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7/25/2019 EBN Critical
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ISU ETIS & EBN IN CRITICAL CARE
Ninuk Dian K
FAKULTAS KEPERAWATAN
UNIVERSITAS AIRLANGGA
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Isu etis di Keperawatan Kritis
1
2
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ASPEK LEGAL, END OF LIFE, LOSS
AND GRIEVING
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KELALAIAN
• kegagalan melakukan askep disebut kelalaian
menyebabkan kerugian pada pasien
masalah hukum
• Kelalaian dibuktikan: membandingkan kerja
perawat dengan standar
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Contoh kelalaian
• Pasien tidak di monitor ketat: amputasi
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Kasus
• Ny. K datang ke IGD RS A dengan keluhan nyeri
dada hebat menjalar ke dagu, leher dan
lengan kiri.
• Dokter tidak berada di tempat dan susah
dihubungi.
• Apa yang harus dilakukan oleh perawat?
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Penyelesaian
• Bila perawat diperlukan melakukan tindakan
medik yang tidak di bawah pengawasan
langsung dan segera harus berdasar
protokol.
• Delegasi dokter yang tidak jelas/dipertayakan
bila dilaksanakan dan psien menderita
kerugian: konsekuensi sekunder harusditanggung perawat/dokter
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ISU b.d. Tindakan bantuan hidup
• DNR: sah/eutanasia?
• Surat wasiat/surat kuasa• Pengambilan keputusan wali
• Penolakan tindakan pendukung hidup
• Kematian otak• Donor organ
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Kasus
• Tn. X dirawat di ICU dengan multiple traumadengan kondisi tidak sadar, menggunakanventilator dengan mode control FiO2 60%. GCS 1X 2, klien mendapatkan dopamine 10 gama,dobutamin 8 gama. Setelah 1 bulan dirawat kliendinyatakam MOF. Hasil diskusi dengan keluargadidapatkan bahwa keluarga sudah tidak mampulagi membiayai biaya perawatan pasien dalam 3
hari kedepan. Keluarga meminta perawat untukmencabut saja ventilatornya .
• Apa yang harus dilakukan oleh perawat?
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Keywords:
• MBO
• Keluarga tidak mampu lagi membiayai pasien
• Keluarga meminta penghentian bantuan hidup
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Learning issues:
• Hak-hak pasien dan kaitannya dengan hukum
• Pasien mati batang otak
• End-of-life decision making• Aspek social budaya
• Aspek agama/nilai yang dianut pasien dan
keluarga
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ETIK
• Melibatkan prinsip-prinsip dan aturan yang
membimbing dan menjadi dasar tindakan.
• Etik individu: serangkaian nilai-nilai moralyang menjadi dasar perilaku seseorang
• Etik profesi: perilaku dan standar yang telah
disetujui untuk diterapkan oleh anggota dari
kelompok profesi tertentu
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Prinsip etik
• Asas menghormati otonomi klien
• Klien mempunyai kebebasan untuk
mengetahui dan memutuskan apa yang akandilakukan terhadapnya, untuk ini perlu
diberikan informasi yang cukup
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Prinsip etik
• Asas kejujuran
Tenaga kesehatan hendaknya mengatakan yangsebenarnya tentang apa yang terjadi, apa yang
akan dilakukan serta risiko yang dapat terjadi.• Asas tidak merugikan
Tenaga kesehatan tidak melakukan tindakan yangtidak diperlukan dan mengutamakan tindakan
yang tidak merugikan klien serta mengupayakanrisiko yang paling minimal atas tindakan yangdilakukan.
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Prinsip etik
• Asas Manfaat
• Semua tindakan yang dilakukan terhadap klien harusbermanfaat bagi klien untuk mengurangi penderitaanatau memperpanjang hidupnya
• Asas kerahasiaan
• Kerahasiaan klien harus dihormati meskipun klien telahmeninggal.
• Asas keadilan
• Tenaga kesehatan harus adil, tidak membedakankedudukan sosial ekonomi, pendidikan, jender, agama,dan lain sebagainya. (Hariadi, 2004)
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Kode etik, perawat:
• Menghargai kebutuhan, nilai, budaya, dan kerentananindividu dalam memberikan asuhan keperawatan
• Menerima hak individu untuk membuat pilihan b.d.
