A journey's end, and new roads beckoning

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Overcoming barriers to self-management: The person-centred diabetes foot behavioural agreement

Objective - Behavioural agreements have been proposed as a clinical strategy for improving concordance with diabetes foot self-management practices, both for individuals ‘At-risk’ of, and with active, diabetes foot disease. This narrative review sought to explore the potential supportive role of person-centred diabetes foot behavioural agreements in promoting protective foot self-management behaviours among ‘At-risk’ individuals. Conclusions - Health care professionals (HCPs) involved in diabetes foot risk stratification and management dedicate considerable time, effort and resources to the prevention of diabetic foot ulcers (DFU) and lower extremity amputation (LEA) and are uniquely placed to deliver person-centred diabetes self-management education and support (DSMES) interventions. Written, verbal and non-verbal agreements are consistent with a wider global move toward DSMES approaches, respectful of people’s preferences, and supporting them to undertake protective self-care behaviours. Practice implications - It is theorised that clear communication of the roles of the person with diabetes, their family or carers and HCPs may improve concordance with self-management behaviours. Rather than a punitive measure or means of facilitating discharge of ‘non-concordant’ individuals, person-centred behavioural agreements should be framed positively, as a means of delineating, prescribing and supporting individual diabetes foot-care responsibilities. This is an area worthy of further research.38pubpu

Qualitative exploration of patient and healthcare professional perspectives on barriers and facilitators to foot self-care behaviors in diabetes

Introduction Diabetic foot ulcers contribute significantly to morbidity and mortality associated with diabetes, but are preventable with good foot self-care. This study sought to explore the perspectives of patients and healthcare professionals (HCPs) on barriers and/or facilitators to foot self-care behaviors in diabetes and areas of consensus and/or tension between patient and HCP perspectives. Research design and methods This was a sequential, qualitative study that used a hermeneutic phenomenological approach. Phase I involved nine in-depth, semi-structured patient interviews. Phase II involved seven in-depth semi-structured interviews with HCPs (podiatrists, diabetes nurses, foot health practitioners (FHPs) and general practitioners (GPs)). In phase III, findings from phases I and II were brought back to two patient interview groups (five patients in total) to try and identify any areas of consensus and tension between HCP and patient perspectives. Results Patient and HCP perspectives had several areas of alignment: concerns over consequences of diabetes complications; the importance of patient education and frustrations around aspects of health service delivery. There were also some notable tensions identified: mixed messaging from HCPs around whose responsibility patient foot health is; and who patients should initially consult following the development of a foot problem. Overall, patients expressed that motivation to undertake good foot self-care behaviors was generated from their lived experiences, and was enhanced when this aligned with the information they received from HCPs. HCPs appeared to attribute lack of patient motivation to lack of knowledge, which was not raised by patients. Conclusions This study has identified points of misalignment between the views of patients and practitioners that may help to explain why adherence to foot self-care among patients with diabetes is low. Our results suggest that better outcomes may stem from HCPs focusing on supporting autonomous motivation for self-care and enhancing the rationale through referencing patients’ own experience rather than focussing on increasing patient knowledge. Renewed focus on consistency of messaging by HCPs around the roles and responsibilities relating to foot health in diabetes, and the benefit of foot-specific training being provided to non-foot specialist HCPs may also help to improve uptake and adherence to foot self-care behaviors in diabetes.https://doi.org/10.1136/bmjdrc-2022-003034pubpu

