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
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
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■ 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
■ 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
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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
A circumstance where the nursing care is continuously being given
and with which a patient interacts
Human being Environment
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
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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
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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 …