Perawatan diri mereka• Memberikan askep berkualitas pada semua orang
• Menjaga kerahasiaan pasien, menggunakan jugdementprofesional saat menentukan kapan harus membagiinformasi yang dimiliki tentang pasien demikepentingan terapi dan kesejahteraan pasien
• Janji Ners
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Informed consent
• Semua tindakan yang melibatkan kontak
dengan tubuh pasien secara sengaja merup
tindakan invasi terhadap integritas tubuh
memerlukan persetujuan pasien
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Persetujuan sah bila:
• Pembuat keputusan memahami untung rugi
keputusan yang dibuat serta pilihan-pilihan
yang ada
• Dibuat tanpa paksaan
• Dibuat oleh orang yang secara hukum
kompeten
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Orang yang boleh memberikan
consent:• Mampu memahami dan meretensi informasi
• Mampu menelaah informasi dan menimbang
untung rugi/baik-buruk• Mampu membuat keputusan berdasar info
yang diberikan
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PERSETUJUAN UTK BERPARTISIPASI
DLM RISET KESEHATAN
• Norma etik dalam riset biomedik: autonomy,beneficience, non maleficience & Justice(Declaration of Helsinki , 1975).
• Pasien berhak atas informed consent sebelummereka berpartisipasi dalam riset.
• Partisipasi seseorang dalam riset harusdiberikan secara suka rela dan berdasarkanpengetahuan tentang risiko dan keuntunganberpartisipasi.
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End of life decision making
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• Di rawat di ICU: seringkali merupakanpercobaan, jika gagal, klg harus
mempertimbangkan dari pemulihan ke
paliatif
• Perubahan dari pengobatan ke pemberian
rasa nyaman, aspek plg sulit dlm praktik
kedokteran dan keperawatan di ICU
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• Advance technology in health care
• Possible to sustain, prolong, restore the life
with the use of complex tech and associatetherapies such as mech ventilation, ecmo, iab
counterpulsation devices, hd, organ transplat
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• Combination of advance tech and therapy
are part of everyday management in crit
care settings
• Tech is capable of maintaining some of vital
funct, but less able to provide cure
• Managing critically ill patients in many
cases represents a provision of supportiverather than curative tx
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End of Life and Palliative care
• Melibatkan masalah etik yang kompleks
• Penanganan pasien lebih banyak ditujukan
untuk kebutuhan spiritual dan psikologis kliendan juga keluarga
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End of life and palliative
• A common ethical dilemma is r.t to
maintaining life at all costs and relieving
suffering associated with prolonging life
ineffectively
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• Assessment of their post critical illness quality
of life is complex, emotive and forms the basis
of significant debate
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End of life decision making
• Usually very difficult and traumatic
• As a result, there is sometimes a lack of
consistency and objectivity in the initiation,continuation and withdrawal of life supporting
tx in a critical care setting
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Kasus
• Tn. X dirawat di ICU dengan multiple traumadengan kondisi tidak sadar, menggunakanventilator dengan mode control FiO2 60%. GCS 1X 2, klien mendapatkan dopamine 10 gama,dobutamin 8 gama. Setelah 1 bulan dirawat kliendinyatakam MOF. Hasil diskusi dengan keluargadidapatkan bahwa keluarga sudah tidak mampulagi membiayai biaya perawatan pasien dalam 3
hari kedepan. Keluarga meminta perawat untukmencabut saja ventilatornya .
• Apa yang harus dilakukan oleh perawat?
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THE MULTI LAYERED APPROACH
Patient Preferences
Medical Goals
Foundational Principles, Type of Ethical Problem
Contextual
features:
legal,
social, family,
economic
societal
Quality of lifeissues
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Definitions of End-of-Life
Categories:
• cardiopulmonary resuscitation (CPR)
• brain death
• withholding life-sustaining treatment
• withdrawing life-sustaining treatment
• and active shortening of the dying
process.
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Withholding treatment
a decision that was made not
to start or increase a life-sustaining intervention.
Patients not undergoingCPR were classified as withholding
therapy.
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Withdrawing treatment
a decision that was made to actively
stop a life-sustaining intervention
presently being given.
