EvidenceBased Practice

What is - Evidence?
Segala sesuatu yang memberikan
materi/bahan atau informasi yang pada
akhirnya dapat dijadikan bukti atau mungkin
menjadi dasar, sebagai kebenaran, yang
dapat digunakan mendukung atau
membantah tentang suatu issu/kasus
(Webster)

EBN can be defined as the application of valid, relevant, researchbased information in nurse decision-making.
Research-based information is not used in isolation, however, and
research findings alone do not dictate our clinical behaviour
Rather, reseach evidence is used alongside our knowledge of our
patients (their symptoms, diagnoses, and expressed preferences),

Evidence-Based
Practice
Evidence-Based Practice
Ketelitian, keterbukaan, kejelasan, dan
kebijaksanaan yang sekarang digunakan sebagai
bukti terbaik dari tenaga-tenaga kesehatan yang
ahli, dan nilai-nilai pasien untuk membuat keputusan
tentang pelayanan kepada pasien.
(Sackett, 2000)

Evidence-based nursing practice

adalah suatu penyampain proses keputusan yang
dibuat diantara praktisi, pasien dan pihak penting
lain yang yang di dasarkan pada bukti penelitian,
pengalaman dan yang disukai pasien, clinical
expertise, dan sumber informasi penting lainnya.
(STTI , 2007)

Evidence-Based Practice
EBP diartikan sebagai penggunaan
evidence yang terbaik dalam
membuat keputusan terhadap
perawatan pasien (Sackett et al.
2000 dalam Moule dan Goodman
2009).

Evidence-Based Practice
Dalam membuat keputusan tentang
evidence-based tentang perawatan pasien
perawat seharusnya:
1.menggunakaan evidence terkini yang
tersedia
2.mempertimbangkan dengan
mengutamakan pasien
3.menggunakan pengalaman dan
keahliannya untuk membuat sebuah
keputusan.

The components of EBN

decision
1. Judgement and expertise of the
Nurse
2. Valid, Relevant Research Evidence
3. Patient Preferences and
Circumstances
4. Available Resources

Langkah2 penerapan EBP

Langkah pertama yang seharusnya
dalam menerapkan EBP adalah dengan
membuat sebuah fokus pertanyaan.
Sacket et al. (1997) dalam Craig dan
Smyth (2007) menjelaskan bahwa untuk
membuat pertanyaan lebih fokus dapat
menggunakan sebuah kerangka metoda
yang diberi nama P-I-C-O (population,
intervention, comparison, dan outcome).

PICO

Population
Bisa merujuk ke usia tertentu, jenis kelamin, jenis penyakit,
tingkat keparawatan panyakit. Populasi ini tegantung dengan
apakah hasil yang diharapkan sangat luas ataukah tingkat
populasi tertentu.
Intervention :
dapat berupa sebuah tes atau sebuah paparan dan comparison
intervention jika memang ada. Memutuskan sebuah outcome
tidak harus diptuskan secara langsung tapi dapat difasilitasi
dengan mempertimbangkan perspektif pasien.
Outcome secara umum kemungkinan adalah susah untuk
diukur sehingga untuk mendapatkan objektifitas outcome harus
lebih spesifik (Craig dan Smyth 2007). Pertanyaan ini dapat
dibangun dengan menggunakan tiga atau empat bagian (untuk
lebih jelas bisa dilihat di tabel 1).

Tabel 1. Bagian pertanyaan dalam

PICO
Population, Patient atau Problem

definisikan pertanyaan tentang apa dan siapa

Interventions

definisikan intervensi, tes, atau paparan

Comparison intervention (jika ada)

definisikan alternatif intervensi dan

apakah dibandingkan dengan intervensi

Outcomes

definisikan
pentingnya
manfaat, dan bahaya.

outcomes,

Sumber: Craig dan Smyth (2007)

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
Early 1990s 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

1997 Jan 2011 198 Evidence Reports published by the EBP centers
May, 2005 Episiotomy Use
no health benefits from episiotomyroutine use is harmful

Recent Evidence Reports

193. Alzheimer's Disease and Cognitive Decline
192. Lactose Intolerance and Health
190. Enhancing Use and Quality of Colorectal Cancer Screening
189. Exercise-induced Bronchoconstriction and Asthma
188. Impact of Consumer Health Informatics Applications
187. Treatment of Overactive Bladder in Women
185. Management of Ductal Carcinoma in Situ (DCIS)
184. Treatment of Common Hip Fractures
151. Nurse Staffing and Quality of Patient Care
140. Tobacco Use: Prevention, Cessation, and Control
This is just one example of literature syntheses that are available
to support EBP.

