Abstract
Background
Diabetes and associated diabetic foot ulcers require coordinated management, including several health care professional (HCPs). Therefore, an interprofessional (IP) team-based approach is essential for effectively managing and educating the population on diabetic foot self-management strategies. However, the perceptions of the HCPs related to the importance of IP teamwork in diabetic foot care and their readiness to work in an IP team are less explored.
Methods
This qualitative study aimed to investigate the HCPs' perception on the importance of IP collaboration in diabetic foot care and their readiness to work as part of an IP team in teaching patients’ effective diabetic foot self-management techniques. The study includes seven HCPs involved in diabetic foot management patient education and treatment. In-depth interviews using an interview guide and a thematic analysis of the interview transcripts were undertaken.
Results
Every participant was strongly motivated to be an IP team member. The following themes were identified that supported IP team-based approach in diabetic foot care: ‘patient-centric practices,’ ‘comprehensive care,’ ‘teamwork and coordination for improved patient outcome,’ ‘integrated approach,’ ‘professional knowledge amalgamation,’ ‘time-management,’ ‘education in a favorable environment,’ ‘constant motivation and support through educational modules,’ and ‘commitment and policy reforms.’
Conclusions
The HCPs' were aware about the benefits of IP team-based approach in diabetic foot care. They further expressed their willingness to work as part of an IP team and suggested appropriate teaching methods for diabetic foot self-management. This manuscript thus attempts to create an awareness about the importance of IP approach in teaching the proper practices of diabetic foot care. The problems faced in implementing an IP approach in diabetic foot care and the possible solutions are also discussed.
Keywords: Diabetes mellitus, Diabetic foot, Foot ulcer, Healthcare team, Interprofessional education, Patient care
Introduction
Diabetes-related foot ulcers are long-term consequences.1,2 Approximately 15% of diabetic foot ulcers (DFUs) deteriorate and lead to lower limb amputations, posing a global clinical dilemma and a societal cost burden.3 It has a substantial negative influence on patients, affects the quality of life in terms of psychological and physical performance compared to the general population, and incurs enormous expenses for health services.
In patients with diabetes, lack of information about foot self-care is the leading cause of DFU. Poor foot care habits and a lack of understanding have been identified as significant risk factors for diabetic foot issues.7 There is a need to explain these factors to the patients. An educational intervention on diabetic foot self-management may effectively resolve the problem.8
Because of the disease's complexity, achieving targeted goals, such as diabetic foot treatment, necessitates a collaborative approach, including many health care professionals (HCPs). As a result, an interprofessional (IP) team-based strategy may solve this issue.
An IP team is a group of individuals from different health care disciplines that function in a collaborative and integrated manner. Previous research has linked IP care teams to better DFU diagnosis and management than conventional community care services. IP teamwork is considered the optimal approach for the care of complex chronic wounds, including DFUs, and has shown a decrease in the occurrence of accompanying complications such as amputations.4 IP teams improve patient care, save expenses, shorten patients' lengths of stay, and minimize medical mistakes.5
In addition to patient care, an IP team-based approach involves team discussions on group processes. The growth of a team is promoted here, and leadership is shared. A collaborative assessment and treatment plan are scheduled in an IP team-based approach.6
A team-based IP collaborative approach is already in practice for diabetic foot care in countries abroad and has reaped greater benefits.4 However, its usefulness and the readiness of the HCPs to work as an IP team, problems of implementation in an Indian setting is less explored.
The aim was to investigate HCPs' readiness to work as part of a well-motivated IP team and its use in teaching effective diabetic foot self-management techniques to individuals with diabetes. The study also intends to collect input from members of the IP team and use it in designing and developing an educational module to improve the knowledge and practice of diabetic foot care.
Material and methods
This phenomenological type of qualitative study included HCPs responsible for patient education and treatment related to diabetic foot management. In our subsequent studies, these HCPs would serve as members of the IP team, teaching good practices of diabetic foot self-management to patients with diabetes.
The research team engaged the study participants through semi-structured interviews conducted in June–August 2021. The Institutional ethics committee approved the conduct of the study (IEC No 698-2020). The study participants were interviewed before the formation of the IP team. Written informed consent was obtained from them. All guidelines as per the Declaration of Helsinki and good clinical practice guidelines were followed.
The HCPs were chosen for their competence and experience in diabetic foot care and willingness to be a part of the IP team. The authors adopted a purposive sampling method.9
We identified seven HCPs, one each from the following streams: Medicine, Endocrinology, Surgery, Physiotherapy, Diet and Nutrition, Nursing, and an Anatomist experienced in health professions education. All the HCPs excluding the anatomist were actively involved in diabetic foot care.
