A Report about Larval Therapy & Leg ulcer
Introduction and overview of Evidence Based Practice
Evidence based practice (EBP) is the ability to utilize evidence to make decisions about the care given to an individual patient. The practice of evidence based nursing involves combining both clinical evidence and nursing knowledge, acquired through clinical practice and experiences, to deliver a more efficient and effective diagnosis and to recognise a patient`s difficulties and preferences when making clinical decisions about their care (Sackett, 1997).
Sackett and colleagues emphasize that there is a strong link between EBP and the decisions we make in our everyday practice. Any decisions made should be specified and clearly thought about, utilizing evidence to enhance decisions. The role of the professional judgment is to use the best currently available evidence to deliver a high standard of care, for individuals, to the best of our ability, while always keeping the patient`s needs and preferences in mind (Aveyard & Sharp, 2013).
In this assignment, my chosen topic is Larval therapy and Leg ulcers. I choose this subject because leg ulcers are a common condition (O'Brien,2011). There is an estimated 1.7% of people aged 65 years or over suffering from leg ulcers in the UK (Adeyi, Muzerengi & Gupta, 2009), costing the NHS 400 million a year (Stephen-Haynes, 2011).
A leg ulcer is a common condition which affects people quality of life especially in the elderly population (O'Brien,2011) and with the elderly population increasing, wound healing of leg ulcer will become more important (Adeyi, Muzerengi & Gupta, 2009). As healthcare professionals it is important to evaluate treatments to ensure optimum care is given.
Appraisal of two research papers
In this section I will evaluate two pieces of primary research. Both studies were sourced using the UWE library search.
The first paper is a qualitative paper; that looks at patients' perceptions and experiences of leg ulceration and larval therapy (McCaughan, Cullum & Dumville, 2013). To collect data the researcher used a phenomenological approach. This method is useful for gaining in-depth understanding of individual phenomena and a way of collecting rich data that describe an experience as it is lived by the person (Waters, 2016). It helps to gain insights into people’s motivations and actions, and helps to stop assumptions (Lester, 1999).
Qualitative research is designed to collect rich, contextualized understanding of a human responsive through study it cannot be generalize (Polit & Beck, 2010), as it is not based on statistical controls and random sample, it is not designed to produce generalizable findings (Niaz, 2007). So even know this paper found that majority of people were willing to try larval therapy due to the type of research done, we can not assume that the wider population would agree.
Semi-structured interviews was used to collect data, this technique provides reliable, comparable, qualitative data using a set of questions (Bernard, 1988). A semi-structured interview allows participants to express their own views. However, the questions need to be planned so they do not lead or restrict the answers given, potentially causing bias (Cohen & Crabtree, 2008). Data collected was analysed using a coding framework, the results are clearly presented in a table. This approach is useful in studies where participants’ results are predictable (Gläser & Laudel, 2013). Nevertheless, this method can influence the research and cause inaccurate results (Burnard et al, 2008).
There was eighteen participates in the study (12 men, 6 women), this is small sample. The number of participates are important when carrying out research, If the sample is too small, there may not be enough data to support the research aim (Mason, 2010). This research could have had a higher sample size to provide more accurate results.
Governance approval and written consent was obtained from participants,, they were given assurances concerning the confidentiality and anonymity of their responses. It is important to ensure that individuals are aware of the consequences and advantages of research, so they are able to decide voluntarily whether to take part (Smith, 2003). Furthermore the NMC code of conduct (2015) states, confidentiality and privacy of individuals should be respected.
The research findings were that the majority of participate were willing to try larvae therapy because of their desire to heal their ulcers. To ensure the findings were accurate an experienced qualitative researcher (independent to the study) was asked to check the coding of three interviews, this ensures the quality of the paper. However, the disadvantage of this method is that it can be used as a gate-keeper and research that is too advanced can go unpublished (Rhodes, 2013).
Limitations of the study were, more men than women took part. This does not reflect the population as leg ulcers are more prevalent in women. Seven of the male participants had had prior contact with ‘maggots’ through farm work or fishing, which seemed to influence their acceptance of larval therapy (McCaughan, Cullum & Dumville,2013).
In conclusion, most participates were willing to try larval therapy, the use of questionnaires are a beneficial tool to gain patient perspectives and enhance care. The research suggests larval treatment would be accepted by patients. However, the study only had a small sample size, so it cannot be generalized.
A quantitative study, conducted in 2013, used a randomised controlled trial to compare larval therapy against a standard dressing (Mudge et al, 2013). Participates were randomly selected into two groups, to enable assessment of effectiveness of the two treatments and determine whether there is a relation between treatment and outcome (Stolberg et el, 2004). Using random control trials will minims the chances of any bias and provides clear results of which treatment works best (Duflo, Glennerster & Kremer, 2007).
Data was analysed by using the last value carried forward technique, results have been clearly presented in a table. This method is commonly used when participates are likely to drop out, the last observed value is used to input missing data at a later stage (Xu, 2009). However, it assumes that the individual’s results would have stayed the same from the point where they left the research, rather than improving or decreasing, resulting in inaccurate findings (Molnar, Hutton & Fergusson, 2008).
