Investigating the experience of receiving podiatry care in a tertiary care hospital clinic for people with diabetes related foot ulcers

Ten participants were recruited during December 2020. Demographic data of the participants are listed in Table 3 and Additional file 4. All participants were male, with a mean age of 69.4 years and standard deviation of 15.3 years. Seventy percent of participants were retired and 30% were unemployed. Seventy percent were living at home with a partner or family member. Eighty percent of participants had been receiving podiatric DFU management for over nine months, with 70% of participants reporting a history of DFU infection.

Table 3 Participant demographic data

Four themes were identified to describe participants’ experience of podiatric care for DFUs: Trusting podiatrists with the right expertise; Personalised care; Happy with service but not prescribed equipment, and; It’s a long journey. Key factors in podiatric care that influenced participants’ experience were identified within the themes, including: demonstration of expertise, consistency in client-practitioner relationship, client-centred care, and innovation in equipment prescription.

Theme 1. Trusting the podiatrists with the right expertise

Participants described the importance of trusting the podiatrist providing their DFU care as they perceived their DFU recovery to rely on the podiatrist’s expertise. Trust was associated with the podiatrist demonstrating professionalism in communication and behaviour such as, organisation and structure during appointments, and skill in DFU debridement and dressings. Use of good hygiene and infection control practices during DFU treatment also supported the participants’ trust of the podiatrist. Some participants specifically associated these qualities of expertise with the tertiary care context of the clinic. Trust helped participants to be confident in following the podiatrist’s advice and instructions about foot care,

“They’re the experts, so take their advice as much as possible and just make sure you do the right things” (P03).

“They know what they’re doing, they know more than me. I don’t know what they are doing anyways” (P02).

In contrast, participants lost trust when a podiatrist was perceived to not demonstrate the knowledge and skills expected of an expert practitioner. This included descriptions of “cutting too deep” during debridement or evidence of poor infection control and hygiene in the clinic such as inappropriate use of personal protective equipment.

“The only problem I had was a podiatrist over on the other side. He didn't seem to worry about hygiene or anything” (P02).

Three participants believed that a podiatrist’s debridement technique was the cause of further DFUs. One participant associated a change of dressing by a podiatrist with an infection in their DFU,

“If I hadn’t gone to the podiatrist in the first place, I might never have had an ulcer” (P01).

Building a relationship with the same podiatrist helped to build participants’ trust that the podiatrist was familiar with their DFU, and had the knowledge and skills to provide the most effective DFU treatment for them,

"It makes a big difference to who you know, and how you get on with them" (P06).

Many participants expressed they were hesitant to change podiatrists as they were concerned it would have a negative effect on their DFU management. One participant associated a negative DFU outcome with a change from the tertiary health clinic to a community podiatrist,

“They discharged me and sent me up the road, where I see a separate podiatrist. Like an outsource podiatrist. But then obviously the problem came back” (P03).

Despite their concern, participants perceived they had little control over the consistency of their treating podiatrist in the tertiary health setting due to the busy schedule of the clinic or the turnover of staff,

“Every time I get a good one, they get transferred” (P02).

This first theme describes the importance of perceived expertise for participants to have trust in podiatry care. Podiatrists strengthened trust through demonstrations of professionalism and expertise in DFU management. Consistency in the relationship between client and podiatrist was a key influence on trust.

Theme 2. Personalised care

Throughout their experiences, participants described their appreciation for podiatric care being personalised to their needs and concerns. Three participants were particularly appreciative of the innovation shown by podiatrists in developing treatment plans to suit their personal goals and minimise interruptions to their lifestyle,

"She (podiatrist) is trying everything. If it doesn't work, it’s certainly not her fault or the hospital’s fault" (P07).

Participants wanted information from podiatrists about their DFU and care that was understandable to them and meaningful to their individual concerns and lifestyle. For some it was important to know about their DFU aetiology and six participants described a clear understanding of why they had an DFU,

“The first thing I would say to them, tell the person how they got the ulcer” (P01).

Other participants described the importance of knowing the relationship between the DFU and blood supply, with the risk of amputation recognised as a potential consequence of a poorly managed DFU,

“You know with diabetics, it’s not one problem. It’s eyes, feet, ulcers, blood pressure. The heart as well” (P03).

Four participants described not receiving the information they wanted from the podiatrist or the information was provided in a way they did not understand. These participants expressed disappointment and confusion about their lack of knowledge, yet perceived the responsibility for providing the information to be with the podiatrist,

“I was just stumped. It didn’t make sense to me. That something was going on with my feet” (P06).

“The people, they communicate, but they’re not telling me what I want to know. I’m not here to grill them” (P01).

This second theme describes the importance of personalised and client-centred care in participants’ experience of podiatry care for DFU. This was achieved by podiatrists collaborating with the client about their goals and treatment options. Effective provision of information addressed the person’s individual concerns about their condition and was provided in a way understandable to the individual.

Theme 3. Happy with the service, but not always with prescribed care

Overall, participants were satisfied with the delivery of podiatric treatment they had received in the tertiary health clinic for their DFU but were burdened by the equipment prescribed and self-management expected of them between appointments. Visiting the podiatry clinic at the hospital was generally perceived as routine, comfortable, and uneventful,

“It’s fairly stress-free. It was easy to get in and out. Not too much drama” (P04).

