The International Working Group on the Diabetic Foot (IWGDF) defines diabetic foot ulcers (DFU) as full-thickness wounds of the foot presenting with infection, and destruction of skin tissue as a consequence of neuropathy and/or peripheral artery disease in patients with diabetes (van Netten et al, 2020). DFU are associated with a number of complications, such as lower extremity amputation (LEA) and mortality (Costa et al, 2017). Studies have documented that DFU complications significantly impact on subjective wellbeing and spirituality, engendering feelings of powerlessness and loss of hope for recovery (Salomé et al, 2013a; 2013b). When spiritual health is at risk, patients may experience emotional problems that hinder desired outcomes (eg delayed wound healing) (Sridhar, 2013; Britteon et al, 2017). Psychological stress retards the initial inflammatory phase of the wound healing process and affects the hypothalamic-pituitary-adrenal, sympathetic-adrenal medullary axes (Glaser and Kiecolt-Glaser, 2005; Guo and Dipietro, 2010).
Since spiritual health is an element of holistic care, several studies have addressed spiritual care in diabetes care. Women and senior citizens with DFU can have a lack of hope and spirituality (Salomé et al, 2017). Spiritual care helps to improve body image in patients who have undergone LEA (Imeni et al, 2018). Watkins et al (2103) highlighted the importance of spirituality and social support in performing diabetes self-care activities. Spiritual care increases a patient's self-care, hope, strength and quality of relationships (Gupta and Anandarajah, 2014). Spiritual intelligence has a fundamental role in improving outcomes of patients with diabetes (Rahmanian et al, 2018), where ‘intelligence’ is the individuals' ability to solve a particular problem and adapt to the surrounding environment (Rahmanian et al, 2018). By using this ability, patients with DFU can enhance their knowledge and skills in performing self-care at home.
The aforementioned studies have underlined that spiritual care interventions are an important part of total patient care, foster patients' wellbeing, and prevent the long-term risks of DFU. However, there are a number of questions still to be answered. What is the role of nurses in providing spiritual care in patients with DFU? What is the role of the family and community in supporting the implementation of spiritual care? This article discusses spiritual care in patients with DFU using the spiritual care framework developed by Veloza-Gómez et al (2017) to guide the analysis (Figure 1).
For spiritual care to be easily implemented by wound care nurses, a model of care for patients with DFU was generated (Figure 2). Finally, the findings offer a theoretical perspective that can be put into practice to develop spiritual interventions and prevent spiritual crises in patients with DFU.
Literature search process
The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) method was used to perform a literature search (Moher et al, 2009). The Scopus, SAGE, SpringerLink, ProQuest, PubMed and CINAHL databases as well as Google Scholar were searched using the following key words: ‘spiritual care in nursing’, ‘spiritual care in diabetes’, ‘spiritual care in diabetic foot ulcers’, ‘spiritual care assessment’, ‘spiritual care intervention’, ‘spiritual care evaluation’, ‘spiritual support’, ‘role nurses and spiritual care in diabetic foot ulcers’, and ‘role of family, community and spiritual care in diabetic foot ulcers’.
Inclusion criteria were articles in English, relevant to the spiritual care from a nursing perspective, review studies focusing on the spiritual care in DFU or diabetes, studies using quantitative and qualitative design, and articles published between 2000 and 2020. The exclusion criteria were studies not describing spiritual care in DFU or diabetes. The initial search retrieved 192 articles. Following title and abstract assessment, 93 and then a further 36 articles were excluded as they were not relevant. A full-text review was conducted on 63 articles. From these, a further 31 articles were excluded for failing to meet the inclusion criteria. A total of 32 articles was included in the final analysis (Table 1).
