EVIDENCE BASED EVIDENCE BASED NURSINGNURSING

FERIKA INDARWATI, S.Kep.,M.Ng.,NsFERIKA INDARWATI, S.Kep.,M.Ng.,Ns

TUJUAN PEMBELAJARANTUJUAN PEMBELAJARAN

- MEMAHAMI TENTANG APA ITU EBNMEMAHAMI TENTANG APA ITU EBN- MENGAPA HARUS MENGGUNAKAN MENGAPA HARUS MENGGUNAKAN

EBNEBN- BAGAIMANA CARA MEMPEROLEH EBNBAGAIMANA CARA MEMPEROLEH EBN- BAGAIMANA CARA BAGAIMANA CARA

MENGAPLIKASIKANNYAMENGAPLIKASIKANNYA

What is Evidence Based What is Evidence Based Practice?Practice?

Suatu proses dimana hasil penelitian, pengetahuan klinik dan critical

thinking/reasonong dipakai untuk membuat keputusan terkait dengan intervensi yang efektif untuk pasien.

Research vs. EBPResearch vs. EBP

EBP is EBP is notnot about conducting research it about conducting research it is about is about USING RESEARCHUSING RESEARCH

Research=Research= systematic process of gathering and systematic process of gathering and synthesising empirical data to generate synthesising empirical data to generate knowledge about a given topicknowledge about a given topic

EBP=EBP= the conscientious, explicit and judicious the conscientious, explicit and judicious use of best current evidence in making decisions use of best current evidence in making decisions about care for clientsabout care for clients

What is EBN?What is EBN?

Evidence-Based Practice (EBP), salah Evidence-Based Practice (EBP), salah satunya adalah Evidence-Based Nursing satunya adalah Evidence-Based Nursing (EBN), merupakan pendekatan yang dapat (EBN), merupakan pendekatan yang dapat digunakan dalam praktik perawatan digunakan dalam praktik perawatan kesehatan, yang berdasarkan evidence atau kesehatan, yang berdasarkan evidence atau faktafakta

Contoh kasusContoh kasus

Selama ini, khususnya dalam Selama ini, khususnya dalam keperawatan, seringkali keperawatan, seringkali ditemui praktik-praktik atau ditemui praktik-praktik atau intervensi yang berdasarkan intervensi yang berdasarkan “biasanya juga begitu”. “biasanya juga begitu”. Sebagai contoh, cairan yang Sebagai contoh, cairan yang digunakan dalam perawatan digunakan dalam perawatan luka adalah povidone-iodine luka adalah povidone-iodine 10%. praktik ini dipakai 10%. praktik ini dipakai “over & over” meskipun “over & over” meskipun yang bersangkutan yang bersangkutan menjelang pensiun. menjelang pensiun.

Bila diberikan masukan, Bila diberikan masukan, kadang-kadang jawaban kadang-kadang jawaban yang keluar adalah : ” yang keluar adalah : ” Selama ini juga begini, Selama ini juga begini, pasiennya juga sembuh kok, pasiennya juga sembuh kok, kok repot…” Padahal, kok repot…” Padahal, berdasarkan penelitian yang berdasarkan penelitian yang terbaru, air kran atau air terbaru, air kran atau air matang saja bisa digunakan matang saja bisa digunakan untuk perawatan lukauntuk perawatan luka

Why need to use EBN?Why need to use EBN? Tenaga perawat kadang dipenuhi oleh rasa ketidakpastian Tenaga perawat kadang dipenuhi oleh rasa ketidakpastian

tindakan apa yang paling efektif untuk mendapatkan hasil tindakan apa yang paling efektif untuk mendapatkan hasil yg terbaik untuk pasienyg terbaik untuk pasien

Evidence based Nursing (EBN)Evidence based Nursing (EBN)

EBN EBN pendekatan yg dpt membantu perawat untuk pendekatan yg dpt membantu perawat untuk memberikan kualitas pelayanan yang terbaik dalam memenuhi memberikan kualitas pelayanan yang terbaik dalam memenuhi kenutuhan pasien dan keluarganyakenutuhan pasien dan keluarganya

Meningkatkan kualitas intervensi keperawatan dari yang Meningkatkan kualitas intervensi keperawatan dari yang berbasis tradisi atau kebiasaan menjadi intervensi berbasis berbasis tradisi atau kebiasaan menjadi intervensi berbasis fakta dan hasil risetfakta dan hasil riset

Perspectives on EvidencePerspectives on Evidence

Research Evidence

Clinical expertise

Patient / User perspectives

Nursing action

Nursing outcomesPractice context

ANY QUESTIONSANY QUESTIONS?

