British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT SPBS38 British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT
©
2
01
9
M
A
H
ea
lth
ca
re
L
td
A nursing metaparadigm perspective
of diabetic foot ulcer care
D
iabetic foot ulcers (DFUs) are a serious
consequence of diabetes, affecting patients’ health
outcomes and may lead to lower extremity
amputation (Parekh et al, 2011). In recent years,
the incidence of lower extremity amputation because of
ulceration has increased; and robust epidemiological reports
have found excess mortality in patients with diabetic
foot syndrome (Chammas et al, 2016; Narres et al, 2017).
The International Diabetes Federation stated that 9.1 to
26.1 million people with diabetes will suffer from DFUs
each year (Armstrong and Boulton, 2017). DFUs are the
most significant and devastating problem that patients
with diabetes face (Priyadarshika and Sudharshani, 2018).
Numerous studies have documented that DFUs commonly
lead to such health issues as decreased patient quality of
life, problems in the social environment, impacts on overall
health, and an increased nursing workload (Aalaa et al,
2012; Fejfarová et al, 2014; Sekhar et al, 2015; Macioch
et al, 2017). Patients exhibiting blood glucose levels of
HbA1c ≥8 mmol/mol, peripheral arterial diseases (PAD),
hypertriglyceridemia, hypertension, neuropathy, infection,
neuroischemic foot, and with a history of smoking, are
recognised as being at a high risk of DFUs and lower
extremity amputation (Boyko et al, 2018).
A theory-based approach, taking into account the
multidimensional aspects of the nursing metaparadigm, may
improve the outcome for individuals living with DFUs. The
nursing metaparadigm is a framework that looks at problems
through a framework consisting of the human being, the
environment, health, and nursing.
A thorough understanding of the concept of the nursing
metaparadigm would help nurses to facilitate successful
DFU care. In contrast, poor theoretical understanding may
lead to the impeding of knowledge development and slow
the translation of research into clinical practice (Fawcett,
1999). Each aspect of the nursing metaparadigm contributes
an important part to the nursing process (Fawcett, 1999;
2005). Implementing the nursing metaparadigm in
greater detail will demonstrate its significance to generate
further nursing interventions (Branch et al, 2015; Rosa
et al, 2017). Ultimately, it is essential that nurses integrate
this metaparadigm into DFU care in order to provide
comprehensive nursing care and manage the complexities
arising, such as fear of amputation, impact on employment,
infection, compliance with casts and shoes, foot deformity,
blindness, neuropathy, peripheral arterial disease, impotence,
and gastrointestinal problems. In doing so, clinical nurses
have an opportunity to influence individual outcomes by
encouraging maintenance of healthy feet, recognising current
problems, and providing evidence-based care as well as
multidisciplinary interventions (Delmas, 2006).
However, to date, no articles have attempted to offer any
discussion concerning the nursing metaparadigm perspective
relating to DFU care. Even though the domains of person,
environment, health, and nursing have been agreed upon by
theorists (Fawcett, 1983), it is difficult to use these abstract
models in terms of application in clinical practice. Therefore,
a newly synthesised operational definition was required to
further explain each domain of the nursing metaparadigm.
For that reason, the objective of this article is to identify why
the theory of a nursing metaparadigm originated by Fawcett
should be a fundamental part of DFU care. In this article,
the authors explore the relevant evidence that could present
a concise direction and role for a nursing metaparadigm in
DFU care. A description of the attributes of each domain
Sumarno Adi Subrata, PhD Candidate, Doctor of Philosophy
Program in Nursing, International and Collaborative with Foreign
University Program, Mahidol University, Thailand; and Nursing
Lecturer, Department of Nursing, Faculty of Health Sciences,
Universitas Muhammadiyah Magelang, Indonesia,
[email protected]
Rutja Phuphaibul, Professor of Nursing, Ramathibodi School
of Nursing, Faculty of Medicine, Ramathibodi Hospital, Mahidol
University, Thailand
Accepted for publication: October 2018
ABSTRACT
Diabetic foot ulcers (DFUs) are a serious complication of diabetes that
impact on the patient, their social environment, overall health, and on
nursing practice. Nursing scholars have integrated theories on practice to
overcome these problems, but a lack of agreement in the available literature
acts as a barrier to implementing these in practice. For that reason, using
a nursing metaparadigm as a theoretical framework would assist nurses
in managing care purposefully and proactively, thus possibly improving
outcomes. There has been little discussion about the nursing metaparadigm
in relation to DFU care. This article aims to identify why Fawcett’s theory
of the nursing metaparadigm is important as a fundamental part of DFU
care. Understanding this will help to elucidate the phenomenon of DFUs.
