The study included seven in-depth interviews that had the comments of the seven HCPs (five males and two females) who consented to be a member of the IP team working in diabetic foot care.
The participants' average age was 44 years (range: 35-60). Professional experience varied from 10 to 35 years, with a mean value of 19 years.
Perceptions of the HCPs on the importance of the Inter-Professional approach in the management of diabetic foot care
The participants collectively agreed that diabetic foot self-management is essential and should be carefully followed by all individuals with diabetes. All the study participants firmly believed in the core competencies of IP education and practice, i.e., values, ethics, roles and responsibilities, IP communication teams, and teamwork, as indicated in the responses. They also expressed their willingness to work alongside other professions in managing diabetic foot care.
IP team-based approach in diabetic foot management:
All research participants voted that an IP team-based approach to diabetic foot treatment was the best. The following snippets were derived: IPE and IPP become highly relevant because 'patient-centric practice' is regarded as an essential criterion in healthcare administration. Furthermore, as noted by the participants, a "comprehensive approach to patient treatment" is always preferred. The key elements identified for effective patient outcomes were 'teamwork' and 'coordination.'
Themes identified: ‘Patient-centric practice,' 'Comprehensive care,' 'Teamwork and coordination for better patient outcome.'
" The interprofessional education or the clinical care.. is an important.. ‘uhh’.. teamwork required for the management of patient. If you look at the present clinical scenario (pauses) the patient centric practice is the important criteria in the clinical system. Therefore, IP education and the clinical care play an important role in the management of the patient." (Participant 2).
" An interprofessional team-based approach is extremely important I think, because the disease itself is.. ‘uh’.. not confined to one particular specialty, it is a disease which involves ‘mmmmm’… expertise from various subspecialties like a physician, an endocrinologist, a cardiologist, an orthopedician, a surgeon, a plastic surgeon, a vascular surgeon, you name the specialty and that specialty will be involved in its treatment" (Participant 4).
" Talking about diabetic foot, ‘uhh’.. it’s a.. a.. thing to thought of.. and these kinds of patients really need a personal care.. where few team members need to work together. It’s not that only a nutritionist will work and see the case and just leave it. I need to talk to doctors, ‘uhh’.. ‘uhh’.. endocrinologists, to know that what exactly is the case and how do we handle it. So I need to understand how bad is the case, what is the need of diet for that patient? What kind of medication he is on? For that, I need to talk to different team/set of people… with whom we can discuss and help in the better improvement of that particular… patient" (Participant 6).
IP versus multidisciplinary approach in diabetic foot care:
All participants chose an IP strategy over a multidisciplinary approach. The following justifications back this up: an 'integrated IP approach' is always preferable since it gives the patient all of the required information and treatment in a holistic manner. Furthermore, an IP strategy would result in reinforcement, with each member of the IP team repeating the basic self-care requirements, making patients more careful about self-management of diabetic foot. As noted in the study, an IP team-based strategy would aggregate all professional knowledge that would be simplified and communicated to the patient population.
Themes identified: ‘Integrated approach,' 'Reinforcement,' 'Simplified approach,' 'Amalgamation of professional knowledge.'
“An integrated approach in conveying the patient the necessary information is always going to be ‘ummm’ better! Because he will hear one consolidated story about how he is going to manage.. (pauses) himself and what awaits him in future, rather than ‘ummm’ following a guerilla warfare.. and giving bits and pieces of ‘uh’ ‘uh’ ‘uhh’ care. So it’s always better, you know to have.. have.. all services and all information’s and all education under one roof. So, I’m.. I’m all in for that” (Participant 4).
" So with respect to patient education, first and fore most if you look at the Indian scenario, patients do not give so much importance to the foot. So when they come under an umbrella, where several people are discussing and ‘uhh’ giving importance, they.. they understand how serious is the illness and probably.. ‘uhh’ first and foremost the care again will improve. Also, if you involve somebody who is educating the patients like a counsellor or an educator, ‘uhh’ giving input on how they can improve the practices better with respect to foot care and offloading etc, then that will further enhance the educational part and compliance to treatment” (Participant 3).
IPE in improving the knowledge and practices of diabetic foot self-management:
Education helps to improve the knowledge and practices of self-management of diabetic foot among individuals with diabetes, as stated in the current study.
The current study highlights that IPE is a comprehensive step toward raising awareness and teaching patients about correct foot care methods. Participants in the survey also indicated that it provides greater outreach and teaches necessary knowledge in a suitable environment.
Themes identified: ‘Comprehensive education and awareness,' ‘Better outreach,' ‘Education in a conducive environment.'
" In a common OPD visit where all type of patient are seen, ‘uh’ probably we will not be able to concentrate. But… If we have a special clinic for ‘diabetic foot care’ similar to the one in our hospital, to some extent we will be able to concentrate” (Participant 1).
" I would correlate with the current COVID scenario. It would be difficult for the person.. ‘uhh’.. ‘uhh’..patient to travel from a far place and visit clinic regularly. So.. in that aspect, commuting might not be possible all the time. So, in that aspect I think educating patient along with educating the family also would help them manage the diabetic foot care better” (Participant 7).
IP teamwork and communication in imparting diabetic foot care education:
Effective IP teamwork and communication can considerably help a patient-centered approach to diabetic foot self-management. It also helps with collective feedback and good time management, as noted by the participants. According to the study, IP teamwork and communication provide an opportunity to 'learn with and about others' and would also result in 'behavioral change communication.'
Themes identified: 'Patient-centered,' 'Collective feedback and effective time management,' 'Learning with, from, and about each other,' 'Behavioural change communication.'
