PP week 1

Power point presentation discussion with at least 14 pages including presentation, conclusion and references.

Tile: “Metaparadigm. Discuss four most frequently cited domains of nursing’s metaparadigm”

Book: Middle Range Theories. Application to Nursing Research and Practice.

Autor: Sandra J. Peterson/ Timothy S. Bredow.

Fifth Edition

 British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT 

 “A nursing metaparadigm perspective of diabetic foot ulcer care.” Journal Research document selected. March 28, 2019 

Please could you include small pictures if needed or tables, the professor is strict and very demanding, thanks.

British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT SPBS38 British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT

©
2

01
9

M
A

H
ea

lth
ca

re
L

td

A nursing metaparadigm perspective
of diabetic foot ulcer care

D
iabetic foot ulcers (DFUs) are a serious
consequence of diabetes, affecting patients’ health
outcomes and may lead to lower extremity
amputation (Parekh et al, 2011). In recent years,

the incidence of lower extremity amputation because of
ulceration has increased; and robust epidemiological reports
have found excess mortality in patients with diabetic
foot syndrome (Chammas et al, 2016; Narres et al, 2017).
The International Diabetes Federation stated that 9.1 to
26.1 million people with diabetes will suffer from DFUs
each year (Armstrong and Boulton, 2017). DFUs are the
most significant and devastating problem that patients
with diabetes face (Priyadarshika and Sudharshani, 2018).
Numerous studies have documented that DFUs commonly
lead to such health issues as decreased patient quality of
life, problems in the social environment, impacts on overall
health, and an increased nursing workload (Aalaa et al,

2012; Fejfarová et al, 2014; Sekhar et al, 2015; Macioch
et al, 2017). Patients exhibiting blood glucose levels of
HbA1c ≥8 mmol/mol, peripheral arterial diseases (PAD),
hypertriglyceridemia, hypertension, neuropathy, infection,
neuroischemic foot, and with a history of smoking, are
recognised as being at a high risk of DFUs and lower
extremity amputation (Boyko et al, 2018).

A theory-based approach, taking into account the
multidimensional aspects of the nursing metaparadigm, may
improve the outcome for individuals living with DFUs. The
nursing metaparadigm is a framework that looks at problems
through a framework consisting of the human being, the
environment, health, and nursing.

A thorough understanding of the concept of the nursing
metaparadigm would help nurses to facilitate successful
DFU care. In contrast, poor theoretical understanding may
lead to the impeding of knowledge development and slow
the translation of research into clinical practice (Fawcett,
1999). Each aspect of the nursing metaparadigm contributes
an important part to the nursing process (Fawcett, 1999;
2005). Implementing the nursing metaparadigm in
greater detail will demonstrate its significance to generate
further nursing interventions (Branch et al, 2015; Rosa
et al, 2017). Ultimately, it is essential that nurses integrate
this metaparadigm into DFU care in order to provide
comprehensive nursing care and manage the complexities
arising, such as fear of amputation, impact on employment,
infection, compliance with casts and shoes, foot deformity,
blindness, neuropathy, peripheral arterial disease, impotence,
and gastrointestinal problems. In doing so, clinical nurses
have an opportunity to influence individual outcomes by
encouraging maintenance of healthy feet, recognising current
problems, and providing evidence-based care as well as
multidisciplinary interventions (Delmas, 2006).

However, to date, no articles have attempted to offer any
discussion concerning the nursing metaparadigm perspective
relating to DFU care. Even though the domains of person,
environment, health, and nursing have been agreed upon by
theorists (Fawcett, 1983), it is difficult to use these abstract
models in terms of application in clinical practice. Therefore,
a newly synthesised operational definition was required to
further explain each domain of the nursing metaparadigm.
For that reason, the objective of this article is to identify why
the theory of a nursing metaparadigm originated by Fawcett
should be a fundamental part of DFU care. In this article,
the authors explore the relevant evidence that could present
a concise direction and role for a nursing metaparadigm in
DFU care. A description of the attributes of each domain

Sumarno Adi Subrata, PhD Candidate, Doctor of Philosophy
Program in Nursing, International and Collaborative with Foreign
University Program, Mahidol University, Thailand; and Nursing
Lecturer, Department of Nursing, Faculty of Health Sciences,
Universitas Muhammadiyah Magelang, Indonesia,
adisubrata@ummgl.ac.id

Rutja Phuphaibul, Professor of Nursing, Ramathibodi School
of Nursing, Faculty of Medicine, Ramathibodi Hospital, Mahidol
University, Thailand

Accepted for publication: October 2018

ABSTRACT
Diabetic foot ulcers (DFUs) are a serious complication of diabetes that
impact on the patient, their social environment, overall health, and on
nursing practice. Nursing scholars have integrated theories on practice to
overcome these problems, but a lack of agreement in the available literature
acts as a barrier to implementing these in practice. For that reason, using
a nursing metaparadigm as a theoretical framework would assist nurses
in managing care purposefully and proactively, thus possibly improving
outcomes. There has been little discussion about the nursing metaparadigm
in relation to DFU care. This article aims to identify why Fawcett’s theory
of the nursing metaparadigm is important as a fundamental part of DFU
care. Understanding this will help to elucidate the phenomenon of DFUs.
Moreover, identifying the elements of the DFU care framework is essential
to improve reflective practice and intervention. This article discusses the
concept of the nursing metaparadigm and its implications for practice in the
care of patients with DFUs.

Key words: Diabetic foot ulcers ■ Nursing metaparadigm ■ Nursing practice

S40 British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT

©
2
01
9
M
A
H
ea
lth
ca
re
L
td

■ Reciprocal interaction worldview
■ Simultaneous action worldview
■ Recipients of nursing care
■ Belief
■ Physiological and psychological
aspects

■ Partnership with society
■ Self- and family management

■ Engagement on wound care
training

■ Caring process (continuity of care,
disease experience, and disease
management)

■ Nursing process (assessment,
labelling, planning, intervention,
and evaluation)

■ Carative factors
■ Diabetic foot ulcer health promotion
■ Multidisciplinary approaches

Human being Nursing

Environment Health

■ Gene/environmental interaction
■ Lifestyle
■ Context of daily practice
■ Ethical perspective
■ Life principle
■ Ideologies influencing the
patient’s life

■ Five system variables
(physiological, psychological,
sociocultural, developmental, and
spiritual)

■ Optimal healing environment

■ Person’s wellbeing
■ Access to healthcare services
■ Foot care behaviour
■ Multidimensional approach
■ Quality of life
■ Five dimensions of health (effects,
attitudes, activities, aspirations,
and accomplishments)

Nursing
metaparadigm
perspectives

of diabetic foot
ulcer care

Figure 1. Nursing metaparadigm perspective of diabetes foot ulcer care

in the nursing metaparadigm as it is related to DFU care is
explored (Figure 1). This article provides a fresh perspective
on DFU care, which may improve interventions and health
outcomes. Additionally, the findings of this article could be
tools for designing and conducting DFU research.

A brief history of the nursing metaparadigm
and its conjunction with DFU care
A metaparadigm can be described as ‘a set of concepts and
propositions that sets forth the phenomena with which a
discipline is concerned’ (Miller et al, 2003). Historically,
three domains of the nursing metaparadigm (man, health,
and nursing) were identified by Florence Nightingale,
several nursing scientists, and clinicians in the 19th and
20th centuries. The ‘environment’ domain was discussed by
Donaldson and Crowley (1978). In the meantime, Fawcett
conceptualised Nightingale’s concept into ‘man, society,
health, and nursing’ (Fawcett, 1978; 1984;1992). Several
amendments have been made during the development of
the nursing metaparadigm. ‘Man’ was changed to ‘person’
to create a gender-neutral expression. ‘Society’ was also
switched to ‘environment’ for a wider perception of
nursing practice. The latest change was ‘person’ into ‘human
being’, as a response to the evaluation that ‘person’ was not
understandable in some cultures (Figure 2) (Fawcett, 2005).

Fawcett also identified three specific relationships among
the domains: person-health, person-health-environment, and
person-health-nursing (Fawcett, 1984). Fawcett emphasised
that the concepts of patients and health must be related
to the enhancement of the optimal functioning of human
beings. A person will interact with their environment
and nursing theory allows nurses to understand patients’
behaviour in normal and critical situations. In addition,
the association between nursing and health emphasises
that nursing interventions are able to change a patient’s
health status (Fawcett, 1996). This metaparadigm allows
nurses to see the patient holistically. Fawcett’s ideas provide
a conceptual framework that underlies nursing practice
(McEwen and Wills, 2007). Incorporating the nursing
metaparadigm into nursing practice will encourage
comprehensive nursing care that will accelerate patients’
healing (Bender and Feldman, 2015; Bender, 2018).

This historical overview explores the evolution of the
nursing metaparadigm and describes the major drivers
shaping the role boundaries of each domain of metaparadigm
in nursing practice. The patient with a DFU encounters
problems as a human being, with their overall health
and their environment and nursing aims to overcome
these problems. A detailed description of those aspects is
given below.

Human being
Fawcett defined a human being as an open system that
is unique, dynamic and multidimensional with self-
responsibility. As the theory was developed, Fawcett
specified that the ‘human being’ may have a ‘reciprocal
interaction world view’ or a ‘simultaneous action world
view’ (Fawcett, 2006).

