Annals of Long-Term Care: Clinical Care and Aging. 2014;22(7/8):23-28.
Affiliations: 1Geriatric Education Center, College of Osteopathic Medicine, Nova Southeastern University, Fort-Lauderdale-Davie, FL; 2Department of Geriatrics, College of Osteopathic Medicine, Nova Southeastern University, Fort-Lauderdale-Davie, FL; 3Masters of Public Health Program, College of Osteopathic Medicine, Nova Southeastern University, Fort-Lauderdale-Davie, FL
Abstract: As the prevalence of diabetes continues to rise, it is imperative to provide healthcare professionals with the training they need to manage the disease and to prevent complications. However, preventive care of foot problems can be particularly challenging in the long-term care (LTC) population. In this article, the authors describe a study that evaluated the efficacy of an evidence-based program for training nurses in LTC facilities that had two objectives: (1) to increase the knowledge and skills of nurses about foot care in residents with diabetes to prevent and manage diabetic foot lesions; and (2) to encourage nurses to incorporate regular foot examinations in clinical practice. The results of the study show that implementation of the training program can heighten awareness of the barriers involved when executing quality improvement initiatives in LTC environments.
Key words: Diabetes, diabetic foot problems, foot ulcers, long-term care, nurse training, patient education, preventive care.
The prevalence of type 2 diabetes mellitus is increasing, and it appears to affect a disproportionate number of older adults. In fact, 26.9% of persons aged 65 years and older living in the United States had diabetes in 2010 as compared with 11.3% of persons aged 20 years and older.1 It stands to reason that as the prevalence of diabetes continues to increase, there is significant risk that diabetic complications, including foot problems, will also increase.2 The most common cause of hospitalizations among persons with diabetes is diabetic foot problems, including ulcerations, infections, and gangrene.3 The risk of such complications increases in the geriatric population, as older adults with diabetes are more likely to have multiple chronic diseases and comorbidities.4
The cost and burden of care for diabetic foot problems is substantial.5 In 2012, nearly $245 billion was spent annually in direct and indirect medical costs related to diabetes care.6 An in-depth review and analysis of several studies across the world noted that the financial consequences of managing diabetic foot problems are huge, even when the costs of educational programs are not included in financial analyses.7 The burden of care is higher among institutionalized older adults, as these individuals are often managing a wide range of physical and cognitive disorders.8 The contributory factors for diabetic foot ulcers among older adults include peripheral arterial disease, sensory neuropathy, and joint malformations.4,9 As such, preventive care of foot problems in older adults can be challenging, particularly considering the range of multiple diseases, numerous medications, and sometimes limited caregiver support in the long-term care (LTC) population.
As diabetes and its complications become more prevalent, it is imperative to provide education, training, and practice support to healthcare professionals working in LTC settings, as untreated foot problems can trigger depression, limit independence, and reduce quality of life for older adults.10 Management and preventive care of diabetic-related foot complications are also essential to reduce the risk of lower-extremity amputations, an increasing problem among individuals with diabetes.11 Proponents of diabetic foot management suggest a nationwide educational campaign to encourage healthcare professionals to conduct routine foot examinations for persons with diabetes and periodic follow-ups for individuals at risk of developing foot complications.7,12 Patient and provider education in diabetes foot management can help support the early diagnosis and treatment of potential foot complications, thereby reducing the risk of lower-extremity amputations. Few studies, however, document the contribution of training and education in the area of foot care management for LTC residents with diabetes.
To overcome the knowledge gap faced by healthcare professionals in the area of diabetes foot care, we designed an evidence-based program (EBP) that targets diabetes foot care knowledge among nurses practicing in LTC environments. We hypothesized that nurses who participate in an EBP on diabetes foot care will have improved knowledge of different components of foot examinations, including foot inspection and pedal pulse assessments, appropriate foot care practices, and patient education. The specific objectives of the EBP training study were to increase the knowledge and skills of registered nurses (RNs) and licensed practical nurses (LPNs) about diabetic foot care, and to encourage healthcare professionals to incorporate regular foot examinations and foot care education in their practice to prevent and manage diabetic foot lesions. This article outlines the key components of our EBP program and describes both the achievements and limitations of carrying out the EBP in three Florida LTC facilities. The two practical resources we used to assess the aforementioned objectives as well as information on obtaining the EBP materials are also provided.
