APA reference

García, J. F., Abad, J. F., López, & Fernández. (2024). British Journal of Nursing, 33(15), S4–S15. https://doi.org/10.12968/bjon.2024.0006

Purpose

1. Describe the profile/characteristics of patients with neuropathic and neuro-ischaemic diabetic foot ulcers who get referred to an advanced practice nurse (APN) in advanced chronic wounds.

2. Determine whether a given intervention program on primary-care and nursing-home nurses (professional performance, knowledge, referral behavior, and product use) affected professional performance.

3. Follow-up, assessment, and outcome (healing, amputations, deaths) of the patients with neuropathic and neuro-ischaemic ulcers referred to the APN prior to the training and post-training.

Hypothesis or Research Question

The article has not indicated a formal null/alternative hypothesis. It rather explains particular study objectives/ research questions:

What are the peculiarities of the patients of neuropathic and neuro-ischaemic DFUs of the specialist APN?

Are APN-led nurse training sessions associated with the positive outcomes (in terms of professional performance (knowledge, proper referrals, product use), and continuity of care)?

Are there any changes in the outcomes (healing time, rates, amputations, mortality) after intervention/ introduction of the role?

These are called research questions/objectives that direct the study as compared to hypothesis testing.

Theoretical Framework

To organize the study, there is no clear statement or application of the theoretical framework (e.g., behavioural, nursing-theory model). Instead, the paper is a retrospective descriptive / quality-improvement study of a service change in the integrated diabetic-foot pathway of Andalusia. The authors locate the work within the framework of clinical practice guidelines and health-service pathway logic (referrals made to the Andalusia integrated diabetic foot pathway and IWGDF guidelines), and the rationale behind the study is the service-delivery / care-coordination and quality-improvement concepts as compared to a formal mid-range nursing theory.

Research Design

The research was a retrospective descriptive study aimed at determining the outcomes of patients with diabetic foot ulcers (DFUs) who were referred to an Advanced Practice Nurse (APN) in complex chronic wounds. It also evaluated the effectiveness of a training intervention on primary care and nursing home nurses in terms of diabetic foot management. Clinical records and the Andalusian electronic wound registry system were used to generate data in the 6.5-year (2015-2021) period.

Statistical Methods

The analysis of the data was conducted by descriptive sequential statistics:

Frequencies and percentages of categoric variables (type of ulcer, amputation, death).

Continuous variables (healing time, age) means and standard deviation.

Data were analyzed with the help of Excel PivotTables and SPSS v21.0.

Pre and post training intervention were compared to assess changes in knowledge of the nurse, continuity of care, and patient outcomes.

Variables

A. Dependent Variables:

• Patient outcomes: The percentage of healing, healing time, rates of amputation (major/minor), and mortality.
• Nurse outcomes: Pre/post questionnaire provides knowledge and performance improvement after training.

B. Independent Variables:

• Type of ulcer (neuropathic/neuro-ischaemic).

Setting / Population / Sample

Population: The group of adult patients is an APN population with diabetic foot disease who refer to the APN to manage a wound.

Sample: 103 patients (78 men and 25 women; mean age [?] 69 years) who had been referred between June 2015 and December 2021.

Sampling strategy: Convenience random non-probability sampling of all qualified patients who fit the referral criteria.

Inclusion criteria: Patients who had neuropathic ulcers or neuro-ischaemic ulcers that appeared difficult to heal despite an appropriate treatment period of 2-4 weeks.

Exclusion criteria: Patients were transferred to another district where follow-up could not be done.

Validity / Reliability

Internal validity in the study is supported by uniform data collection by use of a centralized electronic registry of data (Diraya) and validated by the district management. The centralized approach of one Advanced Practice Nurse (APN) who carried out all data collection over 6.5 years made everything standardized and reduced inter-rater variability. The retrospective design and non-random sampling, however, reduce the reliability. They did not employ any psychometric tools other than descriptive statistics and did not have any control or randomization to consider external confounding variables, including comorbidities or COVID-19 disruptions. Procedural validity was enhanced through ethical approval and data verification procedures.