A ‘reciprocal interaction world view’ signifies that the
human being consists of bio-psycho-social elements (Lai and
Hsieh, 2003). Studies have found that individuals with DFUs
frequently display several psychological and social issues,
including increased tensions between patients and their
caregivers (spouses or partners), a reduction in the pursuance
of social activities, limited employment, and financial
difficulty (Goodridge et al, 2005; Fejfarová et al, 2014).

A prolonged time living with a DFU may lead to
depression. Occurrence is three times higher in type 1
diabetes patients and two times higher in type 2 diabetes
patients than in those without diabetes (Roy and Lloyd, 2012;
Winkley et al, 2012). Nurses must support individuals’ mental
as well as physical health needs. Thus, a comprehensive mental
assessment may provide important information to improve
the care and delivery of nursing services (de Jesus Pereira et
al, 2014). The nurse’s role is also one of educator—imparting
knowledge in order to enhance the individual’s ability to deal
with mental health problems. Some patients with depression
may need to be referred to a mental health nurse, who can
support them throughout the assessment, diagnosis and
management phases (Maydick and Acee, 2016).To be effective,
an interprofessional approach incorporating the individual
with DFU, their family or caregiver, and their significant
others, should be used during interventions.

A ‘simultaneous action world view’ refers to human

British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT S43S42 British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT

©
2
01
9
M
A
H
ea
lth
ca
re
L
td

Figure 2. The four nursing metaparadigm concepts defined by Fawcett, 1996; 2006;
Fawcett and DeSanto-Madeya, 2013

beings interacting with their environment in a way that
may be organised, disorganised and subject to change, but is
ultimately organised and orderly (Fawcett, 2006; Chung et
al, 2007). One study documented that individuals living with
chronic wounds (such as DFUs) presented with more mental
health problems than those without wounds; accordingly,
they reported various negative feelings such as isolation,
stress, depression and worry (Upton et al, 2014). All nursing
interventions must be focused on both physical and mental
dimensions. Self-management programmes (ie, foot self-
care and behavioural therapy) are also necessary to prevent
complications, improve patients’ understanding of risk
factors, and to increase their ability to manage the disease
(Olson et al, 2009; Bonner et al, 2016; Van Netten et al,
2016). Coordination between different specialties is required
to manage the physical, psychological and psychosocial
aspects of DFUs. Counselling of both individuals and their
families in their own language is imperative, particularly
for those admitted to the intensive care unit (ICU) with
diabetic complications. Health professionals should be
clearly informed about the harmful effects of DFUs and
their complexities, so that they can communicate these to
the individuals and their families in an appropriate manner
(Neeru et al, 2015).

The concept of a ‘human being’ is associated with the
recipient of nursing care encompassing individuals, families
or caregivers, and their surrounding communities (Fawcett,
2000). It is important that a person at risk of DFUs has a
good partnership with their family or caregivers so that they
are all aware of the signs and symptoms of DFUs, such as the
loss of the protective sensation, and know the importance
of daily foot care (Mayfield et al, 2003). Having a DFU may
cause a loss of productivity if the person cannot work, and a
subsequent loss of status, and extra family expenses (Keskek
et al, 2014; Raghav et al, 2018). The complexities of DFUs
means the illness impacts on social contexts. Therefore, nurses
need to consider how individuals interact with their families

and communities when planning DFU care. Addressing the
family and social environment for individuals with DFUs is
important since this is the context in which the majority of
disease management occurs. Through their communication
and attitude, nurses can provide many forms of support, such
as providing insulin injections, changing wound dressings,
and giving emotional support. Involving family members and
communities in DFU interventions may improve diabetes
self-management (Baig et al, 2015).

Recognising the complexity of the human experience
is an essential element of nursing care (McEwen and Wills,
2007). Individuals with DFUs commonly experience several
health issues such as hypertension, nephropathy, retinopathy,
a past history of DFUs, and long-term diabetes—both type 1
and type 2—neuropathy, sleep disturbance, increased pain
perception, limited mobility, social isolation, a restricted life,
and fears concerning the future (Ribu and Wahl, 2004; Yekta
et al, 2011). Nevertheless, some patients may not recognise
these issues or even ignore them, thus potentially leading
to complex conditions. Accordingly, clinical nurses, along
with other health professionals, must be able to identify
such problems in order to carefully plan and implement a
comprehensive treatment process (Papaspurou et al, 2015).
Nurses, as the largest group of health professionals, are
mandated to examine risk status concerning recurrence,
assessing new or deteriorating foot ulcers and providing
basic foot-care health promotion. They may work as the
key diabetes educator in the diabetes care teams (Registered
Nurses’ Association of Ontario, 2004).

Human beings have a unique set of beliefs that nurses
must take into account (Branch et al, 2015). These beliefs can
lead to the adaptation of self-care that can decrease the risk
of DFUs and influence daily foot-care behaviours positively
(Vedhara et al, 2016). Conversely, other beliefs about diabetes
may increase the risk factors associated with experiencing
a recurrence of ulceration (Hjelm and Beebwa, 2013).
Changing and challenging patients’ problematic beliefs,
behaviours and lifestyles is considered the first-line approach
in providing successful DFU care (Searle et al, 2005). It is
important for nurses to assess the effect of existing beliefs
on a patient’s diabetes management (Macaden and Clarke,
2010). Nurses should not make an assumption based on an
individual’s cultural beliefs; rather, nurses who know that
culture is subjective and dynamic, can generate individualised
care plans based on each patient’s cultural needs (Fleming
and Gillibrand, 2009).

When offering treatment to individuals living with DFUs,
nurses must keep in mind the human being as a whole,
thus taking into account the diverse elements of their life
and their influences on their condition. Understanding the
consequences of DFUs and implementing evidence-based
care is vital if the nurse is to deliver successful treatment and
to reduce the risk of lower extremity amputations (Cárdenas
et al, 2015; Goie and Naidoo, 2016). The interventions also
ought to consider how the complexities linked with diabetes
may impact on patients’ beliefs as well as their emotional
and behavioural reactions to DFUs. Putting into practice
health promotion programmes according to the health belief
model is advantageous in terms of predicting and altering

An open system that is unique,
dynamic, multidimensional, and

has self-responsibility

A circumstance where the nursing
care is continuously being given

and with which a patient interacts

Human being Environment

Health Nursing

A person’s wellbeing ranges
from a high level of wellness to

terminal illness as experienced by
the clients

Actions given in tandem by nurses
as follows: assessment, labelling,

planning, intervention, and
evaluation

Nursing
metaparadigm

DIABETIC FOOT

British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT S43

©
2
01
9
M
A
H
ea
lth
ca
re
L
td

self-care behaviours of individuals living with a DFU (Farsi
et al, 2009). In addition, a holistic treatment method that
places emphasis on the body, mind, and soul should be taken
into account. For example, meditation-based therapies may
offer immediate positive benefits in such individuals because
of their ability to improve self-care behaviour, self-reliance,
and self-control (Priya and Kalra, 2018). With respect to
diabetes, the health belief model, social cognitive theory,
and the transtheoretical model can all be integrated into
interventions as they address the complexities of behavioural
change as well as the improvement of clinical outcomes
(Burke et al, 2014).

Environment
Fawcett mentioned ‘environment’ as a place where nursing
care is delivered (Fawcett and DeSanto-Madeya, 2013).
Environment undoubtedly influences the state of the
human being; while the human being also influences
their environment (Fawcett, 2000). Several environmental
factors increase the incidence of DFU, including poverty,
urbanisation, HIV infection, unhygienic conditions, poor
financial support, cultural practices, and a barefoot lifestyle
(Desalu et al, 2011).

Diabetes and its complexities are linked with a strong
gene-environmental interaction, which is influenced by
modernisation and lifestyle changes such as the intake of
unhealthy food, a lack of physical activities, and a high
level of mental stress (Ramachandran et al, 2010; Shah and
Kanaya, 2014). Additionally, studies have acknowledged the
complex interaction between genes and the environment
that alter genetic expression as this is vital in contributing
pathogenic diabetes mechanisms and their consequences (ie,
DFUs) (Jirtle and Skinner, 2007). However, the mechanism
concerned with how environmental factors lead to DFUs
still remains underexplored in the literature. Health
promotion programmes are an important part of the care
of patients with diabetes, because of the severity of the
diabetic foot problems that can occur (Tamir, 2007). Nurses
should aim to create a therapeutic environment based on the
patient’s needs and ethical perspectives in order to prevent or
reduce the impact of those internal and external factors that
could complicate the illness (Lopes, 2008).

The ‘environment’ domain also concentrates on the
life principles that influence patients’ lives. For example,
some individuals with a DFU may present with feelings
of hopelessness and helplessness. They have lost their
self-esteem, fear being poor because they cannot work,
feel isolated and are afraid of being dependent on others
(Hjelm and Beebwa, 2013). Psychosocial interventions are
highly effective in addressing emotional issues along with
improving glycaemic control in patients with diabetes (Xie
and Deng, 2017). Cognitive behavioural therapy-based
(CBT) techniques focusing on psychological factors and
self-management might therefore be the most effective
interventions (Vileikyte and Gonzalez, 2014).

Neuman and Fawcett (2011) pointed out that the
‘environment’ consists of five client system variables:
■■ Physiological
■■ Psychological

■■ Sociocultural
■■ Developmental
■■ Spiritual.