| Main topics | Authors, years | Findings |
|---|---|---|
| Interpretation of spiritual care | Werfalli et al, 2020 | Emotional support and encouragement |
| Keukenkamp et al, 2018 | Motivational interviewing in diabetes | |
| Hebert et al, 2001 | Intensive discussion related to spiritual need | |
| Kalra et al, 2018 | Psychological assessment | |
| Fisher et al, 2012; Polonsky et al, 2005 | Using the Diabetes Distress Score 17 | |
| Adu et al, 2019 | Social or compassionate relief programmes | |
| Steinsbekk et al, 2012 | Group-based diabetes self-management education | |
| Massey et al, 2019 | Wellbeing interventions | |
| Mishra et al, 2017 | Assessing the patient's culture, beliefs, social and family support | |
| George et al, 2006 | The 30-item Beliefs and Behavior Questionnaire | |
| de Vera, 2003; Rao et al, 2015 | Assisting patients with prayer | |
| Patients and family in spiritual care | Subrata and Phuphaibul, 2019 | Assessing physical and mental health |
| Halliday et al, 2017 | Using Well-being Questionnaire (WHO-5) | |
| Janssen et al, 2016 | Using Patient Health Questionnaire-9 (PHQ-9) | |
| Shapiro et al, 2018 | Using Problem Areas in Diabetes (PAID) | |
| Rebolledo and Arellano, 2016; Baig et al, 2015; Hu et al 2014; Rivera-Hernandez, 2016; Salahshouri et al, 2018 | Optimising the family roles in spiritual care | |
| Role of the nurse in spiritual care | Frouzandeh et al, 2015; Yang et al, 2017 | Spiritual care training |
| Cockell and McSherry, 2012 | Empowering nurses' motivation and identifying adequate training | |
| Aalaa et al, 2012 | Optimising nurses' role in diabetes education | |
| Turns, 2012 | Assessing DFU in housebound patients | |
| Seaman, 2005 | Multidisciplinary team | |
| Kalra et al, 2018 | Psychological interventions | |
| Koenig, 2014 | Spiritual care team | |
| Willemse et al, 2018 | Collaborating with specialist spiritual carer | |
| Isaac et al, 2016 | Combining spiritual care with patient-centred care |
DFU=diabetic foot ulcer
Findings
The significance of spiritual care in patients with DFU
The concepts of religiousness and spirituality have been debated, yet no consensus has been found (King and Koenig, 2009; Puchalski et al, 2009). Theoretically, religiousness is an extension of personal beliefs, followings and practices associated with a particular religion (Parker et al, 2003).
By contrast, spirituality is an aspect of being human, and refers to the way in which individuals seek, and express the meaning of life (Puchalski et al, 2009). Studies have emphasised that spirituality has a great impact on diabetes care (Singh and Ajinkya, 2012; Duke and Wigley, 2016) and patients with DFU are at risk of experiencing mental health issues, such as body image disturbances, depression, and anxiety (Ahmad et al, 2018; Nurhikmah et al, 2019). Thus, integrating spiritual care can help patients to cope with those psychological problems (Verghese, 2008).
In this article, Veloza-Gómez et al's (2017) interpretation of spiritual care, particularly the relationships between the patient and the family and the role of the nurse in spiritual care, have been used to explore the importance of spiritual care in nursing practice for patients with DFU.
Interpretation of spiritual care
‘Interpretation of spiritual care’ was defined as the particularities of spiritual care, its end goal, and the sense of religion in spiritual care (Veloza-Gómez et al, 2017). ‘The particularities of spiritual care’ consist of emotional supports, open-mindedness, and active listening (Veloza-Gómez et al, 2017). Wound care nurses need to provide emotional support and encouragement, which can improve patients' self-care and self-management (Werfalli et al, 2020). Motivational interviewing (MI) use is also appropriate to strengthen patients' motivation and commitment to behaviour-change goals in diabetes (Keukenkamp et al, 2018). Health professionals can provide opportunities for patients to discuss spirituality and interpersonal skills for patients (Hebert et al, 2001). In addition, early psychological assessment is also important to evaluate patients' psychosocial health when practising spiritual care at home (Kalra et al, 2018). The Diabetes Distress Score 17 (DDS17) can be administered to assess diabetes-related distress (Polonsky et al, 2005; Fisher et al, 2012).
‘Its end goal’ indicates providing basic human needs such as the search for relief, advice, and the source of wellbeing (Veloza-Gómez et al, 2017). To relieve the psychological burden, it is recommended that patients be referred to specific social or compassionate relief programmes provided by nurses in the community (Adu et al, 2019). Group-based diabetes self-management education and sharing of experiences can be used to improve patients' abilities in self-care (Steinsbekk et al, 2012). Wellbeing interventions, which are simple and broadly used, may be suitable for increasing patients' self-efficacy and motivation (Massey et al, 2019). When providing interventions, wound care nurses need to consider the patient's culture, beliefs, social and family support (Mishrai et al, 2017).
‘The sense of religion in spiritual care’ highlights the nurses' response to religious requests, including belief, respect, and religious care (Veloza-Gómez et al, 2016). One study documented an association between medication beliefs and medication adherence in patients with diabetes (Olorunfemi and Ojewole, 2018). Therefore, any assessment related to patients' beliefs needs to take into consideration DFU care. The 30-item Beliefs and Behavior Questionnaire (BBQ) has potential applications to evaluate adherence beliefs, patients' experiences and behaviour (George et al, 2006). Nurses are recommended to assist patients to pray, where appropriate and in accord with a patient's beliefs and religion (de Vera, 2003). Praying may help patients to adjust emotionally to their illness and support their spiritual health (Rao et al, 2015).