Design of the Evidence-Based Program
We (authors Tewary and Pandya) developed an EBP training module, which involves one basic 45-minute presentation by a physician and a trained diabetes educator. The training is designed for a small group (ie, an average of 7-8 nurses in each session) to ensure close interaction with the instructors, with time allocated for participant comments and questions. The content of the diabetes foot assessment and foot education training module is delivered through an equal balance of lecture, video, and practical demonstrations.
The lecture component is facilitated by a PowerPoint presentation containing 30 slides. The slides include a brief overview of diabetes and diabetes-related complications (eg, foot problems, amputation risk) and information on appropriate history-taking and record-keeping, performing a physical examination, toenail care, appropriate specialist referral, proper footwear selection, and Medicare coverage of therapeutic shoes (ie, “diabetic shoes”). The training lecture reinforces the importance of performing periodic skin checks, musculoskeletal examinations, and pedal pulse assessments, and provides staff and residents with educational materials, which include one handout for the patient explaining daily, routine foot care, and a handout for healthcare professionals explaining how to conduct a routine foot examination.
In addition to the lecture facilitated by the PowerPoint presentation, the importance of foot assessments were discussed in a short video provided by the Indian Health Service.13 The video also demonstrates the proper techniques involved in performing a monofilament examination, using a tuning fork, and checking the pedal pulses. The physician who was involved in our EBP training demonstrated the use of a tuning fork for our study participants. Monofilament examinations and using a tuning fork were explained, however, participants were not expected to perform a monofilament examination or to use a tuning fork, as this is out of their scope of practice in the LTC setting. Also, LTC facilities typically do not provide these instruments for a foot examination.
An electronic copy of the final training module, which includes the PowerPoint slides and the video used in this study, can be obtained by contacting Sweta Tewary at email@example.com.
Study Methods and Procedures
We carried out our EBP study in three LTC facilities in Broward County, Florida, between November 2011 and March 2013. Nova Southeastern University’s Institutional Review Board approved the study. A total of 103 nurses received our EBP, and all of them were provided with standardized explanations of the procedures before initiating the study. Although the module was designed to be administered in small groups, as previously noted, the number of participants varied for each facility due to the nurses having conflicting work shifts.
All of the participating nurses were asked to complete a pre- and post-test survey, which we used to evaluate the effectiveness of the EBP to increase the level of knowledge. The knowledge survey, which included some demographic questions and Likert-style questions, was developed through a thorough review of all existing literature and educational materials available in the existing literature. A printable handout of a sample pre-test/post-test survey can be accessed by clicking the PDF image to the right.
To evaluate whether the training improved the nurses’ skill in performing clinical foot examinations, we analyzed chart data from 130 patients at 3 months before the EBP and 3 months after the EBP. The Figure provides an example of a patient foot screening chart review tool. Chart audits were completed through a chart audit tool developed for documenting the prevalence of foot problems.14 Each assessment included the documentation of patient history, skin checks, pedal pulses, ulcers, and amputations.
A paired-samples T-test was conducted to compare pre- and post-test scores in all three LTC facilities. Demographic data were analyzed using descriptive statistics to describe the sample. Completed pre- and post-test surveys were received from 79 participants, which included nine from LTC 1, 19 from LTC 2, and 51 from LTC 3. Approximately 58% of participants were LPNs and 13% were RNs (the remaining 29% did not report their certifications). Of these respondents, 92% were women, 49% were black, 31% were Hispanic, 60% were college graduates, and 45% were bilingual, with English as their primary language.
Clinical practice change was determined based on chart reviews that analyzed the difference in the proportion of participant foot assessments (103 nurses) over the total patient sample (130 patients) before and after the training sessions. Participants’ foot assessments included the total number of foot examinations or the assessments completed before and after the training.