Physiological variable
The physiological variable refers to what an individual thinks
about their body, home, and neighbourhood. An individual
with a DFU often wishes that their ulcer will either heal
or improve (Hjelm and Beebwa, 2013). When arranging
diabetes treatments, nurses, patients and their families are
advised to discuss self-management, functional limitations
and caregiver support (Morrow et al, 2008). Patients ought
to be given enough knowledge to make decisions regarding
treatment. ‘Knowledge’ refers to meal planning, physical
activities, weight control, routine blood glucose monitoring,
medication, and foot care (Baghbanian and Tol, 2012).

Psychological variables
The psychological variable reflects an individual’s perceptions
related to their current disease. Patients with DFUs
experience a ‘self-perception dilemma’—for example,
balancing the choice of wearing footwear to look and feel
normal and choosing footwear to protect their feet from foot
ulceration (Paton et al, 2014). This issue implies that foot
self-care-focused psycho-educational interventions may be
significant, and should target both patients’ misunderstanding
in relation to DFU risks, along with their emotional distress
(Vileikyte and Gonzalez, 2014).

Sociocultural variable
The sociocultural variable examines the meaning patients
ascribe to the social and cultural aspects of their daily
lives (Verberk, 2016). DFUs often lead to social isolation
resulting in low self-esteem, with the condition worsened
by sociocultural factors such as the habit of walking
barefoot (Neeru et al, 2015). Psychosocial assessment is an
important part of routine nursing care in individuals with
DFUs. Involving family members in a coping mechanism
approach may be helpful; this may involve using acceptance
techniques, cognitive reappraisal, problem-focused coping,
and pursuing social support. A wide spectrum of approaches
can be employed, including motivational interviewing, CBT,
and empowerment-based programmes. These interventions
can help deal with patients’ fears about diet and weight
issues, hypoglycaemia, and the risk of long-term diabetes
complications (Harvey, 2015).

Developmental variable
The developmental variable focuses on the individual’s
response to the changes needed to adopt a healthy lifestyle
and how they respond to the side-effects of treatments (Raz,
2013). Understanding how a patient responds may affect
treatment decisions and will improve therapy selection and
individual health outcomes (Cantrell et al, 2010).

Spiritual variable
The spiritual variable is concerned with how a person’s
spiritual beliefs affect how they view their condition
(Neuman and Fawcett, 2011). For example, some Muslim

British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT S45S44 British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT

©
2
01
9
M
A
H
ea
lth
ca
re
L
td

DFU patients may feel their illness has brought them closer
to God, may believe the disease erases sins, may fear God’s
punishment or their DFU may cause them to return to
religious practice. They may believe in God’s miracles and
mercy, and also that the healing process is a gift from God or
a reward (Salehi et al, 2012). In contrast, some patients do not
feel that their condition has brought them closer to God. One
study found that patients with diabetes varied considerably
in their views on the impact of spirituality on their illness,
from minimal to profound (Gupta and Anandarajah, 2014).
Therefore, in some patients diabetes self-management
interventions may be enhanced by including a spiritual
dimension (Baig et al, 2014). One study found that greater
religiosity in a diabetic population rendered significantly
better glycaemic control (How et al, 2011). In line with
this reasoning, Koenig argues that religion builds a positive
attitude towards all situations and encourages the person
to be motivated and to be able to deal with unfortunate
experiences in life, including disease (Koenig, 2004).

Nurses can use their understanding of the ‘environment’
domain to improve patients’ health status, drawing on
evidence-based treatment recommendations. The optimal
healing environment framework can also be used in nursing
interventions as it aims to improve healing and health creation,
which is a critical aspect of disease management (Huisman
et al, 2012). In addition, strategies for diabetes prevention
should aim at fostering a ‘diabetes-protective lifestyle’ while
concurrently enhancing the resistance of the human organism
to pro-diabetic environmental and lifestyle aspects (Kolb
and Martin, 2017). These strategies potentially accelerate the
healing process and improve patients’ health outcomes.

Health
Fawcett described ‘health’ as a person’s wellbeing—
ranging from a high level of wellness to terminal illness as
experienced by individuals (Fawcett, 1996). Complications
of diabetes affecting the limbs are common, multifaceted,
and costly. Diabetic foot ulceration is a severe public health
issue that is more likely to develop in older people who have
had diabetes for many years, with hypertension, a history
of smoking, and diabetic retinopathy (Zhang et al, 2017).
Moreover, an individual with a DFU has a greater than
twofold increased mortality compared with non-ulcerated
diabetic individuals (Chammas et al, 2016). This critical issue
may encourage and assist nurses in being proactive rather
than reactive when promoting health among DFU patients.
Early interventions to prevent DFUs and limb amputations,
along with an entire assessment for decreasing the incidence
of micro- and macrovascular complexities, should be
considered (Al-Rubeaan et al, 2017).

Patients must have the ability to perceive, seek, reach,
engage with and in many countries pay for healthcare
services, otherwise their disease will become more
complicated (Levesque et al, 2013). Poor access to
healthcare services has been shown to be related to the
greater frequency of foot ulceration (Prompers et al, 2007).
Four barriers to healthcare access need to be identified
by clinical nurses: lack of knowledge regarding healthcare
services, unique sociocultural and religious beliefs, previous

experiences with healthcare providers, and the influence of
significant other(s) (Alzubaidi et al, 2015).

Patients’ behaviour may be viewed as an aspect of health.
Incorrect self-foot care behaviour is linked to an increased
risk of DFUs, therefore, patients with diabetes should be
guided on how to perform foot care correctly in order to
prevent ulceration or recurrence of ulceration and other
complications of diabetes (Suico et al, 1998). Foot care refers
to daily foot examination, avoiding extremes of hot and cold
underfoot, and the use of appropriate footwear when walking
(Saurabh et al, 2014). Nurses should promote routine foot
care, giving special attention during follow-up care to those
from rural regions in countries with a tradition of people
walking barefoot, provide or signpost weight-loss programmes,
and manage neuropathy comprehensively with the purpose of
reducing the incidence of DFUs (Mariam et al, 2017).

Quality of life also links with the ‘health’ domain of
the nursing metaparadigm (Parse, 1990). DFUs impact on
patients’ health-related quality of life due to lower extremity
amputations (Goodridge et al, 2005). The presence of
ulceration affects a person’s functioning and mobility and
decreases quality of life (Winkley et al, 2009). Moreover, the
anxiety associated with re-ulceration and recurrence of foot
infection also leads to a poor quality of life (Price, 2004).
Stress from unemployment, patients’ dependency status,
diabetic foot pain, and problems arising from daily foot ulcer
dressing may be the primary triggers of a lower quality of
life among individuals with DFU. Assessing the patient’s feet
at regular intervals, especially if they are at a high level of
risk of ulceration, and educating patients and their families
with reference to foot care, will reduce the cost of treatment
along with improving patients’ quality of life (Sothornwit et
al, 2018).

Pender (1990) stated that the ‘health’ domain of the
nursing metaparadigm had five dimensions:
■■ Effects
■■ Attitudes
■■ Activities
■■ Aspirations
■■ Accomplishments.

Effects
‘Effects’ refer to the psychological aspects of health. For
example, certain emotions and feelings may moderate
the immune function (Kiecolt-Glaser and Glaser, 1987).
Psychological stress impacts DFU healing (Gouin and
Kiecolt-Glaser, 2011; Woo, 2012). In addition, a higher
level of anxiety and depression is associated with prolonged
wound healing (Cole-King and Harding, 2001). Depression
can affect the immune system, resulting in prolonged
infection and delayed wound healing (Kiecolt-Glaser and
Glaser, 2002). Integrating mental health nurses into the
multidisciplinary team treating individuals with DFUs, and
early diagnosis and management may help improve healing
rates and reduce healthcare expenditure (Steel et al, 2016).

Attitudes
‘Attitudes’ are the beliefs a persons has about their life
situations that influence health (Pender, 1990). Incorrect

DIABETIC FOOT

British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT S45

©
2
01
9
M
A
H
ea
lth
ca
re
L
td

beliefs about the diabetic foot potentially increase the
likelihood of DFU (Hjelm and Beebwa, 2013). Individuals
with diabetes have been found to have a mixture of
correct and incorrect information and beliefs about foot
care (Sayampanathan et al, 2017). Healthcare providers
should endeavour to provide foot care education with the
intention of reducing the burden of DFU complexities.
This involves preventing and managing trauma and foot
infection, managing abnormal pressure points, managing
associated cardiovascular diseases, managing pre-existing
vascular damage and peripheral neuropathy, improving
poor glycaemic control, dealing with foot deformities, and
improving awareness and self-care (Seyyedrasooli et al, 2015).

