Research In Clinical Practise

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Research In Clinical Practise

Introduction to Portfolio

The research articles to be critiqued relate to the author's area of practice; community nursing and in particular; the cost-effectiveness of community leg ulcer clinics. The author currently manages a leg ulcer clinic and an insight into the research underpinning their cost-effectiveness would be of benefit in her quest to deliver evidence-based practice in line with the principles underpinning clinical governance.

Management of venous leg ulcers had advanced considerably over the last decade. This is due to various factors from greater knowledge of the aetiology of leg ulceration to more recent developments, such as dedicated leg ulcer clinics (Dowsett, 2004). However, it is a concern that leg ulcer clinics are being justified by nurses and organizations based on uncontrolled studies and narrative accounts (Bosanquet et al, 1993; Fletcher, 1995; Stevens et al, 1997; Thorne, 1998; Audit Commission, 1999). It has been widely suggested that the establishment of community leg ulcer clinics could increase healing rates for leg ulcers and standardise care (Moffatt et al, 1992; Simon et al, 1996; Stevens et al, 1997). However, research surrounding their cost effectiveness is extremely limited.

As interest in healthcare research grows, the number of definitions and explorations of the topic has increased. Most definitions of research follow a similar theme with the search for knowledge being emphasised as a fundamental reason for undertaking research studies (Clifford, 1997). Cormack (2000) defined research as an attempt to increase the sum of what is known by the discovery of new facts or relationships through a process of systematic scientific enquiry - the research process.

Nursing has been striving to become a research based profession since the Briggs Report (1972) and the lack of apparent integration of research findings into nursing practice has been lamented consistently ever since (Walsh and Ford, 1989). As long ago as 1989 the Department of Health (DoH), in their Strategy for Nursing stated; 'All clinical practice should be founded on up-to-date information and research findings.

Practitioners should be encouraged to identify the needs and opportunities for research presented by their work. Research is fundamental to achieving evidence-based practice in nursing. Evidence-based health care aims to promote clinical and cost-effective care/treatment through the explicit, conscientious, and judicious use of the currently available best evidence from research to guide decisions (Sackett et al, 1996).

Recently, there has been an increasing emphasis on evidence-based practice. The NHS information strategy, the development of the NHS net and the National Electronic Library for Health all testify to the NHS commitment of bringing research evidence closer to clinical decision makers (Thompson et al 2001). Journal based initiatives are also available such as Evidence Based Nursing (Cullum et al. 1997) and Clinical Effectiveness in Nursing (Newell 1997). Furthermore, guidance can be found in publications such as NICE (National Institute of Clinical Excellence) guidelines.

Evidence-based nursing and clinical governance presuppose research, without it evidence will remain elusive and no credence will be given to clinicians who base their work on routine and tradition alone (Lawton et al, 2000).

Often, consumers mistakenly believe that if a research report was accepted for publication then the study must be sound. Unfortunately, this is not necessarily the case. Indeed most research will have limitations and weaknesses and, for this reason, no single study can provide unchallengeable answers to research questions (Polit and Hungler, 1997). Rees (1997) adds that we must remember that there is rarely such a thing as the perfect research project.

Research findings should be challenged before practitioners change their practise and this can be achieved through critiquing research articles. The purpose of critical evaluation is to ensure that if implementation of findings is proposed, patients will derive genuine benefits. Therefore, a critical review must identify the strengths and weaknesses within a piece of research and should be carried out in a systematic manner (Eachus, 2003). Polit and Hungler (1997) assert that a good critique objectively identifies areas of adequacy and inadequacy, virtues as well as faults. They go on to say that, a critique of research should reflect a thoughtful, objective and balanced consideration of the study's validity and significance. They concur with Eachus (2003) that the process of scanning an article should be thorough and systematic. Cormack (2000) concludes that by being aware of the form and function of the various parts of a research article, readers are in a position to evaluate the worth of the material presented. The form and function of the various parts of a research article can be evaluated by following a research critique framework, such as the Cormack framework (2000) (Appendix I), in order to minimise the potential for bias. This includes evaluation and comparison of research methods, sample selection processes, data collection methods and methods of data analysis, ethical considerations and future research and learning. Rees (1997) believes in critiquing it is important to do two things; describe the content under the headings within the critique framework and state how well the author has accomplished that particular element.

Literature Search.

The author undertook a literature search using electronic databases, during November 2004 (Appendix II) posing the question;

'Is treatment in a community leg ulcer clinic cost effective compared to treatment in the patient's home?'.

From this, only one relevant randomised controlled trial (RCT) was found;

* Morrell C, Walters S, Dixon S, Collins K, Brereton L, Peters J, Brooker C, (1998) Cost effectiveness of community leg ulcer clinics: randomised controlled trial. BMJ, 316(7143) 1487-91.

Three other studies answering the question posed were found to be suitable for the purpose of research appraisal:

* Bosanquet N, Franks P, Moffatt C, et al (1993) Community leg ulcer clinics: cost-effectiveness. Health Trends, 25(4)146-8. ISSN: 0017-9132.

* Moffatt CJ, Franks PJ, Oldroyd M, et al (1992) Community clinics for leg ulcers and impact on healing. BMJ, 305(5)1389-92.

