Introduction
The diagnosis of diabetes mellitus creates new risks for patients that involve all spheres of people’s lives. Apart from causing the need for continuous medical assessment of one’s glucose levels, this condition also leads to several other complications. One of the most widespread issues that follow diabetes mellitus is foot problems. According to statistics, diabetic foot ulcers can affect as many as 6% of people living with diabetes worldwide (Armstrong, Boulton, & Bus, 2017). Moreover, foot neuropathy is not just a danger to one’s comfort and lifestyle – it is also a risk factor for severe complications, amputation, and even death. In the United States, diabetes is the cause of more than half of all foot amputations (Fletcher, 2019). Analyzing such high numbers, it is apparent that the problem of foot complications is a serious topic that requires immediate research and change.
Nonetheless, some scholars note that the prevention of foot ulceration is less researched than its treatment. Therefore, medical studies involve themselves in finding ways to effectively treat ulcers without considering the strategies to prevent the problem from occurring. According to Fletcher (2019), prevention is a needed approach to addressing complications of diabetes mellitus. While treatment leads to positive outcomes, it puts stress and an economic burden on people and medical facilities. In contrast, preventive healthcare protects patients from developing problems, lowering their pain and expenses without compromising their health.
This report considers the case of preventive foot care for people with diabetes. It provides a literature review that explores the problem of foot neuropathy and demonstrates the effectiveness of preventive care. The description of theoretical concepts aims to prove that preventive healthcare is in line with the goals of the national healthcare provision system to protect patients from harm. The report outlines a multifaceted solution that integrates patient education, clinical check-ups, as well as pharmaceutical and surgical help. Finally, it provides a research evaluation instrument to assess the quality of the considered suggestions.
Literature Review
Various complications of diabetes have been a topic of academic research for decades. Foot problems are among the most recognized risks that patients with diabetes have. Nonetheless, the strategies for treatment often target already developed ulcers, instead of considering ways to prevent the problem from occurring. Pop-Busui et al. (2017) investigate the issue of diabetic neuropathy, noting that almost half of all patient cases can stay asymptomatic for long periods. Thus, many people are at risk of the condition progressing without any preventative measures. The authors state that foot neuropathy often becomes a cause for amputation, driving the prices for diabetes care up and complicating treatment (Fletcher, 2019). This issue also raises the rates of morbidity since ulceration exposes people to infections (Bus & van Netten, 2016). Thus, the authors show that, while being one of the late outcomes of neuropathy, foot problems are underdiagnosed or not discovered in time for effective prevention.
The history of diabetic foot ulcers’ occurrence and treatment is discussed by Armstrong et al. (2017). The authors present statistics about the rates of foot complications to show how common and challenging this problem is in the healthcare industry. According to Armstrong et al. (2017), the risk of death for a patient with diabetes and foot ulcers is more than three times as high as that for a patient without foot ulcers. Moreover, surgeries often follow the development of foot ulcers – around 20% of all ulcerations end in an amputation (Armstrong et al., 2017). Consequently, diabetes-related amputations fail to provide relief for patients or lower their risks. Mortality rates for patients with diabetes who underwent amputation are higher than 70% (Armstrong et al., 2017). These numbers indicate that healing is not as effective as the studies exploring it may find. Therefore, a shift in perspective is essential for providing patients with preventive care strategies.
The disadvantages of healing procedures are plentiful not only for patients but also for medical facilities. In emergency departments and hospitals in general, admissions and visits of a patient with a foot ulcer constitute a substantial risk (Armstrong et al., 2017). The costs for treating ulcers are high as well – in some cases, they are at one level with cancer treatments. In the United States, approximately “$176 billion is spent annually on direct costs for diabetes care” (Armstrong et al., 2017, p. 2368). A third of this sum is delegated to foot care, which means that foot ulcers require a major part of all spending, although their prevention is much less costly and results in significant improvements in one’s health. According to the American Diabetes Association (2018), foot ulceration requires a multidisciplinary approach to treatment, implying that many specialists are involved in expensive and time-consuming healing procedures. The lack of preventive measures does not benefit healthcare professionals, patients, and the government.
