Jabatan Fungsional Perawat

dan Angka Kreditnya

R.B. Edy Santoso, S.Kep., Ns., M.Kep

 Dasar Hukum
 UU 38 tahun 2014
 Kepmenpan 25 tahun 2014

 Permenkes Nomor 1796 Tahun 2011

 Permenkes Nomor 46 Tahun 2013

 Permenkes 148 Tahun 2010

 Permenkes Nomor 17 Tahun 2013  perubahan

PMK 148
 “A team of experts does not make
an expert team”

5
Swezey, Salas, eds. Teams: Their training and performance. 1992:3-29.
Newhouse RP & Spring B. Interdisciplinary
Evidence-based Practice: Moving from
Silos to Synergy. Nurs Outlook 2010;
58(6):309-317.

“Moving from silos to

synergy in interdisciplinary
EBP will require a
paradigm shift.”
 Interprofessional Education and
Interprofessional Collaboration

IPE When students from two or more professions

learn about, from and with each other to
enable effective collaboration and improve
health outcomes (WHO, 2010)

IPC When multiple health workers from different

professional backgrounds work together with
patients, families, careers, and communities to
deliver the highest quality of care (WHO, 2010)
 Professional & Interprofessional
Competency
Professional Behavioral demonstrations of an
Competency integrated set of knowledge, skills, and
attitudes that define the domains of
work of a specific health profession
applied in specific care contexts

Interprofessional Behavioral demonstrations of an

Competency integrated set of knowledge, skills and
attitudes for working together across the
professions, with other health care
workers, and with patients/families/
communities/populations to improve
health outcomes in specific care contexts
 IOM 5 Core Competencies,
adapted to IPEC Expert
Panel Work Provide
Utilize Patient-
Informatics Centered
Care
Work in
Interprofessional
Teams
“Core
Competencies”
Employ Apply
Evidence- Quality
Based Improvement
Practice
 Core Competencies:
Four Domains

Values/ Roles/
Ethics Responsibilities

Work in IP
Teams 
Core
Competencies

Teamwork
Communication Processes
 Satterfield JM et al. 2009. Toward a
Transdisciplinary Model of Evidence-
Based Practice. The Milbank
Memorial Quartely 87(2): 368-390.
Current Developments in
Evidence-Based Practice
 Medicine
 Nursing

 Psychology

 Social work

 Public health
Methods

 The core issues and challenges in

EBP are identified by comparing and
contrasting EBP models across
various health disciplines.
 Then a unified, transdisciplinary EBP
model is presented, drawing on the
strengths and compensating for the
weaknesses of each discipline.
Evidence-Based Medicine
(EBM)
 1992 - Paradigm Shift:
Evidence-Based Medicine
 De-emphasizes intuition, unsystematic clinical
experience, and pathophysiologic rationale as
sufficient grounds for clinical decision making
 Stresses the examination of evidence from
clinical research
 Requires new skills of the physician, including
efficient literature searching and the application
of formal rules of evidence evaluating the clinical
literature
 WHAT IS EBM?
Evidence-based medicine (EBM)
requires the integration of:

1. The best research evidence

with
2. Our clinical expertise
and
3. Our patient’s unique values and
circumstances.
 Best Research Evidence
 Valid and clinically relevant research, often from
the basic sciences of medicine, but especially
from patient-centered clinical research into the
accuracy of diagnostic tests (including the clinical
examination), the power of prognostic markers,
and the efficacy and safety of therapeutic,
rehabilitative, and preventive regimens.
 New evidence from clinical research both
invalidates previously accepted diagnostic tests
and treatments and replaces them with new ones
that are more accurate, more efficacious, and
safer.
 Hierarchy of evidence

Quality Type of evidence

1a (best) Systematic review of randomized controlled trials
1b Individual randomized controlled trials with narrow confidence interval

1c All or none case series (when all patients died before a new therapy was introduced,
but patients receiving the new therapy now survive)

2a Systematic review of cohort studies

2b Individual cohort study or randomized controlled trials with <80% follow up

2c Outcome research; ecological studies

3a Systematic review of case-control studies
3b Individual case-control study
4 Case series
5 (worst) Expert opinion
 Strength of
Recommendation
A Strong evidence of efficacy and substantial
clinical benefit support a recommendation for use
B Moderate evidence of efficacy or strong evidence of efficacy
but limited clinical benefit support a recommendation for
use
C Insufficient evidence to support a recommendation for or
against use, or evidence of efficacy might not outweigh
adverse consequences or alternative approaches
D Moderate evidence of lack of efficacy or of adverse outcome
support a recommendation against use
E Good evidence of lack of efficacy or of adverse outcome
supports a recommendation against use
21
 Clinical Expertise

 The ability to use our clinical skills and past

experience to rapidly identify each patient’s
unique health state and diagnosis, their
individual risks and benefits of potential
interventions, and their personal circumstances
and expectations.
 Patient Values
 The unique preferences, concerns and
expectations each patient brings to a clinical
encounter and which must be integrated into
clinical decisions if they are to serve the
patient.

Patient Circumstances
• Their individual clinical state and the
clinical setting.
 How Do We Actually Practice EBM?

 Step 1: converting the need for information

(about prevention, diagnosis, prognosis, therapy,
causation, etc.) into an answerable question.
 How Do We Actually Practice EBM?

 Step 2: tracking down the best evidence with

which to answer that question.
 Step 3: critically appraising that evidence for its
validity (closeness to the truth), impact (size of
the effect), and applicability (usefulness in our
clinical practice).
 Step 4: integrating the critical appraisal with
our clinical expertise and with our patient’s
unique biology, values, and circumstances.
 How Do We Actually Practice EBM?