* Simon DA, Freak L, Kinsella A, Walsh J, Lane C, Groarke L, McColum C, (1996) Community leg ulcer clinics: a comparative study in two health authorities. BMJ, 312: 1658-61.

A mini-review entitled; 'Community leg ulcer clinics vs. home visits: which is more effective?' was undertaken in 2002 by Thurlby and Griffiths. This review looked at three aspects of the management of leg ulcers: healing rates, re-occurrence rates and cost-effectiveness. Following a literature search, Thurlby and Griffiths, (2002) rejected several studies from their mini-review concluding that the control group within the study by Moffatt et al (1992) was historical, the study by Simon et al (1996) was non-random and Bosanquet et al (1993) compared community clinics to hospital care (Thurlby and Griffith, 2002). Thurlby and Griffith (2002) included only one study - Morrell et al, 1998.

As it is a RCT, the first of the two articles selected by the author is;

Morrell C, Walters S, Dixon S, Collins K, Brereton L, Peters J, Brooker C, (1998) Cost effectiveness of community leg ulcer clinics: randomised controlled trial. BMJ, 316(7143) 1487-91.

The article is from the British Medical Journal (BMJ). The BMJ aims to publish rigorous, accessible and entertaining material that will help doctors and medical students in their daily practice, lifelong learning and career development. In addition, it seeks to be at the forefront of the international debate on health. To achieve these aims, the BMJ publishes original scientific studies, review and educational articles, and papers commenting on the clinical, scientific, social, political, and economic factors affecting health. (BMJ, 2004).

From here on in, this article will be referred to as 'Morrell et al' and is exhibited as 'Appendix III'.

Thurlby and Griffith (2002) chose not to include the article by Simon et al (1996) within their mini-review; however, in order to compare a non-random study with a RCT, the author has also chosen to critique the article:

Simon DA, Freak L, Kinsella A, Walsh J, Lane C, Groarke L, McColum C, (1996) Community leg ulcer clinics: a comparative study in two health authorities. BMJ, 312: 1658-61.

From here on in, this article will be referred to as 'Simon et al' and is exhibited as 'Appendix IV'.

Both articles have been cited on numerous occasions by other authors and appear to be well substantiated. Utilising the Cormack framework (2000), the author will critique the above articles and in doing so will attempt to establish the quality of the research underpinning the cost-effectiveness of community leg ulcer clinics and whether they are, indeed, based on uncontrolled studies and narrative accounts, as suggested by Bosanquet et al (1993); Fletcher (1995); Stevens et al (1997); Thorne (1998); and the Audit Commission (1999).


The Cormack framework (2000) states that a title should be concise and informative and indicate the content and research approach used. Eachus (2003) agrees, stating a title should be concise, giving a good indication of the content of the report.

The title utilised by Morrell et al is concise and informative, stating the research approach used - a RCT. Likewise, the title utilised by Simon et al is also concise and informative and states that the research approach is a 'comparative study'. Both articles, therefore, fulfil the aims within Cormack's framework (2000).

According to Parahoo (1997), there is no real right or wrong title, only a misleading or confusing one and neither title is misleading or confusing.


Whether the authors have appropriate academic qualifications and appropriate professional qualifications and experience are questioned within the Cormack framework (2000). Eachus (2003) informs us that the authors of a research article may or may not be well known in the field and that the institute to which they are attached may give an indication as to the quality of the article.

The authors of the first article are; Jane Morrell (research fellow), Stephen Walters (statistician), Simon Dixon (lecturer), Karen Collins (research associate), Louise Brereton (research associate), Jean Peters (research fellow) and Charles Brooker (professor of nursing). The institutes to which the authors are attached are; the School of Health and Related Research, University of Sheffield; the School of Nursing and Midwifery, Samuel Fox House, Northern General Hospital, Sheffield; and the School of Nursing, University of Manchester. It is clear that the authors have appropriate academic qualifications and appropriate professional qualifications. The authors are well known in the field of leg ulcer management and the institutes to which they are attached indicate that the quality of the article is likely to be high.

The authors of the second article are; Deborah Simon (research nurse specialist), Louise Freak (research nurse specialist), Annette Kinsella (data manager), Julia Walsh (community research sister), Chris Lane (community research sister), Louise Groarke (research nurse specialist) and Charles McCollum (professor of surgery). The institutes to which the authors are attached are; the University Department of Surgery, University Hospital of South Manchester; Stockport District Health Authority and; Trafford District Health Authority. Simon et al have appropriate academic qualifications and professional qualifications; however, their qualifications in the field of research do not equal those of the authors of Morrell et al. However, the Simon et al are also well known in the field of leg ulcer management, albeit to a lesser extent. The institutes to which they are attached give an indication that the quality of the article may be poorer - as only one university is stated.
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Overall, in comparison to Morrell et al, Simon et al seem less likely to attain good quality research.


Cormack (2000) enquires as to whether the abstract identifies the research problem. Crookes and Davies (1989) believe that an abstract is a brief summary of the article and usually identifies what type of information is being presented. Eachus (2003) believes that an article's abstract should be a concise statement that gives the reader a clear idea of what the researcher(s) were trying to achieve, how they were trying to achieve it and whether it was achieved.


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