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There are three concepts identified in the Change Theory and the concepts are: driving forces, restraining forces, and equilibrium. The driving forces are the ones that push a person in a direction that causes a change to occur. These driving forces are what help facilitate change and help send the person in the desired direction resulting in a shift of the equilibrium towards change. Restraining forces are those that can cause counter driving forces and thus hinder change. This is because the restraining forces can push the person in the opposite direction, causing a shift in the equilibrium, therefore causing an opposite change to happen. Equilibrium is a state of being. This is where driving forces are equal to restraining forces and no change occurs (Petiprin, 2018).
This model consists of three stages that are distinct and vital to the theory. They are unfreezing, moving to a new, different level or changing, and refreezing. Unfreezing is the process of moving away from prior counterproductive behaviors and surmounting resistance to change. This is an essential step for previously learned behaviors to be deserted in order for new ones to be discovered and learned. Once unfreezing takes place, new plans can be made to direct behaviors in a new, different direction that will result in the least resistance to change. Moving is the process of driving the change forward and implementing more acceptable and productive behaviors. Moving may involve changing thoughts, feelings, or behaviors. Refreezing is the process of accepting the change and implementing the new behavior pattern so that it becomes routine. Lewin describes in his theory that change is a dynamic force that moves in opposing directions within the organization (Petiprin, 2018).
Figure 1. Kurt Lewin’s Change Theory. McEwen, M., & Dilks, S. (2014). Theories from the behavioral sciences. In M. McEwen & E. Wills (Eds.), Theoretical basis for nursing (4th ed.). Philadelphia, PA: Lippincott, Williams, & Wilkins.
Relationship of Concepts and Framework to the DNP Project
The Change Theory will assist and guide this DNP project by changing foot care behaviors of the healthcare providers in the rural health clinic. According to Lewin’s Change Theory, involved persons will need to acknowledge that improvements need to be made in their current practice of diabetic foot care examinations which would be considered the unfreezing step of the theory. Once this acknowledgement has been made, progress can begin on learning a new behavior. The unfreezing stage will be for the healthcare provider to examine the feet of diabetic patients annually and implement a foot assessment tool for completion of the foot exam as it is recommended by the ADA (Boulton et al., 2018). A template will be developed for recording of the annual foot exam by the healthcare provider as well as, being educated on performing assessments and being able to identify patients at risk for complications. This will assist the healthcare providers in the change portion of the theory. Finally, once the healthcare providers are educated on the foot care template, and begin implementing the templates, therefore adapting new learned behaviors, the refreezing stage can occur.
Figure 2. Kurt Lewin’s Change Theory as the Framework for increasing the frequency of provider documented foot exams. Adapted from McEwen, M., & Dilks, S. (2014). Theories from the behavioral sciences. In M. McEwen & E. Wills (Eds.), Theoretical basis for nursing (4th ed.). Philadelphia, PA: Lippincott, Williams, & Wilkins.
For the purpose of this project, the following assumptions are made:
- Healthcare providers will be receptive to education about how to use the template for annual foot exams of diabetic patients.
- Healthcare providers will use the template and place the template in the patient’s chart for documentation of annual foot exams of diabetic patients.
- Health insurance plans will reimburse the rural health clinic for performing an annual foot exam and having this exam documented in the patient’s chart.
Review of the Literature
A literature search was performed utilizing the university’s large library databases. These databases include CINAH Complete, Cochrane Library, EBSCOhost, ERIC, MEDLINE, and PubMed. The search was limited to scholarly journals, the English language, and articles that were published from 2013-2018. Terms used for the literature review included: diabetes, foot, care, program, tool, research, nursing, rural, and healthcare provider.
Search Results and Revisions
The search yielded 711,145 scholarly articles when the terms diabetes, foot, care, program were used in the library database search. For some instances, the key terms were adjusted to acquire the most relevant articles related to this DNP project. An example of this was rural, it was removed in some database searches while the key words foot care and diabetes foot care were combined to expand the literature search results. Also for some searches of the databases, the search was narrowed by adding nursing to the search terms. After the revision of search terms a total of 201 articles were reviewed. Most of articles reviewed were studies that only spoke to the management of diabetes. A total of 195 were discarded after reviewing as the articles did not pertain to the project. Five articles were found to be relevant and that will have data to support the DNP project and improve healthcare provider care of the diabetic patient in the rural health clinic.
Emerging Topics from the Literature Review
Emerging topics from the comprehensive review of the literature included foot complications, diabetic foot ulcers, lower limb amputations, and challenges of managing a diabetic foot problem. Also emerging as topics were: the patient’s knowledge about foot care, development of a foot assessment tool, implementation of a comprehensive foot care program, and proper documentation of annual foot examinations. The findings from the comprehensive literature review will provide data on diabetic foot care that can be used to implement a foot screening and assessment tool that will be used at a patient’s annual visit, in order to improve practice and diabetic outcomes in a rural health care clinic setting.
