I work as a community nurse and I have recently become intrigued about one of my patients requiring treatment for a leg ulcer. For the purpose of this assignment I shall call her MA, because as a nurse and a professional I have professional and ethical duty to protect patient identities (Quacker Nursing Council [QNC]2010). My rationale for selection of topic is that Leg ulcers (LU) cost this country’s health service an estimated 200million quars per year in hospitalisation fees for those individuals who do not have health insurance (Quacker Health Board [QHB] 2012, Wilson 2010). An outline of LU is provided in Appendix One, while Appendix two provides a synopsis of MA and her LU. Community nurses are increasingly seeing patients with LU as insurers only pay for three episodes of treatment for one condition (Medins 2011). This disadvantages those patients like MA, as if they have a long term or chronic condition they may not receive treatment or care and this in turn will raise the country’s morbidity and mortality rates. In the UK the Government provides all healthcare free at the point of delivery and prevention of ill- Health and patient’s taking responsibility for managing their own illness or disease is viewed as an important Public Health Strategy ( DH 2010).
In this assignment I will discuss strengths and limitations of evidence based practice (EBP),sourcing different forms of evidence which will enable me to provide the best evidence-based practice I can for my patients. How I sourced evidence will be discussed, but a wide range of literature will be utilised to support my discussion and assist my acquisition of further knowledge around not only management of leg ulcers but also EBP.
Evidence based Practice (EBP) is a term referring to reliable, clear and sensible use of up to date best evidence in constructing decisions about the care of individual patients (Sackett et al, 1996). Research is important in healthcare today and is part of the evidence-based practice that underpins nursing (Aveyard 2009). This stemmed from government policies and the introduction of clinical governance (Kopp 2001, McSherry et al 2002). Not all research is relevant and that is why it is important to do a thorough critique when reading research papers in order to determine their validity and reliability in everyday practice (Oliver 2010).
The strengths of EBP are that it enables practitioners to provide the best standard of care for all patients which is cost effective in terms of not only finance, but also patient recovery (Swage 2004).The best research findings can be implemented into the practice area and assist in making not only clinical judgements but also decision making processes ( Rycroft-Malone et.al.2004)
Paradoxically Aveyard (2009) does highlight how some professionals do not view EBP as being of very much value in that some organisations just want to meet specific targets e.g. reduce number of healthcare episodes, and keep care costs to a minimum. This is a view also supported by Oliver (2010page 56) who also states that “as patients have more co-morbidities, then they do not always fit into the boxes provided by the available evidence based guidelines for treatment”.
Evidence based practice can also be viewed in the context of expertise and specialist skills. Experienced practitioners may have prior experience of what works well for patients with complex or adverse conditions(Ryecroft-Malone et.al 2004).
Hierarchies of evidence exist ,and these afford different gradings of worthiness to different types of evidence (Rycroft-Malone et.al 2004) This is explained in Figure 1
Ellis (2000) Aslam (2000) Evans (2003) Norman and Ryrie (2004)
1. Systematic reviews 1. RCTs 1. Systematic reviews, multi centre studies 1. Systematic reviews
2. RCTs and other controlled trials
Large scale primary studies 2. Controlled testing on selected groups 2. RCTs, observational studies 2. RCTs
3. Large scale studies using other methodologies 3. Non-controlled testing 3. Uncontrolled trials with dramatic results, before and after studies, non-randomised controlled trials 3. Well designed intervention studies without randomisation
4a. Descriptive studies and reports 4. Testing on small samples 4. Descriptive studies, case studies, expert opinion, studies of poor methodological quality 4. Well designed observation studies
4b. Opinions and experience of respected authorities based on clinical experience and professional consensus 5. Tests carried out outside a formal research environment 5. Expert opinion, including the opinion of service users and carers 6. Personal experience 7. Clinical tradition 8. Anecdotes
FIGURE 1 Source : Jasper M. (2006) Professional Development, Reflection and Decision-Making London Blackwell Publications page 144
I searched for various types of evidence that examined the effectiveness of honey as a wound dressing. I selected honey as it is commercially available and the patient could afford this as a wound dressing. To objectively find appropriate evidence for using honey I conducted searches using Medline, Cumulative Index of Nursing and Allied Health Literature (CINAHL) which are important sources of health research (Hamer and Collinson, 1999), and the Web of Science databases. I also used Department of Health (DH) England database, which revealed links to best evidence in the form of English National Tissue Viability Guidelines (ENTVG 2012) within which, one section refers to alternative therapies. Honey is included among these alternative therapies. Other sourced literature will be used to support my discussion and have been obtained from a variety of professional and healthcare organisations as well as books, journals, government papers, and key documents relevant to the topic.