Moreover, identifying the elements of the DFU care framework is essential
to improve reflective practice and intervention. This article discusses the
concept of the nursing metaparadigm and its implications for practice in the
care of patients with DFUs.
Key words: Diabetic foot ulcers ■ Nursing metaparadigm ■ Nursing practice
S40 British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT
©
2
01
9
M
A
H
ea
lth
ca
re
L
td
■ Reciprocal interaction worldview
■ Simultaneous action worldview
■ Recipients of nursing care
■ Belief
■ Physiological and psychological
aspects
■ Partnership with society
■ Self- and family management
■ Engagement on wound care
training
■ Caring process (continuity of care,
disease experience, and disease
management)
■ Nursing process (assessment,
labelling, planning, intervention,
and evaluation)
■ Carative factors
■ Diabetic foot ulcer health promotion
■ Multidisciplinary approaches
Human being Nursing
Environment Health
■ Gene/environmental interaction
■ Lifestyle
■ Context of daily practice
■ Ethical perspective
■ Life principle
■ Ideologies influencing the
patient’s life
■ Five system variables
(physiological, psychological,
sociocultural, developmental, and
spiritual)
■ Optimal healing environment
■ Person’s wellbeing
■ Access to healthcare services
■ Foot care behaviour
■ Multidimensional approach
■ Quality of life
■ Five dimensions of health (effects,
attitudes, activities, aspirations,
and accomplishments)
Nursing
metaparadigm
perspectives
of diabetic foot
ulcer care
Figure 1. Nursing metaparadigm perspective of diabetes foot ulcer care
in the nursing metaparadigm as it is related to DFU care is
explored (Figure 1). This article provides a fresh perspective
on DFU care, which may improve interventions and health
outcomes. Additionally, the findings of this article could be
tools for designing and conducting DFU research.
A brief history of the nursing metaparadigm
and its conjunction with DFU care
A metaparadigm can be described as ‘a set of concepts and
propositions that sets forth the phenomena with which a
discipline is concerned’ (Miller et al, 2003). Historically,
three domains of the nursing metaparadigm (man, health,
and nursing) were identified by Florence Nightingale,
several nursing scientists, and clinicians in the 19th and
20th centuries. The ‘environment’ domain was discussed by
Donaldson and Crowley (1978). In the meantime, Fawcett
conceptualised Nightingale’s concept into ‘man, society,
health, and nursing’ (Fawcett, 1978; 1984;1992). Several
amendments have been made during the development of
the nursing metaparadigm. ‘Man’ was changed to ‘person’
to create a gender-neutral expression. ‘Society’ was also
switched to ‘environment’ for a wider perception of
nursing practice. The latest change was ‘person’ into ‘human
being’, as a response to the evaluation that ‘person’ was not
understandable in some cultures (Figure 2) (Fawcett, 2005).
Fawcett also identified three specific relationships among
the domains: person-health, person-health-environment, and
person-health-nursing (Fawcett, 1984). Fawcett emphasised
that the concepts of patients and health must be related
to the enhancement of the optimal functioning of human
beings. A person will interact with their environment
and nursing theory allows nurses to understand patients’
behaviour in normal and critical situations. In addition,
the association between nursing and health emphasises
that nursing interventions are able to change a patient’s
health status (Fawcett, 1996). This metaparadigm allows
nurses to see the patient holistically. Fawcett’s ideas provide
a conceptual framework that underlies nursing practice
(McEwen and Wills, 2007). Incorporating the nursing
metaparadigm into nursing practice will encourage
comprehensive nursing care that will accelerate patients’
healing (Bender and Feldman, 2015; Bender, 2018).
