Prioritizing the Prevention of Diabetic Foot Disease: We Each Have a Role to Play.

BACKGROUND: Individuals living with diabetes mellitus (DM) are at an increased risk for multiple serious health complications including diabetic foot disease (DFD). Daily, DFD contributes to increased morbidity, mortality, increased hospitalization, limb amputation, and reduced quality of life. Prevention of DFD is a foundational component of diabetes management. PURPOSE: The purpose of this study was to explore how individuals manage the care required to protect their feet from DM related foot complications. METHODS: This qualitative descriptive study utilized semi structured interviews to explore the perspectives of 23 participants on preventing foot care complications associated with DM. All data were analyzed using reflexive thematic analysis. RESULTS: Participants were challenged to consistently make health choices that were congruent with recommended DM self-management for the prevention of DFD. In addition, participants intuited multiple mixed messages from healthcare providers and workplaces that appeared to diminish their individual responsibility to self-manage their DM. Findings were organized under two main themes: a) Ineffective coping: Distancing self from disease b) Vacillating responsibility: Multiple mixed messages. CONCLUSIONS: Nurses are in a unique position to provide the education and support needed to assist individuals in carrying out the many recommended self-care strategies to reduce the risk of DFD. Contextually, nurses must encourage consistent messaging among health care providers and workplaces to prioritize the health needs of individuals living with diabetes and to support the challenging work these individuals must navigate every day. It will take a concerted effort to reinforce the message that diabetes care is a priority for everyone.

A Call to Journal: Grief Work and Poetry-A Reflection.

In this poetic work, journaling is shared as a means to navigate grief. The call is to spiritual leaders to encourage those grieving to be creative in their journey. This is a tool to support understanding the experience of grief as a healthcare provider.

"My Cancer Is Worth Only Fifteen Weeks"? A Critical Analysis of the Lived Experiences of Financial Toxicity and Cancer in Canada.

BACKGROUND: Cancer patients experience financial hardship due to rising expenses related to cancer treatment and declining income levels associated with reduced employability. Employment Insurance Sick Benefits (EI-SB) is a social income support program which provides temporary income replacement to Canadians when they fall ill. Although EI-SB is designed to maintain continuity of income during an illness, little is known about the perspectives of cancer patients who receive EI-SB. This knowledge can inform the development of public policies which are responsive to the needs and priorities of cancer patients. METHODS: We conducted a theory-informed thematic analysis of data collected from twenty semi-structured interviews with participants who were receiving care in a cancer centre in Cape Breton, Nova Scotia and had received EI-SB. A coding framework was developed using Taplin and colleagues' intermediate outcomes of patient care across the cancer care continuum. Interpretation of findings was guided by the synergies of oppression theoretical lens. RESULTS: Three overarching themes describe the experiences of cancer patients receiving social income support: Economic exclusion, in which the structure of the labour market and social welfare system determine access to workplace benefits and continuity of reasonable income; financial toxicity, a vicious cycle of financial burden and increasing financial distress; and constrained choices, where cancer influences employability and lowered income influences the need to be employed. CONCLUSION: Cancer patients need income support programs that are tailored to match their healthcare priorities. In addition, policies which strengthen working conditions and facilitate a reintegration to work when possible will be important in addressing the structural drivers of income insecurity experienced by cancer patients.

Health professionals' perspectives on delivering patient-focused wound management: a qualitative study.

OBJECTIVE: This study examined the perspectives of health professionals on the barriers and solutions to delivery of patient-focused wound management and outcomes. METHODS: A qualitative, descriptive study design was used. Participants were health-care managers, clinical leaders, nurses and allied health members who are part of wound care services. Open-ended surveys were distributed to participants in a series of learning workshops, and data analysed to identify leading themes. RESULTS: A total of 261 participants took part and 194 surveys were returned (response rate: 74%). From the analysis five themes emerged: patient/family wound-related education; health professional wound-related education; implementation of evidence-based wound care and dissemination of evidence-based wound information across professions and contexts; teamwork and respectful communication within teams; and a higher value and priority placed on wound care through collaborative teams by managers, leaders and policymakers. CONCLUSION: Findings suggest that ongoing, system-wide education is needed to improve prevention, assessment, treatment and management of four wound types: venous leg ulcer (VLU), diabetic foot ulcer (DFU), pressure ulcer (PU) and surgical wounds. Health professionals are committed to delivering best practice in wound care. Participants identified that effective patient-focused, evidence-based wound care involves having a health-care system with a clear mandate to ensure wound care is a priority. A high value placed on wound care by managers and clinical leadership could transform the present systems. Additionally, effective and widespread dissemination of evidenced-informed practice information is crucial to positive patient outcomes. Education and team commitment for consistent and respectful communication would improve care delivery.

