteria described

Time Frame of study

Length of total study

Time Frame of treatment

Length of intervention

Intervention

Intervention description

Data collection

Dependent variables, independent variables

Analysis

Technique used

Results

Results reported in terms of research questions (hypotheses)

Conclusions

Conclusions of study

Limitations

Subjects lost to follow-up

Blinding

Did person giving intervention know whether the subjects were in


the experimental or control groups

STEP 4
INTEGRASI DALAM PELAYANAN

Integrasi Bukti Ilmiah


Dalam Pelayanan

Memungkinkan untuk diterapkan


Bukti ilmiah yang ada harus bisa
diintegrasikan dan menyatu dengan
pelayanan sehari-hari
Misalkan dalam clinical care pathway

STEP 5
EVALUASI HASIL GUNA

Evaluasi Hasil Guna

Self-evaluation
Dapat menggunakan indikator
outcome pelayanan
Misal:
Dekubitus
Plebitis
ISK
dll

Models
Three models for research utilization
in nursing serve as a foundation to
understand evidence-based nursing
practice :
(1) The Conduct and Utilization of
Research in Nursing (CURN) project
(2) The Stetler Model of Research
(3) Iowa Model for Research in Practice

The Conduct and Utilization of


Research in Nursing (CURN) project

The CURN Project was designed to


develop and test a model for using
research-based knowledge in clinical
practice settings. Research utilization
is viewed as an organizational
process. Planned change is integrated
throughout the research utilization
process. Systems change is essential
to establishing research-based
practice on a large scale.

The Stetler Model of Research


Utilization

The Stetler Model of Research Utilization applies


research findings at the individual practitioner
level. The model has six phases:
(1) preparation,
(2) validation,
(3) comparative evaluation,
(4) decision making,
(5) translation and application, and
(6) evaluation.

Critical thinking and decision making are


emphasized.

Iowa Model for Research in Practice

The Iowa Model of Research in Practice


infuses research into practice to improve
the quality of care [8], and is an
outgrowth of the Quality Assurance Model
Using Research (QAMUR)[9] .
Research utilization is seen as an
organizational process. Planned change
principles are used to integrate research
and practice.
The model integrates evidence-based
healthcare acknowledges and uses a
multidisciplinary team approach.[10]

Current national and international


projects in EBN

Centre for Evidence-Based Nursing (UK)

Evidence-Based Nursing (0nline Journal)

Evidence-Based Nursing and Midwifery (T


he Joanna Briggs Institute)

Nurse Prescribing (National Prescribing C


enter,
UK)

Summary Points

This module contains many resources to assist


nurses to develop and improve their skills in EBN.
EBN is a way of thinking and practicing that
requires discipline and practice to continually
assess, "where is the evidence for this?", and to
weigh the validity and reliability of daily
practice activities.
Ongoing skill building is required once a basic
understanding of EBN is acquired.
Nurses and other health professions daily confront
questions about assessment, treatment,
prevention and cost-effectiveness of care.

As health care costs continue to climb, this


emphasis will only increase.
The principles of critical appraisal span health
professions and disciplines and overlap with
epidemiology and science in general.
Our patients expect nursing care based on best
practice evidence.
The art of nursing, never to be underestimated,
also needs to be studied to validate those
contributions to quality care.
In the future, qualitative nursing research will
be included in the critical appraisal process to add
essential components to nursing knowledge.

Research-based nursing journals

There are a number of journals currently available


which are specific or very relevant to evidencebased nursing. This is a list of such journals. Most
of them can be found either in print and/or online
via MNCAT, the University of Minnesota catalog. NT
Research Biological Research for Nursing
Canadian Journal of Nursing Research
Journal of Nursing Measurement
Western Journal of Nursing Research
Scholarly Inquiry for Nursing Practice
Advances in Nursing Science
Oncology Nursing Forum

Nursing Research
Evidence Based Nursing
Online Journal of Knowledge Synthesis
Clinical Nursing Research
Nurse Researcher
Applied Nursing Research
Research in Nursing and Health Nursing
Science Quarterly
Journal of Nursing Scholarship
Annual Review of Nursing Research

EBN internet resources

Evidence-based Clinical Practice Working Group,


Department of Clinical Epidemiology and
Biostatistics, University of McMaster, Canada.
http://www.fhs.mcmaster.ca/ceb/acts/ebcp.htm
Books related to EBN:
http://www.astuk.com/products-bykeywords/evidence-based-nursing.html
University of Hertfordshire, UK, has a informative
web page to explain evidence-based medicine.
http://www.herts.ac.uk/lis/subjects/health/ebm.htm
A wonderful EBM website from University of Toronto,
Canada, aims to develop, disseminate, and
evaluate resources that can be used to practise and
teach EBM for undergraduate, postgraduate and
continuing education for health care professionals
from a variety of clinical disciplines.
http://www.library.utoronto.ca/medicine/ebm/

