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August, September, October 2018
The Bulletin
ADVOCACY UPDATE
CEO NOTE
Connection of Advocacy and the Metaparadigm of Nursing
Leadership from a
Wheelchair
Audrey Hopper, RN
Director, ISNA and INF Board of Directors
I was recently surrounded
by some of my favorite
nerdy nurses and we were
discussing how to better
prepare nursing students
to
competently
practice
straight out of nursing school.
Nursing is more than just
skilled tasks like placing IV’s
or Foley catheters. When the
tasks are taken away, what
is it that nurses actually do?
During our brainstorming session we came up with
some action words like observe, assess, communicate,
coordinate, care, activate, empower, partner, create
and act on solutions, teach, and advocate. This nonexhaustive list is at the heart of who we are as nurses.
Turning this list into something we teach to students
I will leave in the capable hands of my nursing
education colleagues, but it did start me thinking
about what our ethical duty is to our nursing practice
and the connection of advocacy.
Our
nursing
predecessors
considered
the
global concept of what is nursing and created a
metaparadigm (theoretical framework) consisting of
four concepts that identify the general foundation
of nursing practice: nursing, person, health, and
environment. The role of nursing and the definitions of
person, health, and environment can take on different
interpretations but for clarity the general definition of
these concepts within the metaparadigm are: nursingthe actions or interventions related to the art and
science of nursing; person- the recipient of nursing
care ranging from patient, family, and community;
health- relative to the person, wellness/illness
continuum encompassing aspects such as physical,
psychological, mental, emotional, and spiritual being;
and environment- internal and external factors that
impact health (geographic location, education, social
status, financial resources, insurance, access to
healthcare, language, culture, genetics, coping skills,
family dynamics, etc.). These four concepts have been
the focus for nursing since Florence Nightingale’s
theory of nurse manipulation of the environment to
enhance patient health. ANA has declared 2018
the Year of Advocacy and there are many exciting
ways to explore how advocacy applies to the nursing
metaparadigm.
The Merriam-Webster definition of advocacy is
the act or process of supporting a cause or proposal
and an advocate is a person who pleads, defends, or
supports. The importance of nurses as an advocate
is woven throughout the ANA definition of nursing
as “the protection, promotion, and optimization
of health and abilities, prevention of illness and
injury, alleviation of suffering through the diagnosis
and treatment of human response, and advocacy
in the care of individuals, families, communities,
and populations” and written in Provision 3 of the
Code of Ethics “The nurse promotes, advocates for,
and strives to protect the health, safety, and rights
of the patient.” The nursing metaparadigm (nurse,
person, health, environment) is woven throughout the
foundation of nursing and calls for advocacy. Nurses
support patients by using the process of advocacy to
support healthy environments. Examples of nurse
advocacy at the bedside include: facilitating patient
and family focused communication between healthcare
team members; nurse led, patient-focused practices
change and process improvements; nurse governance
of workplace safety policies; and patient/family
focused nurse representation on unit or health system
wide committees. Baccalaureate-prepared nurses
are educated to be an advocate and speak up at the
bedside to preserve human dignity, patient equality,
and freedom from suffering.
Advocacy beyond the bedside is applying nursing
practice to protect, enhance, and preserve the health
of communities and populations. This requires the
application of our unique nursing skills in an atypical
environment. When I first started interacting as a
nurse advocate outside of my workplace I felt like
a ‘fish out of water.’ I had to learn how to navigate a
new environment full of its own rules and regulations
including a new language, key stakeholders, and
values. But this is what nurses are good at! We know
how to assess new situations with multiple factors,
prioritize needs, retrieve resources to interpret and
support our assessments, and clearly communicate
and implement holistic solutions through coordination
and interpersonal relationships. Do not get distracted
by the politics, focus on the policies that impact health
and environment because those are universal and
bipartisan. Leverage the resources available through
trustworthy advocacy groups, nonprofit organizations,
government administrations, professional and patient
organizations, and local coalitions. Advocacy beyond
the bedside can be slow and confusing. Working
with established groups that share similar values and
concerns makes the work fun and inspiring. And when
you get tired or frustrated advocating at the bedside
or beyond always remember your why. Why did you
become a nurse, why does this specific population
or issue matter to you, what kind of impact can you
make, and if you do not speak up who will?