This historical overview explores the evolution of the
nursing metaparadigm and describes the major drivers
shaping the role boundaries of each domain of metaparadigm
in nursing practice. The patient with a DFU encounters
problems as a human being, with their overall health
and their environment and nursing aims to overcome
these problems. A detailed description of those aspects is
given below.
Human being
Fawcett defined a human being as an open system that
is unique, dynamic and multidimensional with self-
responsibility. As the theory was developed, Fawcett
specified that the ‘human being’ may have a ‘reciprocal
interaction world view’ or a ‘simultaneous action world
view’ (Fawcett, 2006).
A ‘reciprocal interaction world view’ signifies that the
human being consists of bio-psycho-social elements (Lai and
Hsieh, 2003). Studies have found that individuals with DFUs
frequently display several psychological and social issues,
including increased tensions between patients and their
caregivers (spouses or partners), a reduction in the pursuance
of social activities, limited employment, and financial
difficulty (Goodridge et al, 2005; Fejfarová et al, 2014).
A prolonged time living with a DFU may lead to
depression. Occurrence is three times higher in type 1
diabetes patients and two times higher in type 2 diabetes
patients than in those without diabetes (Roy and Lloyd, 2012;
Winkley et al, 2012). Nurses must support individuals’ mental
as well as physical health needs. Thus, a comprehensive mental
assessment may provide important information to improve
the care and delivery of nursing services (de Jesus Pereira et
al, 2014). The nurse’s role is also one of educator—imparting
knowledge in order to enhance the individual’s ability to deal
with mental health problems. Some patients with depression
may need to be referred to a mental health nurse, who can
support them throughout the assessment, diagnosis and
management phases (Maydick and Acee, 2016).To be effective,
an interprofessional approach incorporating the individual
with DFU, their family or caregiver, and their significant
others, should be used during interventions.
A ‘simultaneous action world view’ refers to human
British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT S43S42 British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT
©
2
01
9
M
A
H
ea
lth
ca
re
L
td
Figure 2. The four nursing metaparadigm concepts defined by Fawcett, 1996; 2006;
Fawcett and DeSanto-Madeya, 2013
beings interacting with their environment in a way that
may be organised, disorganised and subject to change, but is
ultimately organised and orderly (Fawcett, 2006; Chung et
al, 2007). One study documented that individuals living with
chronic wounds (such as DFUs) presented with more mental
health problems than those without wounds; accordingly,
they reported various negative feelings such as isolation,
stress, depression and worry (Upton et al, 2014). All nursing
interventions must be focused on both physical and mental
dimensions. Self-management programmes (ie, foot self-
care and behavioural therapy) are also necessary to prevent
complications, improve patients’ understanding of risk
factors, and to increase their ability to manage the disease
(Olson et al, 2009; Bonner et al, 2016; Van Netten et al,
2016). Coordination between different specialties is required
to manage the physical, psychological and psychosocial
aspects of DFUs. Counselling of both individuals and their
families in their own language is imperative, particularly
for those admitted to the intensive care unit (ICU) with
diabetic complications. Health professionals should be
clearly informed about the harmful effects of DFUs and
their complexities, so that they can communicate these to
the individuals and their families in an appropriate manner
(Neeru et al, 2015).
The concept of a ‘human being’ is associated with the
recipient of nursing care encompassing individuals, families
or caregivers, and their surrounding communities (Fawcett,
2000). It is important that a person at risk of DFUs has a
good partnership with their family or caregivers so that they
are all aware of the signs and symptoms of DFUs, such as the
loss of the protective sensation, and know the importance
of daily foot care (Mayfield et al, 2003). Having a DFU may
cause a loss of productivity if the person cannot work, and a
subsequent loss of status, and extra family expenses (Keskek
et al, 2014; Raghav et al, 2018). The complexities of DFUs
means the illness impacts on social contexts. Therefore, nurses
need to consider how individuals interact with their families
and communities when planning DFU care. Addressing the
family and social environment for individuals with DFUs is
important since this is the context in which the majority of
disease management occurs. Through their communication
and attitude, nurses can provide many forms of support, such
as providing insulin injections, changing wound dressings,
and giving emotional support. Involving family members and
communities in DFU interventions may improve diabetes
self-management (Baig et al, 2015).
