APRIL 2014
The Role of Qualitative Research in Understanding Diabetic Foot Ulcers and Amputation C M E 1 AMA PRA Category 1 CreditTM
ANCC 2.3 Contact Hours
Janet L. Kuhnke, RN, BA, BScN, MS & Enterostomal Therapist & Faculty & BScN Collaborative Program & St. Lawrence College/Laurentian University & Cornwall, Ontario, Canada Patricia Hill Bailey, RN, BN, MHSc, PhD & Professor & School of Nursing & Laurentian University & Sudbury, Ontario, Canada M. Gail Woodbury, BScPT, MSc, PhD & Assistant Professor, Adjunct Faculty & School of Rehabilitation Therapy & Queen’s University & Kingston, Ontario, Canada Mona Burrows, RN(EC), BScN, MScN, NP-PHC & Faculty & BScN Collaborative Program & St. Lawrence/Laurentian University & Cornwall, Ontario, Canada All authors, staff and planners, including spouses/partners (if any), in any position to control the content of this CME activity have disclosed that they have no financial relationships with, or financial interests in, any commercial companies pertaining to this educational activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least 13 of the 18 questions correctly. This continuing educational activity will expire for physicians on April 30, 2015.
PURPOSE: To enhance the learner’s competence with knowledge about using qualitative methodologies to understand diabetic foot ulcers and amputations. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to: 1. Analyze qualitative research methodologies. 2. Summarize how conclusions from qualitative research relate to diabetes mellitus and its complications.
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ABSTRACT
individuals to share their personal stories, researchers ‘‘choose people [purposive samples] who are willing to describe [articulate] their experience [and] who can adequately reflect on their experience and verbally describe it.’’6 Although qualitative methods are not without drawbacks, challenges, and limitations, 7,8 they do offer a depth of understanding of the experience of living with or experiencing a diabetic foot ulcer that other research approaches may not offer. As cited in Sandelowski,2 Selikoff states ‘‘qualitative findings are said to show the tears that statistical accounts wipe off.’’ The language within qualitative research studies, however, may not always make the research process transparent for the uninitiated.9 Nevertheless, ‘‘the researcher’s goal within all qualitative models, regardless of the differing approaches and methods, is to ‘interpret’ and or ‘reconstruct’ subjective meaning.’’10 Within this inquiry paradigm, researchers need to be clear on the philosophical foundation and methodological approach they are using and clearly outline this for the reader. Qualitative studies may be conducted as part of a larger study, to initially explore an issue where little research exits, and/or in partnership with a quantitative study. Qualitative studies contribute greatly to the understanding of an individual’s experience with diabetes, diabetic foot ulcers, and amputations.
Persons living with diabetes are at high risk for foot complications, lower extremity trauma, injury, ulceration, infection, and potential amputation. Qualitative health research helps to explore and understand more fully the complexities of diabetes. Qualitative health research seeks to understand what is happening and going on for the individual and his/her support persons. In addition, qualitative health research enables clinicians to appreciate how different qualitative research approaches can explore illness from the perspective of the individual living with the disease. KEYWORDS: diabetic foot ulcers, qualitative research, diabetes complications ADV SKIN WOUND CARE 2014;27:182–8
INTRODUCTION Qualitative health research is used by interdisciplinary teams to explore states of health, maintenance, and illness from the perspective of the individual, family member, caregiver, or clinician, rather than reporting only the researchers’ perspective. Qualitative research seeks to ‘‘elicit emotions and perspectives,’’ beliefs and values, and actions and behaviors for the purpose of understanding the participants’ responses to health and illness, the meanings they construct about the experience, and their subsequent actions.’’1 Qualitative health research findings are the ‘‘grounded theories, ethnographies, phenomenologies, and other integrated descriptions or explanation produced from the analysis of data obtained from interviews, observations, documents, and artifacts.’’2 In qualitative research, the building of new knowledge occurs when one develops a research question asking ‘‘what is happening or going on?’’ Then, the methodology is chosen that best supports answering the research area of interest.3 This article highlights several key qualitative methodologies seen in studies seeking to understand diabetes and related diabetic foot complications, ulcerations, and potential amputations. In recent years, new and thoughtful qualitative methodologies have emerged to answer specific research questions.4,5 Research approaches are ‘‘developed in different disciplines [of practice], different traditions, and on the basis of different ideas of science.’’6 Overall, these approaches and methods emphasize the collection of individual and group firsthand accounts or self-report of life experiences and events through interviews and/or observations. Interview data, observations, and narratives are recorded, typed, or transcribed into texts, narrative data sets, or accounts to be further studied by the researcher. When recruiting and selecting WWW.WOUNDCAREJOURNAL.COM