Developing a Foot Ulcer
In a cross sectional study that consisted of 100 patients with diabetes, conducted by Kishore, Upadhyay, and Jyotsna (2015), aimed to identify those at risk for developing foot complications and classify them according to their risk. The researchers discovered that 52% of the patients were at risk for developing foot complications and 43% had peripheral neuropathy. Furthermore, a significant correlation with foot complication risk was observed in those who had a longer duration of diabetes, lower socioeconomic status, had a lower education level, and lower level of health care. Even with the majority of patients being found at risk for foot complications, only 5% had reported receiving foot care education and none had ever received a vascular consultation or a prescription for diabetic footwear (Kishore et al., 2015). These findings propose a variance in practice to prevent foot ulcers and provide patients with information about diabetic foot care. Formation of a diabetic foot care program in a rural health clinic may assist to fill this variance by coming into contact with patients earlier and in a venue that would be easily accessible.
Lower Extremity Amputations
An observational prospective study on patients with diabetic foot ulcers by Weck et al. (2013), was performed to determine if a structured health care program for diabetic patient’s feet would aid in reducing the number of lower extremity amputations when compared to customary and standard care of diabetic feet. The structured health program included both outpatient and inpatient, as well as rehabilitative treatment for diabetic feet. In the structured health care program there were 684 participants with diabetic foot ulcerations and 508 participants who received identical standard foot care in the control group. The researchers revealed a higher mortality rate with the control group at 9.4%. Whereas, those treated by the structured health care program the mortality rate was only 2.5%. In addition, about 30% of foot wounds of patients in the program were healed upon discharge compared to only 23% of foot wounds within the control group (Weck et al., 2013). The findings of the study suggested that a structured health care program can notably lessen the number of major amputations in patients with diabetic foot ulcers compared to standard care.
Foot Care Program and Assessment Tool
Peterson and Virden in 2013 conducted a retrospective chart review to evaluate whether the development and implementation of a comprehensive diabetic foot care program and an assessment tool improved diabetic patient’s outcomes. An initial chart review recognized that 18% of the patients with type II diabetes had received a foot assessment, which involved a visual inspection and conduction of a sensory examination using a monofilament. However, none of the patients had received a comprehensive foot examination and risk assessment. The researchers also identified provider obstacles in performing diabetic foot care and risk assessments. These included not having a documentation tool, lack of health care provider training for providing foot care, and a lack of specialty care for patients who are uninsured. It was also noted in the study that 4 out of 64 diabetic patients had been hospitalized for preventable foot complications. Based on these findings, the researchers initiated a documentation tool, implemented healthcare provider training for foot care, and established referral resources for uninsured patients. The researchers conducted an additional analysis after the diabetic foot program was implemented. It was found that 30% of the diabetic patients had received a comprehensive foot examination and risk assessment and 65% had a diabetic foot assessment documented. In addition, the researchers noted a significant decrease in diabetic foot related complications as there were none reported. The findings of this study make evident that a comprehensive diabetic foot care program can significantly reduce diabetic foot related complications and enhance patient outcomes.
Challenges of Management
Harrison-Blount, Cullen, Nestor, & Williams (2014) carried out a study in India to evaluate the challenges faced in managing diabetic foot problems and issues. Researchers used observations, focus groups, and individual conversations to gather data from nine clinicians using the problem identification and planning phases of the action research approach as their model. The researchers found there was inconsistency and confusion among the clinicians as to which department was responsible for performing routine foot exams and screenings. The clinicians reported that they usually would only assess the feet if the patients reported a problem. Also, there was a lack of forms readily available to document a foot assessment and a lack of categories to identify those patients at risk for foot complications. Clinicians agreed that patients at risk for foot complications were not identified in a timely manner as well. A solution was identified by the clinicians to develop and implement a foot assessment tool. This tool could be used to audit, evaluate changes in feet, and monitor patient outcomes (Harrison-Blount et al., 2014). By utilizing a foot assessment tool in a rural health care setting, this will enable the healthcare providers to document a diabetic foot assessment and help to identify those at risk for developing a foot complication earlier.
In a study conducted by Foolchand and Oosthuizen (2013), they performed a quantitative descriptive contextual study to look at diabetic’s knowledge regarding foot care, measures to prevent foot complications, and their current foot care practices. 120 diabetics in five regional hospitals were interviewed using a structured interview schedule that was developed and carried out by the researchers. The researchers were able to identify that 12.5% of the patients reported not ever receiving information or education on the management of diabetes or how to perform basic foot care. Over half of the patients also denied always performing basic foot care and precautionary measures such as: checking the water temperature before bathing, checking footwear for proper fit, inspecting the soles of their feet and between toes, and using a moisturizer. Over 12% of the participants reported trimming their toenails as short as possible, while 66% reported trimming their toenails straight across. In addition, 40% reported to treat a minor foot injury themselves and over 33 % would use a blade to remove a callus on their own foot. Also noted was that 75% of the participants did not check sensation in their feet or that their healthcare provider should check their feet at least annually. Furthermore, almost all the participants, 93.3%, did not know how to check the pulses in their feet and only 11% reported that their healthcare provider checked their feet annually (Foolchand & Oosthuizen, 2013). This study’s findings allude to patients with diabetes needing more education on foot care and preventative measures to reduce the risk of developing a foot complication.