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Withdraw of tx
Guidelines
Pharmacologic Paralysis and End-of-
Life Care. Neuromuscular blockingagents, such as pancuronium, vecuronium,
and atracurium, can be involved in
end-of-life care
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Withholding and withdrawing
• Withholding and withdrawing from life
support is considered ethically acceptable and
clinically desirable if it reduces unnecessary
patient suffering in patients whose prognosis
is considered hopeless
• Based on understanding that pat will most
probably die from underlying disease
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Life support, includes:
• Ventilatory support
• Inotropic support
• HD• etc
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• In most cases where there is doubt about
the efficacy and appropriateness of a lifesustaining treatment, it may be consideredpreferable to commence tx, with an optionto review and cease tx in particular after
broad consultation with team and family• Because ethical positions are
fundamentally based in an individual own’sbeliefs and ethical perspective, it may be
difficult to gain consensus view on acomplex clinical situation
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Active shortening of the dying process
a circumstance in which someone performed an
act with the specific intent of shortening the
dying process; these acts did not include
withholding or withdrawing treatment
although withholding or withdrawing could
occur prior to SDP. Examples included an
intentional overdose of narcotics, anesthetics,or potassium chloride.
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Cardiopulmonary resuscitation
a death despite use of ventilation
and cardiac massage, that is,
failed or unsuccesful CPR
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DNR
• Decision against any further proactive tx such
as CPR
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Brain death
a documented cessation
of cerebral function and meeting
the criteria for brain death.
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Brain death, criteria
• Irreversible coma
• Loss of brainstem reflexes
• Loss of respiratory function
• Cessation of intracranial blood flow
• Respon to pain stimuli• Pupillary respons to light
• Corneal reflex
• Gag reflex
• Cough reflex
• Oculovestibular reflex
• Apnoe test
• Oculcephalic reflex (doll’s eyes)
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• In some countries, patient with dx of brain
death is suggested to commence organ
donation
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Nancy was in a persistent vegetative state after a serious
automobile accident. She was dependent, lived in a
long-term care facility, and received tube feedings formany years. On the basis of their belief that Nancy
would not want to continue to live under these
circumstances, her parents requested that the feeding
tube be removed and that Nancy be allowed to die. TheMissouri Supreme Court stated that no one could
exercise Nancy’s right to refuse treatment without “clear
and convincing evidence” of her wishes. After a long and
arduous struggle with the healthcare system and thecourts, Nancy’s family and attorney were able to present
the sufficient evidence. The feeding was stopped and
Nancy was allowed to die
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What do you think
about Nancy’s case??
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Killing vs. Allowing to Die ??
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Strategies for improving end-of-life
communication in the intensive care
unit (ICU)1. Communication skills training for clinicians
2. ICU family conference early in ICU course
• Evidence-based recommendations for conducting
family conference:
• Find a private location
• Increase proportion of time spent listening to family
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• Value statements made by family members.
• Acknowledge emotions.
• Listen to family members.
• Understand who the patient is as a person.
• Elicit questions from family members.
• Identify commonly missed opportunities
• Listen and respond to family members.
• Acknowledge and address family emotions.
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•Explore and focus on patient values and treatmentpreferences.
• Affirm nonabandonment of patient and family.
• Assure family that the patient will not suffer
• Provide explicit support for decisions made by the family
• Additional expert opinion recommendations for conducting family conference:
• Advance planning for the discussion among the clinicalteam
• Identify family and clinician participants who should beinvolved.
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• Focus on the goals and values of the patient.
• Use an open, flexible process.
• Anticipate possible issues and outcomes of thediscussion.
• Give families support and time.3. Interdisciplinary team rounds
4. Availability of palliative care and/or ethicsconsultation
5. Development of a supportive ICU culture forethical practice and communication
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Research highlight
• A research by Truog et al (2008) concludes thatFamily-centered care, which emphasizes theimportance of the social structure within whichpatients are embedded, has emerged as acomprehensive ideal for managing end-of-life care in
the ICU.• ICU clinicians should be competent in all aspects of
this care (practical and ethical aspects of withdrawingdifferent modalities of life-sustaining treatment andthe use of sedatives, analgesics, and
nonpharmacologic approaches to easing the sufferingof the dying process.