Recognising the complexity of the human experience
is an essential element of nursing care (McEwen and Wills,
2007). Individuals with DFUs commonly experience several
health issues such as hypertension, nephropathy, retinopathy,
a past history of DFUs, and long-term diabetes—both type 1
and type 2—neuropathy, sleep disturbance, increased pain
perception, limited mobility, social isolation, a restricted life,
and fears concerning the future (Ribu and Wahl, 2004; Yekta
et al, 2011). Nevertheless, some patients may not recognise
these issues or even ignore them, thus potentially leading
to complex conditions. Accordingly, clinical nurses, along
with other health professionals, must be able to identify
such problems in order to carefully plan and implement a
comprehensive treatment process (Papaspurou et al, 2015).
Nurses, as the largest group of health professionals, are
mandated to examine risk status concerning recurrence,
assessing new or deteriorating foot ulcers and providing
basic foot-care health promotion. They may work as the
key diabetes educator in the diabetes care teams (Registered
Nurses’ Association of Ontario, 2004).
Human beings have a unique set of beliefs that nurses
must take into account (Branch et al, 2015). These beliefs can
lead to the adaptation of self-care that can decrease the risk
of DFUs and influence daily foot-care behaviours positively
(Vedhara et al, 2016). Conversely, other beliefs about diabetes
may increase the risk factors associated with experiencing
a recurrence of ulceration (Hjelm and Beebwa, 2013).
Changing and challenging patients’ problematic beliefs,
behaviours and lifestyles is considered the first-line approach
in providing successful DFU care (Searle et al, 2005). It is
important for nurses to assess the effect of existing beliefs
on a patient’s diabetes management (Macaden and Clarke,
2010). Nurses should not make an assumption based on an
individual’s cultural beliefs; rather, nurses who know that
culture is subjective and dynamic, can generate individualised
care plans based on each patient’s cultural needs (Fleming
and Gillibrand, 2009).
When offering treatment to individuals living with DFUs,
nurses must keep in mind the human being as a whole,
thus taking into account the diverse elements of their life
and their influences on their condition. Understanding the
consequences of DFUs and implementing evidence-based
care is vital if the nurse is to deliver successful treatment and
to reduce the risk of lower extremity amputations (Cárdenas
et al, 2015; Goie and Naidoo, 2016). The interventions also
ought to consider how the complexities linked with diabetes
may impact on patients’ beliefs as well as their emotional
and behavioural reactions to DFUs. Putting into practice
health promotion programmes according to the health belief
model is advantageous in terms of predicting and altering
An open system that is unique,
dynamic, multidimensional, and
has self-responsibility
A circumstance where the nursing
care is continuously being given
and with which a patient interacts
Human being Environment
Health Nursing
A person’s wellbeing ranges
from a high level of wellness to
terminal illness as experienced by
the clients
Actions given in tandem by nurses
as follows: assessment, labelling,
planning, intervention, and
evaluation
Nursing
metaparadigm
DIABETIC FOOT
British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT S43
©
2
01
9
M
A
H
ea
lth
ca
re
L
td
self-care behaviours of individuals living with a DFU (Farsi
et al, 2009). In addition, a holistic treatment method that
places emphasis on the body, mind, and soul should be taken
into account. For example, meditation-based therapies may
offer immediate positive benefits in such individuals because
of their ability to improve self-care behaviour, self-reliance,
and self-control (Priya and Kalra, 2018). With respect to
diabetes, the health belief model, social cognitive theory,
and the transtheoretical model can all be integrated into
interventions as they address the complexities of behavioural
change as well as the improvement of clinical outcomes
(Burke et al, 2014).
Environment
Fawcett mentioned ‘environment’ as a place where nursing
care is delivered (Fawcett and DeSanto-Madeya, 2013).
Environment undoubtedly influences the state of the
human being; while the human being also influences
their environment (Fawcett, 2000). Several environmental
factors increase the incidence of DFU, including poverty,
urbanisation, HIV infection, unhygienic conditions, poor
financial support, cultural practices, and a barefoot lifestyle
(Desalu et al, 2011).