Just leg pain? Think again: What health leaders must know about peripheral arterial disease.

Approximately 800,000 Canadians have Peripheral Arterial Disease (PAD). Peripheral arterial disease is also a leading cause of limb amputation. Yet public and clinical awareness of PAD is very limited. This article discusses the "Just Leg Pain? Think Again" awareness campaign the Canadian Association of Wound Care has launched in response. This article also summarizes PAD risk factors, screening, linkage with diabetes, treatment and care interventions, PAD care innovations, and the need for policy leadership on this issue.

Si vous pensez que c'est juste un mal de jambe détrompez-vous: ce que les leaders en santé doivent savoir sur la maladie artérielle périphérique.

Environ 800 000 Canadiens ont une maladie artérielle périphérique (MAP), une cause majeure d'amputation. Pourtant, le public et les cliniciens connaissent très peu cette maladie. Le présent article traite de la campagne de sensibilisation Si vous pensez que c'est juste un mal de jambe… détrompez-vous que l'Association canadienne du soin des plaies a lancée pour contrer cette tendance. Il porte également sur les facteurs de risque et le dépistage de la MAP, son lien avec le diabète, son traitement et ses soins, ses innovations en matière de soins de la MAP et la nécessité de faire preuve de leadership sur le plan des politiques.

The role of qualitative research in understanding diabetic foot ulcers and amputation.

PURPOSE: To enhance the learner's competence with knowledge about using qualitative methodologies to understand diabetic foot ulcers and amputations. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to:1. Analyze qualitative research methodologies.2. Summarize how conclusions from qualitative research relate to diabetes mellitus and its complications. Persons living with diabetes are at high risk for foot complications, lower extremity trauma, injury, ulceration, infection, and potential amputation. Qualitative health research helps to explore and understand more fully the complexities of diabetes. Qualitative health research seeks to understand what is happening and going on for the individual and his/her support persons. In addition, qualitative health research enables clinicians to appreciate how different qualitative research approaches can explore illness from the perspective of the individual living with the disease.

Factors associated with health-related quality of life in chronic leg ulceration.

BACKGROUND: Individuals with chronic leg ulceration may have significantly impaired health-related quality of life (HRQOL) due to pain, impaired mobility, poor sleep, depression, restricted work capacity, and social isolation. The study purpose was to examine the associations among sociodemographic and clinical factors and HRQOL in a large sample of community-dwelling adults being treated for leg ulcers. METHODS: Data are from the cross-sectional baseline assessment of the Canadian Bandaging Trial, a multi-center, randomized controlled trial conducted to assess time to healing with two forms of high-compression bandaging. All participants received a comprehensive, standardized clinical assessment, and completed the 12-item Short Form (SF-12) and McGill Pain Questionnaire. SF-12 data were compared to age- and sex-adjusted norms, and multivariable logistic regression was used to identify factors associated with whether individuals were below, or at/above their normative values on the physical and mental component summary (PCS, MCS). RESULTS: Of 424 individuals enrolled over a 50-month period, 407 (96 %) completed the SF-12. Mean age was 65 ± 17 years, and 55 % were women. Mean PCS was 39.1 ± 9.9 with 91 (22.4 %) scoring at/above the mean value for their age and sex; equivalent values for the MCS were 51.4 ± 9.9 and 209 (51.4 %). Higher levels of pain, younger age, larger size and longer duration of ulcer, and limited mobility were associated with poorer HRQOL. CONCLUSIONS: Findings confirm the considerable burden of illness associated with leg ulcers. Given the chronic and recurring nature of the condition, strategies focused on improving HRQOL and healing are needed for this vulnerable population.

Best practices for the management of foot ulcers in people with diabetes.