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Caring for dying patients in ICU
• Privacy
• Dignity
• A noise free environment with minimaldisturbance
• Relief of pain
• Provision of comfort
• Support for both pt and relatives
• Coordination of bedside visits
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Caring ...
• Discussion re arrangements, wishes,
belongings, and cultural consideration after
the patient’s death
• Guiding and supporting fam during this time
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Symptom management
• Pain
• Dyspnoea and respiratory distress
• Delirium• Specific medication: opioid
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Consideration at the time of death
• Determination of brain death
• Organ donation
• Bereavement and support
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EVIDENCE-BASED PRACTICENinuk Dian K
1
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Evidence-based Nursing
‘The process by which nurses make clinical
decisions using the best available research
evidence, their clinical expertise and patient
preferences, in the context of available
resources’
Dicenso et al., 1998
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Komponen EBN
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Tahapan EBN
1 Reflecting on your practice and questioning
2 Framing an answerable question
3 Searching for the evidence4 Appraising the evidence
5 Implementing and evaluating
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Melakukan refleksi dan
membuat pertanyaan
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1. Reflecting on your practice and
questioning
• Reflect on your clinical practice
• Identify areas of uncertainty
•A better way of doing things
• Ask why do we do it this way
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Refleksi
• Pasien Kritis berbau tidak sedap
• Kejadian infeksi cukup tinggi
•dll
• dll
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Merumuskan masalah yang bisa
dijawab
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Memfokuskan pertanyaan
Memecah pertanyaan menjadi komponen-
komponen (PICOT/PECOT):
•Participants (& setting)
• Intervention/Exposure
• Control
•Outcome
• Time
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Contoh:
Apakah oral hygiene dengan sikat gigi dan
gosok lidah lebih efektif dibandingkan
dengan kasa dalam mengurangi biakan
kuman di mulut pasien ICU dewasa dengan
ventilator?
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Participant dan Tempat• Populasi khusus: misal: pasien ICU lansia
• Kelompok umur? Jenis kelamin?
• Diagnosis? Orang-orang dengan penyakittertentu misalnya GBS
• Lokasi geografi• Suku bangsa
• Penting: populasi harus spesifik tetapi
rasional
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Tempat
Tempat yang ingin diteliti?
• ICU
•HDU
• Emergency ICU
• Specific ICU: CCU, PICU, NICU
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Intervensi (exposure)
Intervensi apa yang diberikan pada partisipan?
• Obat?
•Paket pendidikan kesehatan?
• Bentuk pelayanan yang berbeda?
• Paparan suara dan cahaya
•Sesuatu yang menyenangkan misalnya pijat
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Kontrol
• Plasebo?
• Perawatan standar?
•Intervensi yang lain?
• Tidak ada penyakit
• Hilangnya faktor risiko (misal: suara dan
cahaya berlebihan)
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Outcome yang diharapkan?
• Reduction in symptoms?
• Improved quality of life?
•Reduced number of deaths?
• Reduced costs?
• Improved service delivery?
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Waktu
• Is the outcome measured immediate?
• Are outcomes measured at different time
points?
• Is it a longitudinal study where outcomes are
measured over 20 years?
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3. Mencari evidence
Sumber-sumber informasi:
• Papers published in peer review journals &systematic reviews
•Colleagues, newsletters, CPGs, hospital webpages, drug manuals, personal communication,
textbooks, protocol manuals,distilled/consolidated research, databases, dst..dst..
