Evaluation of the effect of nurse education on patient‐reported foot checks and foot care behaviour of people with diabetes receiving haemodialysis

To assess whether a programme of nurse education increased the frequency with which nurses conducted foot checks on people with diabetes undergoing haemodialysis and to evaluate whether this influenced self‐reported foot care behaviour.


Introduction
People undergoing dialysis have a high prevalence of diabetes [1,2]. The risk of developing diabetic foot disease is much higher in those with renal impairment [3], and their outcomes, including amputation and mortality, are also worse than those of people without renal disease [4].
There is a need to more effectively manage diabetic foot disease in people undergoing dialysis. Renal-focused health professionals view foot problems as a minor part of an already complex set of care needs [5] and the focus of medical attention is diverted to the process of dialysis [6]. There have been calls for improved foot care and education from both individuals with diabetes and renal health professionals, in order to improve outcomes [7]. Valabhji [8] suggested that foot surveillance programmes could significantly improve outcomes if they result in more rapid access to specialist care when diabetic foot disease occurs. Selfmanagement education has been shown to have positive effects on both amputation rates and quality of life in patients on dialysis units [9].
The aim of the present study was to evaluate whether training of nursing staff at haemodialysis units to carry out foot examinations and to educate people with diabetes on the importance of foot care, was reflected in the frequency of foot examination and reported foot-care behaviour.

Participants and methods
No ethical approval was required as the study was a service evaluation. A non-randomized stepped-wedge design was used [10,11].
All people with diabetes attending four haemodialysis units in the Nottingham area were invited to complete a questionnaire, which comprised questions on demographic variables, the number of times health professionals (nurse, podiatrist and doctor) had examined their feet, foot self-care behaviour [using the Nottingham Assessment of Functional Foot-care (NAFF)] [12] and the number of active foot problems.
A single education session was delivered to six identified nurses by an experienced diabetes podiatrist, and included a protocol for monthly foot examination, clarification of referral processes to specialist services and foot care information for patients. The nurses trained were diabetes link nurses at each of the respective units. These nurses had an interest in diabetes care and the training was congruent with their link nurse role. The nurses who received the training were encouraged to pass on the information to their colleagues. The aim of the foot check was to identify active, previously unreported foot problems and to deliver foot care advice. The intervention was introduced to one of the four participating units in sequence every 2 months. The order of introduction to the different units was not-randomized but was pragmatic.
The questionnaire on the frequency of foot examination by health professionals and the NAFF were repeated for all patients attending each unit at 2-monthly intervals for 8 months.

Results
A total of 95 people with diabetes attending for haemodialysis were included in the evaluation. Their mean (SD) age was 67.7 (12.3) years and 52 (54.7%) were men.
The demographic characteristics and baseline scores for patients on each unit were compared using a chi-squared test for categorical data and ANOVA for ordinal data. There were no significant differences between units at baseline (P > 0.05). Demographic characteristics available in Table S1.
Chi-squared analysis was used to examine the effect of the intervention over time. Cross tabulation of the proportion of patients examined by nurses, podiatrists and doctors is shown in Table 1.
There was an overall significant effect of time on the rate of examination by nurses. An increase in the frequency of examination occurred after the intervention programme (P = 0.007). Significant effects of time were also seen in two of the four individual units. There was no significant overall effect of time on the frequency of foot examination by podiatrists (P = 0.29) or doctors (P = 0.56), although there was a significant increase in foot examination by podiatrists in one unit after intervention (P = 0.007). These results support the effect of the intervention on foot examination by nurses.
Scores on the NAFF were examined using two-way ANOVA. There was a significant effect of unit (F = 12.4, df 3, 290; P < 0.001) and time (F = 83.3, df 4, 290; P < 0.001) on NAFF scores and a significant unit by time interaction (F = 1.9, df 12, 290; P = 0.03). The results are also shown in Table 1. These indicate that most change occurred between baseline and the second assessment, and not in response to the instigation of the intervention. There was a significant difference between baseline and 8 months in the sample as a whole (P < 0.001).

Discussion
The findings show that after implementation of an education programme for nurses on haemodialysis units about the need for regular foot checks in people with diabetes on dialysis, there was a change in the frequency with which nurses examined patients' feet and in reported foot care behaviour. There was no significant effect on the frequency of foot examination by podiatrists or doctors or on the self-reported frequency of foot problems.
The patients were similar across dialysis units with regard to demographic characteristics and baseline frequency of foot checks, and on the NAFF. Demographic characteristics and baseline NAFF scores available in Table S1. The pattern of results suggested the intervention was associated with an increase in the frequency of foot checks undertaken by nurses but not by podiatrists or doctors. The intervention was not, however, directed towards doctors even though they were aware of the education programme being offered. This supports the interpretation that the change in frequency of nurse foot checks was in response to the intervention and not part of an overall awareness that was being raised as a result of the study taking place.
The pattern of results on the NAFF suggested that simply administering the questionnaire led to an improvement of self-reported foot care behaviours. Scores improved in all four units between baseline and the second assessment, despite the intervention only having been implemented at one unit. Administration of the NAFF may have raised awareness of foot care amongst the patients and this alone may have caused the improvement.

What's new?
• Quick and simple foot checks can be carried out by nurses on busy dialysis units.
• Educating nurses about the need for checking patients' feet increased the frequency with which foot checks were carried out.
• Completing questionnaires about foot care behaviour improved the frequency of carrying out recommended foot care behaviours.
Despite this, nurses reported anecdotally that there was an increase in people asking for foot care advice and an improvement in communication between patients and nurses with regard to foot care. Podiatrists reported an increase in the number of relevant referrals to their service, with improved communication between the dialysis units and the podiatry service. These findings support some previous research [8] on access to specialist services, The present study has some limitations. The order of delivery of intervention to the units was not randomized. The assessments were collected by the staff involved in the study and therefore data entry was not blind as to whether patients were attending units where education of nurses had taken place. It is not known how many individuals were asked to complete the questionnaires, so the response rate is unknown. There were some missing data on questionnaires and therefore the number of patients at each stage was not consistent ( Table 1). The overall results of the present study, however, suggest the possibility that the request to complete the NAFF questionnaire itself resulted in an improvement in self-reported foot care, while the education programme led to an increased frequency of nurses undertaking foot checks.
The stepped-wedge design proved a practical way of evaluating a clinical service. The results also indicate that a fully powered study with randomization of units to the delivery of education and objective recording of patient outcomes is warranted.

DIABETICMedicine
Evaluation of foot care education for haemodialysis nurses S. L. Brand et al.