Activities
‘Activities’ can be interpreted as patterns of energy distribution
and the person’s ability to take part in play, meaningful work,
and positive life patterns (Pender, 1990). Patients with DFUs
may expend greater energy on supporting wound healing
than those without DFUs (Sheahan et al, 2017). An individual
with a DFU is advised to wear their off-loading devices at all
times, ie, when walking, exercising and during other activities
until the ulcer heals (Armstrong et al, 2003). Employing an
off-loading device is an effective treatment for healing plantar
foot ulcers and preventing their recurrence (Bus, 2016). These
will be prescribed by the podiatrist who will focus on the
interplay between the frequency (weight-bearing activity),
quality (dynamic foot function) and magnitude (pressure)
involved. Likewise, foot-specific exercise programmes at
an appropriate stage in the neuropathic process should be
considered (Cerrahoglu et al, 2016). A progressive and well-
observed weight-bearing physical activity, including balancing
exercises and leg strengthening, can be influential for patients’
health outcomes (DiLiberto et al, 2016). Foot assessment as a
part of routine foot-screening and the evaluation of findings
ought to guide clinical decisions, which may improve dynamic
foot function among other appropriate interventions such as
wearing the appropriate footwear (Formosa et al, 2016; Mishra
et al, 2017). Specialist centres offering the opportunity to
participate in exercise training should work in tandem to alter
patients’ lifestyles by encouraging appropriate daily physical
activities (Francia et al, 2014; Matos et al, 2018).

Aspirations
‘Aspirations’ refer to self-actualisation and the extent to
which a patient actively engages in social interactions
(Pender, 1990). Support from individual social networks
and the community is linked with better diabetes self-
management and health-related outcomes (Koetsenruijter
et al, 2015). Social support, particularly from the individual’s
family, has a pivotal role in controlling blood glucose and
HbA1c levels (Rad et al, 2013; Shao et al, 2017). Health
professionals and policy makers are encouraged to provide
community support groups for patients with diabetes
(Hill et al, 2013; Hu et al, 2015). The social network-
based intervention Powerful Together with Diabetes in the
Netherlands aimed at improving diabetes self-management
and helped to diminish social problems in socially deprived
neighbourhoods (Vissenberg et al, 2017). A strong

relationship between patients with DFUs and their health
providers and family will promote compliance with diabetic
self-care activities.

Accomplishments
‘Accomplishments’ refer to ‘transcendence, creativity, and
enjoyment’ as attributes of the health state (Pender, 1990).
This refers to personal achievements in coping with diabetes
and preventing or healing DFUs. In type 1 diabetes linked
with complex insulin therapies, the objective is to help
individuals attain better control of blood glucose levels by
adjusting insulin doses. In type 2 diabetes, improvement
in blood glucose levels is commonly based on behavioural
changes, including reduced calorie intake and increased
physical activity (Franc et al, 2011). Thus, establishing and
executing appropriate diabetes guidelines for individuals with
diabetes is of critical importance. Nurses should determine
the related factors that contribute to the failure of current
interventions with the intention of developing the most
advantageous strategies for the enhancement of therapies.

Achieving an optimum health condition
The health domain and disease are the main aspects
of patient-centred care that require multidimensional
approaches. In order to achieve an optimum health
condition, clinical nurses, in collaboration with other health
professionals, must be engaged in accelerating wound
healing and diminishing risk factors for limb amputation
(Komelyagina et al, 2016; Buggy and Moore, 2017). Likewise,
DFUs require specific and comprehensive treatment, which
cannot be carried out by one healthcare provider alone, but
must involve a multidisciplinary team (Bentley and Foster,
2007). Hence, to be effective, it is necessary for each of these
elements to be combined to attain optimum health among
individuals with or at risk of DFUs. In addition, nurses are
advised to implement comprehensive care plans that are
focused not only on treating the physical illness but also on
improving patients’ mental health status.

Nursing
Fawcett (1996) described ‘nursing’ as actions given by
nurses in a systematic and organised process, encompassing
assessment, labelling, planning, intervention, and evaluation.
Florence Nightingale noted that nurses have a responsibility
to promote health and prevent disease complications
(Winkelstein, 2009). In the care of patients with DFUs,
nurses are actively involved in preventing limb amputations
by providing early detection of any changes in foot sensation,
promoting foot care, using advanced wound dressings and
applying advanced technologies such as utilising growth
factor therapy (Seaman, 2005; Aalaa et al, 2012). To maintain
a proper balance between theory and practice, a nurse
must be up to date with current knowledge and practice
in the field (Ajani and Moez, 2011). Wound-care training,
continuous professional development, evidence‐based
practice implementation and wound-care research should be
fostered (Kumarasinghe et al, 2018).

The nursing domain also encompasses clinical nurses,
their attributes and how they use their knowledge and skills

British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT S47S46 British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT

©
2
01
9
M
A
H
ea
lth
ca
re
L
td

when providing care (Branch et al, 2015). The American
Diabetes Association (ADA) states that daily and proper care
is relevant in preventing DFU complications (ADA, 2013).
Clinical nurses are required to be experts in performing
DFU management to attain improved patient outcomes.
Patient assessment should identify the risk factors for limb
amputation, as well as other related complications. These
are focused on vascular adequacy, neurological or sensory
condition, suitability of footwear, presentation of foot
malformation, wound size, the severity of tissue damage, and
environmental factors (Roberts and Newton, 2011).

The ‘nursing’ domain includes a caring process consisting
of five conceptualisations of caring: caring as an intervention,
caring as a moral imperative, caring as a human trait, caring
as an interpersonal interaction, and caring as an effect
(Morse et al, 1991). In the case of the patient with a DFU,
the caring process involves three areas: continuity of care,
disease experience, and disease management (Aliasgharpour
and Nayeri, 2012). As a result, nurses must ‘understand how
they affect patients’ because every therapeutic interaction
among nurses and patients should have an impact on patient
wellbeing (LeVasseur, 1999). From a nursing perspective, the

approach given by nurses includes initial assessments and
goal-setting (Eggleton and Kenealy, 2009).

There are four major goals in nursing: patient care, health
promotion, achieving patient concordance with treatment
and prevention of disease. To achieve these goals, nurses
can play different roles such as healthcare provider, leader,
researcher, educator, care connector, and supporter of the
rights of patients (Black et al, 1997). Prevention of DFUs is
divided into two parts:
■■ Patient education (annual foot screening, self-inspection,

self-care practice, wearing appropriate footwear)
■■ Making the necessary alterations for a healthy lifestyle

(performing regular exercise, avoiding smoking, and
ensuring glycaemic, blood pressure and blood lipid
control) (Dangol, 2011).
Providing these interventions requires ‘carative’ factors

rather than solely curative factors. Showing care for the
patient as a whole person, involving the mind, body, and soul,
will encourage a healing process (Pajnkihar et al, 2017). DFU
and lower extremity amputation not only precedes morbidity,
disability, and mortality, but also renders immense negative
impacts in respect of psychological stress, dependency, social
isolation, and trauma (Dangol, 2011).

DFU interventions cannot be undertaken solely by nurses
and must involve a multidisciplinary team including the
GP, diabetes educator, podiatrists and hospital consultants.
Diabetes nurse specialists are an essential part of this team
(Amirmohseni and Nasiri, 2014).Nurses act as a key link
to the multidisciplinary team. The ADA recommends a
multidisciplinary team approach to DFU care (ADA, 2013).

Nurses should provide positive physical and psychological
support that may sustain long-term coping strategies and protect
DFU patients from the negative consequences of chronic
diabetes. Furthermore, improved personal resources, for instance,
greater resilience, would promote better cognitive functioning,
stronger willpower and lead to an improved quality of life.

Implications for research and nursing practice
This article focuses on the shared goals and wider
perspectives concerning the all-important nursing
metaparadigm of DFU care. The nursing metaparadigm
is a key element of nursing theory and has been rapidly
developed and integrated into nursing practice (Schim et
al, 2007). The nursing metaparadigm is relevant to current
nursing practice due to its ability to identify the scope of
knowledge as a practical guideline in providing DFU care.
Mutual interactions amid domains of this metaparadigm
(human being, environment, health, and nursing) will
enhance patient outcomes and the quality of nursing care.

This nursing metaparadigm creates the potential for
improvements in DFU care by:
■■ Providing the fundamental standpoint of nursing practice

in DFU care
■■ Helping nurses to understand their purpose and role in

the healthcare setting concerning DFU complexities
■■ Supporting nurses to make appropriate decisions about

interventions on DFUs
■■ Allowing nurses to plan and implement care

systematically so as to obtain enhanced outcomes

Table 1. Diabetic foot risk stratification and triage developed by the
Scottish Intercollegiate Guideline Network

Categories Definition Action

Active Presence of active
ulceration

Spreading infection

Critical ischaemia

Gangrene or unexplained
hot and red swollen foot
with or without the presence
of pain

Rapid referral and management by
a member of a multidisciplinary foot
team

Agreed and tailored management or
treatment plan according to patient
needs

Provide written and verbal education
with emergency contact numbers

Referral for specialist intervention
when required

High Previous ulceration or
amputation or more than
one risk factor present,
e.g., loss of sensation or
signs of peripheral vascular
disease with callus or
deformity

Annual assessment by a specialist
podiatrist

Agreed and tailored management or
treatment plan by specialist podiatrist
according to patient needs

Provide written and verbal education
with emergency contact numbers

Referral for specialist intervention if
or when required

Moderate One risk factor present
e.g., loss of sensation or
signs of peripheral vascular
disease without callus or
deformity

Annual assessment by a podiatrist

Agreed and tailored management or
treatment plan by podiatrist according
to patient needs

Provide written and verbal education
with emergency contact numbers

Low No risk factors present e.g.,
no loss of sensation, no
signs of peripheral vascular
disease and no other risk
factors

Annual screening by a suitably trained
health professional. Agreed self-
management plan

Provide written and verbal education
with emergency contact numbers

Appropriate access to podiatrist if or
when required

Source: Scottish Intercollegiate Guidelines Network, 2017

DIABETIC FOOT

British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT S47

©
2
01
9
M
A
H
ea
lth
ca
re
L
td

■■ Improving the communication with others due to the fact
that DFU interventions require collaboration with other
health professionals

■■ Enriching the professional status among nurses in daily
clinical practice

■■ Helping to describe, explain, and predict phenomena in
DFU care

■■ Serving to guide assessment, management, and evaluation
of nursing care

■■ Bridging the gap between theory, research and the realities
of everyday practice in DFU care

■■ Providing a framework to strengthen the practice of
research in DFU care.