Duality of practice in clinical research nursing

Mairghread Ellis - ORCID: 0000-0002-3474-533X https://orcid.org/0000-0002-3474-533XBackground: International evidence suggests that Clinical Research Nurses (CRN) can have a dual role incorporating both clinical care and research responsibilities. This duality of role often assists in meeting the clinical care and research needs of the participants and can contribute to the credibility of the CRN role. Conversely, it can also lead to feelings of confusion and role conflict as CRN’s time is divided. Aim: To identify and explore experiences of clinical and research roles among CRNs. This emerged as a theme in a wider research project exploring CRNs’ experiences of working with clinical nurses. Methods: Following an Interpretative Phenomenological Analysis approach, 10 CRNs participated in face-to-face semi-structured interviews. Transcribed data were analysed and a number of themes emerged. Duality of role was one of these. Findings: Findings indicated that if CRNs fulfil a dual role, this can assist in care provision, research delivery and in building positive relationships with clinical nurses. However, there were also instances when a dual role led to clinical nurses questioning the value of research and to issues with competing demands of clinical care and research. These experiences had an important impact on some of the CRNs and led to reflection on the value of their role. Conclusions: This study identifies new understandings of a dual role of the CRN. The findings will inform the preparation and practice of this group of nurses, whilst also leading to a deeper understanding of the CRN’s role in care and research delivery. It will also contribute to a wider appreciation of organisational factors and social interactions that impact on health care research.https://doi.org/10.1177/1744987121107097627pubpub1-

Charcot neuroarthropathy patient education among podiatrists in Scotland: a modified Delphi approach.

From PubMed via Jisc Publications Router.Publication status: epublishHistory: received 2018-08-20, accepted 2018-09-12Background This evaluation sought to determine current Charcot neuroarthropathy (CN) diabetes patient education practices among Scottish National Health Service (NHS) and academic podiatrists and evaluate novel visual tools and develop expert consensus for future practice. Methods Questionnaires collected mixed qualitative and quantitative responses, analysed concurrently within a convergence coding matrix. Delphi methodology permitted member-checking and agreement of consensus over two rounds. Results Fourteen participants (16.28%) completed a Round One questionnaire, leading to the generation of four themes; Experience; Person-Centred Care and the Content and Context of CN patient education. Seven consensus statements were subsequently developed and six achieved over 80% agreement among 16 participants (18.60%) with a Round Two questionnaire. Respondents agreed CN patient education should be considered for all ‘At-risk’ individuals with diabetic peripheral neuropathy (DPN). Verbal metaphors, including the ‘rocker-bottom’ foot, soft or brittle bones, collapsing, walking on honeycomb and a shattering lightbulb were frequently employed. Visual tools, including visual metaphors and The Charcot Foot Thermometer, were positively evaluated and made available online. Conclusions Key findings included respondent’s belief that CN education should be considered for all individuals with DPN and the frequent use of simile, analogy and metaphor in CN education. The concept of ‘remission’ proved controversial due to its potential for misinterpretation.115

It’s time we talked about Charcot foot: Results of a podiatry patient education questionnaire

Ellis, Mairghread - ORCID 0000-0002-3474-533X https://orcid.org/0000-0002-3474-533XIn contrast with diabetic foot ulceration (DFU) and lower-extremity amputation (LEA), current Scottish patient information leaflets reserve Charcot foot education for individuals ‘In Remission’ from, or with active, Charcot foot. A small group of Scottish NHS podiatrists recently agreed Charcot foot education should be delivered to all ‘At-risk’ individuals with diabetic peripheral neuropathy. This study sought to compare discussion about diabetes foot disease and Charcot foot between ‘At-risk’ and ‘In Remission’ groups among this cohort. Fourteen participants completed an ‘At-risk’ component of the Charcot foot patient education questionnaire, while six also completed an ‘In Remission’ component. Topics investigated for both groups included DFU and LEA risk, footwear and insoles, and signs of infection and Charcot foot. Frequency of discussion data was captured with a five-point Likert scale. Median response and interquartile range (IQR) were described and compared between groups. Median values and IQR for discussion of DFU and LEA risk were 5 (IQR 1) and 3 (IQR 1.25) respectively for ‘At-risk’ groups, and 5 (IQR 0.25) and 3 (IQR 2), respectively, among the ‘In Remission’ group. For discussion of footwear and insoles, the median response was 4 (IQR 1) for ‘At-risk’ and 5 (IQR 1) for ‘In Remission’ groups, reversed for discussion of signs of infection. The greatest between-group discrepancy was found for discussion of Charcot foot, with median responses and IQR found to be 3 (IQR 2) and 5 (IQR 0.25) for ‘At-risk’ and ‘In Remission’ groups, respectively. This discrepancy has potential implications for Charcot foot educational strategies, audit and research. It is proposed that ‘always’ should be the benchmark for frequency of Charcot foot education, not just for those ‘In Remission’ but also those ‘At risk’.https://www.diabetesonthenet.com/journals/issue/590/article-details/its-time-we-talked-about-charcot-foot-results-of-a-podiatry-patient-education-questionnairehttps://www.diabetesonthenet.com/journal/the-diabetic-foot-journal22pubpub