"I believe in that and in favour of patients, we all should work in a team, communicate and coordinatecoordinate. It should not be that ‘uhh’.. only my medication should work or my physiotherapy should work or my diet plan should work! No!! It is that everything should work together. And it should! And it will!! Only if we work together it will. It is just like the family rite. It is not only the husband's duty or wife's duty. It is done all together so it is a teamwork. That's why it is called as a team… and it will work! That's what I believe in.
Understanding a patient only from my perspective is not at all enough. I will know about his diet. I will not know anything about his adherence to exercise, how much he can exercise. How much he can work. Or I will not be knowing what kind of medicines will help him to come out of it. So…. something, we also have something called as food and drug interactions. So… what kind of food I am giving him what If it has an interaction with the drug. So that I will be knowing from a physician.. like this particular medicine is not suiting to the food what I have told. So I can change. So the kind of food what I am giving may not be able/ not enough for him to exercise. So he needs little more protein in his food. So I can help him in that way. So I feel working in a team with all these views will help for a better outcome of a patient" (Participant 6).
“Suppose you have a patient who has come with a foot problem.. so you would want to look at several things. First you would need a clinician to manage his underlying metabolic problem, then you would need a ‘uhh’ vascular surgeon to look for any vascular compromise. He would decide what would be the next line of treatment or doesn’t require any treatment. And then.. of course the physiotherapy team would be definitely needed to educate about the offloading options including his gait and those aspects. An orthotist would then recommend appropriate footwear. So different specialties would definitely give the feedback and that would be the best care for the patient. And also definitely it would be time saving for both patients and clinicians" (Participant 3).
IP educational module for diabetic foot care
The participants were enthusiastic about the notion of developing and executing an IP instructional program for diabetic foot care and made the following suggestions: Customized to the patient's specific requirements. The module will aid in delivering regular reinforcement for learning and adhering to good foot care habits. It will enable time management and outline the roles and duties of the team's HCPs.
Themes identified: ‘Customized based on patient needs,' 'Constant motivation and reinforcement,' 'Efficient Time management,' 'Defined roles and responsibilities in a team.'
" We need to understand the need of our community. Any educational material if it is developed at the (recalls) institutional level, without taking the confidence of the stakeholder it is going to fail. Whereas when we develop this IP education material, first important stakeholder is the patient. Therefore, when we, develop interprofessional educational material, we need to give lot of importance to the need of our client or patient population. And once they understand and also ones they know that these steps need to be clearly followed, the adherence to that module will be better from the patient’s point of view" (Participant 2).
“We may have to reinforce the healthcare aspect towards them, by implementing a module. It is because all the time doctor, ‘ah’.. ‘ah’.. or the team cannot be in communication with patient. (pauses).. So therefore, we have to give certain resources for them to handle at their own phase, so that they can understand them better and they can take care of their diabetic foot better” (Participant 7).
An additional file (Additional file 2) shows the HCPs' domain-specific assessments on the relevance of the Inter-professional approach in the treatment of diabetic foot care. In addition, the research participants made a few suggestions, which are presented in table 1.
Table 1: Participant’s suggestions towards improved IP team-based approach to patient care
IP team-based approach in diabetic foot management
• Having an IP team can detect early foot problems, help in educating the people, and prevent complications
• Several professions available under a single umbrella as a single unit or a clinic offering foot care services would be helpful for the patient
• IPP renders personal care to the patients
• IPE and IPP could focus on the needs of the service users, and the caregivers
IP versus multidisciplinary approach in diabetic foot care
|• Conducting IP team led health camps routinely and frequently
• Dedicated centers (involving various healthcare professionals, say a physician, endocrinologist, physiotherapist, dietician, nurse, counsellor/educator) on Diabetic foot care needs to be setup
• Health care professionals need to play multiple roles: an advocate, a negotiator, and importantly they have to do lobbying to the administration, to teach health education as a part of the care in day-to-day hospital care, it could be primary prevention care or the secondary prevention care
IPE in improving the knowledge and practices of diabetic foot self-management
• Having a special clinic for 'diabetic foot care.'
• Appropriate educational resources, i.e., IEC (Information, education, and communication) materials, should be designed keeping the patients' best interests in mind.
• At the rural level, trained ASHA workers can conduct a community or a door-to-door survey, screen the people, and provide adequate education on diabetic foot care.
• Group therapy, i.e., allowing a group of patients to interact on diabetic foot care-related issues, can help.
• Conduct one-way communication using IEC materials; two-way communications involving seminars, symposiums, consultation meets, focused group discussions.
• Educating the caregiver along with the user (patient) will be effective
• Identification of individuals with recently diagnosed diabetes and early education to prevent future foot problems
IP teamwork and communication
• The roles and responsibilities of the IP team members need to be clearly defined.
• Team members should timely and effectively communicate among themselves and clearly and collectively convey the necessary information to the patients.
• IP teamwork should aim towards proper screening and early detection of foot problems. Convey appropriate preventive measures, and the team should design effective treatment strategies.
• Creation of awareness and sensitization related to the benefits of IP teamwork by conducting continuing education and faculty development programs.
IP educational module for diabetic foot care
• The educational module should be well structured and developed in the interest of the patient's benefit. The content should be prepared based on the community's needs. Clearly define the roles and responsibilities of the IP team members.
• Before creating the module, one should
• carry out a primary assessment of the knowledge, attitude, and practices of diabetic foot care among the patients. Customize the module based on the patient's needs.
• The module should be simple and ideally made available in the comfort of the patients' and caregivers' homes.
• One may use the online mode, i.e., WhatsApp, to impart the educational module considering the covid pandemic and maximum outreach.