PRAKTIK BERBASIS FAKTA (PBF)

DALAM KEPERAWATAN
(Evidence-Based Practice in Nursing)

Kusman Ibrahim, PhD

Fakultas Ilmu Keperawatan - Universitas Padjadjaran
 Mengapa EBP?

• Meningkatkan kualitas pelayanan

• “Best possible outcomes at possibly lower cost”
• Mengikuti kemajuan/perkembangan
• Tuntutan lembaga akreditasi, organisasi profesi,
dan pihak ketiga/pembayar jasa
• Mempersempit “research-practice gap”
• Meningkatkan kemampuan pengambilan
keputusan klinis
• Kontribusi terhadap pengembangan ilmu
keperawatan
Table 4. Core Competencies for Health Professions

1. Provide patient-centered care - identify, respect, and care about patients’ differences, values,
preferences, and expressed needs; relieve pain and suffering; coordinate continuous care; listen to,
clearly inform, communicate with, and educate patients; share decision making and management; and
continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a
focus on population health.

2. Work in interdisciplinary teams - cooperate, collaborate, communicate, and integrate care in teams to
ensure that care is continuous and reliable.

3. Employ evidence-based practice - integrate best research with clinical expertise and patient values for
optimum care, and participate in learning and research activities to the extent feasible.

4. Apply quality improvement - identify errors and hazards in care; understand and implement basic
safety design principles, such as standardization and simplification; continually understand and measure
quality of care in terms of structure, process, and outcomes in relation to patient and community needs;
and design and test interventions to change processes and systems of care, with the objective of
improving quality.

5. Utilize informatics - communicate, manage knowledge, mitigate error, and support decision making
using information technology.

From: IOM Health Professions Education, 2003, p. 4.

 Traditional Basis for Nursing Practice

• Rituals, unverified rules

• Anecdotes, isolated experiences
• Customs, opinions, unit cultures
• Physicians’ authority
(Stetler, 1998)
Beberapa contoh.....
Ketika menjadi mahasiswa
belajar bahwa mencukur
area operasi sebelum operasi
untuk mencegah infeksi

Riset membuktikan:
Pencukuran lebih
meningkatkan dari pada
menurunkan infeksi pos-
operasi
(Kjonniksen et al, 2002)
 Beberapa contoh.....
Sebagai perawat anak , saya
diajarkan bahwa perawatan tali
pusar dengan alkohol berguna
untuk mencegah infeksi pada
tali pusar bayi baru lahir

Riset membuktikan:
Membersihkan tali pusar dengan air
steril memperpendek waktu
pelepasan tali pusar tanpa
menimbulkan infeksi (Medves & Brien,
1997)
 Beberapa contoh.....
Kassa sudah digunakan beratus-
ratus tahun dalam perawatan
luka

Riset membuktikan:

Balutan semioklusif mampu

menurunkan infeksi lebih dari 50 %
dibanding dengan balutan
tradisional kassa (Hutchinson, 1989, 1993)
 EBP vs Research Utilization (RU)

• Samakah EBP dengan pendayagunaan riset?

• RU:
“proses analisis kritis dan evaluasi terhadap
hasil-hasil riset dan menentukan bagaimana
hasil tersebut cocok/bisa diterapkan dalam
praktik keperawatan”
 EBP vs Quality Improvement(QI)

• Samakah EBP dengan peningkatan mutu?

• QI:
“lebih fokus pada luaran sistem, proses, fungsi,
klinis, kepuasan, dan biaya. Tidak diarahkan
untuk menghasilkan ilmu pengetahuan, namun
lebih sebagai alat manajemen untuk
meningkatkan luaran dari suatu unit pelayanan”
contoh: meningkatkan kepuasan pasien melalui
pengurangan kebisingan ruangan
 EBP vs Nursing Research(NR)

• Samakah EBP dengan riset keperawatan?

• NR:
“pencarian yang sistematis yang dirancang
secara khusus untuk mengembangkan,
memperkuat, dan menambah keilmuan
keperawatan”
NR bisa kuantitatif, kualitatif, mixed method
contoh: pengaruh relaksasi dan guided imagery
terhadap kecemasan preoprasi
Dalam praktik sehari-hari dilapangan, sering
ditukarbalikan penggunaan istilah:

RU

EBP

QI NR
 Definition of EBP

• “Process by which nurses make clinical decisions

using best available evidence, clinical expertise,
& patient preferences in the context of available
resources” (DiCenso, 1998)
• Evidence-based nursing practice is the process
of shared decision-making between practitioner,
patient and significant others, based on research
evidence, the patient’s experiences and
preferences, clinical expertise, and other robust
sources of information. (STTI, 2007)
Evidence-Based Practice
EBP in Nursing
 Evolution of EBP

• 1991 – Evidence-based medicine -first described in the

American College of Physicians Journal Club.
• 1992 – the Evidence-based Medicine Working Group
described it as a “paradigm shift” in JAMA