Searching the literature to find answers to yourquestions
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Level of evidences
1. Systematic reviews
2. Randomised controlled trials
3. Cohort studies
4. Case-control studies
5. Surveys
6. Case reports
7. Respected authorities/expert committees8. Opinion
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Dasar dari tingkatan evidence
Systematic review mendokumentasikan
homogenitas hasil sejumlah penelitian RCT
berkualitas tinggi sehingga merupakan bukti
yang paling tidak bias dan memberikanestimasi efek dari intervensi
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Sumber sistematik review
The Cochrane Library
• ‘Publication type’ in Medline = Meta-analysis
• ‘Publication type’ in CINAHL = Systematic review
NHS CRD Database of Abstracts of Reviews of Effectiveness (DARE)
‘Distilled’ information sources
• Evidence Based Nursing (EBN)
• Evidence Based Medicine (EBM)• ACP Journal Club
• Best Evidence
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Sumber referensi ilmiah:
• Primer: jurnal, majalah, skripsi, tesis, disertasi,
laporan penelitian
• Sekunder: abstrak, bibliografi
• Tersier: textbook, ensiklopedia
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Sumber-sumber artikel
• CINAHL
• Scopus: abstract only
• The Cochrane Library• Medline / Pubmed
• Web of Science
• Google Scholar• Journal collections (ScienceDirect, Synergy
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Sumber Ilmiah Perpustakaan Unair
• Hardcopy: Buku, jurnal, karya ilmiah sivitas
akademika
• Softcopy: ebooks, e-journal yang dilanggan
perpus ataupun Dikti, ADLN
• Fasilitas lain di ruang baca
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Strategi pencarian
Butuh strategi karena:
• Informasi yang tersedia sangat banyak dan
luas
• Untuk memperoleh informasi yang relevan
• Menghemat waktu
• Mempermudah pencarian
• Mendapat info lain yang berkaitan
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Operator bantuan pencarian di
jurnal elektronik
• Boolean operators/boolean logic (AND, OR,
NOT) e.g virus ebola
• Frase (“...”) mencari symber informasi
mengandung frase yang tepat sama
• Truncation (pemotongan kata atau
penggunaan akar kata ...*
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SCOPUS
• Berisi abstrak research online, bukan fulltext
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Springerlink
• Database yang dapat dimanfaatkan adalah
semua jurnal yang tersedia
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Science direct
• Current: veterinary (science and medicine)
lainnya abstract saja
• Backfiles (< 1995): business-manag, accounting,
economics, econometrics, finances, psychology,nursing and health professions, vet, forensic med,
pathology and medical tech, orthopedics sports
med and rehab tahun depan unair akan
berlangganan fulltext. Saat ini bisa
memanfaatkan fasilitas kartu sakti: ITS
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Sage Premier
• HSS (Humanities and Social Sciences: 351
journals
• STM (Science-technical-medical): 144 Journals
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Proquest
• Art module, Business, agriculture, biology. Sociology journals
• Ebsco: academic source premier, business, medline
with fulltext
• Gale:
• Gale virtual lib (ensiklopedia + penelitian berbagaidisiplin)
• Gale science standard package (fisika, math, nano tech)
• Gale arts, humanities & edu (humaniora & pendidikan)
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Sumber lain
• Google scholar
• Familiar Google interface for articles, books andacademic websites
• Go to Find Database.
• Search results ranked by Google algorithm• Links to cited articles and full text
• Very easy to use
• Free journals; cara mencari: “ list ... journal” will
include unpublish journals• Google book: ketik judul, cari adakah yang gratis di
gigapedia atau web ebook yang lain
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Melakukan critical appraisal
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4. Critical appraisal
• Assessing the quality of the research identified
• Involves the use of criteria against which to
measure or evaluate steps of the research
process
• Guides/tools to assist in critical appraisal:
JAMA guides, BMJ series – ‘How to read a
paper’
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Prinsip Critical appraisal
• Setiap rumusan masalah berimplikasi pada
design penelitian yang sesuai.
• Gunakan dan baca hanya penelitian yang
menggunakan design yang tepat untuk
menjawab pertanyaan.
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Prinsip Critical appraisal
• Adalah menelaah kualitas penelitian.
• Menggunakan kriteria tertentu untuk menilai suatupaper
• Tools: JAMA
Pertanyaan yabg harus diajukan setiap membaca hasilpenelitian adl:
• Apakah hasil penelitian valid?
•Apa hasil penelitiannya?
• Akankah hasil penelitian membantu saya dalammerawat pasien?
A k h t j di b tk d
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Apakah tujuan disebutkan dengan
jelas?
Dalam pendahuluan, lihat:
• Why was the study conducted?
• Are the research question, aims &/or objectivesclearly stated?
• Is the significance of the study clearly identified?
• Studies which have unclear aims are unlikely toproduce meaningful results
• Are the method and study design appropriate?
• Are the philosophical underpinnings of theresearch described?