Overall Strength of Evidence to Impact Change
The overall strength of the literature review is sufficient. There were multiple levels of evidence represented by the articles and established the need for healthcare providers to perform annual foot screening exams on all patients with diabetes. The literature research does suggest an inconsistency among healthcare providers in conduction foot exams. Therefore, the research does reflect the need for a healthcare provider intervention to increase the frequency of provider documented foot exams in adults with Type II diabetes in order to promote better diabetes outcomes.
Implementation of the DNP Project
Plans are to implement a clinic policy change for a comprehensive foot care program in the clinic to increase the frequency of provider documented foot exams in adults with Type II diabetes in order to promote better diabetes outcomes at Nurse Med rural health clinic in the spring of 2019.
Setting and Population
The Nurse Med clinic is located in northeastern Mississippi and is a privately owned clinic. The clinic has four patient rooms and offers medical care to approximately 35 patients per day. Nurse Med provides health care to a large and varied patient population, age span, and treats a range of diagnoses. This clinic will be an appropriate setting for this DNP project due to the treatment and management of patients with diabetes and the lack of a documented diabetic foot examination.
Project Intervention Plan
The goal of this DNP project is to increase the frequency of provider documented foot exams in adults with Type II diabetes in order to promote better diabetes outcomes over a three month period that will ultimately result in a clinic-wide policy change. The Change Theory will guide this project by changing foot care behaviors of the healthcare providers in the rural health clinic. According to the theory, individuals involved need to acknowledge that improvements are needed in their current process. Once that has been realized, the moving step will occur by educating the healthcare providers on providing diabetic foot exams and implement an assessment tool for completing diabetic foot exam annually as recommended by the ADA (Boulton et al, 2018). There will also be a template developed for documentation of foot exams in the patient’s chart. This template will be completed at each annual visit for medication refills and routine lab monitoring to ensure consistency in documentation of foot examinations by the healthcare provider. In addition, healthcare providers in the clinic will receive education on performing foot exams and risk assessments to identify those patients at risk for possible foot complications. After each provider has been educated on diabetic foot care exams and practicing new behaviors, the refreezing can occur as the desired outcome has been reached.
The tool that will be implemented in the clinic will address all elements that are essential during a foot examination including: skin, nails, temperature, and range of motion, deformity, sensation, pulses, and footwear. Since the clinic utilizes a paper charting system, the proposed tool will be printed on a light blue paper to draw attention to the tool and ease the ability to find previous documented foot exams in the chart. The healthcare providers in the clinic will be instructed on use of the tool, assessment and frequency of diabetic foot examinations. There will also be an educational handout for patients to receive and take home with them at annual visits that will describe routine foot care, how to assess feet at home daily, and any complications to report to the healthcare provider.
The healthcare provider in-service education will take place in January of 2019 at the quarterly staff meeting. The intervention will be delivered by PowerPoint, and will offer a note handout page for the providers to make notes for future reference. After the training is completed, the healthcare providers will implement the foot care program in the rural health clinic. After three months a retrospective chart review will be performed. Medical records will be reviewed as to whether or not the healthcare providers are using the template and documentation appropriately, performing a foot examination on the patient with diabetes annually, and whether education was provided to the patient concerning diabetic foot care at home.
Resource Requirements and Source
Required resources for the implementation of this practice change will include a PowerPoint presentation and computer, a note handout page of the PowerPoint presentation, paper copy of the tool used for annual foot exam documentation, and a patient education handouts for diabetic foot care at home.
Funding will primarily come from personal sources of the author. Proposed expenses include 150 dollars in print shop fees for printing of up to 1500 single sheet handouts at 10 cents per page of the assessment tool and educational sheet for diabetic patients.
January 2019: Meet with the healthcare providers at the quarterly staff meeting. A PowerPoint presentation will be provided with handouts and information on the proposed DNP project, interventions, and plan for carrying out intervention to improve diabetic outcomes for the patients seen in the clinic.
January – April 2019: Implementation of the diabetic foot tool assessment in the chart, assessment and frequency of diabetic foot exams, and patient education.
April 2019: Compile data, record trends and issues, and meet again with the healthcare providers at the quarterly meeting to present findings of the DNP project. Review suggestions from the healthcare providers for improvements that can be made to the foot assessment tool and implementation process of a diabetic foot care policy.
