Diabetic foot assessments are increasingly provided by practice nurses, yet a survey shows that nurses receive little training in how to do these assessments, whether before or after registration
Practice nurses play a key role in diabetes management. Working in a shared care model with podiatrists, they often undertake diabetic foot assessments. However, there is evidence that they do not receive adequate education and training in diabetes care and foot assessment, before or after registration. This has recently been confirmed by a survey of practice nurses in the Sandwell and West Birmingham Hospitals Trust area. This article describes the survey’s background and outcomes, which have led the authors to suggest including diabetic foot assessments in the undergraduate nursing curriculum and creating a mandatory training module as part of continuing professional development.
Citation: Lakha T, Lee BC (2018) Are practice nurses equipped to do diabetic foot assessments? Nursing Times [online]; 114: 8, 36-38.
Authors: Trupti Lakha is specialist diabetes podiatrist, Department of Foot Health; Brian C Lee is consultant in diabetes and endocrinology, Department of Diabetes and Endocrinology; both at Sandwell and West Birmingham Hospitals Trust.
- This article has been double-blind peer reviewed
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Diabetic foot care used to be managed by podiatrists but, in recent years, practice nurses have started undertaking diabetic foot assessments (DFAs) as part of diabetes care plans. To reduce the risk of diabetes-related foot complications, the National Institute for Health and Care Excellence (2015) recommends that DFAs are conducted by skilled and trained health professionals. However, do practice nurses receive adequate training on diabetes and its foot-related complications, both as undergraduates and in employment? This article reports on a recent survey of 46 practice nurses exploring how well equipped they were to fulfill their role in diabetic foot care.
Shared care model
Diabetes-related foot complications used to be managed by specialist podiatrists trained in diabetic foot care. However, today, podiatrists are not usually patients’ first point of contact. With the introduction of the Quality and Outcomes Framework, clinical commissioning groups (CCGs) and GP-led surgeries, practice nurses have taken a more prominent role in caring for people with diabetes, working with podiatrists in a shared care model.
These nurses undertake initial diabetes care plans and play a key role in diabetic foot health, including:
- Screening to identify patients at risk of complications;
- Offering treatment;
- Liaising with health professionals such as podiatrists when needed.
They therefore need the right knowledge, skills and competencies to fulfill their role in diabetes management.
Beyond the recommendation that DFAs are conducted by skilled and trained health professionals (NICE, 2015), best-practice guidelines stress the role of education to ensure nurses have the competence, knowledge and skills to assess the risk of foot ulcers, educate patients and refer them when needed (Franklin, 2013). Educational institutions have been encouraged to incorporate this into the nursing undergraduate curriculum (Franklin, 2013). However, the consensus is that student nurses do not receive enough education on DFAs (Moore and Clarke, 2011).
Cardwell et al (2016) observed that, among 86 third-year student nurses, 55% had substantial knowledge gaps in aspects of diabetes management. This may have been due to a lack of basic diabetes education at university, or of ward-based training during placements – or both. Although NICE guidance has evolved to take account of the fact that nurses are taking a greater role in managing the diabetic foot, it seems that undergraduate training has not kept pace with this change.
In the West Midlands, there is a high prevalence of diabetes and significant NHS resources are spent on treating the condition and its complications. This, coupled with the concerns about nurses’ training, led us to survey practice nurses in the Sandwell and West Birmingham Hospitals Trust area in 2015-16 to find out more about their knowledge, skills and competence in this field.
We designed a questionnaire with five closed questions and a sixth allowing additional free text. We asked about knowledge and training received at undergraduate level, whether practice nurses perform DFAs as part of their work, their confidence in doing so, postgraduate DFA training in employment, and what tests and interventions they perform and use with patients.
The questionnaire was sent by post to 70 local GP surgeries that employ practice nurses. Having obtained no response to this postal contact, we contacted the nurses by phone and invited them to meet face-to-face to complete the questionnaire; 46 out of 69 (67%) agreed. Their responses are detailed in Table 1 and Fig 1; additional information reported here was gained from participants in conversation during the face-to-face meetings.
At undergraduate level, no respondent had been trained in performing DFAs and none had received “detailed” knowledge about diabetes and its foot-related complications; most (91.3%) had received “a little” training and 8.7% had not received any.
In employment, 82.6% of respondents had received post-graduate DFA training and 76.0% were performing DFAs. However, 80.0% did not feel confident in how, and why, they were performing the tests included in DFAs.
