TREND AND ISSUES IN CRITICAL CARE Ninuk Dian K
FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA Maret 2012
ISSUES ETIK: ASPEK LEGAL, END OF LIFE, LOSS AND GRIEVING
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KELALAIAN •
Perawat mempunyai tugas terhadap pasien untuk memberikan tindakan keperawatan kegagalan melakukan askep disebut kelalaian menyebabkan menyebabkan kerugian kerugian pada pasien masalah hukum
•
Kelalaian dibuktikan: membandingkan kerja kerja perawat dengan standar
Kelalaian: •
Tugas
•
Kelalaian tugas
•
Penyebab Penyebab langsung
•
Kerusakan
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KELALAIAN •
Perawat mempunyai tugas terhadap pasien untuk memberikan tindakan keperawatan kegagalan melakukan askep disebut kelalaian menyebabkan menyebabkan kerugian kerugian pada pasien masalah hukum
•
Kelalaian dibuktikan: membandingkan kerja kerja perawat dengan standar
Kelalaian: •
Tugas
•
Kelalaian tugas
•
Penyebab Penyebab langsung
•
Kerusakan
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Contoh kelalaian •
Pasien tidak di monitor ketat: amputasi
Kasus •
Ny. K datang ke IGD RS A dengan keluhan nyeri dada hebat menjalar ke dagu, leher dan lengan kiri.
•
Dokter tidak berada berada di tempat dan susah dihubungi.
•
Apa yang harus dilakukan oleh perawat?
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Penyelesaian •
Bila perawat diperlukan melakukan tindakan mendik yang tidak di bawah pengawasan langsung dan segera segera harus berdasar protokol.
•
Delegasi dokter yang tidak jelas/dipertayakan bila dilaksanakan dan psien mendderita kerugian: konsekuensi sekunder harus ditanggung perawat/dokter
ISU b.d. Tindakan bantuan hidup •
DNR: sah/eutanasia?
•
Surat wasiat/surat kuasa
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Pengambilan Pengambilan keputusan keputusan wali
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Penolakan Penolakan tindakan pendukung hidup
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Kematian otak
•
Donor organ
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Kasus •
Tn. X dirawat di ICU dengan multiple trauma dengan kondisi tidak sadar, sadar, menggunakan ventilator dengan mode control control FiO2 60%. 60%. GCS 1 X 2, klien mendapatkan dopamine 10 gama, dobutamin 8 gama. Setelah 1 bulan dirawat klien dinyatakam MOF. Hasil diskusi dengan keluarga didapatkan bahwa keluarga keluarga sudah tidak mampu lagi membiayai biaya perawatan perawatan pasien dalam 3 hari kedepan. Keluarga meminta perawat untuk mencabut saja ventilatornya ventilatornya . • Apa yang harus dilakukan oleh perawat?
Keywords: •
MBO
•
Keluarga Keluarga tidak mampu lagi membiayai pasien
•
Keluarga Keluarga meminta penghentian bantuan hidup
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Learning issues: •
Hak-hak pasien dan kaitannya dengan hukum
•
Pasien mati batang otak
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End-of-life decision making
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Aspek social budaya
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Aspek agama/nilai yang dianut pasien dan keluarga
ETIK •
Melibatkan prinsip-prinsip dan aturan yang membimbing dan menjadi dasar tindakan.
•
Etik individu: serangkaian nilai-nilai moral yang menjadi dasar perilaku seseorang
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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 akan dilakukan terhadapnya, untuk ini perlu diberikan informasi yang cukup
Prinsip etik •
Asas kejujuran Tenaga kesehatan hendaknya mengatakan yang sebenarnya tentang apa yang terjadi, apa yang akan dilakukan serta risiko yang dapat terjadi. • Asas tidak merugikan Tenaga kesehatan tidak melakukan tindakan yang tidak diperlukan dan mengutamakan tindakan yang tidak merugikan klien serta mengupayakan risiko yang paling minimal atas tindakan yang dilakukan.