– Clinical observations and experience, principles of pathophysiology,

knowledge gained from authoritative figures, and common sense --
are no longer a sufficient guide for clinical practice, decision-making,
or the development of practice guidelines

Suzanne Prevost, RN, PhD

Associate Dean for Practice
University of Kentucky College of Nursing
President-Elect – Sigma Theta Tau International
 Evolution of EBP
• Early 1990’s – US Prev. Services TF – began developing EB
Guidelines for Screening and Prevention

• 1992 – AHCPR (now AHRQ) – started publishing systematic

reviews and consensus statements in the form of Clinical
Practice Guidelines, starting with the guideline for Acute Pain,
19 guidelines were produced from ’92-’96

• 1993 - the first annual Cochrane Colloquia was held at the New
York Academy of Sciences

• 1993 – Online Journal of Knowledge Synthesis for Nursing

Evolution of EBP

1997 – Jan 2011 – 198 Evidence Reports

published by the EBP centers

– May, 2005 – Episiotomy Use

– “…no health benefits from
episiotomy…routine use is harmful …”
 Evolution of EBP

• 1998 – Evidence-Based Nursing journal debuted

• 1999 – The UK Department of Health stipulated that, to

enhance the quality of care, nursing, midwifery, and health
visiting practice must be evidence-based

• 2002 - JCAHO begins requiring monitoring of evidence-based

core measures

• 2004 – WorldViews on Evidence-Based Nursing

• 2004 – AACN began publishing “Practice Alerts”

 Evolving Interest in Evidence-Based Practice

600
530
500

400

300

200
139
100
67 83
35 47 51
25
0 0 0 1 0 0 5
'91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04
2011 – Medline search > 38,000
 Within one decade, the concept of
evidence-based practice has evolved
and been embraced by nurses in nearly
every clinical specialty, across a variety
of roles and positions, and in locations
around the globe.

EBP – means many things to many

people
 Factors Contributing to Emphasis on Evidence-
Based Nursing Practice

• Scientific knowledge expansion

– Knowledge expands exponentially q 2 yrs
– 12 yrs. from now – 128 x as much knowledge

• Knowledge availability -- The Internet

• Highly educated nurses in clinical settings

– APNs – focusing on evidence-based clinical problem-solving
– Clinical Nurse Researchers
– DNP Movement
 Factors Contributing to Emphasis on
Evidence-Based Nursing Practice

• Aggressive pursuit of cost-effectiveness

• Focus on quality of care, Risk & error reduction
• Highly educated consumers
• JCAHO/Accreditation expectations
• Increased attention to institutional image
– Magnet hospital movement
• Most nurses agree that EBP is important… but
how do we make it happen?
What is the 1st step toward EBP for the
practicing nurse?
• Asking good clinical questions
• Nurses must be empowered to ask
critical questions in the spirit of looking
for opportunities to improve nursing
care and patient outcomes
• Risk-taking environment
 Nursing vs. Medical Questions
• Often more exploratory
• Less frequently focused on intervention selection
• Less evidence to support many nursing interventions
• Most nursing interventions have less capacity for
harm
• Many nursing challenges often go beyond individual
clinical interventions
(e.g. nurse staffing, education, recruitment)
 Panduan Pertanyaan: PICO
Suatu pertanyaan klinis, harus mencakup minimal 3 dari 4
elemen PICO:
• Patient
– Age, sex, ethnicity, etc.
– Condition, diseases, general health status
• Intervention
– Education, diagnostics, treatment plan, self-care, etc.
• Comparison Intervention
– Placebo, etc.
• Outcome
– Expected and actual effects on patient
Apakah intervensi keperawatan penghentian tembakau
menghasilkan penurunan rerata jumlah penderita penyakit
jantung yang datang ke rumah sakit akibat merokok?

• Pasien
– (dewasa) pasien penyakit jantung
– Perokok
– Keluar dari rumah sakit
• Intervensi
– Program penghentian tembakau dipimpin oleh perawat
• Comparison
– (Non-nurse led tobacco cessation programs
• Self-administered,wat non-nurse administered, etc.)
– No comparison
• Outcome
– Penurunan rerata penggunaan tembakau diantara grup
pasien
 Pertanyaan Klinis Keperawatan

• Pada pasien pos-operasi, apakah pemberian

analgetik prn atau ATC menimbulkan
pengurangan rasa sakit yang lebih baik?
• Diantara pasien-pasien kritis, apakah kunjungan
yang dibebaskan (tidak dijadwal ketat) bisa
menurunkan kecemasan pasien?
 Pertanyaan Pengelola Keperawatan

• Pada unit perawatan medikal-bedah,

apakah bekerja 8 jam per shif atau 12 jam
per shif yang menghasilkan lebih banyak
kesalahan pengobatan (medication errors)?
Key Questions to Ask When Considering
EBP

• Why have we always done “it” this way?