Diabetes and its complexities are linked with a strong
gene-environmental interaction, which is influenced by
modernisation and lifestyle changes such as the intake of
unhealthy food, a lack of physical activities, and a high
level of mental stress (Ramachandran et al, 2010; Shah and
Kanaya, 2014). Additionally, studies have acknowledged the
complex interaction between genes and the environment
that alter genetic expression as this is vital in contributing
pathogenic diabetes mechanisms and their consequences (ie,
DFUs) (Jirtle and Skinner, 2007). However, the mechanism
concerned with how environmental factors lead to DFUs
still remains underexplored in the literature. Health
promotion programmes are an important part of the care
of patients with diabetes, because of the severity of the
diabetic foot problems that can occur (Tamir, 2007). Nurses
should aim to create a therapeutic environment based on the
patient’s needs and ethical perspectives in order to prevent or
reduce the impact of those internal and external factors that
could complicate the illness (Lopes, 2008).
The ‘environment’ domain also concentrates on the
life principles that influence patients’ lives. For example,
some individuals with a DFU may present with feelings
of hopelessness and helplessness. They have lost their
self-esteem, fear being poor because they cannot work,
feel isolated and are afraid of being dependent on others
(Hjelm and Beebwa, 2013). Psychosocial interventions are
highly effective in addressing emotional issues along with
improving glycaemic control in patients with diabetes (Xie
and Deng, 2017). Cognitive behavioural therapy-based
(CBT) techniques focusing on psychological factors and
self-management might therefore be the most effective
interventions (Vileikyte and Gonzalez, 2014).
Neuman and Fawcett (2011) pointed out that the
‘environment’ consists of five client system variables:
■■ Physiological
■■ Psychological
■■ Sociocultural
■■ Developmental
■■ Spiritual.
Physiological variable
The physiological variable refers to what an individual thinks
about their body, home, and neighbourhood. An individual
with a DFU often wishes that their ulcer will either heal
or improve (Hjelm and Beebwa, 2013). When arranging
diabetes treatments, nurses, patients and their families are
advised to discuss self-management, functional limitations
and caregiver support (Morrow et al, 2008). Patients ought
to be given enough knowledge to make decisions regarding
treatment. ‘Knowledge’ refers to meal planning, physical
activities, weight control, routine blood glucose monitoring,
medication, and foot care (Baghbanian and Tol, 2012).
Psychological variables
The psychological variable reflects an individual’s perceptions
related to their current disease. Patients with DFUs
experience a ‘self-perception dilemma’—for example,
balancing the choice of wearing footwear to look and feel
normal and choosing footwear to protect their feet from foot
ulceration (Paton et al, 2014). This issue implies that foot
self-care-focused psycho-educational interventions may be
significant, and should target both patients’ misunderstanding
in relation to DFU risks, along with their emotional distress
(Vileikyte and Gonzalez, 2014).
Sociocultural variable
The sociocultural variable examines the meaning patients
ascribe to the social and cultural aspects of their daily
lives (Verberk, 2016). DFUs often lead to social isolation
resulting in low self-esteem, with the condition worsened
by sociocultural factors such as the habit of walking
barefoot (Neeru et al, 2015). Psychosocial assessment is an
important part of routine nursing care in individuals with
DFUs. Involving family members in a coping mechanism
approach may be helpful; this may involve using acceptance
techniques, cognitive reappraisal, problem-focused coping,
and pursuing social support. A wide spectrum of approaches
can be employed, including motivational interviewing, CBT,
and empowerment-based programmes. These interventions
can help deal with patients’ fears about diet and weight
issues, hypoglycaemia, and the risk of long-term diabetes
complications (Harvey, 2015).
Developmental variable
The developmental variable focuses on the individual’s
response to the changes needed to adopt a healthy lifestyle
and how they respond to the side-effects of treatments (Raz,
2013). Understanding how a patient responds may affect
treatment decisions and will improve therapy selection and
individual health outcomes (Cantrell et al, 2010).