Social interaction could be a valued part of the podiatric care experience, either with the podiatrist and other clinic staff, or with other people they met while travelling out of home for the appointment,

“It’s an outing, I’m usually home anyway. I go and have a coffee with some friends there every morning just about, then I’m home for the rest of the day” (P02).

In contrast to the service experience, the prescription of an offloading footwear device was consistently perceived to be burdensome. Most participants who had been prescribed equipment such as a cast walker described the rationale for offloading to allow the DFU to heal. They also acknowledged their responsibilities in managing the equipment between podiatry appointments,

“The secret to success is wearing the moonboot” (P07).

Yet they also reported use of the equipment to be a significant challenge and inconvenience to their lifestyle. These challenges experienced with adapting prescribed equipment into their lifestyle were perceived to not always be understood by the treating podiatrist. One participant described wearing his prescribed socks only when attending clinic appointments as he perceived his frustrations and inconvenience with the socks was not accepted by the podiatrist,

“They (podiatrist) didn’t like the idea that I wasn't wearing any socks. So, I wear socks when I come in here. I don't wear them normally” (P01).

In contrast, a few participants reported positive experiences when podiatrists recognised the difficulties and demonstrated innovation to adapt the prescribed equipment so their lifestyle burden was reduced,

“Last time she put in extra blocks in the orthotics and now she’s put a carbon plate in, she’s trying her best” (P07).

Burdens of offloading devices were experienced as both physical and psychological consequences, with some participants complaining of physical exhaustion from wearing a removable cast walker every day. The challenges experienced by participants with DFU offloading equipment and dressings forced some into a more sedentary lifestyle,

“You walk around for a long time but it’s like walking with a concrete brick” (P03).

Social roles and meaningful activities were negatively impacted by commitments to DFU management procedures. These included difficulties caring for grandchildren and attending school drop-off when using a removeable cast walker, and difficulties taking the cast walker on and off limiting the participant’s ability to drive a car to meet friends or attend a workplace,

"It's frustrating not being able to just get in the car and go where I feel like going, makes a difference and friends have to come and see me rather than me going to see them” (P09).

Keeping DFU dressings dry and clean was also described as a problem for many participants which prevented participation in outdoor leisure activities including going to the beach, riding a bike or going on walks,

"I can't go to the water. I haven't been in the pool for two years" (P09).

This third theme describes the widespread challenge and burden of using prescribed equipment during podiatry care for DFU. This burden often had negative effects on a participants’ ability to participate in meaningful roles and activities. The negative experience of equipment use was not always recognised by the podiatrist. The experience of using equipment could be improved by podiatrists innovating use of equipment to better meet the participant’s needs.

Theme 4. It’s a long journey

Podiatric care for a DFU was experienced by all participants as a long and interrupted journey. Six participants struggled with acceptance of their DFU and implementing offloading equipment into their lifestyle. Several participants had almost healed their DFU before experiencing an DFU infection and the need for continued treatment,

"And then it (ulcer) breaks down again. It's a never-ending cycle" (P10).

“It’s one step forward and two steps back” (P05).

Participants recognised that despite engaging in regular podiatric DFU treatment, the healing process for a DFU could not be rushed.

"It's going to take a long time. It's just something that you can't rush. If you rush it, you'll get to a certain point and just break down again. Then you’re back to square one" (P10).

Participants were grateful for emotional support and medical attention they received from podiatrists and other health professionals during this long journey,

“There were vascular surgeons, three or four nurses, I felt like a real king” (P07).

However, the journey of podiatric DFU treatment included unpleasant experiences. Infection of a DFU was a common and significant setback for several participants which created doubt about timely DFU resolution. The need to return to work presented setbacks for one participant as the physical requirements of their work delayed DFU healing. The long, interrupted duration of podiatric DFU care had significant impacts on the wellbeing of participants,

"Your legs are your pillars. So, having any wounds affect your mobility or your way of life is life changing" (P08).

Countless setbacks when engaging with podiatric care for their DFU was associated with some participants demonstrating a pessimistic outlook towards timely DFU resolution and their return to a regular lifestyle. Guilt and frustration were also experienced by participants whose partners were required to increase household workload and transport them to and from podiatry appointments. Two participants experienced difficulty maintaining full time employment due to time commitments attending frequent podiatry appointments and use of a removeable cast walker.

For most participants, the DFU was a co-morbidity to other chronic health problems. Sometimes the DFU was experienced as less of a concern compared to significant medical conditions,

“When you've had your chest cut open, this is nothing. It's a fairly minor inconvenience” (P04).

However, many participants experienced significant stress managing podiatric DFU treatment alongside their co-morbidities,

“Having a medical condition on top is like having the weight of the world on your shoulders” (P08).

This final theme describes the long and frequently interrupted duration of podiatry care for participants. The common experience of infections and slow healing had significant effect on lifestyles and wellbeing can be acknowledged and support offered by podiatrists during delivery of care.

留言 (0)

沒有登入
gif