The next step was to gather the HCP's feedback on developing an IP team to educate diabetic foot self-management best practices to patients with diabetes. The roles and responsibilities of every member in the IP team was to be clarified. It was also necessary to establish the level of motivation of the HCPs to collaborate in an IP team for diabetic foot care. Fig. 1 depicts a schematic representation of the IP team formed by the HCPs.
Fig. 1.
Schematic representation of the IP team formation. IP, interprofessional.
Participants' perspectives were obtained through one-on-one interviews in their natural settings considering the participants' schedules and prior commitments.
The principal investigator performed the semi-structured interviews using an interview guide created by the study team (Appendix A. Supplementary data Annexure 1). Each interview lasted for 45–60 min and was audio recorded.
The interview recordings were transcribed to text, and the final transcripts were verified for clarity and correctness by the members of the study team. Participants in the research were categorized as participants 1, 2, 3, and so on to guarantee anonymity and de-identification. The transcripts were then imported for processing using MAXQDA Analytics Pro 2020 (VERBI GmbH, Berlin, Germany).
Thematic analysis was performed on the participant replies. The authors coded the material after reading and rereading the content. The codes were then examined to find the pattern, and the themes were identified. To identify the domains, an inductive and semantic technique was used.10
Fig. 2 depicts the methodology summarized in a flow chart.
Fig. 2.
Methodology summarized as a flow chart.
Results
The study included in-depth interviews from seven HCPs. The participants' average age was 44 years (range: 35–60). Professional experience in diabetes care (excluding the anatomist) varied from 10 to 35 years, with a mean value of 19 years.
The participants collectively agreed that diabetic foot self-management is essential and should be carefully followed by all individuals with diabetes. They also expressed their willingness to work alongside other professions in managing and teaching the proper practices of diabetic foot care. Fig. 3 depicts a word cloud built from the response driven themes by the HCPs.
Fig. 3.
Word cloud built from the response driven themes by the HCPs. HCP, health care professional
We identified the following five domains that defined the features identified by participants and emphasized the relevance of the IP approach in diabetic foot care treatment.
-
1.
IP team-based approach to diabetic foot management
-
2.
IP versus multidisciplinary approach in diabetic foot care
-
3.
Interprofessional education (IPE) in improving the knowledge and practices of diabetic foot self-management
-
4.
IP teamwork and communication in imparting diabetic foot care education
-
5.
IP educational module for diabetic foot care
-
6.
Challenges faced in implementing an IP approach to diabetic foot management and possible solutions
Domain 1: IP team-based approach in diabetic foot management
All research participants voted that an IP team-based approach to diabetic foot treatment was the best. The following snippets were derived: IPE and Interprofessional practice (IPP) become highly relevant because ‘patient-centric practice’ is regarded as an essential criterion in healthcare administration. Furthermore, as noted by the participants, a “comprehensive approach to patient treatment” is always preferred. The key elements identified for effective patient outcomes were ‘teamwork’ and ‘coordination.’
Themes identified: ‘Patient-centric practice,’ ‘Comprehensive care,’ ‘Teamwork and coordination for better patient outcome.’
“ An interprofessional team-based approach is extremely important I think, because the disease itself is… ‘uh’… not confined to one particular specialty, it is a disease which involves ‘mmmmm’ … expertise from various subspecialties like a physician, an endocrinologist, a cardiologist, an orthopedician, a surgeon, a plastic surgeon, a vascular surgeon, you name the specialty and that specialty will be involved in its treatment"(Participant 4).
Domain 2: IP versus multidisciplinary approach in diabetic foot care
All participants chose an IP strategy over a multidisciplinary approach with the following justifications: an ‘integrated IP approach’ is always preferable since it gives the patient all the required information and treatment in a holistic manner. Furthermore, an IP strategy would result in reinforcement, with each member of the IP team repeating the basic self-care requirements, making patients more careful about self-management of diabetic foot.
Themes identified: ‘Integrated approach,’ ‘Reinforcement,’ ‘Simplified approach,’ ‘Amalgamation of professional knowledge.'
“ So with respect to patient education, first and fore most if you look at the Indian scenario, patients do not give so much importance to the foot. So when they come under an umbrella, where several people are discussing and ‘uhh’ giving importance, they.. they understand how serious is the illness.”(Participant 3).