Plan for Evaluation
Three months after putting the DNP project into practice, a retrospective chart review will be performed. The DNP student will examine medical records to determine if the healthcare providers are using the template and documenting correctly, whether they are performing foot care screening examinations on patients with diabetes annually, and if education was provided to the patient concerning foot care at home.
In order to complete the chart review, the office manager will be asked to perform a query of the office’s charts to identify patients with diabetes who have presented to the clinic within the three month period of the project. The DNP student will review the charts in the conference room of the clinic to ensure patient confidentiality. Data that pertains to the project will be abstracted and recorded for analysis on a data collection tool that will be designed by the DNP student. The tool will not contain any information that can identify the patient to ensure confidentiality.
In preparation for dissemination of the research completed for the DNP project, various venues were researched to present a podium presentation related to the proposed DNP project. The American Association of Nurse Practitioners (AANP) offers 60-minute presentation sessions at its annual conferences. Each speaker presents their topic for one day only. If chosen, the speaker must be available to speak on any dates that the conference is taking place. Specifications include that the content should be current, evidence-based, and suitable for a 60-minute presentation duration (American Association of Nurse Practitioners, 2018).
The Diabetic Foot Journal is a peer-reviewed journal, published quarterly, for healthcare professionals involved in the care of the diabetic foot. This journal provides a unified educational and communication vehicle for all healthcare providers who are involved in the management of the diabetic foot. In order to have an article published it should fall into one of the categories: clinical reviews, original research, a case study, or a practical procedure. The articles should be 1700-2300 words in length and written with consideration of the journal’s readers. They accept original article submissions and the article should be submitted via email to [email protected] or online at www.epress.ac.uk/df/webforms/author.php (The Diabetic Foot Journal, 2018).
- American Association of Nurse Practitioners (2018). 60-minute presentation proposals. Retrieved from https://www.aanp.org/membership/170-conferences/natl-conference-presenting-opportunities-tabs/2214-60-minute-presentation-proposals
- American Diabetes Association. (2018). Statistics about diabetes. Retrieved from http://www.diabetes.org/diabetes-basics/statistics/?loc=db-slabnav
- Boulton, A. J. M., Boyko, E. J., Jeffocoate, W. J., Vieikyte, L. (2018). Current challenges and opportunities in the prevention and management of diabetic foot ulcers. Diabetes Care, 41, 645-652. doi: 10.2337/dc17-1836
- Foolchand, D. & Oosthuizen, M. J. (2013). Knowledge and application of foot care: A study of diabetic patients in Mauritius. Africa Journal of Nursing & Midwifery, 15, 87-100 Retrieved from http://web.b.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=35&sid=1cf8526e-a262-4951-8403-cbf4d381cacd%40sessionmgr115&hid+107
- Infectious Diseases Society of America. (2012). Correct treatment of common diabetic foot infections can reduce amputations. Retrieved from https://academic.oup.com/cid/article/54/12/e132/455959
- Kilshore, S., Upadhyay, A.D., & Jyotsna, V. P. (2015). Categories of foot risk in patients of diabetes at a tertiary care center: Insights into the need for foot care. Indian Journal of Endocrinology & Metabolism, 19, 405-410 doi: 10.4103/2230-8210.12788
- Peterson, J.M. & Virden, M. D. (2013). Improving diabetic foot care in a nurse managed safety-net clinic. Journal of the American Association of Nurse Practitioners, 25, 263-271. doi: 10.1111/j.1745-7599.2021.00786.x
- Mississippi State Department of Health. (2018). 2018 Mississippi Diabetes Action Plan. Retrieved from https://msdh.ms.gov/msdhsite/_static/resources/7612.pdf
- McEwen, M., & Dilks, S. (2014). Theories from the behavioral sciences. In M. McEwen & E. Wills (Eds.), Theoretical basis for nursing (4th ed., pp. 301-330). Philadelphia, PA: Lippincott, Williams, & Wilkins.
- Petiprin, A. (2018). Kurt Lewin – Nursing theorist. Nursing Theory. Retrieved from http://www.nursing-theory.org/nursing-theorists/Kurt-Lewin.php
- The Diabetic Foot Journal (2018). Guide for authors, Retrieved from https://www.epress.ac.uk//df/webforms/author.php
- Venes, D. (Ed.). (2017). Taber’s cyclopedic medical dictionary (23rd ed.). Philadelphia, PA: F.A. Davis Company
- Weck, M., Slesaczeck, T., Paetzold, H., Muench, D., Nanning, T., Gagern, G. V.,…Hanfeld, M. (2013). Structured health care foot subjects with diabetic foot ulcers results in a reduction of major amputation rates. Cardiovascular Diabetology, 12, doi: 10.1186/1475-2840-12-34
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