Generalizability

The study can only be generalized to similar healthcare settings, namely, the regions with integrated diabetic foot pathways and APN-led chronic wound management programs. The sample (n = 103) is too small, and it is geographically confined to Andalusia, Spain. Results might not be completely applicable to health systems without similar systems of care coordination and nurse specialists’ positions. However, findings are valuable to other European and global health systems that might be taking into account nurse-led diabetic wound care pathways.

Findings

·       Among 103 patients (average age of 69 years), 59% patients healed their ulcers, and the mean healing time was 13.1 months.

·       Amputation rate 50 total (32 neuro-ischaemic, 18 neuropathic).

·       Mortality rate: 36; half of the deaths are within one year of diagnosis.

·       Intervention training: 168 nurses were enrolled in a 7-hour training; after the training, there was more than a 10 percent reduction in the use of inappropriate products, and the quality of referrals increased.

·       There was a worse outcome (increased amputation and mortality rates) with neuro-ischaemic ulcers.

·       COVID-19 had a bad influence on follow-up, which postponed healing and complicated it.

·       In general, the APN role enhanced coordination and early referral, but had a relatively insignificant positive effect on the outcomes, which is why a more expedited referral system and multidisciplinary teamwork are essential.

Implications of the research for

a.     nursing

b.     education

c.     policy making

a. Nursing:

• Strengthens the importance of Advanced Practice Nurses in the inter-setting coordination and chronic wound management.
• It highlights the importance of nurse-led education to enhance the ability to detect early, referrals, and evidence-based management of ulcers.
• Favors lifelong learning in the management of diabetic feet and the detection of risks.

b. Education:

• Finds that short, intensive training programs are effective in enhancing nurse competence and quality care.
• Instructs the necessity of the involvement of diabetic foot management and multidisciplinary communication in continuing education programs.
• Promotes simulation and case education to enhance wound care clinical reasoning.

c. Policy Making:

• Proponents of the official inclusion of APN functions in chronic disease care pathways.

• Calls for policy investment in early-intervention programs, standardized referral criteria, and national registries for diabetic foot outcomes.
• Proposes that fast, formalized clinical pathways (so-called time is tissue model) can be implemented in health systems to minimize amputations and mortality.

Limitations

·       Retrospective design: Causes loss of causality and control of confounding.

·       It is a small sample, region-specific, which diminishes extrapolation to other regions.

·       No control group: Makes it challenging to ascribe the gains either to the APN or to the training intervention.

·       Bias in the data: It may be based on existing records, thus resulting in incomplete and inconsistent data entries.

·       External factors: Due to the COVID-19 pandemic, follow-up care was disrupted, and its outcomes were altered.

·       Absence of longitudinal patient-reported outcomes, e.g., quality of life, or satisfaction.

Bias

Retrospective design is connected to selection and information bias. The information was taken by a single APN, which offered a gap of time to enable bias on the part of the observers. It is also probable that there was a referral bias because all complicated cases were referred. The disruptions of COVID-19 also had an influence on the outcomes.

Recommendations

Enhance referral processes. Develop training and life-long learning, promoted by APNs. Enhance the interprofessional cooperation. Enhance uniformity of referral criteria and reflect the potential research using validated tools.

Synthesis of the article

The research claims that APN-led treatment of diabetic foot enhances coordination, the quality of referral, and nursing practice, but with no significant change in patient outcome. The group at high risk of having neuro-ischemic ulcers; therefore, the intervention should be taken earlier and with more vigor.

Is this a valuable article for EBP? Why or why not?

Yes. It provides evidence on wound care that is effectively led by APNs, training efficacy, and care coordination in a realistic way. For clinics with limited resources, these practical insights can be more actionable than findings from large-scale controlled trials. Although its size and sample are small, it presents real-life practical information to improve the process of diabetic foot management and systems.