The patient and the family in spiritual care
‘The patient and the family in spiritual care’ describes ‘the patient’ as an integral human being and subject of daily care, and ‘the family’ as a source of support (Veloza-Gómez et al, 2017). Other components from Veloza-Gómez et al (2017) include ‘knows the patient’ and ‘needs of the patient’, both of which can be identified by performing physical and psychological assessments (Subrata and Phuphaibul, 2019). Assessment can be made using the Well-being Questionnaire (WHO-5), Patient Health Questionnaire-9 (PHQ-9), and Problem Areas in Diabetes (PAID) Scale (Kalra et al, 2013). WHO-5 evaluates subjective wellbeing and consists of five simple and non-invasive questions (Halliday et al, 2017). PHQ-9 assesses the symptoms of depression in clinical practice (Janssen et al, 2016). The PAID scale measures emotional distress in association with the burden of diabetes (Shapiro et al, 2018). Following assessment of a patient's condition, interventions should be delivered followed by evaluation of the patient's knowledge and need (Veloza-Gómez et al, 2017).
For Veloza-Gómez et al (2017) ‘the family’ consisted of the importance of family, family experience, family needs, family connection and family love. The family, as a spiritual caregiver, can assist patients to fulfill their emotional and spiritual needs at home (Rivera-Hernandez, 2016; Salahshouri et al, 2018). Family members play a significant role in improving patients' attitudes and beliefs (Rebolledo and Arellano, 2016). Family members are often asked to share the responsibility for disease management and give support (social and emotional) (Baig et al, 2015). Therefore, including family members may help to improve patients' healthy behaviours, promoting diabetes self-management (Hu et al, 2014). Family love is useful for patients to cope with their complex situations and restore patients' hope in the midst of suffering (Veloza-Gómez et al, 2017). To strengthen the therapeutic relationship with wound care nurses, a collaboration between patient and family is required throughout the implementation of spiritual care.
The role of the nurse in spiritual care
‘The role of the nurse in spiritual care’ consists of the qualities of the nurse, nursing intervention, and the scenario of nursing practice (Veloza-Gómez et al, 2017). Veloza-Gómez et al, (2017) defines ‘the qualities of the nurse’ as the capacity, comprehension, vocation and commitment to the provision of spiritual care. For example, wound care nurses undertake spiritual care training that helps them to understand a patient's sense of honor, experience and values (Frouzandeh et al, 2015). Similarly, spiritual care training improves nurses' skills and knowledge in overcoming issues related to patient quality of life and spiritual wellbeing (Yang et al, 2017). Owing to limited sources of spiritual care training, health policymakers and nursing organisations are recommended to develop training that ensures wound care nurses have sufficient knowledge and skills to give spiritual care. Training materials should include ways of understanding spirituality and spiritual care, identifying the spiritual needs of patients and designing nursing care plans (Frouzandeh et al, 2015), as well as ways to empower motivation and to identify what constitutes adequate training (Cockell and McSherry, 2012).
‘Nursing intervention’ refers to nurse–patient interactions, nurse satisfaction and patient–family or nurse mutual benefit (Veloza-Gómez et al, 2017). Diabetes nurses play a key role in providing foot and wound care (Aalaa et al, 2012). Community nurses, as firstline healthcare providers for assessing DFU in housebound patients, will have the necessary skills and knowledge to manage DFU (Turns, 2012). Multidisciplinary team involvement is also needed to successfully manage DFU (Seaman, 2005). A model of psychological intervention based on the severity of any mental health problems can be used to help patients with diabetes (Kalra et al, 2018). Furthermore, since family members contribute to disease management, involving them in diabetes care improves outcomes for patients (Baig et al, 2015).
‘Scenario of nursing practice’ refers to a patient's health, the complexity of the service, the importance of the work, and time management (Veloza-Gómez et al, 2017). Veloza-Gómez et al (2017) explained that these elements should be considered by nurses when delivering spiritual care in clinical practice. When nurses work with a ‘spiritual care team’ (Koenig, 2014) or specialist spiritual carers (Willemse et al, 2018) quality of care can be optimised. Implementation of spiritual care in a hospital setting enhances the patients' spiritual growth and compliance (Heidarzadeh and Amohammadi, 2017). Additionally, a combination of spiritual care, patient-centered care and shared decision-making will improve the patient outcomes (Isaac et al, 2016).