 Step 5: evaluating our effectiveness and

efficiency in executing steps 1–4 and seeking
ways to improve them both for next time.
Evidence-Based Nursing
(EBN)
Evidence-Based Nursing

 Compared with EBM, EBN usually

relies more on evidence from
nonrandomized designs.
 Without randomized controlled trials
(RCTs), the sources for nursing
evidence are quality improvement (QI)
data, financial analysis, and/or patient
satisfaction data.
Evidence-Based Nursing
 Nearly all EBN process models follow
a process similar to EBM in which a
practice relevant question is posed,
evidence is acquired and appraised,
and it is applied to practice and
evaluated.
 The EBN models do differ in the
specific steps, level of prescriptive
detail, and tools available to support
the process.
Evidence-Based Nursing

 EBN pushes beyond EBM in the

areas of qualitative research and the
integration of the patient’s
experiences into practice decisions.
 Partly because of the dearth of RCT
evidence, EBN flattens the evidence
hierarchy, giving greater weight to
qualitative data, patient satisfaction,
QI data, and cost-effectiveness.
Evidence-Based Nursing

 By highlighting contextual and patient-

generated responses, EBN strongly
underscores assessing and
incorporating the patient’s preferences
into the clinical decision-making
process.
Evidence-Based Practice
in Psychology (EBPP)
Evidence-Based Practice
in Psychology (EBPP)
 In 1995, the American Psychological
Association (APA) commissioned the Task
Force on Promotion and Dissemination of
Psychological Procedures.
 Its objective was to establish rigorous
criteria, including the replication and use of
a treatment manual(s), to identify
“empirically supported treatments” (ESTs),
and to select treatments that met these
criteria.
Evidence-Based Practice
in Psychology (EBPP)
 The APA’s need to align psychology
with the other health care professions
led it to form an evidence-based task
force in 2005.
 The APA’s definition of EBPPs
resembled both the evidence-based
practice definition adopted earlier by
the IOM (2001) and the original EBM
three-circle model.
Evidence-Based Practice
in Psychology (EBPP)
 Patients’ preferences were expanded to
include patients’ characteristics, values,
and context.
 The task force also viewed variables such
as identity and sociocultural factors (e.g.,
age, gender, ethnicity, social class,
religion, income), functional status (e.g.,
ability to work), readiness to change, level
of social support, and developmental
history as germane to the clinical decision-
making process.
Evidence-Based Practice
in Psychology (EBPP)
 This clear articulation of variables to
be considered in the patient’s “circle”
represents a substantial step forward
from earlier EBM models.
Evidence-Based Social
Work Practice (EBSWP)
Evidence-Based Social
Work Practice (EBSWP)
 The adoption of EBSWP was facilitated
by a marked increase in practice
research as well as by mechanisms for
evidence dissemination.
 Since 1999, for example, the Campbell
Collaboration has promoted the
development and dissemination of high-
quality systematic reviews in social
welfare, criminal justice, and education.
Evidence-Based Social
Work Practice (EBSWP)
Evidence-Based Social
Work Practice (EBSWP)
 The process of EBSWP is similar to
the EBM process, with its five steps
preceded by the step of becoming
motivated to use EBSWP.
 The practitioner’s expertise is given a
central place because of the complex
skills needed to integrate the domains
illustrated in figure 3.
Evidence-Based Social
Work Practice (EBSWP)
 Also in keeping with social work’s
emphasis on the importance of
individualization, the EBSWP process
stresses assessment early in the
process and continuing throughout.
Evidence-Based Public
Health (EBPH)
Evidence-Based Public
Health (EBPH)
 In 1997, Jenicek defined EBPH as the
“use of epidemiological insight while
studying and applying research, clinical,
and public health experience and
findings in clinical practice, health
programs, and health policies”
 Subsequent definitions have both
expanded and deepened through EBPH
practice questions and the identification
of high-quality evidence
Evidence-Based Public
Health (EBPH)
 In 2004, Kohatsu extended the
definition of EBPH to communities’
input and preferences in decision
making.
 In a model modified from Muir Gray,
the three circles of EBM have become
scientific evidence, population needs
and values, and resources.
 Evidence-Based Public
Health (EBPH)
 As the tenets of EBPH have been
illuminated, several new components have
emerged:
 Making decisions based on the best available scientific
evidence (both quantitative and qualitative).
 Using data and information systems systematically.
 Applying program-planning frameworks (often based in
behavioral science theory).
 Engaging the community in assessment and decision making.
 Making sound evaluations.
 Disseminating what is learned to key stakeholders and decision
makers.
Evidence-Based Public
Health (EBPH)
Evidence-Based Public
Health (EBPH)
 EBPH has made three contributions to
the EBP models.
 First, much like nursing and social work, EBPH
expands the types of data to be considered as
evidence. Because RCTs often are not available for
complex, frontline work, they usually do not inform
public health decisions.
 Second, EBPH addresses the issue of resource
allocation in overburdened systems.
 Third, EBPH has constructed amore detailed, iterative
stepwise process that guides both the decision
making and the initial questions.
A New Transdisciplinary Model
of Evidence-Based Practice

 The primary criticisms of EBM:

 The evidence is too narrowly defined;
 The role and value of practitioners and
their expertise are unclear;
 Resources and/or contextual factors
are ignored; and not enough attention
is paid to clients’ preferences.
Conclusions

 A unified, transdisciplinary EBP

model would address historical
shortcomings by redefining the
contents of each model circle,
clarifying the practitioner’s expertise
and competencies, emphasizing
shared decision making, and adding
both environmental and organizational
contexts.