Patients' experiences of post radiotherapy skin reactions

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MIS Distal Metatarsal Metaphyseal Osteotomy in the treatment of metatarsalgia: MOXFQ patient reported outcomes

Baer, Gillian - ORCID 0000-0002-1528-2851 https://orcid.org/0000-0002-1528-2851Introduction The aim of this paper is to present validated patient reported outcomes for MIS Distal Metatarsal Metaphyseal Osteotomy (DMMO) in the treatment of metatarsalgia. We aim to evaluate the DMMO procedure, report patient satisfaction with the operated foot and report any complications of this procedure.Patients and Methods Between 2014 and 2016, patients who had failed conservative treatment for metatarsalgia were identified in the orthopaedic outpatient clinic. Twenty four consecutive patients requiring DMMO plus/minus toe straightening were prospectively studied. Patients requiring additional procedures at the time of surgery were excluded. Patients completed the validated Manchester-Oxford Foot Questionnaire (MOXFQ) three weeks pre-operatively and 1 year postoperatively. The MOXFQ results were analysed using Paired t-tests. A supplementary question was asked regarding patient satisfaction with the operated foot.Results There were 20 women and 4 men with a mean age of 64 years (sd 8.6). Statistically significant differences were found between the pre and postoperative MOXFQ. The postoperative MOXFQ score demonstrated a poorer result for two patients, no change for two patients and improvement in 20 patients, with four of these patients recording the lowest possible score. There was a 29.5 point improvement in mean metric MOXFQ Index score. Seventy-nine percent (n=19) of patients were satisfied or very satisfied with the operated foot. The average recoil of the metatarsal heads following DMMO was M2 4.01mm, M3 4.55mm, M4 4.16mm. There was one delayed union and no non-unions. Further reported complications were a gastric bleed, pulmonary embolism (VTE), and one intra operative broken burr.Conclusion Our study demonstrates a clinically important and statistically significant improvement in patient reported outcomes following DMMO, with 79% of patients satisfied or very satisfied with this procedure. The average recoil of the metatarsal heads following DMMO was M2 4.01mm, M3 4.55mm, M4 4.16mm with one delayed union and no non-unions.https://doi.org/10.1016/j.foot.2019.10166143pubpu

The patient podiatrist relationship - contextualising professionalism within the clinical encounter

Introduction Patients are the key resource of health care practitioners, and much emphasis is laid on partnerships of care, with the patient being informed, autonomous and empowered. Many questions arise from current practice - are podiatrists fully embracing this model of practice? Do patients fully engage with their practitioner? How do podiatrists feel that patients perceive us? Research in nursing and occupational therapy stresses that practitioners must 'connect' with patients, and at times act as chameleons, changing to match the environment of each patient encounter (Aranda and Street, 1999; Rosa and Hasselkus, 1996). This study aimed to explore podiatrist's perceptions and experiences of the relationship they hold with their patients. Methods A phenomenological approach, informed by Gadamers's hermeneutic philosophy for gaining meaning and understanding was utilised, with the researcher's influence as 'native' being accepted in co-construction and interpretation of data from 8 Podiatrists in Central Scotland (4NHS, 4 private practitioners). Corec and QMU granted ethical permissions. Results Six categories of meaning emerged: relationship, engagement, role, image, reward and personal development. This fed into one overarching theme - Professionalism. Discussion Theories of dramaturgy (Goffman, 1959) and Liminality (Turner, 1969) are used to interpret and explain the findings. Baldwin's (2006) model of professionalism is utilised to demonstrate that phronesis (practical wisdom) and tacit knowledge are important and undervalued aspects of professionalism, alongside episteme (knowledge) and techne (profession specific skills). The study findings suggest a model of professionalism which focuses on the individual patient - practitioner interaction, with phronesis being a more important element of professionalism than traditional models have accepted.sch_podunpub1181unpu

Presentation of doctoral research

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