Nurse Staffing and Quality

of Patient Care
Objectives: To assess how nurse to patient ratios
and nurse work hours were associated with patient
outcomes in acute care hospitals
Results: Higher RN staffing was associated with
less mortality, failure to rescue, cardiac arrest,
hospital acquired pneumonia, and other adverse
events. Limited evidence suggests that the higher
proportion of RNs with BSN degrees was associated
with lower mortality and failure to rescue. More
overtime hours were associated with an increase in
hospital related mortality, nosocomial infections,
shock, and bloodstream infections.

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

2011 Medline search > 38,000

Dalam satu decade,

konsep EBP sudah
diterima dan digunakan
oleh perawat di hampir
setiap spesialisasi
pelayanan dengan
berbagai peran dan posisi
perawat di seluruh dunia
EBP means many things to many
people

Factors Contributing to Emphasis

on Evidence-Based Nursing
Practice
Scientific knowledge expansion
Knowledge availability -- The Internet
Highly educated nurses in clinical settings

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)

Clinical Nursing Questions

Pada pasien pasca operasi, apakah
analgesik X atau analgesik Y yang
lebih baik menurunkan rasa nyeri?
Diantara pasien sakit kritis, apakah
di kontrol atau bebas kunjungan
lebih efektif menurunkan
kecemasan pasien?

What kind of questions might the

Nurse Manager ask?
Pada unit medical bedah, bekerja
dalam 12 jam satu shift atau 8
jam/shif yang lebih sering terjadi
kekeliruan pemebrian obat?

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?

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?

Steps in the EBP Process

Mengembangkan pertanyaan yang baik
Menemukan sumber EB untuk
menjawab pertanyaan
Mengevaluasi kekuatan dan penerapan
evidence
Mengimplementasikan evidence to
practice
Evaluating the effects

 Apabila kita menilai pertanyaan

tersebut dapat menjadi peluang dan
meningkatkan layanan/manfaat,
berikutnya kita harus menemukan
evidance
Where should we look?

Strength of Evidence

Level
Level
Level
Level

I - meta-analysis of multiple studies

II - experimental studies, RCTs
III - quasiexperimental studies
IV - nonexperiemental studies

Level V - case reports, clinical examples

At what level is most nursing evidence?

AACN Levels of Evidence

(Armola, et al. , C C Nurse, 2
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

Manufacturers recommendations only

AACN Levels of Evidence

Armola, et al. , C C Nurse (, 2009)
Level A
Level B
Level C
Level D
Level E
Level M

Meta-analysis or metasynthesis of multiple

controlled studies, supporting a specific action
Controlled, randomized, or nonrandomized
studies, supporting a specific action
Qualitative, descriptive or correlational studies
or systematic reviews with consistent results
Peer-reviewed prof. organ. standards with
studies to support them
Theory-based evidence from expert opinion or
case studies
Manufacturers recommendations only

Preprocessed Evidence

(A. DiCenso, 2009)

Resources to Support
Evidence-Based Practice

Government agencies
Cochrane Collaboration
Professional Organizations
Benchmark Institutions

AHRQ Agency for Healthcare Research and Quality

Cochrane Collaboration
an international, independent, not-for-profit organization of
over 27,000 contributors from more than 100 countries,
dedicated to making up-to-date, accurate information about
the effects of health care readily available worldwide.
Contributors produce systematic assessments of healthcare
interventions, known as Cochrane Reviews, which are
published online in The Cochrane Library.