Domain 3: IPE in improving the knowledge and practices of diabetic foot self-management
The current study highlights that IPE is a comprehensive step toward raising awareness and teaching patients about correct foot care methods. Participants in the survey also indicated that it provides greater outreach and teaches necessary knowledge in a suitable environment. Providing education and information on the proper foot care practices to the patients in the comfort of their homes using the online platforms were also proposed.
Themes identified: ‘Comprehensive education and awareness,’ ‘Better outreach,’ ‘Education in a conducive environment.’
“ I would correlate with the current COVID scenario. It would be difficult for the person.. patient to travel from a far place and visit clinic regularly. So, in that aspect I think educating patient along with educating the family also would help them manage the diabetic foot care better” (Participant 7).
Domain 4: IP teamwork and communication in imparting diabetic foot care education
Effective IP teamwork and communication can considerably help a patient-centered approach to diabetic foot self-management. It also helps with collective feedback and good time management, as noted by the participants. According to this study, IP teamwork and communication provide an opportunity to ‘learn with, from and about others’ and would also result in ‘behavioral change communication.’
Themes identified: ‘Patient-centered,’ ‘Collective feedback and effective time management,’ ‘Learning with, from, and about each other,’ ‘Behavioral change communication.'
“I believe in that and in favour of patients, we all should work in a team, communicate and coordinate. It should not be that ‘uhh’… only my medication should work, or my physiotherapy should work or my diet plan should work! No!! It is that everything should work together. And it should! And it will!! Only if we work together, it will”.(Participant 6).
Domain 5: IP educational module for diabetic foot care
The participants were enthusiastic about developing an IP instructional program for diabetic foot care and made the following suggestions: customized to the patient's specific requirements. The module will aid in delivering regular reinforcement for learning and adhering to good foot care habits. It will enable time management and outline the roles and duties of the team's HCPs.
Themes identified: ‘Customized based on patient needs,’ ‘Constant motivation and reinforcement,’ ‘Efficient Time management,’ ‘Defined roles and responsibilities in a team.'
“We need to understand the need of our community. Any educational material if it is developed at the (recalls) institutional level, without taking the confidence of the stakeholder it is going to fail. Whereas when we develop this IP education material, first important stakeholder is the patient. Therefore, when we, develop interprofessional educational material, we need to give lot of importance to the need of our client or patient population. And once they understand and also ones, they know that these steps need to be clearly followed, the adherence to that module will be better from the patient’s point of view"(Participant 2).
Domain 6: Challenges faced in implementing an IP approach to diabetic foot management and possible solutions
The current practice of clinical care and restricted patient interactions were identified as the major challenges faced in implementing an IP approach to diabetic foot management. Further commitment among the HCPs and lack of proper policies promoting IPE and IPP were also identified as hindering factors. The current clinical care practices for diabetic foot care may be changed by setting up designated places for wherein all the HCPs can interact with the patients in one sitting. Educating the caregivers along with the patients on the proper practice of foot care was stated as beneficial. The need for commitment among the HCPs and reforms in the process of policy making were also proposed.
Themes identified: ‘Current clinical care practices and need for refinement,’ ‘Restricted patient interactions and need for reforms,’ ‘Commitment and policy reforms’.
“I think, in our busy practices, sometimes patient might not be, ummm the foot specifically, may not be addressed. Or the patient may be asked to move to different places to meet different specialists, which umm… they may not do. So … if you’re having a dedicated place where patient is specifically getting information on these that could be helpful” (Participant 3).
“There are few elements which are critical for the success of the interprofessional education. Those are something like a commitment. And the relationship between the different professions. And, uh, uh, which requires a uh, kind of faculty development program or the continuing education. And, uh, uh, yeah. And also a policy. I mean, formulation of the policy which are essential. So these are all the critical elements of interprofessional education. In the context of India, I mean, to take an example of the professional equality, in the Indian context, the health profession is dominated by the doctors. It is not the same in the Western countries or even in the eastern countries. This is considered to be one of the barriers. Likely the commitment is also a barrier and lacking with the proper policies, also a barrier. So I mean for that you know the education is the only way out and creating an awareness, sensitization, the continuing education, faculty development programs etc would be the key components for the success”(Participant 5).
Appendix A. Supplementary data (Annexure 2) shows the HCPs' domain-specific assessments on the relevance of the IP approach in the treatment of diabetic foot care. Further, the participant's suggestions toward improved practices and implementation of IP team-based approach in diabetic foot management is documented in Table 1.
Table 1.
