Professional development for podiatrists in diabetes using a work-based tool

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<ul><li><p>IntroductionDiabetes is one of the most commonreasons for referring a patient to apodiatrist, as 1.42% of people withdiabetes have a new foot ulcer eachyear.1,2 Around 25% of people withdiabetes will develop a foot ulcersometime during their life.3 Footulcers account for about 20% of alldiabetes-related health care costs,and are a precursor of amputationin over 80% of major amputations.4The number of patients with dia-betes is increasing at a rapid rate5which vastly outstrips any increase inthe number of podiatrists. As well asa need for more podiatrists in dia-betes care,6 the proportion of podia-try workload dedicated towards diabetes will need to increase. Therole of podiatrists in the communitydelivering care to patients with dia-betes will increase, and indeed isperceived as desirable by patients.7In addition, the expectations frompatients and other health care pro-fessionals have increased in terms offoot care. </p><p>Despite this, many podiatrists inthe community work in relative isola-tion, and often do not get access todesirable levels of educationalopportunities, due to the pressuresof workload. Locally, our informalfeedback indicated that many podia-trists outwith specific diabetes unitslack confidence and are sometimesanxious about dealing with patientswho have diabetes as they can feelunsupported and vulnerable. Otherfoot-related education programmeshave been used.8 We aimed todevelop an education programmedirected specifically for podiatrists,in an attempt to make it easier to</p><p>deliver, make it more focused for thespecific needs of podiatry, andpotentially make it more sustainable.An education programme was devel-oped which aimed to improve skillsand confidence of podiatrists in thecommunity dealing with patientswho have diabetes.</p><p>MethodsAn educational plan provided edu-cation, training, mentorship andsupport to willing community podia-trists. The project was run by a 1.0whole time equivalent PodiatryPractitioner (job share) who wereseconded for 18 months. </p><p>All podiatrists working in thecommunity of Tayside were sent aquestionnaire by post, and an expla-</p><p>nation of the proposed project (seebelow). They were asked if theywould like to participate. Overall, 34community podiatrists out of 61approached opted to participate inthe project. The training was under-taken over one year and there werethree elements to it, as follows. Formal Theoretical Training wasbased to address the training needsidentified by the questionnaire.Training events were provided bylocal experts who also contributed to the accredited University ofDundee General Diabetes Module.9This included lectures and interac-tive workshops, with accompanyingmaterials and hands-on demonstra-tions. There were 16 hours of educa-tion covering the following topics:</p><p>ORIGINAL SHORT REPORT</p><p>Pract Diab Int October 2008 Vol. 25 No. 8 Copyright 2008 John Wiley &amp; Sons 313</p><p>Professional development for podiatrists indiabetes using a work-based toolGP Leese*, K Brown, V Green</p><p>ABSTRACTThe aim of this project was to deliver a work-based educational package to non-specialised podiatrists in the community that would improve their skills and confidence inmanaging diabetic foot problems.</p><p>A combination of theoretical teaching, attendance at a multidisciplinary foot clinic andreceiving immediate peer review in normal routine practice was provided by a podiatrypractitioner who had expertise and experience in diabetes. This was delivered over aone-year period to 34 out of 61 invited link podiatrists. Participants filled out aquestionnaire before and after the intervention.</p><p>The three-part educational programme was successfully delivered over one year.After the educational year, 91% were more confident in treating foot ulcers, and 91%wished to remain as a diabetes link podiatrist. The community podiatrists were moreaware of diabetes specialist groups (83% after vs 20% before, p</p></li><li><p>ORIGINAL SHORT REPORT</p><p>Podiatry and education</p><p>wound dressings, the validated SCI-DC (Scottish Care Information Diabetes Collaboration) foot riskassessment,1012 foot complications,neuropathy, orthotics, vascularassessments, vascular interventions,general diabetes information, dietet-ics, psychology, dermatology, andcommunication skills. Each sessionwas accompanied by further reading materials and evaluated byquestionnaire. Practical Clinical Skills: each com-munity podiatrist had at least onesession attending the multidiscipli-nary diabetes foot clinic (MDFC) inDundee. The podiatry practitionerback-filled the workload left vacantby the