Rely heavily on RCTs

Primarily focused on effectiveness of interventions,
more medical and pharmaceutical than nursing

Cochrane Collaboration
http://www.cochrane.org

Substitution of Drs by Nurses in

Primary Care
Objectives: to evaluate the impact on patient
outcomes, processes of care, and costs. Outcomes
included: morbidity; mortality; satisfaction;
compliance; and preference.
Studies were included if nurses were compared to
doctors providing a similar primary health care
service. Doctors included: general practitioners,
family physicians, pediatricians, internists or
geriatricians. Nurses included: nurse practitioners,
clinical nurse specialists, or advanced practice
nurses.
Results: 4253 articles were screened, 25 articles met
our inclusion criteria. No appreciable differences
were found between doctors and nurses in health
outcomes, processes of care, or cost; but patient
satisfaction was higher with nurse-led care.

Professional Nursing Organizations

Supporting Evidence-Based Practice

AACN
AWHONN
AORN
ONS
Sigma Theta Tau

Am. Assoc. of Critical Care

Nurses
Succinct dynamic directivessupported by
evidence to ensure excellence in practice and a
safe and humane work environment.

Venous Thromboembolism Prevention

Oral Care in the Critically Ill
Noninvasive BP Monitoring
Verification of Feeding Tube Placement
Ventilator Associated Pneumonia
Dysrthymia Monitoring

Published since 2005

Available free on AACN website
Include ppt presentations and audit tools

Oncology Nursing Society

EBP Resource Center
http://onsopcontent.ons.org/toolkits/evidence/
Also provides topical toolkits, on specific topics,
plus:
How To Find The Evidence
How To Critique Evidence
How To Develop An Evidence Based Presentation
Evidence Based Practice Education Guidelines
Evidence on Clinical Topics
How to Change Practice
Levels of Evidence Table

Sigma Theta Tau EBP Initiatives

Strategic Plan
Online Resources
NKI http://www.nursingknowledge.org > 200
resources for EBP some free, some for purchase

New Award for EBP

Conferences

(formerly Clin Scholarship)

International EBP and Research Congress

July, 2010 Orlando
July, 2011 Cancun
July, 2012 Australia

Journals Supporting EBP

Evidence-Based Nursing
Online Journal of Clinical Innovations
WorldViews on Evidence-Based Nursing
The Online Journal of Knowledge Synthesis
for Nursing (archived, no longer being
published)
Reflections on Nursing Leadership (Vol 28, 2)

Local vs. Global Evidence

Institutional/Local >
National/International
CPI Data/Research Results
Standards & Protocols/Practice
Guidelines
Expert Advice
Patient/Family Preferences

Values and Preferences

EBN - integration of the best
evidence available, nursing
expertise, and the values and
preferences of the individuals,
families and communities
Yasmin Amarsi, RNL, 2002:

The crux is to ensure that

EBN attends to what is
important to nursing and that
caring is not sacrificed on the
altar of scientific evidence.

Amys Blog
I consulted a well-regarded oncologist in New York. After the tests
she regretfully informed me that my disease was not curable. She
recommended an evidence-based course of medications aimed at
slowing the progression. Before I committed, I wanted a second
opinion. I secured an appointment with the pre-eminent
researcher/ clinician in inflammatory breast cancer.
The building was beautiful, the staff attentive. I had no doubt
that the care would be top-notch.
Everything changed when I sat down with the physician. He never
asked about my goals for care. He recommended an aggressive
approach of chemotherapy, radiation, mastectomy, and more
aggressive chemotherapy. My doctor in New York had said this was
the standard, evidence-based protocol for patients in Stage III B
But since I am in Stage IV (with mets) she said I wouldnt get the
benefit of this aggressive, curative approach.

 All of my patients use this protocol, he said.

I was shocked. Does this mean I could get better? I asked.
No, this is not a cure. he answered. But if you respond to the
treatment, you might live longer, although there are no guarantees.
My goals are to maximize my quality of life so I can live, work, and
enjoy my family Would I undergo a year or more of grueling,
debilitating treatment only to live with spinal fractures if the cancer
progressed? Would I get the possibility of quantity and no quality?
I pressed him. Why do the mastectomy? If the cancer has already
spread to my spine. You cant remove it.
His brow furrowed. Well, you dont want to look at the cancer, do
you? He made it sound like cosmetic surgery.
Right now, I feel fine. I can work. I am pain free. Did I want to trade
that for a slim chance of a little extra time (no guarantees, of course)?