Participant's suggestions toward improved practices and implementation of IP team-based approach in diabetic foot management.
| Domain | Suggestions |
|---|---|
| IP team-based approach in diabetic foot management |
|
| IP versus multidisciplinary approach in diabetic foot care |
|
| IPE in improving the knowledge and practices of diabetic foot self-management |
|
| IP teamwork and communication |
|
| IP educational module for diabetic foot care |
|
| Challenges faced in implementing an IP approach to diabetic foot management and possible solutions |
|
Discussion
Health care professionals (HCPs) willingness to be part of a well-motivated IP team teaching effective diabetic foot care practices is rarely investigated. Furthermore, the viewpoints of HCPs on the development of an IP training module to impart the appropriate techniques of diabetic foot self-management among patients with diabetes are understudied. The current study tried to investigate this.
Domain 1: IP team-based approach to diabetic foot management
The current study's findings indicate the usefulness of an IP team-based strategy in diabetic foot treatment. Every participant agreed on the benefits of IPE and IPP and expressed a desire to work as a team to improve diabetic foot treatment and care.
Previous studies thoroughly investigated the benefits of working in an IP team dedicated to diabetic foot care.4,11 IP care teams are related to improved diabetic foot diagnosis and wound healing results compared to standard community care services.4,11
A qualitative study of IP healthcare team members' perspectives on patient barriers to healthcare participation identified limited primary care availability, a lack of understanding of the value of primary care, a lack of trust in primary care providers, and the fear of receiving a wrong diagnosis as significant issues.12
Most of the concerns stated above may be readily handled if the HCPs work together as an IP team. An IP team of HCPs focusing on a specific condition, such as diabetic foot care, available under one roof reduces the difficulties of navigating the healthcare system. It will increase patient trust and alleviate problems such as a lack of understanding of the importance of healthcare practices, a lack of faith in primary care practitioners, and a fear of receiving a faulty diagnosis.13
A previous study on family physicians' perceptions of IP collaboration in diabetes care also stated improved patient care as one of the significant benefits of IP teamwork.14 The study found that IP teamwork is involved in the delegation to other disciplines for educating, planning, and monitoring the treatment regime for diabetes and thereby sharing the responsibility of patient care.14
According to prior research by Powell et al.,12 a shift from disease-centered to patient-centered treatment is crucial. The current study's findings support this assertion and add that patient-centered care is an essential criterion in today's clinical environment. A highly motivated IP team that regards patients as significant stakeholders will deliver excellent treatment and improve management.
Domain 2: IP team-based approach versus multidisciplinary approach in diabetic foot care
As revealed in the current study, an IP team-based approach to diabetic foot care would be an integrated approach and it differs from the multidisciplinary approach. Multidisciplinary care is hierarchical, with everyone working on the same problem within their respective silos. It is impossible to create a unified care plan since each team member uses their knowledge to define individual care goals.15 The same is true when educating people about diabetic foot care. During the production of instructional materials, the particular perspective of each field is articulated. Even though the combined resources are shared, the individuality of each discipline is maintained. In this case, each discipline's knowledge base is distinct and complementary to the others.
Members of a multidisciplinary team have minimal understanding of other disciplines, and communication between team members is limited. On the contrary, with an IP team-based approach, members comprehend each other's fields, collaborate, and engage in critical thinking and problem-solving that extends across academic boundaries.16 Here the HCPs provide their specialized expertise and perspectives on circumstances based on their education. In this case, no one occupation rules supreme over the others.15 The perceptions of HCPs, as observed in the current study, also supported the same. The amalgamation of professional knowledge will help in the improved transmission of information and the essential practice guidelines in diabetic foot care.
Domain 3: IPE in improving the knowledge and practices of diabetic foot self-management
Patients have complicated health demands that need more than one discipline to address.17 It has been shown that HCPs that work in IP teams communicate and solve these complicated and challenging requirements the best.6,17 An IP strategy may allow the exchange of skills and viewpoints to achieve the shared aim of restoring or preserving an individual's health and enhancing results while merging resources.17,18
It has been discovered that IPE can increase healthcare quality by improving healthcare teams' knowledge and collaborative performance.19 Furthermore, health-related messages may be communicated more consistently to the affected community and increase worker self-confidence.19
According to the findings of this study, an IPE is a comprehensive education. It can potentially raise effective awareness that may be used as a preventive method in diabetic foot self-management among people with diabetes. According to the study participants, an IP strategy provides better outreach and allows instruction in a conducive atmosphere. Constant reinforcement and knowledge sharing via online platforms to the patients and care givers were stated to be effective.