88 participates took part but only 64 completed the trial. In quantitative studies, the sample size is determined by data needed, the more varied the data, the larger the sample size (Hardon, Hodgkin & Fresle, 2004). For this study, I think the sample size could have been larger to get more reliable results.
Permission was given to conducted the research from Ethics Committee and informed written consent was obtained. Ethical issues and engagement with research ethics committees are vital to ensure that participates receive the highest level of benefits and provide a positive outcome for the research (Economic & Social Research Council, 2017).
The study suggests that larval therapy debrided leg ulcers considerably more quickly than a hydrogel. The use of larvae in the form of a dressing, debrided in a statistically significantly (p < 0.001) shorter period of time than a hydrogel (Mudge et al, 2013).
P-value helps to determine how reliable the results of a hypothesis test is, this method is used to test the validity of a claim. The claim being tested is called the null hypothesis, if this claim is found to be untrue, then the alternative hypothesis is trusted. P-value is used to determine the strength of the evidence, it is a number between 0 and 1. To comprehend p-value involvement, a small p-value of ≤ 0.05 shows strong evidence against the null hypothesis, so the alternative hypothesis is trusted. A large p-value of > 0.05 indicates weak evidence against the null hypothesis and so it should be rejected (Rumsey, 2016). The p-value in this study is p< 0.001 which means there's less than a 1 in a 1000 chance of the stated result being incorrect based on observed error.
Some limitations of the study were recruitment, the original sample size was not met. Another limitation was there was no evaluation of side effects or complication throughout the research (Mudge et al, 2013).
In conclusion, the research suggests that larval therapy has a positive effect on leg ulcer healing and has a shorter period of time to debride. Using randomised trial is a useful method to minimise the risk of confounding factors influencing the results. However, limitations of the study, such as sample size and evaluation, suggest that more research needs to be done before change could be made.
Meeting patient/service user needs
Nursing and Midwifery Council (2015) states “Recognize and respect the contribution that people can make to their own health and well-being” and “Encourage and empower people to share decisions about their treatment and care”. Patients receiving care should be involved and contribute to health decisions.
As health care professionals, respect and empathy should always be shown to patients, to make them feel valued. Listening and communicating with a patient can result in a treatment plan being made around their needs. Patients are a valued member of the team and also the most important. If patients feel uneasy or find it hard to express themselves, it’s a nurse’s job to reassurance them and encourage them to get involved in their care (Ficarra,2011). There are many strategies and guideline put into place to ensure that patients are involved in their care such as NICE guideline (2012), NMC code of conduct (2015) and service user involved strategy (2013).
EBP enables improvement and enhances care experiences for the better (Stevens, 2013) Service users should be involved in all decisions, such as service planning, care planning, and the recruitment process, to assure the quality of our services. They should be valued in their process and feel that their opinion matters, they are experts by experience. Including any knowledge and life experience, they have gained throughout their lives (NHS, 2013).
Planning and implementing change
Planning and implementing change is necessary for healthcare to optimums care. In this section, I will use NICE guidelines (2007) to show how change can be planned and implemented. There are three stages to go through in order to implement any change.
• Step one: to recognise and understand the barriers you may encounter during a change.
The barriers that you could encounter before implementing change are:
People may not be aware of the need for this change and why?
Other barriers could be motivation, people’s beliefs, their ability to make this change and Practical barriers.
For example, people may think that the standard dressing for leg ulcers are fine and they do not need to know about larval therapy.
• Step two: Identify the barriers to change.
After understanding what the potential barriers are, it is time to identify the barriers that will be faced through the chosen aspect of care that needs to be changed. To identify barriers, different methods could be used such as talking to key individuals, observing clinical practice, using questionnaires, brainstorming and running focus groups.
Using larval therapy as an example, handing out questionnaire, observing clinic practice and talking to staff about larval therapy would be a good way of highlighting barriers.
• Step three: overcame the barriers identified for change.
There are many different approaches and methods to overcome barriers to change, these methods can be used on their own or combined together. Methods used are educational materials to highlight awareness, using educational meetings such as training course or workshops to help change behaviours, educational outreach visits to observe other professionals in their care setting to increase understanding, opinion leaders to help motivate care professionals, clinical audit and feedback and patient-mediated strategies to give patients information and educate on change.
To implement the use of larval therapy a combination of strategies could be used, such as educational materials such as journals, booklets, and leaflets to provide evidence based information and raise awareness of larval therapy. Also, use workshops and training courses for health professionals to gain the skills and confidence they need to provide a new treatment. Alongside an opinion leader to motivate and change behaviours towards larval therapy. After changing people behaviour, enhancing knowledge and motivating staff to make a change, change can then take place.
Using these methods are a great way to provide information, support, knowledge, and understanding to influence people behaviour to implement change. To implement change, it is a long and sometimes difficult process. However, it is necessary to improve healthcare (NICE, 2007).
Conclusion
This assignment has helped me gain a better understanding of EBP and enhanced my ability to assess the reliability of an academic paper, by using critiquing models. This ensures that I am using the best available evidence to make decisions in practice. As nurses, we need to utilize research to provide the best quality of care to our patients (Grove, Gray, Burns, 2015).