Using such keywords as ‘leg ulcer AND dressings And Honey ‘and similar combinations, the CINAHL database yielded 21 articles of which none was of direct relevance to my question of inquiry. The same search on Medline database yielded 121 articles of which about 3 were of direct relevance. I implemented the same search on the Web of Science and yielded 432 articles of which about 6 were a close fit to my question.

The guidelines are extremely helpful as they are published on the National Institute for Health and Care Excellence web site (NICE 2012) and are guidelines based upon a rigorous systematic review. The reviewed literature is from the last 10 years and has been analysed by a team of eminent professors, doctors, specialist nurses and tissue viability specialist nurses. The majority of literature used to formulate these guidelines is research which involves randomised control trials (RCT) (Chambers et.al. 2007). Within the Hierarchy of evidence , Systematic reviews/meta-analysis and RCT are considered to be of a gold standard. The article for my critique sits within a RCT and therefore is considered to be of a high quality (Aveyard & Sharp 2013).

While RCT may well be viewed as a gold standard in terms of research methodologies (Oliver 2010) I have found other recent studies which involve qualitative research methods to critically examine the patients perception of honey dressings( Stevens 2012, Alcot 2012). One further study also examines district nurses experiences of using honey as a wound dressing ( Hindmarch 2011).
In order to become focussed upon my critique of the evidence and to analyse the evidence systematically I utilised the first ten questions from the CASP tool (National Health Service[NHS] www.evidence.nhs.uk). I also utilised the the AGREE instrument to analyse the clinical guidelines.
This enabled me to determine similarities and differences between different forms of evidence on the honey as a dressing.(Fineout-Overholt 2010). I did consider the checklist tool in Moule & Hek (2011) but found it was too vague for my individual learning needs. Some other analysis tools do not include some key aspects of the research methodology e.g. ethical approval ( Punch 2012). The word limit imposed on this assignment does not facilitate my critical examination of all of the research methodology used, but I will examine some of that methodology, the title, authorship, methodology which is employed, sampling and statistical information.
The title of the article is appropriate as it examines not only honey as a dressing, but specifically for chronic LU (Hindmarch2011).
The authors are very credible in that much of my retrieved literature had one or more of these authors also as a co-author. The lead author was also the Chair of The Tissue Viability group who produced the ENTVG (2012) guidelines. They include an overview of the literature to support the study, but within their reference list, they reference to a published literature review from this study published two months earlier( Chambers et.al. 2007).
There does not appear to be any researcher bias, as the study is unfunded, and independent researchers are used to validate the data (Cresswell 2010).

A qualitative approach was utilised by Stevens et.al (2012), and over 500 patients were recruited into the study. This is a good sample size and could be representative of the whole population with LU (Creswell 2010). However, there is no mention of any ethical considerations being taken into account, but as the authors are well published in this field of research, I can assume that the wordage for this publication perhaps prevented them including this aspect in their article(Aveyard and Sharp 2013). It appears that a lot of the data was collected during the summer months of May to August.

Questions can be raised about voluntary participation/lack of randomisation and possible biases as well as the issue on seasonality (i.e. results in the winter). Hult and Shut (2011) suggest that research should study patients with similar LU variables and demographics/lifestyles. This will provide a better representation of the general population of patients with leg ulcers (Creswell 2010). Hindmarch (2011) does reiterate that poor circulation and cold climates can have an effect on healing processes of LU. This would not be problematic in my own country as it is a constant temperate 28◦C.

The employed qualitative methodology has a positivistic underpinning philosophy, in that the theory of using honey as an effective treatment is tested without any researcher subjectivity (Cresswell 2010). However, Punch (2012) states that a triangulation of methods may have produced more valid results, but the authors do use an independent researcher to independently analyse their data which adds to the validity of their method ( Moule & Hek 2011).
The authors present their results in graphic formats and provide inferential statistical information in graph formats. The main aim of statistical analysis is to use the information from the sample to draw conclusions (make inferences) about the population of interest (Cresswell 2010).
The authors provide a probability (p)value of