Discussion
Spiritual care is a part of holistic nursing care, integrating biological, physical, psychological, social, cultural and spiritual aspects (Chan et al, 2006; Caldeira et al, 2013). The International Council of Nurses (ICN) determined that spiritual care is a nurse's responsibility in clinical practice (ICN, 2012) and Baldacchino (2006) described four main competencies for spiritual care in nursing: the role of the nurse as a professional and as an individual; delivery of spiritual care by using the nursing process; nurses' communication with patients, interdisciplinary team and clinical or educational organisations; and safeguarding ethical issues in daily care.
Understanding spiritual needs, such as the need for meaning and purpose in life, to love and to be loved, to feel a sense of belonging and hope, peace and gratitude, is important for wound care nurses. When these needs are fulfilled, physical and psychological outcomes can be improved (Timmins and Caldeira, 2017a). Each patient will have different spiritual needs throughout the healing process (Ettun et al, 2014) and assessment will be necessary using validated instruments, such as the Spiritual Needs Questionnaire (SpNQ) (Büssing et al, 2015; Riklikienė et al, 2019; Timmins and Caldeira, 2017b).
Spiritual care, as part of patient-centred care (Batcheller et al, 2013; Vincensi, 2019), is associated with the improvement of diabetes self-management abilities (Davis et al, 2005; Williams et al, 2016), which in turn improves healing (Casarez et al, 2010). Therefore, health professionals and multidisciplinary teams are encouraged to deliver spiritual care (Sridhar, 2013; Ogrin et al, 2015).
With the high mortality rate in patients with DFU, spiritual and palliative care should be combined in practice to overcome psychological issues (Jeyaraman et al, 2019). El Nawawi et al (2012) emphasized that both palliative care and spiritual care are essential for the patients, particularly when they have spiritual needs and experience life-threatening conditions.
Patients with diabetes often experience depression that negatively impacts self-efficacy (Devarajooh and Chinna, 2017). Low self-efficacy can increase feelings of stress. Instruments, such as the Diabetes Management Self-Efficacy Scale (DMSES) (Messina et al, 2018), can assess self-efficacy. Additionally, health education that focuses on self-efficacy is an appropriate method for maintaining blood glucose levels, behaviours and psychosocial indicators (Jiang et al, 2019).
Patients with diabetes are also more likely to experience grief or loss as a consequence of lower extremity amputation (Spiess et al, 2014). Wound care nurses have a great opportunity to facilitate amputee support groups (Jacobsen, 1998; Marzen-Groller and Bartman, 2005; Nathan and Winkler, 2019). As with leg ulcers, patients often experience negative body-image perceptions (Salomé et al, 2016) and nurses need to provide comprehensive care to deal with any issues (Nishio and Chujo, 2018), which may include body-image assessment, motivating the patient to participate in decision-making, teaching wound dressing techniques, involving family members in daily care at home, providing support groups and evaluating physical alongside psychological outcomes (Butcher et al, 2019).
After an amputation, individuals must adapt to the new appearance of their limb to avoid emotional and social distress (Nunes et al, 2014). Post-amputation management, such as rehabilitation, care after discharge and educating the patient and family, must be planned beforehand (Bhuvaneswar et al, 2007).
Any psychological problems, for example depression, anxiety and anger (de Groot et al, 2016), should also be considered when developing a care plan (Penckofer et al, 2007). The American Diabetes Association recommended several approaches: delivering patient-centered psychosocial care; practising personalised care; effective communications and interactions; assessment and screening for psychosocial issues; diagnostic evaluation; and conducting interventions related to the context of the patient with diabetes (Young-Hyman et al, 2016).
Spiritual care nursing interventions can be religious or non-religious (McBrien, 2010). Religious interventions consist of treating patients without prejudice; giving opportunities to pray; allowing patients to express their values and beliefs; and referring to religious leaders when necessary. Psychological support can be integrated into religious interventions by facilitating religious rituals and cultural beliefs, communicating effectively, valuing spiritual needs, showing respect and involving the family into patient care (Lundberg and Kerdonfag, 2010). When involved, religious leaders can offer advice and guidance regarding health issues and wellness (Stansbury et al, 2012).
Non-religious interventions include a nurse's care for patients and families, effective communication, sympathising with and listening to patients (McBrien, 2010). Nurses can provide structured group education sessions, facilitate peer-support groups and create community awareness and health education (Kasiya et al, 2017). The Implementing the Faith, Importance and Influence, Community, and Address Spiritual History Tool can be useful in holistic care (Williams et al, 2016).
Conclusion
This article discusses spiritual care in patients with DFU, which can be translated into training, planning and delivery in nursing practice. Family and community support are are important in improving coping strategies for patients. Standardisation of spiritual care education in healthcare facilities is also required to ensure that nurses have sufficient competencies to deliver appropriate spiritual care to patients with DFU. There are few studies on spiritual care in DFU and further research is needed to show its significance to DFU care.