■■ Offering the opportunity to specify the contextual
conditions influencing DFU intervention effectiveness.
In the wake of these issues, this article indicates that there

is a growing body of literature directly supporting positive
contributions in association with the nursing metaparadigm
as well as DFU care. Hence, the comprehensive management
of DFU should be addressed in those aspects (human
being, environment, health, and nursing) (Seaman, 2005).
Conducting an appropriate assessment must be taken into
consideration in the course of providing DFU care. To be
effective, the Scottish Intercollegiate Guidelines Network
(SIGN) (2017) guideline on management of diabetes may be
incorporated into the assessment because it clearly identifies
the risk factors of limb amputations as well as other related
complications (Table 1).

Historically, the management of DFU was established
based on the three important basic treatments: sharp
debridement therapy, using the off-loading device, and
diabetic foot health education (Naves, 2016). However,
these treatments have been developed and expanded into
the following:
■■ Use of dressings promoting a moist wound environment
■■ Surgical debridement
■■ Use of a wound off-loading device
■■ Performing vascular assessment
■■ Managing wound infection
■■ Controlling glycaemic index
■■ Collaborating with the multidisciplinary DFU care team,

which is currently becoming a pillar of current treatment
(Everett and Mathioudakis, 2018).
Today, clinical nurses are required to be experts in all of

these elements to attain improved health-related outcomes.
As the incidence of diabetes continues to rise,

appropriate treatment may assist to prevent extensive
surgery and limb amputation. Therefore, providing
comprehensive treatment modalities is imperative to

maximise wound healing. Successful treatment of DFUs
also requires combining holistic and systemic approaches—
treating the whole patient and not just the wound
(Criscitelli, 2018). Notably, a nursing metaparadigm-based
approach offers promising strategies for an enhanced
understanding of the interventions available to address DFU
complexities. In addition, the healthcare team needs to
understand the underlying physiological and psychological
aspects of the patient that can delay wound healing. DFUs
are multifaceted conditions that deserve the most current
evidence-based interventions to achieve the best outcomes.
Clinical nurses must actively engage in managing diabetes
and its complications as well as preventing the severity of
those illnesses.

Conclusion
It is hoped that this article will encourage collaborative
practice between nurses and other healthcare providers
working in DFU care and more generally in the care of
people with diabetes. It is also noted that any nursing
metaparadigm-driven approach in daily practice is
not without its challenges due to the complexities of
implementation. Nonetheless, a theory-driven approach is
well worth the effort in overcoming problems in practice,
particularly in the care of people with DFUs. Further
research is needed to understand outcomes linked with each
domain of the metaparadigm. Broadening of the theoretical
description should also be explored, aimed at thoroughly
identifying and explaining each domain of the nursing
metaparadigm. This will ultimately lead to a standard of care
that prevents the severe side effects of diabetes.

Furthermore, this article aimed to expand the knowledge
base of nurses working in DFU care. Finally, by integrating
the nursing metaparadigm into DFU care, nurses are able to
recognise the unique contribution of a theory that helps to
generate effective care linked to daily nursing practice. BJN
Declaration of interest: none

KEY POINTS
■ Diabetic foot ulcers (DFUs) are multifaceted conditions that deserve the

most current evidence-based interventions to achieve the best outcomes

■ It is essential that nurses integrate the nursing metaparadigm into DFU care
in order to provide comprehensive nursing care

■ The multidisciplinary DFU care team is currently becoming a pillar of current
DFU treatment.

■ Clinical nurses are required to be experts in all aspects of DFU care

CPD reflective questions

■ After reading this article, what other facts or issues on diabetic foot ulcers (DFUs) need to be considered when caring
for this group of patients?

■ How will you know if you are successful in providing DFU care to your patients? Consider the factors that may delay
healing of these wounds

■ What implications does this paper have for your clinical nursing practice in caring for patients with DFUs?

British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT S49S48 British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT

©
2
01
9
M
A
H
ea
lth
ca
re
L
td

PhD funding: the work for this article was supported by the
Indonesia Endowment Fund for Education (LPDP) through a
doctoral scholarship to the Doctor of Philosophy Program in Nursing,
International and Collaborative with Foreign University Program,
Mahidol University, Thailand

Acknowledgment: the authors would like to extend gratitude to
nursing colleagues at the Faculty of Health Sciences, Universitas
Muhammadiyah Magelang, Indonesia. A special thank to the
author’s co-advisor, Dr Margaret Grey, Professor of Nursing, School
of Nursing, Yale University, USA. The article on which she is lead
author, entitled ‘A revised self- and family management framework’
(2015), inspired the lead author in writing this article

Aalaa M, Malazy OT, Sanjari M, Peimani M, Mohajeri-Tehrani M. Nurses’
role in diabetic foot prevention and care; a review. J Diabetes Metab
Disord. 2012; 11(1):24. https://doi.org/10.1186/2251-6581-11-24

Ajani K, Moez S. Gap between knowledge and practice in nursing. Procedia
Soc Behav Sci. 2011; 15:3927–3931. https://doi.org/10.1016/j.
sbspro.2011.04.396

Aliasgharpour M, Nayeri ND. The care process of diabetic foot ulcer patients:
a qualitative study in Iran. J Diabetes Metab Disord. 2012; 11(1):27.
https://doi.org/10.1186/2251-6581-11-27

Al-Rubeaan K, Almashouq MK, Youssef AM et al. All-cause mortality among
diabetic foot patients and related risk factors in Saudi Arabia. PLoS ONE.
2017; 12(11):e0188097. https://doi.org/10.1371/journal.pone.0188097

Alzubaidi H, McNamara K, Browning C, Marriott J. Barriers and enablers to
healthcare access and use among Arabic-speaking and Caucasian English-
speaking patients with type 2 diabetes mellitus: a qualitative comparative
study. BMJ Open. 2015; 5(11):e008687. https://doi.org/10.1136/
bmjopen-2015-008687

Amirmohseni L, Nasiri M. The important role of specialist nurse in the
improvement of patients with diabetic foot ulcer. Letter to the editor.
Jentashapir Journal of Health Research. 2014; 5(5):e23226. https://doi.
org/10.17795/jjhr-23226

Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their
recurrence. N Engl J Med. 2017; 376(24):2367-2375

Armstrong DG, Lavery LA, Kimbriel HR, Nixon BP, Boulton AJM. Activity
patterns of patients with diabetic foot ulceration: patients with active
ulceration may not adhere to a standard pressure off-loading regimen.
Diabetes Care. 2003; 26(9):2595–2597

American Diabetes Association. Standards of medical care in diabetes—2013..
Diabetes Care. 2013; 36(Suppl 1):S11–S66. https://doi.org/10.2337/
dc13-S011

Baghbanian A, Tol A. The introduction of self-management in type 2 diabetes
care: A narrative review. J Educ Health Promot. 2012; 1:35

Baig AA, Locklin CA, Wilkes AE et al. Integrating diabetes self-management
interventions for Americans into the Catholic church setting. J Relig
Health. 2014; 53(1):105–118. https://doi.org/10.1007/s10943-012-
9601-1

Baig AA, Benitez A, Quinn MT, Burnet DL. Family interventions to improve
diabetes outcomes for adults. Ann N Y Acad Sci. 2015; 1353:89–112.
https://doi.org/10.1111/nyas.12844

Bender M. Re-conceptualizing the nursing metaparadigm: Articulating the
philosophical ontology of the nursing discipline that orients inquiry
and practice. Nurs Inq. 2018; 25(3):e12243. https://doi.org/10.1111/
nin.12243

Bender M, Feldman MS. A practice theory approach to understanding the
interdependency of nursing practice and the environment: implications
for nurse-led care delivery models. ANS Adv Nurs Sci. 2015; 38(2):96–
109. https://doi.org/10.1097/ans.0000000000000068

Bentley J, Foster A. Multidisciplinary management of the diabetic foot ulcer.
Br J Community Nurs. 2007; 12(12):S6–S10

Black J, Matassarin-Jacobs E, Luckmann J. Medical-surgical nursing: clinical
management for continuity of care (5th edn). Philadelphia (PA): WB
Saunders; 1997

Bonner T, Foster M, Spears-Lanoix E. Type 2 diabetes-related foot care
knowledge and foot self-care practice interventions in the United States:
a systematic review of the literature. Diabet Foot Ankle. 2016; 7:29758

Boyko EJ, Seelig AD, Ahroni JH. Limb- and person-level risk factors for
lower-limb amputation in the prospective Seattle diabetic foot study.
Diabetes Care. 2018; 41(4):891–898. https://doi.org/10.2337/dc17-2210