The possibility of preventive healthcare strategies in treating diabetes-induced foot problems is researched less than other approaches to care. Bus and van Netten (2016) argue that the view of healthcare should change to focus on prevention rather than treatment. The authors state that curing is a theme that is present in many studies and that one article about prevention is followed by ten studies about healing (Bus & van Netten, 2016). As a result, a significant portion of the population develops ulcers since healthcare facilities fail to locate the problem and education patients about appropriate lifestyle changes. The scholars predict that if the facilities implement preventive care for foot ulceration, up to 75% of all neuropathy cases will be prevented (Bus & van Netten, 2016). This change will lead to a significant decrease in spending for both patients and the government as foot ulceration requires complex treatments including surgeries and amputations.
Other articles support the scholars’ concerns about the small amount of evidence on the topic of foot care. The study by van Netten et al. (2016) finds that the available medical scholarship does not provide sufficient information about the ways to prevent foot ulceration. Although studies offer a variety of solutions, only one of them was investigated enough to present a strong recommendation. In contrast, all other interventions do not have an adequate evidence base for using them as a guideline without further examination. The authors find that a combination of multiple programs is the most effective and supported, thus highlighting the need for changes in the medical system (van Netten et al., 2016). Patient education alone or other simple initiatives are not as effective in raising people’s health quality levels.
Overall, several studies that review preventive approaches recommend several techniques. First of all, intensive education is deemed effective by Ren et al. (2014), who find that nurses’ training impacts the way they address patients’ treatment and learning interventions for better at-home and in-hospital care. Alavi et al. (2014) investigate assessment techniques to detect any signs of ulcers and identify risks that require attention. They suggest a 60-second screening tool for all patients with diabetes that can be used during regular visits. The authors also argue that calluses’ removal is important for preventing pressure ulcers (Alavi et al., 2014). The multifaceted program developed by Bus et al. (2016) includes regular screenings, footwear, foot washing techniques, daily inspections, and medicines for infections. Overall, the variety of these approaches shows that one narrow view of prevention is not beneficial.
Case Description (Theoretical Perspective)
To understand why change is necessary, one has to consider the theoretical approaches to healthcare. According to Kohn, Corrigan, and Donaldson (2000), the basis of health care is rooted in compassion and the protection of other people from harm. Thus, it is the duty of all healthcare providers, including nurses and physicians, to apply their knowledge not just to treat problems, but also to prevent new issues from developing. Thus, medical care has to focus on prevention as the most powerful means of maintaining people’s wellbeing. The failure to stop foot ulcers from occurring can be considered a medical error. Kohn et al. (2000) classify it as a preventive error – while clinicians may not do direct harm to patients, their lack of understanding of preventive strategies is a problem that leads to higher patient risks.
To create a program for introducing new preventive approaches to the medical industry, it is necessary to consider the systematic changes that can affect the quality of nursing care and patient outcomes. The Institute of Medicine (2001) finds that individuals cannot be accountable for a problem as massive as diabetic foot ulcers. Healthcare providing facilities, the government, and educational institutions have to innovate to resolve global and national issues.
Examining the problem of foot ulceration, one can see that the previous scholarship reviewed individual cases of organizations improving their preventive care. As an outcome, while some departments reduced the risks of their patients, the population as a whole still encounters the lack of strategic approaches daily. Thus, the steps proposed by the Institute of Medicine (2001) have to be taken into consideration – facilities need to gather and apply evidence, build support for change, use information technology, and prepare the workforce for new interventions. The quality of patient outcomes will increase if the government will redirect its funding towards prevention, and educational organizations will prioritize awareness-raising and proper preventive techniques in courses.
Discussion of Literature Findings
The synthesis of the literature findings reveals a problem that is present in the national and global approach to foot ulceration. The high number of people who develop ulcers every year demonstrates the failure of the healthcare system to minimize harm. The statistics of patients’ surgeries, amputations, and mortality rates also indicate that healing is ineffective in stopping the ulcers from affecting each aspect of people’s lives. Furthermore, the work of Armstrong et al. (2016) shows that millions of people suffer from this problem, but a large portion of all people with diabetes can be saved from such complications in the future. The authors also find that healing treatment is expensive and complex, leaving many people with finance- and health-related problems even if ulceration is stopped.