This last month has been
challenging. A month ago,
I fell and broke my ankle.
After surgery and rehab, I
have been left to my own
devices to navigate life.
Well I’m here to tell you, life
is very different. No driving,
this is the first time since
I was 16 that it was illegal
for me to drive. Family
has been wonderful and
has taken me everywhere.
Everywhere, I wasn’t flying that is. My son drove
me to Indianapolis for the quarterly meeting of the
ISNA board, and INF board. Marla Holbrook, ISNA’s
Office Manager arranged an alternate meeting site
so that I didn’t have to figure out all the steps at
ISNA.
Last week I flew to Washington DC for ANA’s
Membership Assembly, wheel chair and all. Our
Representatives were our President, Jeni Embree,
and past President, Diana Sullivan and Sandy
Flights. New ANA candidates were elected headed
by President-elect Ernest Grant from North
Carolina. Ernie will be the first male president of
ANA. A true milestone for ANA. On another note,
Jimmy Kimmel received the Presidential Award
for speaking out multiple times on Health Care
Insurance issues.
Policy work was completed by the Membership
Assembly on opioids, presidential endorsement, and
assistive suicide. You can find the plans on www.
nursingworld.org. ISNA Representatives worked
hard for ISNA. I had rented a scooter and I was a
very dangerous driver. By the time we were leaving,
I might have been able to pass a driver’s test. I can
not thank our three Reps enough for assisting me
and especially, Diana Sullivan, who shared a room
with me and helped me immensely.
I would also like to thank the Parkview nurses
who took care of me at regional and on the Rehab
unit. The care was great! Handicapped functioning
is very difficult. Thinking about what individuals
do who are in a wheelchair for very long periods
of time do with our world that is predominately
not handicapped accessible, blows the mind. My
hat goes off to them all. I hope to be a boot with
partial weight barring in a week. PLEASE, PLEASE,
PLEASE.
“Many hands make light work” – John Heywood
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articles for individual use.
A Middle-Range Theory of Acute Pain
Management: Use in Research
Marion Good, PhD, RN
A middle-range theory of acute pain management has
been developed from clinical guidelines published by the
Agency for Health Care Policy and Research for use in
clinical research. From this theory, testable hypotheses
regarding pain management can be deduced, and new
findings can be used to support and extend the theory.
pain
is not only an intense discomfort but can also delay healing
and recovery. Severe and prolonged
pain has been shown to adversely affect immunocompetence and stimulate
sympathoadrenal stress responses, which
can result in infection, urinary retention, muscle tension, and sensitivity of
nociceptors. 14 In recognition of these deleterious effects, the Agency for Health
Care Policy and Research (AHCPR) published guidelines for the management of
acute postoperative pain in 1992. 5 The
goals of the pain management guidelines
are to reduce pain, complications, and
length of hospital stay; to educate patients in communicating unrelieved pain;
and to enhance patient satisfaction with
pain management practices. Recommendations for physicians and nurses include
use of medication, nonpharmacologic adjuvants, patient education, and attentive
care. 5
Moore and 16 have described a theory
that is based on the acute pain guidelines
and have presented initial empiric support, theoretic definitions, and measures.
This article is based on a study funded by the
Mellon Foundation and on a study funded by grant
No. 1 R01 NR 3933-01 awarded to Marion Good,
PhD, RN, by the National Institute of Nursing Research.
Nurs Outlook 1998;46:120-4.
Copyright © 1998 by Mosby, Inc.