How to use EBNHow to use EBN

OverviewOverviewFive Steps:Five Steps: Mengidentifikasi dan membuat pertanyaan yang jelasMengidentifikasi dan membuat pertanyaan yang jelas Mecari sumber literatur Search the literature for relevant Mecari sumber literatur Search the literature for relevant

clinical articles and evidenceclinical articles and evidence Melakukan kritisisasi pada sumber/artikel Melakukan kritisisasi pada sumber/artikel

penelitian/evidence yg ditemukan penelitian/evidence yg ditemukan Mengimplementasikan evidence kedalam praktekMengimplementasikan evidence kedalam praktek Mengevaluasi dampak dari implementasi evidence Mengevaluasi dampak dari implementasi evidence

tersebuttersebut

REFLECT ON PRACTICE; IDENTIFY AREAS OF UNCERTAINTY

PHRASE ANSWERABLE QUESTIONS

SEARCH FOR RESEARCH EVIDENCE

CRITICAL APPRAISAL OF THE RESEARCH

IMPLEMENTATION WHERE APPROPRIATE

AUDIT

Step 1: Formulate a review questionStep 1: Formulate a review question

Questions can be in relation to:Questions can be in relation to: The cause of a conditionThe cause of a condition Diagnosis and assessmentsDiagnosis and assessments Prevention of conditionsPrevention of conditions Prognosis of conditionsPrognosis of conditions Treatment outcomesTreatment outcomes Client concernsClient concerns Economic evaluationEconomic evaluation

Clinical vs. Review QuestionsClinical vs. Review Questions

Clinical Question:Clinical Question: A general question relating to a clinical practice situationA general question relating to a clinical practice situation

Review Question: Review Question: Comes from a clinical questionComes from a clinical question It is clear and specific to guide the searchIt is clear and specific to guide the search A useful question consists of a problem, intervention and A useful question consists of a problem, intervention and

outcome and often takes the form ofoutcome and often takes the form of::

““What is the evidence for the effectiveness of X What is the evidence for the effectiveness of X (intervention) for Y (outcome) in a client with Z (problem or (intervention) for Y (outcome) in a client with Z (problem or diagnosis)”diagnosis)”

How to Write a Review QuestionHow to Write a Review Question

Use PICO format:Use PICO format:

P=P= The population or problem you are The population or problem you are interested in (client group, problem) interested in (client group, problem)

I=I= The intervention that you are interested inThe intervention that you are interested in

C=C= The comparison or alternative The comparison or alternative intervention (if relevant)intervention (if relevant)

O=O= The outcome or reason for using the The outcome or reason for using the interventionintervention

Example of PICO QuestionExample of PICO Question

What evidence is there for the validity and What evidence is there for the validity and relevance of the Barthel Index vs. the COPM as relevance of the Barthel Index vs. the COPM as an assessment of occupational performance for an assessment of occupational performance for

older adults who have a physical disability?older adults who have a physical disability?

Critiquing an EBP QuestionCritiquing an EBP Question

Identify the PICO components of the Identify the PICO components of the following question:following question:

Are self management strategies more Are self management strategies more effective than medical care alone for effective than medical care alone for

improving health status, quality of life and improving health status, quality of life and function amongst adults with coronary function amongst adults with coronary

heart disease?heart disease?