The Diabetes Challenge Worldwide As of 2013, the World Health Organization reports 347 million people worldwide have diabetes, creating a global epidemic.11 In developed countries, diabetes-related lower limb amputations are ‘‘at least 10 times more common in people with diabetes than in non-diabetic individuals.’’12 In 2011, the American Diabetes Association reported a prevalence of diabetes in adults and children at 8.3%; neuropathy was reported in about 60% to 70% of persons with diabetes. In addition, 60% of nontraumatic lower-limb amputations occur in this population.13 In Canada, the Canadian Diabetes Association estimated in 2012 that 9 million Canadians are living with diabetes and pre-diabetes adding to the diabetes issue globally.14 In its 2013 report, the Canadian Diabetes Association estimated that the number of Canadians living with diabetes will increase to 3.7 million by 2019 and emphasized that diabetes is the leading cause of ‘‘blindness, end stage renal disease and nontraumatic amputation in Canadian adults.’’14 With approximately 2.4 million Canadians living with diabetes, an estimated ‘‘345,000 will develop a foot ulcer.’’15 Therefore, understanding the disease and its complications from the perspective of the individual is essential for healthcare professionals providing holistic care. Diabetes mellitus (DM) may be type 1, type 2, or gestational in nature.14 One of the feared complications of diabetes is a diabetic foot ulcer.16 Diabetic foot ulcers are defined as ‘‘infection, ulcerations, and/or destruction of deep tissues associated with 183
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These are powerful practical insights neurologic abnormalities and varTo support individuals living with a chronic to be used when creating culturally ious degrees of peripheral vascular wound, findings suggest regular pain assessments sensitive programs.35 disease in the lower limb; approxand reassessments, mobility assessment imately 40%–60% of all lower exBeitz and Goldberg37 used pheand support access to devices, referring individuals tremity amputations are related nomenology to explore the meaning to diabetes mellitus.’’17 Research of the lived experience of individuals to support groups, and creation of living with a chronic wound (arterial, shows that at least ‘‘85% of lower partnerships with the individual and healthcare venous, diabetic, pressure, unknown). extremity amputation is preceded by professionals. Using interviews and field notes with a diabetic foot ulcer.’’18 16 white (retired) study participants, the researchers analyzed The cost of diabetes in the United States has increased from findings into 3 key cluster themes (physiological, psychological, $174 billion (in 2007 dollars) to $245 billion in 2012, a 41% inand social): ‘‘living with pain, changing eating patterns, losing crease. This is a significant issue for the healthcare system.19,20 In mobility, explaining causes of wounds, receiving care, healing Canada, the cost of diabetes is also significant. In the year 2000, it and recuperating, contending with chronic illness, adapting and was estimated that Canadian healthcare costs exceeded $4.6 billion maladapting, living and aging, dealing with wound treatments, (1996 CAD) and costs were predicted to rise to $8.1 billion by and experiencing altered sleeping habits.’’37 Some of the reported 2016.21 These costs are expected to continue to rise over time. For example, in the province of Ontario, costs are estimated to rise themes were described in other research studies, whereas changfrom $1.8 billion to $3.1 billion by 2016.22 ing eating patterns and living and aging were new findings from this study. Participants varied in their perspectives of how living As rates of diabetes increase, understanding diabetes from the with a wound affected their appetite; some experienced no change, individual’s perspective is essential because living with a diabetic whereas some experienced significant changes. Living (and aging) foot ulcer affects the quality of an individual’s life. Social wellwith a wound varied in the study findings. Residents in the study being, employment status, psychological welfare (self-esteem), relied on past knowledge and life experiences to remain optimistic mobility, physiological health, and overall health are all affected and hopeful and to appreciate the care they received. Some used by living with a foot ulcer.23–32 personal ‘‘self-talk’’ to feel better while living with a chronic wound. Goldberg and Beitz38 further explored the lived experience of PHENOMENOLOGY diverse older adults with chronic wounds (African American, Phenomenology is a philosophical perspective and a qualitative Hispanic; 7 men, 4 women) living in financially fragile