This is a Nursing Resource Collection from


University of Massachusetts Amherst
http://www.library.umass.edu/subject/business/e
bn.html
The unit for Evidence Based Nursing at Malm
University the Department of Nursing and Public
Health, School of Health and Society, recently
formed a unit for Evidence Based Nursing.
http://www.hs.mah.se/Research/Evidenseng.htm
Developing Evidence Based Nursing Practice,
Health Care Practice Research and Development
Unit (HCPRDU) University of Salford, UK.
http://www.salford.ac.uk/ihr/hcprdu/complete/eb
np.htm

NHS research and development: center for evidence based


medicine. The Center was established in Oxford University,
UK. Its broad aim is to promote evidence-based health
care and provide support and resources to anyone who
wants to make use of them. http://cebm.jr2.ox.ac.uk/
The Western Australian Centre for Evidence Based Nursing
and Midwifery, School of Nursing, Curtin University of
Technology, AU.
http://www.curtin.edu.au/curtin/dept/planstats/wacebnm/
Evidence Based Health Care, Saint Louis University, Saint
Louis, MO. http://www.slu.edu/libraries/hsc/wr_ebhc.html
Evidence-based Practice websites for nurse researchers,
by Mary E. Duffy, the Director of the Center for Nursing
Research at Boston College, School of Nursing
http://www.nursing.uc.edu/nrm/duffy11799.htm

Techniques for Locating Evidence-Based Practice


Resources, University of Washington Health
Sciences Libraries
http://healthlinks.washington.edu/ebp/
Evidence-based Medicine resource and information,
Duke University medical center library.
http://www.mclibrary.duke.edu/respub/guides/ebm
/index.html
Nursing Informatics and Evidence-Based Nursing,
University of Wisconsin Health Science libraries

http://www.medsch.wisc.edu/chslib/ad/docs/nurfm
atc.htm

Teaching EBN

Evidence-based teaching is the conscientious, explicit,


and judicious use of current best evidence in making
decisions about the education of professional nurses.An
intensive one-week course is offered at McMaster
University in Hamilton, Ontario Canada entitled: How to
Teach Evidence-based Clinical Practice. Link to their
site. It is competitive to attend this workshop; it is
well-worth the cost. This interdisciplinary group of
health professionals have refined this topic and have
excellent resources. Link to their site:
http://www.cche.net/ebcp/A useful reference for
faculty interested in teaching with an evidence-based
approach is: Stevens, K. & Cassidy, V. (1999).
Evidence-based teaching. Sudbury MA: National League
for Nursing.

Qualitative EB Nursing

Nursing research used qualitative


methods quite commonly because they
are very suitable for developing the
holistic knowledge of the discipline of
nursing. Because most of the EBP/EBN
literature focuses on quantitative
methods, it is important to think about
the somewhat different approach needed
for critical appraisal of qualitative studies.

The following references were used for


this section:

Walker, J. Holloway, I. & sofaer, B. (1999). In the


system: The lived experience of chronic back pain
from the perspectives of those seeking help from
pain clinics. Pain, 80, 621-8.
Ploeg, J. (1999). Identifying the best research
design to fit the question. Part 2. Qualitative
designs. Evidence-based Nursing, 2(2), 36, 37.
Forchuck, C. & Roberts, J. (1993). How to critique
qualitative research articles. Canadian Journal of
Nursing Research, 25, 47-56.

Because qualitative research examines concepts and


phenomena, their study questions will be of a descriptive
nature, such as "What is the lived experience of an
individual experiencing chronic back pain?" Typically
there are smaller sample sizes that are approached
sequentially and in a flexible manner (perhaps using an
interview guide or a series of probing questions).
Sampling ceases when the researcher reaches a point of
"saturation" (i.e. further interviews do not uncover new
themes). Participant observation, a technique that has
evolved from anthropology, is also commonly used. The
analysis process is extensive and intuitive as the
researcher "dwells in the data" uncovering codes, themes
and patterns to produce a rich description of the
phenonema. Direct quotyes from key participants are
used in the report to illustrate key themes.

Common types of qualitative research


are:

ethnography (describes a culture


from an insider perspective)
phenomenology (describes the lived
experience of key informants)
grounded theory (develops theory
through theoretical sampling and
constant comparative methods)

Criteria for Critical Appraisal of


Qualitative Studies:

Are the aims of the study clearly described and


appropriate for this methodology?
Is sampling described and conceptually sound for
this type of qualitative research?
Are the conditions under which data were
collected described and appropriate?
Is the data analysis pathway described in
sufficient detail to indicate trustworthiness of
process?
Are the findings clearly stated with rich
description included?
Are the results/interpretation of findings logical
and clinically useful?