• Do we have evidence-based rationale?
• Or, is this practice merely based on tradition?
• Is there a better (more effective, faster, safer, less
expensive, more comfortable) method?
• What approach does the patient (or the target
group) prefer?
• What do experts in this specialty recommend?
Key Questions to Ask When Considering
EBP

• What methods are used by leading/benchmark,

organizations?
• Do the findings of recent research suggest an
alternative method?
• Are organizational barriers inhibiting the application of
best practices in this situation?
• Is there a review of the research on this topic?
• Are there nationally recognized standards of care,
practice guidelines, or protocols that apply?
• Once we agree upon the question that poses an
opportunity for improvement, then we must
find the evidence

• Where should we look?

• Are all forms of evidence equivalent in quality?

 Steps in the EBP Process
• Developing a well-built question
• Finding evidence-based resources to answer
the question
• Evaluating the strength and applicability of the
evidence
• Applying the evidence to practice
• Evaluating the effects
 Strategi Penerapan EBP

• Menumbuhkan budaya EBP

– Menghargai upaya perawat untuk
mempertanyakan praktik yang sudah
ada (status quo)
– Meningkatkan akses ke perpustakaan,
journal, database, internet, dan peneliti
ahli
– Lokakarya tentang penelitian dan EBP
– Kerjasama penelitian
 Strategi Penerapan EBP
• Membentuk forum/komite penelitian atau EBP untuk
berdiskusi dan mengelola proyek EBP
• Mengidentifikasi area prioritas, contoh:
– Aktivitas keperawatan yang menyita banyak waktu
percuma
– Pertanyaan tentang teknik dan prosedur tertentu
– Praktik keperawatan yang berdasar mitos dan tradisi
– Gap antara praktik dengan hasil-hasil penelitian
terbaru
– Perawatan biaya tinggi
– Intervensi yang lebih beresiko bahaya dibanding
manfaat bagi pasien
 Strategi Penerapan EBP
• Membangun kapasitas keahlian
– Pencarian kepustakaan
– Systematic review
– Kategorisasi tingkat fakta
– Kritik artikel riset (kuantitatif, kualitatif)
– Kritik proposal penelitian
– Isu-isu etik dalam penelitian
– Validitas dan reliabilitas penelitian
– Model-model EBP
– Mengembangkan pedoman praktik klinik
• Putting research into action
• Share the knowledge
 Skill Necessary for EBP
1. Critical thinking skills
2. Exposure to research knowledge
3. Information technology knowledge and skills
4. Information Literacy
5. Role modeling by faculty
6. Communication skills
7. Educational preparation
 Strength of Evidence

• Level I - meta-analysis of multiple studies

• Level II - experimental studies, RCTs
• Level III – quasi experimental studies
• Level IV – non experimental studies
• Level V - case reports, clinical examples
AHCPR/AHRQ

At what level is most nursing evidence?

 AACN Levels of Evidence
• Level A • Meta-analysis or metasynthesis of multiple
controlled studies, supporting a specific action
• Level B • Controlled, randomized, or nonrandomized
studies, supporting a specific action
• Level C • Qualitative, descriptive or correlational studies or
systematic reviews with consistent results
• Level D • Peer-reviewed prof. organ. standards with studies
to support them
• Level E • Theory-based evidence from expert opinion or
case studies
• Level M • Manufacturer’s recommendations only
(Armola, et al. , C C Nurse, 2009)
Level of evidence

Th
ThThe ability to incorporate
Evidence-Based Nursing
into clinical care requires a
basic understanding of the
main research designs
underlying the published
evidence
 Hambatan-hambatan
• Kurang menganggap penting riset untuk
praktik
• Kurang memahami database penelitian
elektronik
• Kesulitan akses kepustakaan dan journal
• Kurang keahlian komputer
• Kurang memahami artikel penelitian
• Kurang faham cara pencarian literatur,
pengetahuan tentang penelitian, dan kritik
penelitian
Dean, Harvard Medical School to students:

“We believe that 50 % of what we are

teaching to you now will prove to be false
5 years later; the problem is that we do
not know which 50 % “
 In God we trust
All others must have evidence

Thank You
 Panduan Tugas EBP
Mahasiswa dibagi kelompok, satu kelompok maksimal 6 orang,
setiap kelompok memilih topik yang berbeda. Langkah-langkah
mengerjakan sesuai panduan pertanyaan berikut:
• Dari pengalaman selama bekerja sebagai perawat di
pelayanan keperawatan, identifikasi 1 (satu) masalah klinik
keperawatan yang menurut anda perlu perubahan ke yanglebih
baik?
• Terkait masalah yang diidentifikasi tersebut, adakah
fakta/evidence/hasil riset yang anda ketahui? Bagaimana
menurut fakta/hasil riset tersebut? Evaluasi kekuatan dan
kemamputerapan hasil riset tersebut
• Bagaimana tahapan-tahapan perubahaan yang akan anda
lakukan?
• Rumuskan kriteria evaluasi keberhasilan program tersebut?