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Prinsip etik • •
• • • •
Asas Manfaat Semua tindakan yang dilakukan terhadap klien harus bermanfaat bagi klien untuk mengurangi penderitaan atau memperpanjang hidupnya Asas kerahasiaan Kerahasiaan klien harus dihormati meskipun klien telah meninggal. Asas keadilan Tenaga kesehatan harus adil, tidak membedakan kedudukan sosial ekonomi, pendidikan, jender, agama, dan lain sebagainya. (Hariadi, 2004)
Kode etik, perawat: • • • •
•
Menghargai kebutuhan, nilai, budaya, dan kerentanan individu 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 jugdement profesional saat menentukan kapan harus membagi informasi yang dimiliki tentang pasien demi kepentingan 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
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
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 sebelum mereka berpartisipasi dalam riset. • Partisipasi seseorang dalam riset harus diberikan secara suka rela dan berdasarkan pengetahuan tentang risiko dan keuntungan berpartisipasi.
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End of life decision making
•
ICU has become a common place to die; ( 22% of all deaths in the US now occur in or after admission to an ICU) • Admission to the ICU is often a therapeutic trial. Only when the trial fails do patients and families consider a change in goals, from restorative care to palliative care. • This change transition from cure to comfort, is one of the most difficult aspects of medical and nursing practice in the ICU
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•
Advance technology in health care
•
Possible to sustain, prolong, restore the life with the use of complex tech and associate therapies such as mech ventilation, ecmo, iab counterpulsation devices, hd, organ transplat
•
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 supportive rather 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 klien dan juga keluarga
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
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 trauma dengan kondisi tidak sadar, menggunakan ventilator dengan mode control FiO2 60%. GCS 1 X 2, klien mendapatkan dopamine 10 gama, dobutamin 8 gama. Setelah 1 bulan dirawat klien dinyatakam MOF. Hasil diskusi dengan keluarga didapatkan bahwa keluarga sudah tidak mampu lagi membiayai biaya perawatan pasien dalam 3 hari kedepan. Keluarga meminta perawat untuk mencabut saja ventilatornya . • Apa yang harus dilakukan oleh perawat?
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The Multi Layered Approach Patient Preferences
Contextual features: legal, social, family, economic
Medical Goals
societal
Quality of life issues
Foundational Principles, Type of Ethical Problem
Lets also remember Medicine is about : “Can we?” Ethics is about: “Should we?”
The ethicist as a hedge
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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.
Withholding treatment a decision that was made not to start or increase a life-sustaining intervention. Patients not undergoing CPR 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.
Withdraw of tx Guidelines Pharmacologic Paralysis and End-ofLife Care. Neuromuscular blocking
agents, 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
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 life sustaining treatment, it may be considered preferable to commenece tx, with an option to review and cease tx in particular after broad consultation with team and family
•
Because ethical positions are fundamentally based in an individual own’s beliefs and ethical perspective, it may be difficult to gain consensus view on a complex clinical situation
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
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.
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
Charles et al. (2003) •
Studied end-of-life practices in 37 ICUs in 17 European countries, January 1, 1999, to June 30, 2000. • Of 31417 patients admitted to ICUs, 4248 patients (13.5%) died or had a limitation of life-sustaining therapy. Of these, 3086 patients (72.6%) had limitations of treatments (10% of admissions). Substantial intercountry variability was found in the limitations and the manner of dying: unsuccessful cardiopulmonary resuscitation in20%, brain death in 8%, withholding therapy in 38%, withdrawing therapy in 33%, and active shortening of the dying process in2%. • Shortening of life-sustaining treatment in European ICUs is common and variable. Limitations were associated with patient age, diagnoses, ICU stay, and geographic and religious factors.
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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 for many 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. The Missouri 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 the courts, Nancy’s family and attorney were able to present the sufficient evidence. The feeding was stopped and Nancy was allowed to die
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
•
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 treatment preferences. 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 clinical team Identify family and clinician participants who should be involved.
•
Focus on the goals and values of the patient. • Use an open, flexible process. • Anticipate possible issues and outcomes of the discussion. • Give families support and time. 3. Interdisciplinary team rounds 4. Availability of palliative care and/or ethics consultation 5. Development of a supportive ICU culture for ethical practice and communication
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Research highlight • A research by Truog et al (2008) concludes that
Family-centered care, which emphasizes the importance of the social structure within which patients are embedded, has emerged as a comprehensive 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 withdrawing different modalities of life-sustaining treatment and the use of sedatives, analgesics, and nonpharmacologic approaches to easing the suffering of the dying process.