Branch C, Deak H, Hiner C, Holzwart T. Four nursing metaparadigm.
Indiana University South Bend Undergraduate Research Journal. 2015;
16: 121-130

Buggy A, Moore Z. The impact of the multidisciplinary team in the

management of individuals with diabetic foot ulcers: a systematic
review. J Wound Care. 2017; 26(6):324–339. https://doi.org/10.12968/
jowc.2017.26.6.324

Burke SD, Sherr D, Lipman RD. Partnering with diabetes educators to
improve patient outcomes. Diabetes Metab Syndr Obes. 2014; 7:45–53.
https://doi.org/10.2147/dmso.s40036

Bus SA. The role of pressure offloading on diabetic foot ulcer healing and
prevention of recurrence. Plast Reconstr Surg. 2016; 138(3 Suppl):179S–
187S. https://doi.org/10.1097/prs.0000000000002686

Cantrell RA, Alatorre CI, Davis EJ et al. A review of treatment response
in type 2 diabetes: assessing the role of patient heterogeneity. Diabetes
Obes Metab. 2010; 12(10):845–857. https://doi.org/10.1111/j.1463-
1326.2010.01248.x

Cárdenas MK, Mirelman AJ, Galvin CJ et al. The cost of illness attributable
to diabetic foot and cost-effectiveness of secondary prevention in Peru.
BMC Health Serv Res. 2015; 15:483. https://doi.org/10.1186/s12913-
015-1141-4

Cerrahoglu L, Kosan U, Sirin TC, Ulusoy A. Range of motion and plantar
pressure evaluation for the effects of self-care foot exercises on diabetic
patients with and without neuropathy. J Am Podiatr Med Assoc. 2016;
106(3):189–200. https://doi.org/10.7547/14-095

Chammas NK, Hill RLR, Edmonds ME. Increased mortality in diabetic
foot ulcer patients: the significance of ulcer type. J Diabetes Res. 2016;
2016:2879809. https://doi.org/10.1155/2016/2879809

Chung LYF, Wong FKY, Chan MF. Relationship of nurses’ spirituality to their
understanding and practice of spiritual care. J Adv Nurs. 2007; 58(2):158–
170. http://doi.org/10.1111/j.1365-2648.2007.04225.x

Cole-King A, Harding KG. Psychological factors and delayed healing in
chronic wounds. Psychosom Med. 2001; 63(2):216–220

Criscitelli T. The future of wound care. AORN J. 2018; 107(4):427–429.
https://doi.org/10.1002/aorn.12118

Dangol N. Nurses’ role in the prevention of diabetic foot ulcer (degree
thesis). Helsinski, Finland: Arcada University of Applied Sciences; 2011.
https://tinyurl.com/yyapt6xa (accessed 7 March 2019)

de Jesus Pereira MT, Magela Salomé G, Guimarães Openheimer D, Cunha
Espósito VH, Aguinaldo de Almeida S, Masako Ferreira L. Feelings
of powerlessness in patients with diabetic foot ulcers. Wounds. 2014;
26(6):172–177

Delmas L. Best practice in the assessment and management of diabetic foot
ulcers. Rehabil Nurs. 2006; 31(6):228–234

Desalu OO, Salawu FK, Jimoh AK, Adekoya AO, Busari OA, Olokoba
AB. Diabetic foot care: self reported knowledge and practice among
patients attending three tertiary hospital in Nigeria. Ghana Med J. 2011;
45(2):60–65

DiLiberto FE, Baumhauer JF, Nawoczenski DA. The prevention of diabetic
foot ulceration: how biomechanical research informs clinical practice.
Braz J Phys Ther. 2016; 20(5):375–383. https://doi.org/10.1590/bjpt-
rbf.2014.0195

Donaldson SK, Crowley DM. The discipline of nursing. Nursing Outlook.
1978; 26(2):113–120

Eggleton K, Kenealy T. What makes care plus effective in a provincial
primary health organisation? Perceptions of primary care workers. J Prim
Health Care. 2009; 1(3):190–197

Everett E, Mathioudakis N. Update on management of diabetic foot ulcers.
Ann N Y Acad Sci. 2018; 1411(1):153–165. https://doi.org/10.1111/
nyas.13569

Farsi Z, Jabari-Moroui M, Ebadi A, Zandi A. Application of health belief
model in change of self care behaviors of diabetic patients. Iran Journal of
Nursing. 2009;22(61):61–72

Fawcett J. The ‘what’ of theory development. In: Theory development: what,
why, how. New York (NY): National League for Nursing; 1978

Fawcett J. Hallmarks of success in nursing theory development. In Chinn WP
(ed). Advances in nursing theory development. Rockville (MD): Aspen
Systems, 1983: 3-18

Fawcett J. The metaparadigm of nursing: present status and future
refinements. Image J Nurs Sch. 1984; 16(3):84–89

Fawcett J. Conceptual models and nursing practice: the reciprocal
relationship. J Adv Nurs. 1992; 17(2):224–228

Fawcett J. On the requirements for a metaparadigm: an invitation to
dialogue. Nurs Sci Q. 1996; 9(3):94–97; discussion 98-106. https://doi.
org/10.1177/089431849600900305

Fawcett J. The state of nursing science: hallmarks of the 20th and 21st
centuries. Nurs Sci Q. 1999; 12(4):311–315; discussion 315-318. https://
doi.org/10.1177/089431849901200411

Fawcett J. Analysis and evaluation of contemporary nursing knowledge:
nursing models and theories. Philadelphia (PA): FA Davis; 2000

Fawcett J. Contemporary nursing knowledge: analysis and evaluation of
nursing models and theories (2nd edn). Philadelphia (PA): FA Davis; 2005

Fawcett J. Contemporary nursing knowledge: analysis and evaluation of
nursing models and theories. Philadelphia (PA): FA Davis; 2006

Fawcett J, DeSanto-Madeya S. Contemporary nursing knowledge: analysis
and evaluation of conceptual models and theories (3rd edn). Philadelphia
(PA): FA Davis; 2013

DIABETIC FOOT

British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT S49

©
2
01
9
M
A
H
ea
lth
ca
re
L
td

Fejfarová V, Jirkovská A, Dragomirecká E et al. Does the diabetic foot have
a significant impact on selected psychological or social characteristics
of patients with diabetes mellitus? J Diabetes Res. 2014; 2014:371938.
https://doi.org/10.1155/2014/371938

Fleming E, Gillibrand W. An exploration of culture, diabetes, and
nursing in the South Asian community: a metasynthesis of qualitative
studies. J Transcult Nurs. 2009; 20(2):146–155. https://doi.
org/10.1177/1043659608330058

Formosa C, Gatt A, Chockalingam N. A critical evaluation of existing
diabetic foot screening guidelines. Rev Diabet Stud. 2016; 13(2–3):158–
186. https://doi.org/10.1900/rds.2016.13.158

Franc S, Daoudi A, Mounier S et al. Telemedicine and diabetes: achievements
and prospects. Diabetes Metab. 2011; 37(6):463–476. https://doi.
org/10.1016/j.diabet.2011.06.006

Francia P, Gulisano M, Anichini R, Seghieri G. Diabetic foot and exercise
therapy: step by step the role of rigid posture and biomechanics
treatment. Curr Diabetes Rev. 2014; 10(2):86–99

Goie TT, Naidoo M. Awareness of diabetic foot disease amongst patients with
type 2 diabetes mellitus attending the chronic outpatients department at
a regional hospital in Durban, South Africa. Afr J Prim Health Care Fam
Med. 2016; 8(1):e1–e8

Goodridge D, Trepman E, Embil JM. Health-related quality of life in diabetic
patients with foot ulcers: literature review. J Wound Ostomy Continence
Nurs. 2005; 32(6):368–377

Gouin J-P, Kiecolt-Glaser JK. The impact of psychological stress on wound
healing: methods and mechanisms. Immunol Allergy Clin North Am.
2011; 31(1):81–93. https://doi.org/10.1016/j.iac.2010.09.010

Grey M, Schulman-Green D, Knafl K, Reynolds NR. A revised self- and
family management framework. Nurs Outlook. 2015; 63(2):162-70.
https://doi.org/10.1016/j.outlook.2014.10.003

Gupta PS, Anandarajah G. The role of spirituality in diabetes self-
management in an urban, underserved population: a qualitative
exploratory study. R I Med J 2014; 97(3):31–35

Harvey JN. Psychosocial interventions for the diabetic patient. Diabetes
Metab Syndr Obes. 2015; 8:29–43. https://doi.org/10.2147/dmso.s44352

Hill J, Nielsen M, Fox MH. Understanding the social factors that contribute
to diabetes: a means to informing health care and social policies for the
chronically ill. Perm J. 2013; 17(2):67–72. https://doi.org/10.7812/
tpp/12-099

Hjelm K, Beebwa E. The influence of beliefs about health and illness on foot
care in Ugandan persons with diabetic foot ulcers. Open Nurs J. 2013;
7:123–132. https://doi.org/10.2174/1874434601307010123

How CB, Ming KE, Chin CY. Does religious affiliation influence glycaemic
control in primary care patients with type 2 diabetes mellitus? Ment
Health Fam Med. 2011; 8(1):21–28

Hu FB, Satija A, Manson JE. Curbing the diabetes pandemic: the need for
global policy solutions. JAMA. 2015; 313(23):2319–2320. https://doi.
org/10.1001/jama.2015.5287