community podiatrist duringthis half-day. The podiatrist was ableto see a concentrated number ofpatients with complicated foot prob-</p><p>lems, and to see the podiatrist withexperience in diabetes-related footproblems, the diabetologist, vascularsurgeon, orthotist and diabetes spe-cialist nurse at work. The session alsoprovided the opportunity to knowwhen patients with foot problemsshould be referred, and how theyshould be referred and to whom. Training was also undertaken bythe podiatry practitioner to provideindividual mentoring and support.This involved joint visits to patients inthe community who had foot prob-lems, between the community podia-trist and podiatry practitioner. Thisone-to-one input helped podiatriststo understand how they could man-age straightforward foot problemsand involve other health care profes-sionals in the management of high-risk foot care within their own setting.</p><p>At the end of the study, a replicaof the original questionnaire wassent out to those participating in theproject (see Table 1). </p><p>ResultsOf the 61 who were approached, 34podiatrists from the community,with no prior specific training in dia-betes, took part in the project. Allthe objectives of the educationalprogramme were achieved over aone-year duration. Eight formal edu-cation sessions were delivered. Eachof the 34 podiatrists had at least onesession at the MDFC, whilst havingtheir normal workload back-filled bythe podiatry practitioner. An addi-tional nine podiatrists had morethan one session at the MDFC. Everypodiatrist received between one andthree sessions in the community</p><p>314 Pract Diab Int October 2008 Vol. 25 No. 8 Copyright 2008 John Wiley &amp; Sons</p><p>Table 1. Results of questionnaire from participants before and after the one-year project, and from non-participantsbefore the project</p><p>Percentage of participants answering Participants: Participants: Non- yes to the question before project after project participants</p><p>n=30 n=23 n=8</p><p>Do you feel you have adequate knowledge of diabetes in 80% 96% 88%general?Are you confident in recognising poorly controlled diabetes? 50% 74% 63%Are you informed of local diabetes specialist groups? 20% 83%*** 88%Are you aware of SIGN 55 guidelines? 70% 91% 88%Are you aware of local guidelines on diabetic foot risk 73% 96%* 100%assessment?Do you know how to use a monofilament? 100% 100% 100%Do you use a wound grading system for diabetic foot ulcers? 20% 26% 0%Do you use digital photography to record ulcer management? 3% 9% 0%Would more experience in wound debridement be of interest 93% 65%** 75%to you?Would more experience in wound dressing be of interest? 100% 96% 88%Do you use sterile dressing packs when changing dressings? 27% 48% 75%Would a visit to the diabetic foot ulcer clinic be of benefit to 93% 74% 74%you?Do you feel there is adequate correspondence when sharing 23% 22% 12%ulcer management between primary and secondary care?Do you provide written foot care advice (including leaflet) to 70% 74% 63%people with diabetes?Would you like more educational literature for your clinics? 97% 87% 75%Would you feel comfortable covering a diabetes foot ulcer 53% 83%* 75%clinic?Compared to before the project would you now be more 91% confident in treating diabetic ulcers in your own clinic?Would you be more confident in recognising a Charcot foot 83% and referring appropriately?Would you like to continue as a diabetes link podiatrist in 91% community?</p><p>* p</p></li><li><p>ORIGINAL SHORT REPORT</p><p>Podiatry and education</p><p>with the podiatry practitioner along-side. This usually revolved aroundthe management of a foot problemthe community podiatrist was uncer-tain or not confident about.</p><p>Of those participating in thestudy, 30 (30/34, 88%) question-naires were completed before theintervention and 23 (68%) after theintervention. Eight questionnaires(8/27, 30%) were completed beforethe intervention by podiatrists whodid not want to be involved. Resultsare shown in Table 1.</p><p>There was an open question ask-ing participants, after the project, asto which aspects they got most bene-fit from. There was an equal spreadbetween the theoretical and the prac-tical aspects (five theory, six practicaland five both). Comments on benefitincluded the opportunity to find outmore about diabetes in general, thechance to see different types of dress-ings, the opportunity to have theirpractice observed, the discussion onCharcot foot, and many others.