0029-6554/98/$5.00 + 0 3511188146
120
Good
To encourage further research to support
this theory, this article summarizes the
new theory, grounds it in practice, deduces hypotheses for research, and reports new findings to support the theory.
The acute pain management guidelines
are based on research, but their authors
recommend that they be tested to further
validate them for clinical practice? However, the guidelines are not in testable
form. They can be tested only when formalized as a middle-range theory, with concepts and propositions at an intermediate
level of abstraction. 7,s This nursing theory
of acute pain management provides a
conceptual structure composed of prescriptions for nursing activity and goals to
develop practice knowledge for reducing
pain after surgery or trauma. 6 Its ultimate
goal is to ensure that patients have less
intense pain after undergoing an operation, with minimal side effects of medication. The theory has been used to teach
pain management to nurses in succinct
principles that can be easily learned; it is
useful for nursing research because it provides a framework for hypothesizing the
most effective combination of treatments
for acute pain management.
The pain theorywas developed from
the guidelines because these guidelines
constitute the current standard of practice. Although it is intended for nursing
practice and research, it could also be
used by physicians and patients. The
theory, which synthesizes established findings and recommendations and presents
them concisely, may be summarized as
follows:
To achieve a balance between analgesia
and side effects in adults with moderate
to severe acute pain, the nurse should
administer potent pain medication plus
pharmacologic and nonpharmacologic
adjuvants. The nurse should assess pain
and side effects regularly, and teach patients to participate. If unacceptable relief or side effects are experienced, the
nurse should intervene, reassess, and
reintervene if necessary to meet the relief
goal set with patient.
S U M M A R Y OF THE T H E O R Y OF
BALANCE BETWEEN A N A L G E S I A
A N D SIDE EFFECTS
The middle-range theory of balance between analgesia and side effects comprises
eight intervention concepts in three
propositions that predict the outcome
concept of balance (Figure 1). To summarize, the propositions predict that (1)
multimodal intervention, (2) attentive
pain management, and (3) patient participation contribute to the balance between analgesia and side effects. This
balance is important because when opioids are used, the risk of side effects such
as nausea, itching, and drowsiness also
increases and should be countered. Reduction of severe pain and control of
medication side effects are important for
ethical, humanitarian, and economic reasons.
The structure of the theory of balance
between analgesia and side effects is
shown in Figure 1, with concepts, relationships, and propositions. 6 The propositions are as follows:
1. Multimodal intervention–Giving
potent pain medication along
with pharmacologic and nonphar-
VOLUME 46 • NUMBER 3
NURSING OUTLOOK
Attached is a draft paper for you TO proofread, correct, add, or delete language as you see fit. The paper cannot exceed 4-5
pages (excluding the title and reference page) so do not add additional pages. Please make sure I did it correctly in APA
style.
I have provided the sources for you to confirm if they are cited correctly in the paper and also for you to add from the
sources for the paper to sound better.
a. HERE ARE THE INSTRUCTIONS: (Topic is: (Middle Range Theory: A Middle Range Theory of Acute Pain Management)
Please also format it to APA style for me if I did not do it correctly.
Theories are patterns that guide the thinking about, being, and doing of nursing. Theories provide structure to nursing practice and research. Theories
guide nursing practice, stimulate creative thinking, facilitate communication, and at the same time clarify purposes. A metaparadigm is a global concept of
a disciple that identifies the primary phenomena of interest to that discipline. In nursing, the dominate phenomena within the science of nursing revolves
around the concepts of humans, health, environment and nursing.