The respondents had been qualified for between two and 31 years: 28% for 10 years or fewer and 72% for more than 10 years (Fig 2). They had obtained either an old-style nursing diploma or a university nursing degree.
We would expect the longer nurses have been qualified, the more experience and competence they have – provided they have kept up with their continuing professional development (CPD). We would also expect the respondents who had obtained a degree to have been educated to a higher standard than those with a diploma, as the level of qualification upon entry is higher for a degree course.
Our findings show that, irrespective of the number of years since qualifying – and hence irrespective of whether the respondents had obtained a diploma or a degree – the amount of knowledge on diabetic foot and its complications imparted at undergraduate level had been limited (91.3%) or non-existent (8.7%). McHugh and Lake (2010) suggested that, without background knowledge, nurses run the risk of using poor judgement and lack the tools they need to learn from their experience.
Three-quarters of respondents performed DFAs as part of their work, despite having received no training as undergraduates. Respondents stated that their knowledge and training came from either workplace training delivered by specialist podiatrists or formal post-graduate courses. Some respondents had simply been told to perform DFAs because of the demand at their surgery but had not received training.
Most respondents (82.6%) had received post-registration DFA training, but few had received subsequent refreshers due to time constraints and/or lack of funding; 17.4% had received no post-registration DFA training at all. Diabetes UK (2015) reported that, in 2014, “60% of clinical commissioning groups [did] not fund specific diabetes education for health professionals”.
There was a widespread lack of confidence among respondents about carrying out the tests required as part of DFAs. Furthermore, only 71.7% performed neurological and vascular tests on their patients, despite these being particularly relevant to diabetes foot health.
This survey is a snapshot of the situation in our local area. Beyond its limited sample size, there are, as in any survey, limitations such as subjectivity and response bias (Clinton et al, 2005). To add validity to our observations, a survey covering the entire West Midlands NHS region and involving a larger sample of practice nurses would be needed.
This survey highlights inadequate DFA training provided to student nurses and registered practice nurses. We believe that DFAs should be part of both the pre-registration nursing curriculum and of CPD for practice nurses. In addition, every person responsible for diabetic foot health should receive training from a suitably qualified clinician every year and have a professional assessment of their competency.
We recommend that, in the pre-registration nursing curriculum, DFA is incorporated into the existing diabetes module or a separate DFA module is created. This would equip newly qualified nurses with the knowledge, skills and confidence to meet NICE (2015) and Skills for Health (2016) recommendations, and subsequently build on their skills through CPD; a diabetic foot module is proposed in order to address the need for more specific diabetes education in foot health at undergraduate and at employment level. We also recommend the creation of a mandatory online training module on DFAs with graded competency levels for all practice nurses as part of their CPD.
- Diabetic foot care used to be the preserve of podiatrists, but today it is often undertaken by practice nurses
- Diabetic foot assessments should be undertaken by skilled and trained professionals to reduce the risk of complications
- A small-scale survey found that practice nurses lacked adequate education and training in these assessments
- Better pre-registration and post-registration training is needed
- Acknowledgements – The authors would like to thank the practice nurses who took the time to participate in this research study.
Cardwell J et al (2016) Assessment of diabetes knowledge in trained and untrained ward nurses before and after intensive specialist support. Journal of Diabetes Nursing; 20: 2, 60-64.
Clinton M et al (2005) Assessing competency in nursing: a comparison of nurses prepared through degree and diploma programmes. Journal of Clinical Nursing; 14: 1, 82-94.
Diabetes UK (2015) State of the Nation: Challenges for 2015 and Beyond.
Franklin JH (2013) An Educational Program on the Treatment and Prevention of Diabetic Foot Ulcers in the Elderly for Novice Registered Nurses in the Long Term Acute Care and Skilled Nursing Facility [thesis]. San Diego, CA: Point Loma Nazarene University.
McHugh MD, Lake ET (2010) Understanding clinical expertise: nurse education experience, and the hospital context. Research in Nursing and Health; 33: 4, 276-287.
Moore Z, Clarke E (2011) A survey of the provision of education in wound management to undergraduate nursing students. European Wound Management Association Journal; 11: 1, 35-38.
National Institute for Health and Care Excellence (2015) Diabetic Foot Problems: Prevention and Management.
Skills for Health (2016) National Occupational Standards.