 But what about the side effects of radiation? I asked.

Ive heard they are terrible.
He frowned and seemed annoyed by my questions. My
patients dont complain to me about it, he replied.
Inwardly, I shook my head. Of course his patients never
complained to him. Most of them were probably unaware
that less aggressive treatments were viable options. To me,
there were real drawbacks. Undergo aggressive therapy
that might buy me a longer lifeat what cost? I might
never recover my health for the limited period of time I
have.
This doctor, top in his field, was reflecting the bias of our
medical system towards focusing (evidence-based)
survival. He was focused only on quantity and forgot about
quality.

The patients goals and desires, hopes and fears, were not part of the
equation. He was practicing one-size-fits-all (cookbook?) medicine that
was not going to be right for me, even though scientific studies showed it
was statistically more likely to lengthen life.
Based on a perverse set of metrics, this oncologist was offering
technically the best care America had to offer.
Yet this good care was not best for me. It wouldnt give me health.
Instead, it might take away what health I had. It doesnt matter if care is
cutting-edge, technologically advanced, (and evidence-based); if it
doesnt take the patients goals into account, it may not be worth doing.

I returned to my original New York oncologist.

I was determined not only to choose treatment
that would maximize the healthy time I had
remaining, but also to use that time to call on our
health care institutions and professionals to make
a real commitment to listening to their patients.

Moving Toward our Destiny

Evidence-based practice is every nurses
responsibility
What can you do to make this goal a reality?

Educators
Role
EB Education for EB

Practice
Base educational
content on evidence
Seek the most current
forms of evidence, e.g.
journals & online
sources vs. texts
Encourage students to
question and challenge
Teach research content
in a manner that is
interesting and useful

Manager/Administrators
Role
Encourage inquisitive minds
Promote risk-taking and
flexibility in the clinical
environment
Incorporate EBP activities
into performance evals
Provide time & resources
unit internet access
Provide support personnel
Empower staff to make EB
practice changes
Acknowledge and reward EB
improvements

Researchers
Role
Remain clinically in

touch

Conduct clinically useful

studies

Support clinicians in
accessing and
synthesizing the
evidence
Collaborate with
clinicians and patients
Disseminate findings
that are understandable
and accessible
Emphasize clinical
implications

Nurse Clinicians
Role

Worry and Wonder

Be the Inquiring Mind
Question clinical traditions
Stay abreast of the literature
- guidelines
Find your niche and
become the expert
Collaborate with APNs &
researchers
Be an advocate for evidencebased changes
LISTEN to your PATIENTS to
guard
patient & family
preferences

Institute of Medicine October 2010 Report:

The Future of Nursing Leading Change,
Advancing Health
1. Remove scope-of-practice barriers
2. Expand opportunities for nurses to lead and diffuse
collaborative improvement efforts
3. Implement nurse residency programs
4. Increase the proportion of nurses with a baccalaureate
degree to 80% in 2020
5. Double the number of nurses with a doctorate by 2020
6. Ensure that nurses engage in lifelong learning
7. Prepare and enable nurses to lead change to advance
health
8. Build an infrastructure for the collection and analysis
of interprofessional health care workforce data

The Problem Transition to

Practice: Promoting Public
Safety
35 to 60% new nurses leave position in first
year of practice, estimated replacement
cost $46,000 to $64,000 per nurse
10% typical hospitals nursing staff
comprised of new graduates
New nurses experience increased stress 36 months after hire, increased stress levels
are risk factors for patient safety and
practice errors

 NCSBN transition programs reduce

1st year turnover from 35-60% to 613%, results in positive return on
investment from 67 to 885%

What is the Residency Research

Showing?
Retention nationally 94.4% for new grad
first year vs. about 73% without residency
Surveys completed initially, 6 months,
and 12 months; scores improve in new
graduates ability to
organize and prioritize
communicate and be leaders at bedside
decreased stress over the year (less so at
Kentucky)