Using the theory develop a scholarly paper that includes the following criteria:
1. Define the middle range theory and the purpose of the selected middle range theory.
2. Define and discuss the nursing metaparadigm within the context of the selected middle range theory.
a. Explain how the theorist employs and defines each of the four concepts that comprise the nursing metaparadigm within the selected middle
range theory
3. Explain the importance of the selected middle range theory in nursing practice.
a. provide and discuss two examples of use of the selected middle-range theory from current practice
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
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,
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,
adisubrata@ummgl.ac.id
Rutja Phuphaibul, Professor of Nursing, Ramathibodi School
of Nursing, Faculty of Medicine, Ramathibodi Hospital, Mahidol
University, Thailand
Accepted for publication: October 2018
S38
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
British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT
© 2019 MA Healthcare Ltd
A nursing metaparadigm perspective
of diabetic foot ulcer care
■■ Simultaneous action worldview
■■ Engagement on wound care
training
■■ Recipients of nursing care
■■ Caring process (continuity of care,
■■ Belief
disease experience, and disease
management)
■■ Nursing process (assessment,
labelling, planning, intervention,
and evaluation)
■■ Carative factors
■■ Diabetic foot ulcer health promotion
■■ Multidisciplinary approaches
■■ Physiological and psychological
aspects
■■ Partnership with society
■■ Self- and family management
Human being
Environment
Nursing
metaparadigm
perspectives
of diabetic foot
ulcer care
Nursing
Health
■■ Gene/environmental interaction
■■ Person’s wellbeing
■■ Lifestyle
■■ Access to healthcare services
■■ Context of daily practice
■■ Foot care behaviour
■■ Ethical perspective
■■ Multidimensional approach
■■ Life principle
■■ Quality of life
■■ Ideologies influencing the
■■ Five dimensions of health (effects,
patient’s life
■■ Five system variables
(physiological, psychological,
sociocultural, developmental, and
spiritual)
■■ Optimal healing environment
attitudes, activities, aspirations,
and accomplishments)
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).
S40
Human being
Fawcett defined a human being as an open system that
is unique, dynamic and multidimensional with selfresponsibility. As the theory was developed, Fawcett
specified that the ‘human being’ may have a ‘reciprocal
interaction world view’ or a ‘simultaneous action world
view’ (Fawcett, 2006).
A ‘reciprocal interaction world view’ signifies that the
human being consists of bio-psycho-social elements (Lai and
Hsieh, 2003). Studies have found that individuals with DFUs
frequently display several psychological and social issues,
including increased tensions between patients and their
caregivers (spouses or partners), a reduction in the pursuance
of social activities, limited employment, and financial
difficulty (Goodridge et al, 2005; Fejfarová et al, 2014).
A prolonged time living with a DFU may lead to
depression. Occurrence is three times higher in type 1
diabetes patients and two times higher in type 2 diabetes
patients than in those without diabetes (Roy and Lloyd, 2012;
Winkley et al, 2012). Nurses must support individuals’ mental
as well as physical health needs. Thus, a comprehensive mental
assessment may provide important information to improve
the care and delivery of nursing services (de Jesus Pereira et
al, 2014). The nurse’s role is also one of educator—imparting
knowledge in order to enhance the individual’s ability to deal
with mental health problems. Some patients with depression
may need to be referred to a mental health nurse, who can
support them throughout the assessment, diagnosis and
management phases (Maydick and Acee, 2016).To be effective,
an interprofessional approach incorporating the individual
with DFU, their family or caregiver, and their significant
others, should be used during interventions.
A ‘simultaneous action world view’ refers to human
British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT
© 2019 MA Healthcare Ltd
■■ Reciprocal interaction worldview
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.
A circumstance where the nursing
care is continuously being given
and with which a patient interacts
Human being
Environment
Nursing
metaparadigm
Health
Nursing
A person’s wellbeing ranges
from a high level of wellness to
terminal illness as experienced by
the clients
Actions given in tandem by nurses
as follows: assessment, labelling,
planning, intervention, and
evaluation
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 selfcare 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
S42
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
British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT
© 2019 MA Healthcare Ltd
An open system that is unique,
dynamic, multidimensional, and
has self-responsibility
DIABETIC FOOT
self-care behaviours of individuals living with a DFU (Farsi
et al, 2