Spiritual variable
The spiritual variable is concerned with how a person’s
spiritual beliefs affect how they view their condition
(Neuman and Fawcett, 2011). For example, some Muslim
British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT S45S44 British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT
©
2
01
9
M
A
H
ea
lth
ca
re
L
td
DFU patients may feel their illness has brought them closer
to God, may believe the disease erases sins, may fear God’s
punishment or their DFU may cause them to return to
religious practice. They may believe in God’s miracles and
mercy, and also that the healing process is a gift from God or
a reward (Salehi et al, 2012). In contrast, some patients do not
feel that their condition has brought them closer to God. One
study found that patients with diabetes varied considerably
in their views on the impact of spirituality on their illness,
from minimal to profound (Gupta and Anandarajah, 2014).
Therefore, in some patients diabetes self-management
interventions may be enhanced by including a spiritual
dimension (Baig et al, 2014). One study found that greater
religiosity in a diabetic population rendered significantly
better glycaemic control (How et al, 2011). In line with
this reasoning, Koenig argues that religion builds a positive
attitude towards all situations and encourages the person
to be motivated and to be able to deal with unfortunate
experiences in life, including disease (Koenig, 2004).
Nurses can use their understanding of the ‘environment’
domain to improve patients’ health status, drawing on
evidence-based treatment recommendations. The optimal
healing environment framework can also be used in nursing
interventions as it aims to improve healing and health creation,
which is a critical aspect of disease management (Huisman
et al, 2012). In addition, strategies for diabetes prevention
should aim at fostering a ‘diabetes-protective lifestyle’ while
concurrently enhancing the resistance of the human organism
to pro-diabetic environmental and lifestyle aspects (Kolb
and Martin, 2017). These strategies potentially accelerate the
healing process and improve patients’ health outcomes.
Health
Fawcett described ‘health’ as a person’s wellbeing—
ranging from a high level of wellness to terminal illness as
experienced by individuals (Fawcett, 1996). Complications
of diabetes affecting the limbs are common, multifaceted,
and costly. Diabetic foot ulceration is a severe public health
issue that is more likely to develop in older people who have
had diabetes for many years, with hypertension, a history
of smoking, and diabetic retinopathy (Zhang et al, 2017).
Moreover, an individual with a DFU has a greater than
twofold increased mortality compared with non-ulcerated
diabetic individuals (Chammas et al, 2016). This critical issue
may encourage and assist nurses in being proactive rather
than reactive when promoting health among DFU patients.
Early interventions to prevent DFUs and limb amputations,
along with an entire assessment for decreasing the incidence
of micro- and macrovascular complexities, should be
considered (Al-Rubeaan et al, 2017).
Patients must have the ability to perceive, seek, reach,
engage with and in many countries pay for healthcare
services, otherwise their disease will become more
complicated (Levesque et al, 2013). Poor access to
healthcare services has been shown to be related to the
greater frequency of foot ulceration (Prompers et al, 2007).
Four barriers to healthcare access need to be identified
by clinical nurses: lack of knowledge regarding healthcare
services, unique sociocultural and religious beliefs, previous
experiences with healthcare providers, and the influence of
significant other(s) (Alzubaidi et al, 2015).
Patients’ behaviour may be viewed as an aspect of health.
Incorrect self-foot care behaviour is linked to an increased
risk of DFUs, therefore, patients with diabetes should be
guided on how to perform foot care correctly in order to
prevent ulceration or recurrence of ulceration and other
complications of diabetes (Suico et al, 1998). Foot care refers
to daily foot examination, avoiding extremes of hot and cold
underfoot, and the use of appropriate footwear when walking
(Saurabh et al, 2014). Nurses should promote routine foot
care, giving special attention during follow-up care to those
from rural regions in countries with a tradition of people
walking barefoot, provide or signpost weight-loss programmes,
and manage neuropathy comprehensively with the purpose of
reducing the incidence of DFUs (Mariam et al, 2017).
Quality of life also links with the ‘health’ domain of
the nursing metaparadigm (Parse, 1990). DFUs impact on
patients’ health-related quality of life due to lower extremity
amputations (Goodridge et al, 2005). The presence of
ulceration affects a person’s functioning and mobility and
decreases quality of life (Winkley et …