Huisman ERCM, Morales E, van Hoof J, Kort HSM. Healing environment:
A review of the impact of physical environmental factors on users.
Building and Environment. 2012; 58:70–80. https://doi.org/10.1016/j.
buildenv.2012.06.016

Jirtle RL, Skinner MK. Environmental epigenomics and disease susceptibility.
Nat Rev Genet. 2007; 8(4):253–262. https://doi.org/10.1038/nrg2045

Keskek SO, Kirim S, Yanmaz N. Estimated costs of the treatment of
diabetic foot ulcers in a tertiary hospital in Turkey. Pak J Med Sci. 2014;
30(5):968–971. https://doi.org/10.12669/pjms.305.5182

Kiecolt-Glaser JK, Glaser R. Psychosocial moderators of immune function.
Annals of Behavioral Medicine. 1987; 9(2):16–20

Kiecolt-Glaser JK, Glaser R. Depression and immune function: central
pathways to morbidity and mortality. J Psychosom Res. 2002; 53(4):873–
876

Koenig HG. Spirituality, wellness, and quality of life. Sexuality Reproduction
and Menopause. 2004; 2(2):76–82. https://doi.org/10.1016/j.
sram.2004.04.004

Koetsenruijter J, van Lieshout J, Lionis C et al. Social support and health
in diabetes patients: an observational study in six European countries
in an era of austerity. PLoS ONE. 2015; 10(8):e0135079. https://doi.
org/10.1371/journal.pone.0135079

Kolb H, Martin S. Environmental/lifestyle factors in the pathogenesis
and prevention of type 2 diabetes. BMC Med. 2017; 15. https://doi.
org/10.1186/s12916-017-0901-x

Komelyagina EY, Volkovoy AK, Sanbanchieva NI, Zaichikova MF, Maksimov
NV, Antsiferov MB. Multidisciplinary team approach for diabetic foot
patients in an out-patient clinic. Klin Med (Mosk). 2016; 94(2):127–132
(article in Russian)

Kumarasinghe SA, Hettiarachchi P, Wasalathanthri S. Nurses’ knowledge on
diabetic foot ulcer disease and their attitudes towards patients affected: A
cross-sectional institution-based study. J Clin Nurs. 2018; 27(1–2):e203–
e212. https://doi.org/10.1111/jocn.13917

Lai H, Hsieh M. Alternative nursing interventions for facilitating holistic
nursing based on Eastern philosophy. Tzu Chi Nursing Journal. 2003;
2(1):13–19

LeVasseur JJ. Toward an understanding of art in nursing. ANS Adv Nurs Sci.
1999; 21(4):48–63

Levesque J-F, Harris MF, Russell G. Patient-centred access to health care:
conceptualising access at the interface of health systems and populations.
Int J Equity Health. 2013; 12:18. https://doi.org/10.1186/1475-9276-
12-18

Lopes FMBA. Environment as a dimension in nursing metaparadigm. Servir.
2008; 56(5–6):189–199 (article in Portuguese)

Macaden L, Clarke CL. The influence of locus of control on risk perception
in older South Asian people with Type 2 diabetes in the UK. Journal of
Nursing and Healthcare of Chronic Illness. 2010; 2(2):144–152. https://
doi.org/10.1111/j.1752-9824.2010.01054.x

Macioch T, Sobol E, Krakowiecki A et al. Health related quality of life in
patients with diabetic foot ulceration: translation and Polish adaptation of
Diabetic Foot Ulcer Scale short form. Health Qual Life Outcomes. 2017;
15(1):15. https://doi.org/10.1186/s12955-017-0587-y

Mariam TG, Alemayehu A, Tesfaye E et al. Prevalence of diabetic foot
ulcer and associated factors among adult diabetic patients who attend
the diabetic follow-up clinic at the University of Gondar Referral
Hospital, North West Ethiopia, 2016: institutional-based cross-
sectional study. J Diabetes Res. 2017; 2017:2879249. https://doi.
org/10.1155/2017/2879249

Matos M, Mendes R, Silva AB, Sousa N. Physical activity and exercise on
diabetic foot related outcomes: a systematic review. Diabetes Res Clin
Pract. 2018; 139:81–90. https://doi.org/10.1016/j.diabres.2018.02.020

Maydick DR, Acee AM. Comorbid depression and diabetic foot ulcers.
Home Healthc Now. 2016; 34(2):62–67. https://doi.org/10.1097/
nhh.0000000000000340

Mayfield JA, Reiber GE, Sanders LJ, Janisse D, Pogach LM, American
Diabetes Association. Preventive foot care in people with diabetes.
Diabetes Care. 2003; 26(Suppl 1):S78-79

McEwen M, Wills R. Theoretical basis for nursing. Philadelphia (PA):
Lippincott Williams & Wilkins; 2007

Miller BF, Keane CB, O’Toole, M (eds). Miller-Keane encyclopedia and
dictionary of medicine, nursing, and allied health. 7th edn. London:
Saunders/Elsevier; 2003

Mishra SC, Chhatbar KC, Kashikar A, Mehndiratta A. Diabetic foot. BMJ.
2017; 359:j5064

Morrow AS, Haidet P, Skinner J, Naik AD. Integrating diabetes self-
management with the health goals of older adults: a qualitative
exploration. Patient Educ Couns. 2008; 72(3):418–423. https://doi.
org/10.1016/j.pec.2008.05.017

Morse JM, Bottorff J, Neander W, Solberg S. Comparative analysis of
conceptualizations and theories of caring. Image J Nurs Sch. 1991;
23(2):119–126

Narres M, Kvitkina T, Claessen H et al. Incidence of lower extremity
amputations in the diabetic compared with the non-diabetic population:
a systematic review. PLoS ONE. 2017; 12(8):e0182081. https://doi.
org/10.1371/journal.pone.0182081

Naves CCLM. The diabetic foot: a historical overview and gaps in current
treatment. Adv Wound Care (New Rochelle). 2016; 5(5):191–197.
https://doi.org/10.1089/wound.2013.0518

Neeru B, Gagandeep K, Pal AJ, Bajwa SJS et al. Psychosocial, psychiatric, and
clinical implications of diabetic foot ulceration: A prospective analysis.
Journal of Social Health and Diabetes. 2015;3(2):89–94. https://doi.
org/10.4103/2321-0656.152805

Neuman B, Fawcett J. The Neuman systems model. 5th edn. Upper Saddle
River (NJ): Pearson; 2011

Olson JM, Hogan MT, Pogach LM, Rajan M, Raugi GJ, Reiber GE. Foot
care education and self management behaviors in diverse veterans with
diabetes. Patient Prefer Adherence. 2009; 3:45–50

Pajnkihar M, Štiglic G, Vrbnjak D. The concept of Watson’s carative factors
in nursing and their (dis)harmony with patient satisfaction. PeerJ. 2017;
5:e2940. https://doi.org/10.7717/peerj.2940

Papaspurou M, Laschou VC, Partsiopoulou P et al. Fears and health
needs of patients with diabetes: a qualitative research in rural
population. Med Arch. 2015; 69(3):190–195. https://doi.org/10.5455/
medarh.2015.69.190-195

Parekh AK, Goodman RA, Gordon C, Koh HK, HHS Interagency
Workgroup on Multiple Chronic Conditions. Managing multiple chronic
conditions: a strategic framework for improving health outcomes and
quality of life. Public Health Rep. 2011; 126(4):460–471. https://doi.
org/10.1177/003335491112600403

Parse RR. Health: a personal commitment. Nurs Sci Q. 1990; 3(3):136–140.
https://doi.org/10.1177/089431849000300309

Paton JS, Roberts A, Bruce GK, Marsden J. Patients’ Experience of
therapeutic footwear whilst living at risk of neuropathic diabetic foot
ulceration: an interpretative phenomenological analysis (IPA). J Foot
Ankle Res. 2014; 7(1):16. https://doi.org/10.1186/1757-1146-7-16

Pender NJ. Expressing health through lifestyle patterns. Nurs Sci Q. 1990;
3(3):115–122. https://doi.org/10.1177/089431849000300306

Price P. The diabetic foot: quality of life. Clin Infect Dis. 2004; 39(Suppl
2):S129-131. https://doi.org/10.1086/383274

British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT SPBS50 British Journal of Nursing 2019, Vol 28, No 6: TISSUE VIABILITY SUPPLEMENT

©
2
01
9
M
A
H
ea
lth
ca
re
L
td

Priya G, Kalra S. Mind-body interactions and mindfulness meditation in
diabetes. Eur Endocrinol. 2018; 14(1):35–41. https://doi.org/10.17925/
ee.2018.14.1.35

Priyadarshika H, Sudharshani W. Nurses’ knowledge on diabetic foot ulcer
disease and their attitudes towards patients affected: A cross‐sectional
institution‐based study. J Clin Nurs. 2018; 27(1-2):e203-e212. https://
doi.org/10.1111/jocn.13917

Prompers L, Huijberts M, Apelqvist J et al. High prevalence of ischaemia,
infection and serious comorbidity in patients with diabetic foot disease
in Europe. Baseline results from the Eurodiale study. Diabetologia. 2007;
50(1):18–25. https://doi.org/10.1007/s00125-006-0491-1

Rad GS, Bakht LA, Feizi A, Mohebi S. Importance of social support
in diabetes care. J Educ Health Promot. 2013; 2:62. https://doi.
org/10.4103/2277-9531.120864

Raghav A, Khan ZA, Labala RK, Ahmad J, Noor S, Mishra BK. Financial
burden of diabetic foot ulcers to world: a progressive topic to discuss
always. Ther Adv Endocrinol Metab. 2018; 9(1):29–31. https://doi.
org/10.1177/2042018817744513

Ramachandran A, Wan Ma RC, Snehalatha C. Diabetes in Asia. Lancet. 2010;
375(9712):408–418.