Critiquing an EBP QuestionCritiquing an EBP Question

PP II CC OOPeople aged People aged over 35yrs, over 35yrs, with coronary with coronary heart diseaseheart disease

Self Self management management interventionsinterventions

Medical care Medical care alonealone

Health Health Status, Status, quality of life, quality of life, occupational occupational performance/performance/functionfunction

Levels of EvidenceLevels of Evidence

Consider the type of research conducted: Consider the type of research conducted: (hierarchical list)(hierarchical list)

1.1. Systematic reviews, meta analysisSystematic reviews, meta analysis

2.2. Randomised controlled trials (RCTs)Randomised controlled trials (RCTs)

3.3. Non-randomised controlled trialsNon-randomised controlled trials

4.4. Case controlled trialsCase controlled trials

5.5. Cohort studiesCohort studies

6.6. Descriptive studiesDescriptive studies

7.7. Qualitative studiesQualitative studies

8.8. Expert opinionExpert opinion

LEVELS OF EVIDENCE

Kramer BS. Weighing scientific evidence. Washington DC: National Academies Press; 2009

2020

PrimaryPrimary: original : original researchresearch

Secondary: Secondary: review review articlesarticles

Tertiary:Tertiary: textbooks, textbooks, summariessummaries

Primary

Secondary

Tertiary

LEVELS OF PEER REVIEWED INFORMATION

Clark N, IT Applications of EBM Principles. Tallahassee, FL: Florida State University College of Medicine, 2003

SECONDARY SOURCES

Clark N, 2003

LEVELS OF EVIDENCE – 5S

Straus S, Haynes RB. Managing evidence-based knowledge: the need for reliable, relevant and readable resources. CMAJ. 2009 April 28; 180(9): 942–945.

Type of question = type of study Type of question = type of study designdesign

Type of question Suggested study

Therapy RCT > prospective cohort

Diagnosis Prospective, blind comparison to a gold standard

Etiology/Harm RCT > cohort > case control > case series

Prognosis Cohort study > case control > Case series

Prevention RCT > cohort study >case control > case series

Cost Economic analysis

Step 2: Searching the literature to Step 2: Searching the literature to find the evidencefind the evidence

Need to use an organised and systematic Need to use an organised and systematic approachapproach

Develop search strategies before you Develop search strategies before you start, including:start, including:

Databases you will useDatabases you will use Key terms to search underKey terms to search under Set limits of your searchSet limits of your search

Databases to UseDatabases to Use

Need to consider:Need to consider: Is your focus medical or broader?Is your focus medical or broader? Is your focus OT specific?Is your focus OT specific? Do you want literature from a particular Do you want literature from a particular

country or area? (eg. Australia or Asia)country or area? (eg. Australia or Asia) Is there a specific research method you Is there a specific research method you

want to focus on? (eg. systematic review)want to focus on? (eg. systematic review)

Key Terms and Search LimitsKey Terms and Search Limits

Pull out the key terms from your review Pull out the key terms from your review questionquestion Generally the problem, intervention and outcomeGenerally the problem, intervention and outcome Consider alternative or related terms (eg. Occupation Consider alternative or related terms (eg. Occupation

and activity)and activity)

Set limits for your search, includingSet limits for your search, including Language of the articleLanguage of the article Research designResearch design Date of publicationDate of publication

Step 3: Critically Analysing the Step 3: Critically Analysing the EvidenceEvidence

Assess the value and trustworthiness of the Assess the value and trustworthiness of the evidenceevidence

No research is without its flaws, need to ask:No research is without its flaws, need to ask:

““Do the flaws make me question the conclusion?”Do the flaws make me question the conclusion?” 3 broad areas to analyse:3 broad areas to analyse:

The rigor of the researchThe rigor of the research Significance of the resultsSignificance of the results Impact upon your OT practiceImpact upon your OT practice

Step 4: Implementing the evidenceStep 4: Implementing the evidence

Examples of strategies to implement Examples of strategies to implement evidence into practice include: evidence into practice include:

Apply the results to one or a group of Apply the results to one or a group of clientsclients

Reconsider treatment plans/goalsReconsider treatment plans/goals Develop handouts on topics (with other Develop handouts on topics (with other

professionals)professionals)

Considerations when implementing Considerations when implementing evidenceevidence

Who is the right therapist to be implementing the Who is the right therapist to be implementing the evidence?evidence?

What does the evidence say the “right” thing to What does the evidence say the “right” thing to do is?do is?