Care of people with diabetic foot ulcers requires a systematic approach following the wound bed preparation paradigm and the existing best practice recommendations. The purpose of this article is to summarize key evidence and recommendations regarding prevention and management of diabetic foot ulcers that can be translated into practice.

Leg ulcer nursing care in the community: a prospective cohort study of the symptom of pain.

BACKGROUND: Chronic wounds are managed almost entirely by community nurses. Almost all individuals with leg ulcers report acute pain usually related to dressing change. Little is known about pain after healing. The purpose of this study was to explore the course of pain from baseline to time of healing of leg ulcers (venous or mixed etiology). In order to understand this phenomenon and develop implications for nursing practice, objectives included: 1) Measure incidence and prevalence of pain at baseline and healing; 2) Describe characteristics associated with leg ulcer pain at baseline; 3) Identify predictors of leg ulcer pain at healing. METHODS: Data were from one randomized controlled trial (2004-2008) of 424 individuals with leg ulcers in the community receiving evidence-informed nursing management. The primary outcome was pain at the time of healing. Predictive factors included demographic, circumstance of living, clinical and ulcer characteristics. Multivariable logistic regression identified the subset of predictors of pain at healing. Odds ratios (OR) and 95% confidence intervals (CI) are reported. RESULTS: Eighty-two percent of participants reported pain at baseline and 32% at healing. Five percent with no pain at baseline reported pain at healing. Thirty-seven percent reported moderate to severe pain at baseline and 11% at healing. Twenty percent of all those who healed reported pain interfered with work moderately to extremely at time of healing. Being female (OR=1.64, 95% CI 1.00, 2.68, p=0.05), use of short-stretch vs. four-layer bandages (OR=1.73, 95% CI 1.06, 2.82, p=0.03), lower SF-12 PCS (OR=0.97, 95% CI 0.94, 0.99, p=0.02) and MCS (OR=0.98, 95% CI 0.95-1.00, p=0.04) scores, use of non-steroidal anti-inflammatory drugs (OR=2.28, 95% CI 1.06, 4.88, p=0.03), and tender pain (OR=2.17, 95% CI 1.29, 3.66, p=<0.01) were associated with pain at time of healing. CONCLUSIONS: Pain is an issue on admission for chronic wounds and at healing, yet 58% with moderate to severe pain on admission were not taking pain medication(s). Future studies should examine the role of pain at healing and at subsequent ulcer recurrence. Mobility and other factors that may contribute to pain at time of healing should also be assessed. Community nurses are encouraged to consider pain when planning care on admission and also after wound healing, when most patients are discharged from care. TRIAL REGISTRATION: ClinicalTrials.gov, NCT00202267.

Evaluation of a peer-led self-management education programme PEP Talk: Diabetes, Healthy Feet and You.

PEP (Peer Education Programme) Talk: Diabetes, Healthy Feet and You is a peer-led self-management programme developed to address the problems of growing prevalence of diabetes and its complications, and limited health care dollars. An evaluation of the programme, how it might be situated within a public health perspective and potential bridges for its implementation in communities throughout Canada and worldwide, are presented. The programme consisted of workshops that were conducted by volunteer peer leaders and health care professionals in 12 communities in 10 Canadian provinces; the volunteers were supported through monthly mentoring teleconferences, on-line tips and discussion board conversations. A web portal was developed to be used by the team, volunteers and community participants. Workshop curriculum was developed based on diabetes footcare and self-management best practise guidelines. Community participants answered pre-and post-workshop statements that indicated that learning occurred, as indicated by an increase in the number of statements answered correctly. Participants' feedback about the workshops was positive. In telephone follow-up interviews, 97% of respondents reported having changed their foot self-management behaviours. The portal was commonly used according to website visits, but not as much as expected for registration of community participants. It is recommended that this programme be made widely available and tailored to the specific needs of the communities and that further evaluation be conducted.

Role of a point-of-care protease activity diagnostic test in Canadian clinical practice: a Canadian expert consensus ©.

Nonhealing wounds (stalled, healable) challenge affected individuals, wound clinicians, and society. Nonhealing may result despite local factors being corrected. The interplay between tissue degradation, increased inflammatory response, and abundant protease activity is a challenging quandary. A modified Delphi process was utilized to investigate a protease activity test and practice implications.