The analysis of studies investigating various prevention methods presents one with many possibilities for systemic change. It also shows that, at present, organizations on all levels of healthcare providers have flaws that lead to preventive errors. For instance, the educational institutions do not train nurses to properly address diabetes complications, which leads to the staff overlooking or neglecting the risks of foot ulceration. It is possible that hospitals do not foster the culture that values prevention overhealing, thus further contributing to the lack of improvement. As for the strategies themselves, scholars identify approaches that target patients, nursing students, working nurses, healthcare facilities, and governments to enhance patient outcomes.
Case Summary
The problem of diabetes complications is present in many countries, including the US. Currently, foot ulceration is one of the most recognized problems that occur in more than 6% of the global population of people with diabetes (Armstrong et al., 2016). Foot ulcers are dangerous as their development raises the risk of infection, thus leading to amputations. Moreover, ulceration increases the rates of mortality among people with diabetes. The combination of these aspects makes diabetic foot ulcers a serious problem in need of investigation.
The approach to foot ulceration that focuses on their treatment after development is prevalent in modern healthcare. However, it has a limited effect on improving people’s health. It is also costly – surgeries and patients’ admittance to hospitals for healing are often as expensive as some cancer therapies (Armstrong et al., 2016). Thus, contemporary measures should be reassessed to introduce a new program of evaluating and preventing the problem.
Proposed Solutions
The existing scholarship offers several ways to remedy the problem of diabetic foot ulcers. First of all, nursing education is considered to be one of the most influential ideas. According to Ren et al. (2014), training for nurses changes the way professionals who deal with patients with diabetes view these patients’ risks and lifestyle changes. Educational programs that focus on preventive methods and collaboration with patients raise the nurses; understanding of the importance that timely intervention has to preserve people’s health. These courses also highlight the value of lowering prevention errors, thus contributing to the overall quality of care and nurses’ commitment to improving healthcare systems.
When entering the workforce, prepared nurses need to maintain their level of learning and use evidence-based practices to deliver better care. Morey-Vargas and Smith (2015) introduce a program called BE SMART – a combination of different practices that allows nurses to address the problem from multiple angles. This mnemonic includes such steps as “(Be aware of the risk factors, Educate patients and health providers, Structured clinical assessment, Metabolic evaluation and management, Assessment of Risk, and Team care” (Morey-Vargas & Smith, 2015, p. 48). The first step is rooted in education – programs discussed above address this point.
The second part of the solution refers to patients’ education and involves raising awareness about the risks of diabetic foot ulcers. Here, nurses can use different methods to convey the necessary information and contribute to the patient’s understanding. For instance, patients can be directed towards internet resources such as Foot Health Facts (2019) that provides updated professionally approved information about foot care guidelines. These suggestions include daily inspections, bathing instructions, appropriate footwear, signs that patients should look out for, and advice about lifestyle changes. Schaper, van Netten, Apelqvist, Lipsky, and Bakker (2016) note that patient education should also happen in the nurse’s office and should include the presentation of actions that a person should perform daily. Family members and carers should receive this information as well.
Clinical assessment and metabolic evaluation include a variety of tests and instruments for patient examination. For example, the screening tool used in the study by Alavi et al. (2014) demonstrates how nurses trained in preventive evaluations act to discover and stop ulcers from forming. Here, the history of patients (previous amputation, callouses, and lesions), their risk factors (smoking), and presentation (physical exam results) are considered. The regular assessment is a part of prevention recommendations created by the International Working Group on the Diabetic Foot (IWGDF). Bus et al. (2016) argue that screenings should happen at least once a year, with specific cases being examined each one to three months. The recurrence of foot ulcers can be prevented as well as their first appearance using the same recommendations.
Research Evaluation Instrument
To assess the outcomes of implementing new approaches to diabetic foot ulcers, one has to choose a specific tool. Perrin and Snow (2006) propose a Foot Care Confidence Scale that is modified to evaluate the knowledge of people with diabetes. This instrument gathers information about patients’ understanding of guidelines for preventive care and their confidence in applying the instructions in real life. Perrin and Snow (2006) find that the subjects of their study were confident in using the knowledge they acquired from medical professionals.