</p><p>DiscussionThis project was able to deliver theoretical educational input, day-release to the local MDFC withoutaffecting patient waiting times, and acase-related mentoring scheme. Itresulted in many podiatrists feelingmore confident and empowered tolook after patients with diabetes inthe community. Previously they didnot feel confident to do so. Thisincluded 21/23 podiatrists who filledin the questionnaire and at least21/34 of those who participated. Theself-perceived knowledge and abilityof those who did not attend thecourse, but returned a questionnaire,were quite high and this may reflect a cohort of podiatrists who werealready up-skilled, and may not havebenefited from the course. However,the majority of those who did notattend (19/27) did not fill out thequestionnaire and we have no infor-mation on their self-perceived abili-ties, which may have been less as theymay have had less experience. Onceestablished, the clinical skills aspectof this project can be sustained withrelatively low levels of resource, day a week of a senior podiatrist,who would also maintain links withthe podiatrists in the community.</p><p>Similar courses have been developedwhich have successfully educatedboth health care professionals andpatients,8 which help develop an inte-grated community-wide approach.Our project was more focused on theneeds of the podiatrist and may bemore sustainable in the long term.</p><p>At a time when podiatrists aredefining their core competencies,13 acourse like this could be developed asa foundation course to accredit podi-atrists as specialists in diabetes. Thecourse focuses on practical skills andcould be used for work-based assess-ment using a portfolio approachlinked to key core competencies. Itcould be combined with a theoreticalUniversity-based course if the latterwas felt to be required. </p><p>This work-based educationalpackage has helped create a podiatrynetwork by improving communica-tion between podiatrists in multi-disciplinary foot clinics and those in the community. It has also supported diabetes foot care in thecommunity by enhancing the skillsand confidence of community podia-trists and empowering them to carefor such patients.</p><p>Conflict of interest statementThe project was supported by a peer-reviewed grant from the ScottishGovernment.</p><p>References1. Abbott CA, Carrington AL, Ashe H, et</p><p>al. The North West Diabetes CareFoot study: incidence of, and risk fac-tors for, new diabetic foot ulcerationin a community-based cohort. DiabetMed 2002; 19: 377384,</p><p>2. Kumar S, Ashe HA, Parnell LN, et al.The prevalence of foot ulcerationand its correlates in type 2 diabeticpatients: a population-based study.Diabet Med 1994; 11: 480483.</p><p>3. Singh N, Armstrong DG, Lipsky BA.Preventing foot ulcers in patients withdiabetes. JAMA 2005; 293: 217228.</p><p>4. Boulton AJM, Vileikyte L, Ragnarson-Tennval G, et al. The global burden ofdiabetic foot disease. Lancet 2005;366: 17191724.</p><p>5. Zimmet P, Shaw J, Alberti G. Globaland societal implications of the dia-betes epidemic. Nature 2001; 414:782787.</p><p>6. Winocour PH, Morgan J, AinsworthA, et al; Association of British ClinicalDiabetologists. Association of BritishClinical Diabetologists (ABCD): sur-vey of specialist diabetes care servicesin the UK, 2000. 3. Podiatry servicesand related foot care issues. DiabetMed 2002; 19(Suppl 4): 3238.</p><p>7. Lawton J, Parry O, Peel E, et al.Diabetes service provision: a qualita-tive study of newly diagnosed type 2diabetes patients experiences andviews. Diabet Med 2005; 22:12461251.</p><p>8. Donohue ME, Felton JA, Hook A, etal. Improving foot-care for peoplewith diabetes mellitus a randomisedcontrolled trial of an integrated careapproach. Diabet Med 2000; 17:581587.</p><p>9. Diabetes and its Effects. University of Dundee Module.[last reviewed 26/1/08].</p><p>10.Scottish Intercollegiate GuidelineNetwork (SIGN). SIGN Guideline 55:The management of Diabetes. RoyalCollege of Physicians Edinburgh:SIGN, 2001. [last reviewed26/01/08].</p><p>11.Leese GP, Reid F, Green V, et al.Predicting foot ulceration inDiabetes: validation of a clinical toolin a population-based study. Int J ClinPract 2006; 60: 541545.</p><p>12.Leese GP, Schofield CJ, McMurray B,et al. Scottish foot ulcer risk score pre-dicts healing in a regional specialistfoot clinic. Diabetes Care 2007; 30:20642069.</p><p>13.National minimum skills framework forcommissioning of foot care services for peo-ple with diabetes. FDUK, 2006.[last reviewed 26/01/08].</p><p>Pract Diab Int October 2008 Vol. 25 No. 8 Copyright 2008 John Wiley &amp; Sons 315</p><p>Key points</p><p> Linking community podiatry with specialist diabetes foot services improvesoverall patient care</p><p> Community podiatrists with an interest in diabetes need support, and to bepart of a wider network</p><p> The podiatry practitioner role helps to achieve this Modest resources may be required to provide support and education to</p><p>community podiatrists</p><p>OSR Leese 63.08.qxp 26/9/08 15:39 Page 3</p></li></ul>