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Validkah hasil penelitian?
• Apakah besar sampel dijelaskan? Sample sizecalculation (power) – to ensure the sample size islarge enough to detect an effect if there is one
• Are the methods clearly described?
• Statistical analysis?
• Methods section
• Is enough detail provided?
• Beware of large numbers of tests – thegreater the number of tests the greater thelikelihood of spuriously significant results
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Validkah hasil penelitian?
Apakah ada kejadian yang tidak diinginkan
selama penelitian?
• The researchers should acknowledge and
explain any deviations from the original
research design
• Large amounts of missing data may bias the
study findings• Often found in the limitations section
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Validkah hasil penelitian
Apakah besar sampel tetap?
Missing data should be identified
• Numbers of participants reported in subgroups
within tables should add up to N
• Inconsistencies i.e. participants lost to follow-
up should be explained
• Were all patients who entered the study
accounted for?
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Validkah hasil penelitian?
Adakah efek penting yang tidak dilaporkan?
• Are there are any relevant findings that have
not been acknowledged or discussed?
• Are there any confounders/bias not
acknowledged
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Apakah hasil dari penelitian?
• Apakah data dasar dideskripsikan dengan
adekuat?
• Jumalh partisopan harus dilaporkan,
bagaimana rekrutmen responden, data
demografi, dilaporkan sebagai nomor, persen,
mode, median, mean, SD
• Descriptive statistics
Were the basic data adequately
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q y
described?
• Were the groups similar at the start of the
study?
• Simple statistical analyses should be presented
in table or figure format
• More complex statistics should follow
Apakah kelompok sama pada awal perlakuan?
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Apa makna dari Hasil Penelitian?
• Examine the findings of each reported outcome to decide if you believe it is of clinical significance
• A statistically significant finding will not necessarily beclinically significant
Apa beda hasil penelitian dengan penelitian sebelumnya?
• Apakah hasil penelitian konsisten dengan penelitian lain?
• Apakah peneliti menginterpretasikan hasil penelitiandengan mempertimbangkan penelitian sebelumnya?
• Apakah peneliti menghubungkan hasil penelitian denganteori yang ada?
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Riset Kualitatif
• Study things in their natural setting,
attempting to make sense of, or interpret,
phenomena in terms of the meanings people
bring to them
Black ,1994
Contoh metode penelitian kualitatif:
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Contoh metode penelitian kualitatif:
• Documents: Study of documentary accounts of events
• Passive observation: Systematic watching of behaviourand talk in a natural setting
• Participant observation: Observation in which theresearcher also occupies a role
• In-depth interviews: Face-to-face conversation toexplore issues or topics in detail. (Does not use pre-setquestions but a defined set of topics)
• Focus groups: roup interview that explicitly includesand uses group interaction to generate data
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Pertanyaan:
• Struktur: apakah jelas bahwa sampel dipilih mewakili fenomenayang akan diteliti?
• Data collection: Are data sources and methods of collectionspecified? Is there evidence that participant consent is an integralpart of the data collecting process?
• Data analysis: Can the analysis strategy be identified? How does theresearcher show they are reporting the participant’s reality? Isthere evidence the researcher’s interpretation captured theparticipant’s meaning? What evidence is provided to demonstraterigour?
• Describing the findings does the researcher demonstrate themethod for analysing the data? Does the researcher indicate howthe findings relate to theory? Does the researcher link findings toexisting theory/literature or is a new theory generated?
Will the results help me in caring
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Will the results help me in caring
for my patients?
What implications does the study have for your practice
• Should the findings arising from this study be used toinform/change your practice?
• Consider the size of the effect and its clinicallysignificance
• Consider the overall quality of the study to decidewhether the findings are likely to be true
• Is the sample similar to your own patients/clients?
• Does the setting resemble your own setting?
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Implementasi
Making decisions about whether it is appropriate toimplement the research in your practice:
• Research evidence
• Patient’s preferences
• Clinician’s expertise• Healthcare resources
Developing implementation strategies
Contoh:
• Vitamin C reduces the risk & severity of scurvy. Treatment
was effective plus: Cost effective (cheap), Acceptable, lowrisk, available. TAPI membutuhkan waktu > 300 tahununtuk mengimplementasikan
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