Change in Knowledge by LTC Facility
Based on our analysis of pre- and post-test scores, results from the LTC 1 and LTC 3 groups did not show any significant effect in increase in knowledge after the completion of the EBP. The scores at LTC 1 changed from a pre-test mean of 20.10 (standard deviation [SD], 1.05) to a post-test mean of 19.40 (SD, 1.13). The scores at LTC 3 changes from a pre-test mean of 17.4 (SD, 1.4) to a post-test mean of 16.9 (SD, 2.10). The results from LTC 2, however, indicated a significant difference in the scores for pre-test (mean score, 11.94; SD, 1.7) and post-test (mean score, 19; SD, 1.4) knowledge (P<.05).
Clinical Practice Change
Chart reviews completed 3 months before and 3 months after the training indicated a clinically and statistically significant practice change in all three facilities. Only 8% of patient charts included documentation of foot assessments prior to the training, compared with 38% after the training (P=.001). On average, there was a 30% change in quality of documentation after the trainings.
Results from our EBP study suggest that there are differences in foot knowledge and practice across LTC facilities. There could be several reasons attributed to the differences in the results of the knowledge surveys between the three facilities. First, LTC environments differ in their structure, administration, organization, and competencies of hired staff. Second, there is a possibility of measurement error, as staff at LTC 1 received prior education in foot assessment, which we knew from our interactions with the Director of Nursing and nurses at the facility. Third, the knowledge test may have been easier for staff in one LTC facility than for staff in other facilities. The knowledge test could have been easier for staff with a higher level of education, better proficiency in English, and more years of practical experience.
Findings from the pre- and post-test results of knowledge assessments indicate a significant increase in knowledge for staff in LTC 2 after the training, whereas LTC 1 and LTC 3 did not show any knowledge improvement. We surmise from these results that foot care education may increase foot care knowledge among nurses in LTC facilities. Training may also increase nurses’ awareness of the importance of foot care practices that are integral to providing optimal care for persons with diabetes. Although no certified nursing assistants (CNAs) were included in our study, the importance of training CNAs in diabetic foot care was another key observation of the study, as CNAs are often providing a high amount of direct care to residents.
Interestingly, when chart audits were completed post-training, significant differences were found in documentation of foot problems with respect to skin checks, ulcers, history, clarity in documentation of pedal pulses, and specialist referrals. As the results show, there was an average of 30% change in quality of documentation following the trainings.
Selection bias may be a threat to internal validity. Many participants who completed their pre-test did not complete the post-test. Data on respondents with no post-test could be missing due to several reasons, including lack of interest in participation, lack of time, competing responsibilities, or there was a prior history of education. Respondents with no post-test were excluded from the analysis. As a result of selection bias, the significant knowledge increase may be overestimated or underestimated. Selection bias can also threaten external validity because a final biased sample may not be generalizable to the intended population. For instance, any inference drawn, such as foot assessment training increases knowledge about foot assessment, may not be generalizable to people who are experienced in the field of foot care and foot education.
Additionally, this EBP training may have limited practice implications if the LTC facilities have high staff turnover. Therefore, efforts should be made to maximize foot care training and include it as mandatory training for each new hire in the facility. Follow-up training sessions can further help in information retention.
Future efforts should target education toward CNAs in nursing homes, as these individuals are closely involved with care delivery in these settings. The foot assessment form, which is an important tool, was not available in any of the LTC facilities we studied; therefore, efforts should be made to strengthen the documentation procedures and increase the number of foot assessment trainings with variable content based on the learning levels of the staff. Training could be conducted in the form of live lectures, webinars, or videos, completion of which should be made mandatory by the facility administration.
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Disclosures: The authors report no relevant financial relationships.
Address correspondence to: Sweta Tewary, PhD, MSW, 3446 South University Drive, Fort Lauderdale, FL 33328; firstname.lastname@example.org
Acknowledgments: The authors would like to acknowledge their funding agency, Health Resources and Services Administration, for providing support for the evidence-based practice project (grant number UB4HP19211). The authors would also like to acknowledge Julianne Manchester, PhD, project director, Geriatric Education Centers, National Training and Coordination Collaborative, and Christine Cigolle, MD, MPH, assistant professor, departments of family medicine and internal medicine research, assistant professor, Institute of Gerontology, University of Michigan, and research scientist, VA Ann Arbor Healthcare System Geriatric Research, Education, and Clinical Center (GRECC), for providing mentoring on the evaluation and conceptualization of this project.