Caring for dying patients in ICU • • • • • • •
Privacy Dignity A noise free environment with minimal disturbance 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
A Nurse •
Courage
•
Strength
•
Fortitude
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Symptom management •
Pain
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Dyspnoea and respiratory distress
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Delirium
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Specific medication: opioid
Consideration at the time of death •
Determination of brain death
•
Organ donation
•
Bereavement and support
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Ninuk Dian K
EVIDENCE-BASED PRACTICE
Tujuan Instruksional Setelah kuliah ini mahasiswa diharapkan mampu: •
Menjelaskan pengertian evidence based nursing
•
Mencari literature
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Menjelaskan prinsip critical appraisal
•
Menggunakan hasil riset dalam praktik kep kritis
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Latar Belakang •
Tuntutan masyarakat modern keperawatan berkualitas
•
Menyelesaikan masalah: melakukan penelitian dan menggunakan hassil penelitian orang lain dalam praktik keperawatan
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
Tahapan EBN 1 Reflecting on your practice and questioning 2 Framing an answerable question 3 Searching for the evidence 4 Appraising the evidence 5 Implementing and evaluating
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Melakukan refleksi dan membuat pertanyaan
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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1. Cont.. Hal2 yang harus dipertimbangkan •
Hal apa yang penting/menarik perhatian kita?
•
Apa yang penting bagi pasien?
•
Apa yang menjadi masalah/issu bagi kolega?
•
Apa yang perlu dirubah?
•
Jika kita tahu arah perubahan yang ingin dilakukan, bagaimana kita tahu bahwa arah tersebut adalah arah yang tepat?
Merumuskan masalah yang bisa dijawab
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•
Rumusan pertanyaan yang tepat memfasilitasi pencarian informasi • Sumber informasi sangat banyak, tidak praktis jika kita harus membaca mis 18 jurnal/hari (365 hari dalam satu tahun). • Maka perlu dikembangkan ketrampilan mencari informasi yang relevan dan berguna • Ketrampilan seperti itu bermula dari memformulasikan pertanyaan yang bisa dijawab.
Memfokuskan pertanyaan Memecah pertanyaan menjadi komponenkomponen (PICOT/PECOT): •
Participants (& setting)
•
Intervention/Exposure
•
Control
•
Outcome
•
Time
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Contoh: Apakah komunikasi terapeutik yang diberikan 1 jam sebelum injeksi IM lebih efektif dibandingkan standar perawatan biasa untuk mengurangi kecemasan pasien anak usia sekolah dalam proses imunisasi?
Participant dan Tempat • • • • • •
Populasi khusus: misal: orang gelandangan dengan gangguan jiwa. Kelompok umur? Jenis kelamin? Diagnosis? Orang-orang dengan penyakit tertentu misalnya asma atau emfisema Lokasi geografi Suku bangsa Penting: populasi harus spesifik tetapi radional jangan: Lelaki gelandangan dari suku Badui yang sakit jiwa dan asma, usia 20 s.d. 30 tahun.
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Tempat Tempat yang ingin diteliti? •
Perawatan akut?
•
Komunitas?
•
Unit perawatan tertentu?
•
Di rumah?
Intervensi (exposure) Intervensi apa yang diberikan pada partisipan? •
Obat?
•
Paket pendidikan kesehatan?
•
Bentuk pelayanan yang berbeda?
•
Perilaku berisiko (misal: merokok?)
•
Sesuatu yang menyenangkan misalnya pijat
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Kontrol •
Plasebo?
•
Perawatan standar?
•
Intervensi yang lain?
•
Tidak ada penyakit
•
Hilangnya faktor risiko (misal: tidak merokok)
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?
3. Mencari evidence Sumber-sumber informasi: • Papers published in peer review journals & systematic reviews • Colleagues, newsletters, CPGs, hospital web pages, drug manuals, personal communication, textbooks, protocol manuals, distilled/consolidated research, databases, dst.. dst.. Searching the literature to find answers to your questions
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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 committees 8. Opinion
Dasar dari tingkatan evidence Systematic review mendokumentasikan homogenitas hasil sejumlah penelitian RCT berkualitas tinggi sehingga merupakan bukti yang paling tidak bias dan memberikan estimasi efek dari intervensi
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Mencari evidence
Literature yang dipublikasikan •
22,000 healthcare journals
•
More than 9.5 million records from more that 3,900 journals are indexed in Medline
•
CINAHL, the Cumulative Index to Nursing and Allied Health, indexes 1200 journals
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Literatur yang tidak dipublikasikan •
Studies never submitted for publication
•
Conference proceedings
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
Sumber-sumber artikel •
CINAHL
• Scopus • 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
Jurnal online yang dilanggan 1. Unair: •
SCOPUS (http://www.scopus.com/home.url),
•
Springer link (http://www.springerlink.com),
•
science direct (http://www.sciencedirect.com),
•
science online (http://www.scienceonline.org),
•
sage (http://online.sagepub.com).
