A nursing metaparadigm perspective of diabetic foot ulcer care

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 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 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:

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 al, 2009). Moreover, the anxiety associated with re-ulceration and recurrence of foot infection also leads to a poor quality of life (Price, 2004). Stress from unemployment, patients' dependency status, diabetic foot pain, and problems arising from daily foot ulcer dressing may be the primary triggers of a lower quality of life among individuals with DFU. Assessing the patient's feet at regular intervals, especially if they are at a high level of risk of ulceration, and educating patients and their families with reference to foot care, will reduce the cost of treatment along with improving patients' quality of life (Sothornwit et al, 2018).

Pender (1990) stated that the ‘health’ domain of the nursing metaparadigm had five dimensions:

Nursing

Fawcett (1996) described ‘nursing’ as actions given by nurses in a systematic and organised process, encompassing assessment, labelling, planning, intervention, and evaluation. Florence Nightingale noted that nurses have a responsibility to promote health and prevent disease complications (Winkelstein, 2009). In the care of patients with DFUs, nurses are actively involved in preventing limb amputations by providing early detection of any changes in foot sensation, promoting foot care, using advanced wound dressings and applying advanced technologies such as utilising growth factor therapy (Seaman, 2005; Aalaa et al, 2012). To maintain a proper balance between theory and practice, a nurse must be up to date with current knowledge and practice in the field (Ajani and Moez, 2011). Wound-care training, continuous professional development, evidence-based practice implementation and wound-care research should be fostered (Kumarasinghe et al, 2018).

The nursing domain also encompasses clinical nurses, their attributes and how they use their knowledge and skills when providing care (Branch et al, 2015). The American Diabetes Association (ADA) states that daily and proper care is relevant in preventing DFU complications (ADA, 2013). Clinical nurses are required to be experts in performing DFU management to attain improved patient outcomes. Patient assessment should identify the risk factors for limb amputation, as well as other related complications. These are focused on vascular adequacy, neurological or sensory condition, suitability of footwear, presentation of foot malformation, wound size, the severity of tissue damage, and environmental factors (Roberts and Newton, 2011).

The ‘nursing’ domain includes a caring process consisting of five conceptualisations of caring: caring as an intervention, caring as a moral imperative, caring as a human trait, caring as an interpersonal interaction, and caring as an effect (Morse et al, 1991). In the case of the patient with a DFU, the caring process involves three areas: continuity of care, disease experience, and disease management (Aliasgharpour and Nayeri, 2012). As a result, nurses must ‘understand how they affect patients' because every therapeutic interaction among nurses and patients should have an impact on patient wellbeing (LeVasseur, 1999). From a nursing perspective, the approach given by nurses includes initial assessments and goal-setting (Eggleton and Kenealy, 2009).

There are four major goals in nursing: patient care, health promotion, achieving patient concordance with treatment and prevention of disease. To achieve these goals, nurses can play different roles such as healthcare provider, leader, researcher, educator, care connector, and supporter of the rights of patients (Black et al, 1997). Prevention of DFUs is divided into two parts:

Providing these interventions requires ‘carative’ factors rather than solely curative factors. Showing care for the patient as a whole person, involving the mind, body, and soul, will encourage a healing process (Pajnkihar et al, 2017). DFU and lower extremity amputation not only precedes morbidity, disability, and mortality, but also renders immense negative impacts in respect of psychological stress, dependency, social isolation, and trauma (Dangol, 2011).

DFU interventions cannot be undertaken solely by nurses and must involve a multidisciplinary team including the GP, diabetes educator, podiatrists and hospital consultants. Diabetes nurse specialists are an essential part of this team (Amirmohseni and Nasiri, 2014). Nurses act as a key link to the multidisciplinary team. The ADA recommends a multidisciplinary team approach to DFU care (ADA, 2013).

Nurses should provide positive physical and psychological support that may sustain long-term coping strategies and protect DFU patients from the negative consequences of chronic diabetes. Furthermore, improved personal resources, for instance, greater resilience, would promote better cognitive functioning, stronger willpower and lead to an improved quality of life.

Implications for research and nursing practice

This article focuses on the shared goals and wider perspectives concerning the all-important nursing metaparadigm of DFU care. The nursing metaparadigm is a key element of nursing theory and has been rapidly developed and integrated into nursing practice (Schim et al, 2007). The nursing metaparadigm is relevant to current nursing practice due to its ability to identify the scope of knowledge as a practical guideline in providing DFU care. Mutual interactions amid domains of this metaparadigm (human being, environment, health, and nursing) will enhance patient outcomes and the quality of nursing care.

This nursing metaparadigm creates the potential for improvements in DFU care by:

In the wake of these issues, this article indicates that there is a growing body of literature directly supporting positive contributions in association with the nursing metaparadigm as well as DFU care. Hence, the comprehensive management of DFU should be addressed in those aspects (human being, environment, health, and nursing) (Seaman, 2005). Conducting an appropriate assessment must be taken into consideration in the course of providing DFU care. To be effective, the Scottish Intercollegiate Guidelines Network (SIGN) (2017) guideline on management of diabetes may be incorporated into the assessment because it clearly identifies the risk factors of limb amputations as well as other related complications (Table 1).

Historically, the management of DFU was established based on the three important basic treatments: sharp debridement therapy, using the off-loading device, and diabetic foot health education (Naves, 2016). However, these treatments have been developed and expanded into the following:

Today, clinical nurses are required to be experts in all of these elements to attain improved health-related outcomes.

As the incidence of diabetes continues to rise, appropriate treatment may assist to prevent extensive surgery and limb amputation. Therefore, providing comprehensive treatment modalities is imperative to maximise wound healing. Successful treatment of DFUs also requires combining holistic and systemic approaches—treating the whole patient and not just the wound (Criscitelli, 2018). Notably, a nursing metaparadigm-based approach offers promising strategies for an enhanced understanding of the interventions available to address DFU complexities. In addition, the healthcare team needs to understand the underlying physiological and psychological aspects of the patient that can delay wound healing. DFUs are multifaceted conditions that deserve the most current evidence-based interventions to achieve the best outcomes. Clinical nurses must actively engage in managing diabetes and its complications as well as preventing the severity of those illnesses.

Conclusion

It is hoped that this article will encourage collaborative practice between nurses and other healthcare providers working in DFU care and more generally in the care of people with diabetes. It is also noted that any nursing metaparadigm-driven approach in daily practice is not without its challenges due to the complexities of implementation. Nonetheless, a theory-driven approach is well worth the effort in overcoming problems in practice, particularly in the care of people with DFUs. Further research is needed to understand outcomes linked with each domain of the metaparadigm. Broadening of the theoretical description should also be explored, aimed at thoroughly identifying and explaining each domain of the nursing metaparadigm. This will ultimately lead to a standard of care that prevents the severe side effects of diabetes.

Furthermore, this article aimed to expand the knowledge base of nurses working in DFU care. Finally, by integrating the nursing metaparadigm into DFU care, nurses are able to recognise the unique contribution of a theory that helps to generate effective care linked to daily nursing practice.

KEY POINTS

CPD reflective questions