Raz I. Guideline approach to therapy in patients with newly diagnosed
type 2 diabetes. Diabetes Care. 2013; 36 Suppl 2:S139-144. https://doi.
org/10.2337/dcs13-2035

Registered Nurses’ Association of Ontario. Reducing foot complications for
people with diabetes. Toronto: Registered Nurses’ Association of Ontario;
2004

Ribu L, Wahl A. Living with diabetic foot ulcers: a life of fear, restrictions,
and pain. Ostomy Wound Manage. 2004; 50(2):57–67

Roberts P, Newton V. Assessment and management of diabetic foot ulcers.
Br J Community Nurs. 2011; 16(10):485–486, 488–490. https://doi.
org/10.12968/bjcn.2011.16.10.485

Rosa W, Estes T, Watson J. Caring Science Conscious Dying: An
Emerging Metaparadigm. Nurs Sci Q. 2017; 30(1):58–64. https://doi.
org/10.1177/0894318416680538

Roy T, Lloyd CE. Epidemiology of depression and diabetes: a systematic
review. J Affect Disord. 2012; 142(Suppl):S8-21. https://doi.org/10.1016/
s0165-0327(12)70004-6

Salehi S, Ghodousi A, Ojaghloo K. The spiritual experiences of patients
with diabetes-related limb amputation. Iran J Nurs Midwifery Res.
2012;17(3):225–228

Saurabh S, Sarkar S, Selvaraj K, Kar S, Kumar SG, Roy G. Effectiveness
of foot care education among people with type 2 diabetes in rural
Puducherry, India. Indian J Endocrinol Metab. 2014;18(1):106–110.
https://doi.org/10.4103/2230-8210.126587

Sayampanathan AA, Cuttilan AN, Pearce CJ. Barriers and enablers to proper
diabetic foot care amongst community dwellers in an Asian population:
a qualitative study. Ann Transl Med. 2017; 5(12):254. https://doi.
org/10.21037/atm.2017.04.31

Scottish Intercollegiate Guidelines Network. Management of diabetes: a
national clinical guideline. 116. 2017 (updated from 2011). https://www.
sign.ac.uk/assets/sign116 (accessed 8 March 2019)

Schim SM, Benkert R, Bell SE, Walker DS, Danford CA. Social justice: added
metaparadigm concept for urban health nursing. Public Health Nurs.
2007; 24(1):73–80. https://doi.org/10.1111/j.1525-1446.2006.00610.x

Seaman S. The role of the nurse specialist in the care of patients with
diabetic foot ulcers. Foot Ankle Int. 2005; 26(1):19–26. https://doi.
org/10.1177/107110070502600104

Searle A, Campbell R, Tallon D. A qualitative approach to understanding the
experience of ulceration and healing in the diabetic foot: patient and
podiatrist perspectives. Wounds. 2005; 17(1):16-26

Sekhar MS, Thomas RR, Unnikrishnan MK, Vijayanarayana K, Rodrigues
GS. Impact of diabetic foot ulcer on health-related quality of life: a cross-
sectional study. Semin Vasc Surg. 2015; 28(3-4):165–171. https://doi.
org/10.1053/j.semvascsurg.2015.12.001

Seyyedrasooli A, Parvan K, Valizadeh L, Rahmani A, Zare M, Izadi T. Self-
efficacy in foot-care and effect of training: a single-blinded randomized
controlled clinical trial. Int J Community Based Nurs Midwifery. 2015;
3(2):141–149

Shah A, Kanaya AM. Diabetes and associated complications in the South
Asian population. Curr Cardiol Rep. 2014; 16(5):476. https://doi.
org/10.1007/s11886-014-0476-5

Shao Y, Liang L, Shi L, Wan C, Yu S. The effect of social support on glycemic

control in patients with type 2 diabetes mellitus: the mediating roles
of self-efficacy and adherence. J Diabetes Res. 2017; 1–8. https://doi.
org/10.1155/2017/2804178

Sheahan H, Canning K, Refausse N et al. Differences in the daily activity
of patients with diabetic foot ulcers compared to controls in their free-
living environments. Int Wound J. 2017; 14(6):1175–1182. https://doi.
org/10.1111/iwj.12782

Sothornwit J, Srisawasdi G, Suwannakin A, Sriwijitkamol A. Decreased
health-related quality of life in patients with diabetic foot problems.
Diabetes Metab Syndr Obes. 2018; 11:35–43. https://doi.org/10.2147/
DMSO.S154304

Steel A, Reece J, Daw AM. Understanding the relationship between
depression and diabetic foot ulcers. Journal of Social Health and Diabetes.
2016; 4(1):17–24. https://doi.org/10.4103/2321-0656.164792

Suico JG, Marriott DJ, Vinicor F, Litzelman DK. Behaviors predicting foot
lesions in patients with non-insulin-dependent diabetes mellitus. J Gen
Intern Med. 1998; 13(7):482–484. https://doi.org/10.1046/j.1525-
1497.1998.00138.x

Tamir E. Treating the diabetic ulcer: practical approach and general concepts.
Isr Med Assoc J. 2007;9(8):610–615

Upton D, Solowiej K, Woo KY. A multinational health professional
perspective of the prevalence of mood disorders in patients with acute
and chronic wounds. Int Wound J. 2014; 11(6):627–635. https://doi.
org/10.1111/iwj.12018

van Netten JJ, Price PE, Lavery LA et al. Prevention of foot ulcers in the
at-risk patient with diabetes: a systematic review. Diabetes Metab Res
Rev. 2016; 32(Suppl 1):84–98. https://doi.org/10.1002/dmrr.2701

Vedhara K, Dawe K, Miles JNV et al. Illness beliefs predict mortality in
patients with diabetic foot ulcers. PLoS One. 2016; 20;11(4):e0153315.
https://doi.org/10.1371/journal.pone.0153315

Verberk F. Experience and influence of reality: the created environment. In
Verberk F, Merks A(eds). Nursing according to Neuman Systems Model:
Translation and adaptation for the Dutch practice]. Assen, Netherlands:
Van Gorcum: 2016: 122-130 (Article in Dutch)

Vileikyte L, Gonzalez JS. Chapter 14. Recognition and management of
psychosocial issues in diabetic neuropathy. In Zochodne DW, Malik RA
(eds). Handbook of clinical neurology. Amsterdam, Netherlands: Elsevier;
2014

Vissenberg C, Nierkens V, Uitewaal PJM, Middelkoop BJC, Nijpels G,
Stronks K. Development of the social network-based intervention
‘Powerful Together with Diabetes’ using intervention mapping. Front
Public Health. 2017; 5:334. https://doi.org/10.3389/fpubh.2017.00334

Winkelstein W Jnr. Florence Nightingale: founder of modern nursing and
hospital epidemiology. Epidemiology. 2009; 20(2): 311. https://doi.org/
0.1097/EDE.0b013e3181935ad6

Winkley K, Sallis H, Kariyawasam D et al. Five-year follow-up of a cohort
of people with their first diabetic foot ulcer: the persistent effect of
depression on mortality. Diabetologia. 2012; 55(2):303–310. https://doi.
org/10.1007/s00125-011-2359-2

Winkley K, Stahl D, Chalder T, Edmonds ME, Ismail K. Quality of life
in people with their first diabetic foot ulcer: a prospective cohort
study. J Am Podiatr Med Assoc. 2009; 99(5):406–414. https://doi.
org/10.7547/0990406

Woo, K. Exploring the effects of pain and stress on wound healing.
Adv Skin Wound Care 2012; 25(1): 38-44; quiz 45-36. https://doi.
org/10.1097/01.ASW.0000410689.60105.7d

Xie J, Deng W. Psychosocial intervention for patients with type 2 diabetes
mellitus and comorbid depression: a meta-analysis of randomized
controlled trials. Neuropsychiatr Dis Treat. 2017; 13:2681–2690. https://
doi.org/10.2147/NDT.S116465

Yekta Z, Pourali R, Nezhadrahim R, Ravanyar L, Ghasemi-rad M. Clinical
and behavioral factors associated with management outcome in
hospitalized patients with diabetic foot ulcer. Diabetes Metab Syndr
Obes. 2011; 4:371–375. https://doi.org/10.2147/DMSO.S25309

Zhang P, Lu J, Jing Y, Tang S, Zhu D, Bi Y. Global epidemiology of diabetic
foot ulceration: a systematic review and meta-analysis. Ann Med. 2017;
49(2):106–116. https://doi.org/10.1080/07853890.2016.1231932

020 7738 5454 bjn@markallengroup.com @BJNursing

Have an idea for BJN?

Copyright of British Journal of Nursing is the property of Mark Allen Publishing Ltd and its
content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder’s express written permission. However, users may print, download, or email
articles for individual use.