Domain 4: IP teamwork and communication in imparting diabetic foot care education
An IP intervention is an inexpensive and time-saving technique to promote collaboration at an advanced wound care clinic.11 The current study's findings corroborate this, and it adds that collaboration and coordination will help to improve patient outcomes.
Individuals with diabetes should be taught correct foot care techniques by IP team members who understand their roles and duties and demonstrate collaboration and strong communication skills. According to the current study's findings, good IP teamwork and communication would be able to give collective feedback and enable effective time management. It is possible by establishing awareness campaigns, faculty development programs, and focus group sessions on the benefits of IPE and IPP for various HCPs working in an IP team.20, 21, 22 ‘Learning with, from, and about each other’ in IP training can encourage IP learning by providing appropriate profession-specific IP activities and settings in which HCPs can build collaborative and patient-centered care skills.23 As a consequence of these sessions, a ‘behavior change communication’ can eventually lead to improved results, i.e., a ‘patient-centered approach,’ as identified in the current study.
Domain 5: IP educational module for diabetic foot care
In diabetes education, health professional educators are urged to use practical IP techniques.24 One such potential is the creation of an IP instructional module.
Previous research has demonstrated that foot care education programs enhance foot care knowledge and habits among people with diabetes.25,26 However, these approaches may be one time, and the effectiveness may be short-lived. The improvement in knowledge and practice on the development of DFUs may be difficult to assess. The development and implementation of an IP educational module may be more effective as proposed by the present study. In the past, an IP education strategy for general diabetes care resulted in considerable improvements in the patient's health.27 It strengthens our initiative to create an IP educational module on diabetic foot care.
An IP educational module may be customized for the patients. When numerous HCPs are participating, the IP module may also act as a continual source of motivation and reinforcement. Furthermore, as revealed by the current study, the construction of an IP collaborative educational module may help in effective time management.
Domain 6: Challenges faced in implementing an IP approach to diabetic foot management and possible solutions
Poor access to primary medical care facilities, patient beliefs and lack of adherence to medical advice, delays in DFU recognition, limited healthcare resources and practice heterogeneity among specialists have been previously identified as the major challenges faced in implementing an IP approach to diabetic foot management.28 Our findings are concurrent with the above observations and has identified the current practices of clinical care and restricted patient interactions as the major hindering factors. Increased patient load at the tertiary care centers also adds to it.
Implementation of sustainable training programmes for HCPs focusing on diabetic foot management; educational programs that include constant dissemination of information to all HCPs, patients and caregivers; sustenance of working environments that inculcate commitment among the HCPs were proposed as the possible solutions to curb the challenges faced in implementing an IP approach.29 Bringing reforms in the process of policy making and organizing frequent continuing education and faculty development programs on the importance of IPE and IPP in healthcare can also help to manage the challenges.
Conclusions
The current study highlights the HCPs' readiness to work as part of a well-motivated IP team for diabetic foot management. It emphasizes the significance of IPE in strengthening the capacity of HCPs from many disciplines to collaborate effectively, hence improving the quality of patient care. It also exhibits the ideas provided by HCPs in the development of an IP training module for teaching diabetic foot care strategies to patients with diabetes. The problems faced in implementing an IP approach in diabetic foot care and the possible solutions are also discussed.
Patients/ Guardians/ Participants consent
Participants informed consent was obtained.
Ethical clearance
Institute/hospital ethical clearance certificate was obtained.
Source of support
Nil.
Disclosure of competing interest
The authors have none to declare.
Acknowledgments
Healthcare professionals who took time out of their busy routine and willingly consented to participate in the study.
Dr. Jasvinder Kaur Bhatia, Prof & Head of Pathology, Command Hospital Eastern Command, Kolkata, and Dr. Anuja Bhargava, Assistant Registrar-Academics, Era University, Professor & Head of ENT and Head & Neck Surgery, ELMC, Lucknow for validating the interview guide.
For their extended support and encouragement, Dr. Ciraj Ali Mohammed, Director, MAHE FAIMER, and all the faculty and fellows of MAHE FAIMER Institute for Leadership in Interprofessional Education, Manipal Academy of Higher Education.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.mjafi.2023.01.003.
Appendix A. Supplementary data
The following are the Supplementary data to this article.
Interviewer guide
Domain-specific assessments on the relevance of the Inter-professional approach in the treatment of diabetic foot care
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Interviewer guide
Domain-specific assessments on the relevance of the Inter-professional approach in the treatment of diabetic foot care