The scale uses positive and negative statements about various activities that people should perform daily to assess the state of their feet. For example, it includes such phrases as “I can look at my feet daily to check for cuts, scratches, blisters, redness, or dryness” and “I can choose shoes that are good for my feet” (Perrin & Snow, 2006, p. 5). These questions can be given to patients to answer frequently to remind them of the necessary practices and check their confidence in acquired knowledge. The screening can be evaluated based on the level of confidence that patients express with their answers. While it is clear that this questionnaire does not guarantee that people perform these activities, it provides a source of communication between patients and healthcare providers and increases the former’s autonomy.
Conclusion
The problem of diabetic foot ulcers is a topic that required further investigation. The existing research reveals that, although many studies consider preventive efforts and solutions, these programs are not implemented in practice on a global scale. Healthcare systems should shift their focus from healing to prevention to lower the rate of medical errors and protect patients from potential harm. As diabetes is a condition that is followed by many complications, preventive approaches are crucial in treating patients with diabetes.
The reviewed literature presents several strategies to implement preventive care in nursing. First of all, education needs to introduce courses that are based on information about prevention. Second, nurses should conduct regular assessments to document changes and locate possible problems before they develop into a condition. Finally, patient learning has to become an inherent part of any nurse-client interaction since patients’ understanding and confidence plays a significant role in prevention. Overall, researchers need to continue exploring how the issue of diabetic foot ulcers can be addressed to create a program for systemic change.
References
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- American Diabetes Association. (2018). 10. Microvascular complications and foot care: Standards of medical care in diabetes—2018. Diabetes Care, 41(Supplement 1), S105-S118.
- Armstrong, D. G., Boulton, A. J., & Bus, S. A. (2017). Diabetic foot ulcers and their recurrence. New England Journal of Medicine, 376(24), 2367-2375.
- Bus, S. A., & van Netten, J. J. (2016). A shift in priority in diabetic foot care and research: 75% of foot ulcers are preventable. Diabetes/Metabolism Research and Reviews, 32, 195-200.
- Bus, S. A., van Netten, J. J., Lavery, L. A., Monteiro‐Soares, M., Rasmussen, A., Jubiz, Y., & Price, P. E. (2016). IWGDF guidance on the prevention of foot ulcers in at‐risk patients with diabetes. Diabetes/Metabolism Research and Reviews, 32, 16-24.
- Fletcher, J. (2019). How can diabetes affect the feet? Medical News Today. Web.
- Foot Health Facts. (2019). Diabetes foot care guidelines. Web.
- Institute of Medicine. (2001). Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press.
- Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.
- Morey-Vargas, O. L., & Smith, S. A. (2015). BE SMART: Strategies for foot care and prevention of foot complications in patients with diabetes. Prosthetics and Orthotics International, 39(1), 48-60.
- Perrin, B., & Snow, P. (2006). Foot care confidence in people with diabetes. Australasian Journal of Podiatric Medicine, 40(1), 3-8.
- Pop-Busui, R., Boulton, A. J., Feldman, E. L., Bril, V., Freeman, R., Malik, R. A.,… Ziegler, D. (2017). Diabetic neuropathy: A position statement by the American Diabetes Association. Diabetes Care, 40(1), 136-154.
- Ren, M., Yang, C., Lin, D. Z., Xiao, H. S., Mai, L. F., Guo, Y. C., & Yan, L. (2014). Effect of intensive nursing education on the prevention of diabetic foot ulceration among patients with high-risk diabetic foot: A follow-up analysis. Diabetes Technology & Therapeutics, 16(9), 576-581.
- Schaper, N. C., van Netten, J. J., Apelqvist, J., Lipsky, B. A., Bakker, K. (2016). Prevention and management of foot problems in diabetes: A Summary Guidance for Daily Practice 2015, based on the IWGDF Guidance Documents. Diabetes/Metabolism Research and Reviews, 32, 7-15.
- van Netten, J. J., Price, P. E., Lavery, L. A., Monteiro‐Soares, M., Rasmussen, A., Jubiz, Y., Bus, S. A. (2016). Prevention of foot ulcers in the at‐risk patient with diabetes: A systematic review. Diabetes/Metabolism Research and Reviews, 32, 84-98.