What is the right way to implement the What is the right way to implement the intervention?intervention?

What is the right place for the implementation?What is the right place for the implementation? What is the right time to implement?What is the right time to implement?

Step 5: Evaluating the impact of the Step 5: Evaluating the impact of the evidenceevidence

When evaluating the impact, consider:When evaluating the impact, consider:

The client’s outcomesThe client’s outcomes Cost effectivenessCost effectiveness Client satisfactionClient satisfaction Therapist satisfactionTherapist satisfaction

Barriers to EBPBarriers to EBPSome barriers to EBP that have been discussed in Some barriers to EBP that have been discussed in

literature include:literature include: Access and availability to informationAccess and availability to information Limited timeLimited time Lack of EBP skillsLack of EBP skills Confidence in the value of the evidenceConfidence in the value of the evidence Support from managementSupport from management

HOWEVER, BARRIERS CAN ALWAYS BE HOWEVER, BARRIERS CAN ALWAYS BE OVERCOMEOVERCOME

Becoming an Evidence Based Becoming an Evidence Based PractitionerPractitioner

Strategies include:Strategies include: Regularly ask clinical reflective questionsRegularly ask clinical reflective questions Take time to track down the best evidence Take time to track down the best evidence

to support your therapyto support your therapy Use the evidence in your therapyUse the evidence in your therapy Evaluate the impact of this evidence on Evaluate the impact of this evidence on

your therapyyour therapy

Useful ResourcesUseful Resources

Databases:Databases: AMED- AMED- rehab and therapy for allied health rehab and therapy for allied health

professions, accessed through professions, accessed through www.silverplatter.com/catalog/amed.htm

CINAHL-CINAHL- mainly nursing literature but some mainly nursing literature but some allied health, allied health, www.cinahl.com/

Cochrane Library-Cochrane Library- RCTs and Systematic RCTs and Systematic Reviews, Reviews, www.cochrane.co.uk/

Useful ResourcesUseful Resources

Websites:Websites: HealthWeb:HealthWeb: tutorials and guides to searching tutorials and guides to searching

literature- literature- www.healthweb.org/browse.cfm?subjectid=39

British medical journals:British medical journals: articles relating to articles relating to EBP- EBP- http://bmj.bmjjournals.com/collections/

Canadian Centre for Health Evidence:Canadian Centre for Health Evidence: description of EBP description of EBP www.cche.net/usersguides/main.aspwww.cche.net/usersguides/main.asp

Useful ResourcesUseful Resources

Websites Continued:Websites Continued: Joanna Briggs Institute:Joanna Briggs Institute: International International

Research Collaboration, centres incl. Research Collaboration, centres incl. www.joannabriggs.edu.au/about/home.phpwww.joannabriggs.edu.au/about/home.php

ANY QUESTIONS?ANY QUESTIONS?

Thank YouThank You ““Let whoever is in charge keep this simple Let whoever is in charge keep this simple

question in her head:question in her head: Not how can I always do this right thing myself, Not how can I always do this right thing myself,

but how can I provide for this right thing to be but how can I provide for this right thing to be always done?”always done?”

Florence Nightingale, 1860Florence Nightingale, 1860

References:References: Alison Lane- Evidence Based Practice Alison Lane- Evidence Based Practice

Presentation, Pt PiriePresentation, Pt Pirie Mary Russell- Evidence Based Practice Mary Russell- Evidence Based Practice

Presentation, UniSAPresentation, UniSA Taylor, MC 2002, ‘Evidence Based Practice for Taylor, MC 2002, ‘Evidence Based Practice for

Occupational Therapists,’ Blackwell Science Ltd, Occupational Therapists,’ Blackwell Science Ltd, USAUSA

Holm MB 2000, The 2000 Elanor Clarke Slagle Holm MB 2000, The 2000 Elanor Clarke Slagle Lecture: Our Mandate for the New Millenium: Lecture: Our Mandate for the New Millenium: Evidence-Based Practice, American Journal of Evidence-Based Practice, American Journal of Occupational Therapy, vol.54, no.6, pp.575-85 Occupational Therapy, vol.54, no.6, pp.575-85