•
Tipe akses untuk semua jurnal adalah IP base
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Jurnal yang dilanggan 2. Dikti: • Proquest (http://www.proquest.com/pqdauto; dari unair tanpa pw, dari luar: ID 0RQ6SC37JR, pw= pqdikti), • Ebsco (http://search.ebscohost.com; id: ns000144, pwpassword), • Gale Cencage (http://inffotrac.galegroup.com/itweb user name ptn037, pw success). • ProQuest perpunas (http://proquest.pnri.go.id ; user name & pw = anggota) Kelebihan Gale: Download MP3, full text
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 ...*
SCOPUS •
Berisi abstrak research online, bukan fulltext
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Springerlink •
Database yang dapat dimanfaatkan adalah semua jurnal yang tersedia
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
Proquest •
Art module, Business, agriculture, biology. Sociology journals
•
Ebsco: academic source premier, business, medline with fulltext
•
Gale: • Gale virtual lib (ensiklopedia + penelitian berbagai disiplin) • 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 and academic 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
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’
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 suatu paper • Tools: JAMA Pertanyaan yabg harus diajukan setiap membaca hasil penelitian adl: • Apakah hasil penelitian valid? • Apa hasil penelitiannya? • Akankah hasil penelitian membantu saya dalam merawat pasien?
Apakah tujuan disebutkan dengan jelas? Dalam pendahuluan, lihat: • Why was the study conducted? • Are the research question, aims &/or objectives clearly stated? • Is the significance of the study clearly identified? • Studies which have unclear aims are unlikely to produce meaningful results • Are the method and study design appropriate? • Are the philosophical underpinnings of the research described?
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Validkah hasil penelitian? •
Apakah besar sampel dijelaskan? Sample size calculation (power) – to ensure the sample size is large 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 – the greater the number of tests the greater the likelihood of spuriously significant results
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 followup should be explained • Were all patients who entered the study accounted for?
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 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 be clinically significant Apa beda hasil penelitian dengan penelitian sebelumnya? • Apakah hasil penelitian konsisten dengan penelitian lain? • Apakah peneliti menginterpretasikan hasil penelitian dengan mempertimbangkan penelitian sebelumnya? • Apakah peneliti menghubungkan hasil penelitian dengan teori yang ada?
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
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Contoh metode penelitian kualitatif: •
Documents: Study of documentary accounts of events Passive observation: Systematic watching of behaviour and talk in a natural setting Participant observation: Observation in which the researcher also occupies a role In-depth interviews: Face-to-face conversation to explore issues or topics in detail. (Does not use pre-set questions but a defined set of topics) Focus groups: roup interview that explicitly includes and uses group interaction to generate data
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Pertanyaan: Struktur: apakah jelas bahwa sampel dipilih mewakili fenomena yang akan diteliti? • Data collection: Are data sources and methods of collection specified? Is there evidence that participant consent is an integral part of the data collecting process? • Data analysis: Can the analysis strategy be identified? How does the researcher show they are reporting the participant’s reality? Is there evidence the researcher’s interpretation captured the participant’s meaning? What evidence is provided to demonstrate rigour? • Describing the findings does the researcher demonstrate the method for analysing the data? Does the researcher indicate how the findings relate to theory? Does the researcher link findings to existing theory/literature or is a new theory generated? •
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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 to inform/change your practice? • Consider the size of the effect and its clinically significance • Consider the overall quality of the study to decide whether the findings are likely to be true • Is the sample similar to your own patients/clients? • Does the setting resemble your own setting?
Implementasi Making decisions about whether it is appropriate to implement 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, low risk, available. TAPI membutuhkan waktu > 300 tahun untuk mengimplementasikan
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