circummethodology.7 Studies using a phenomenological focus aim to stances. Chronic wounds were described as wounds being predescribe the meaning of illness experiences from the individual’s sent for longer than 8 weeks. The researchers found that diverse perspective.33 Studies may use interviews, observations, docuolder adults experienced ‘‘tolerating pain, missing normal mobilments, and art to collect data for analysis; several individuals who ity, living with chronic illness, and explaining causes of wounds’’ ‘‘have shared the experience’’ (eg, a diabetic foot ulcer) of interest in the same way white older adults did in their 2005 study.37 are the focus of the study.34 35 Struthers et al use phenomenology to examine participants’ New study findings were ‘‘encountering losses, considering experiences of being part of a ‘‘Talking Circle’’ for individuals costs, and changing social roles.’’38 Costs included spending perwith type 2 diabetes from the Northern Plains American Indian sonal savings on care to the point of being dependent on the state Tribes. The study’s objective was to understand the experience of programs (eg, Medicaid, Medicare). Chronic wounds often occur being part of a 12-week diabetes educational intervention. Talking when an individual is coping with other chronic illnesses, adding Circles represent ‘‘important principles in the Aboriginal worldstress and possible disruption to their already busy lives. To supview and belief systems, namely, interconnectedness, quality, and port individuals living with a chronic wound, findings suggest continuity.’’36 Through Talking Circles, researchers learned from regular pain assessments and reassessments, mobility assessment and support access to devices, referring individuals to support the participants that this was an effective, culturally appropriate groups, and creation of partnerships with the individual and means of providing information about type 2 diabetes in their healthcare professionals. community. Eight themes emerged from the study data, including how harmonizing western diabetes information with traditional indigenous methods could be achieved. One study participant GROUNDED THEORY shared how she and her husband were able to merge prayer, Grounded theory is an approach used to purposively develop a traditional medicine practitioners, dreams, traditional rituals, and a theory about a ‘‘dominant social process rather than to describe belief in the Creator to help heal her husband’s diabetic foot ulcer. a particular phenomenon.’’3 The goal of grounded theory is to ADVANCES IN SKIN & WOUND CARE & VOL. 27 NO. 4
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De Vera’s45 study emphasizes the generate or expand a theory that adNarrative research is one of the many research dresses problematic realities for inneed for healthcare professionals to approaches with the aim of providing insight dividuals facing healthcare challenges. learn and regard traditional healing into the lives of individuals by ‘‘transforming The method of grounded theory uses practices as part of the individual’s data from, by, and or about participants constant comparative analysis and belief system. These efforts assist in theoretical sampling, which enhances the integration of traditional healing into literary story formats.’’ engagement in data analysis.39 The methods with western biomedicine, promoting healthy outcomes.42 Taking time to listen to individproduct of a grounded theory study is the identification of patterns or process through the examination of the experiences of uals’ beliefs; encouraging the use of support groups; and learning those experiencing those realities.40 about specific cultural beliefs, perceptions, and healing practices may help with healing of diabetic foot ulcers.46 For example, for individuals living with DM the risk for developing a diabetic foot ulcer and experiencing an amputation is a CASE STUDY real personal fear, though preventable with proper daily foot care.41,42 To understand the individual’s experience, Livingstone Case study research involves the study of ‘‘one person, one group, et al43 used a grounded theory approach, exploring what the one event, one organization, and so on.’’44 The aim is to analyze ‘‘day-to-day life’’ is like for someone with diabetes after ampuand examine in-depth the setting or participants of interest to tation. Using unstructured interviews, grounded theory methods, uncover common and potentially unique transformative exemand data analysis, 3 key categories emerged from the study data: plars available in no other way.47–49 This approach involves use 43 ‘‘imposed powerlessness, adaptive functionality, and endurance.’’ of a case, multiple cases over time, observations, interviews, documents, or reports within a setting or context and examines an Individuals shared stories of moving from single-digit amputaissue not readily explored by other research approaches availtion to more complex procedures and amputations. They shared able.34 Case study approach can ‘‘be designed in a variety of ways what this was like for themselves and their caregivers to experience these events. This small study adds to the understanding and can involve quantitative, qualitative or both investigative apof the ‘‘path of perpetual resilience’’ that individuals experience. proaches.’’50 Zucker50 outlines the difference between a case reThe researchers recommend that clinical teams support an indiview and a case report that healthcare professionals may see in vidual’s psychological adaptation to life after amputation. This is educational formats. The case study differs in that key features ‘‘are important research because clients may experience more than 1 its scientific credentials and its evidence base for professional amputation in their journey living with diabetes.42 application [and it] often involves in-depth interviews with participants and key informants, review of the medical records, observation, and excerpts from patients’ personal writings and diaries.’’50 ETHNOGRAPHY Tian et al51 use a case study research approach to share the case Ethnography seeks to understand culture and human processes, of a 71-year-old woman with a diabetes-related ulcer on her hand; through prolonged engagement, using inside (emic) and outside one limitation of this study is that the individual’s personal per(etic) perspectives, gaining tacit knowledge (deeply embedded spective was not included. In the study, the researchers give the cultural experiences), and using the researcher as an instrument medical history and causes of a diabetic hand ulcer caused by to construct theory.44 Ethnography involves field work, collecting Streptococcus agalactiae and how the wound/amputation site observations, conducting interviews, and communication with closed during a 32-day period after surgery. The individual histhe cultural group to describe the emergent cultural themes.34 tory, laboratory values, surgical care, wound care treatment, and De Vera45 used ethnography to explore and describe perspecoutcomes are shared in the case study. The researchers reflect on tives on healing DM foot ulcers by Yaqui Native Americans the rarity of this case and what is known about ‘‘tropical diabetic (Arizona, United States).44 Eight cultural themes or domains of hand syndrome’’ and its relationship to long-term diabetes, poor meaning emerged from the 8-month data collection period. These blood glucose monitoring, and lack of attention to small wounds.51 included (1) the experience of having foot ulcers, (2) personal Overall, the case study approach used shares a ‘‘rare’’ case in a self-care beliefs and practices, (3) faith and strength (religion, professional format and reminds clinicians of the rapid treatment spirituality, and philosophy of life), (4) types of support (spiritual, required to support positive outcomes in these situations. family, and professional), (5) difficulties with diabetes complications, (6) prevention of foot ulcers through self-care measures, (7) ceremonies, (8) and cultural themes (prayer that gives power for healing, the Yaqui health way of life, foot ulcers as a modern illness, and supports to survive the difficult journey with diabetes). WWW.WOUNDCAREJOURNAL.COM
NARRATIVE RESEARCH Narrative research ‘‘is the study of stories.’’6,8 Narrative research (narrative inquiry) is one of the many research approaches with the 185
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access relevant literature on a topic in aim of providing insight into the As diabetes increases worldwide and the costs a timely and effective manner.49 This lives of individuals by ‘‘transformto the healthcare system and the individual ing data from, by, and or about parapproach is not without its critics at living with the disease increase, understanding ticipants into literary story formats.’’44 every step of the process.55,56 One risk the disease from the perspective of the is the inclusion of weaker studies, A study using narrative inquiry folindividual is crucial. which in turn may weaken the lows research structures that examine metasynthesis result. Researchers using either life stories or limited accounts the approach work closely together and set criteria for incluwithin the larger segments of interview data.48 To explore the sion of studies in the metasynthesis. This methodology offers individual’s life, researchers use interviews and documents to researchers an opportunity to synthesize data from ‘‘phenomehelp tell the story. Once data and stories are collected, the researcher nologies, ethnographies, grounded theories, and other coherent ‘‘stories’’ and ‘‘re-stories’’ the information through data analysis descriptions or explanations of phenomena, events, or cases.’’56 strategies with the goal of developing themes or ordering the data 34 into a chronological order. There are ongoing efforts to standardize this approach. Clinicians working with persons with diabetes assess and For patients, these stories provide access to subject reality, that discuss depression in an effort to understand how it influences is, their truth and the meanings of their experiences. These meanthe functioning and self-care activities by individuals. Gask et al57 ings constitute important personal truths, which are vitally important to understand and provide appropriate care of individuals conducted a metasynthesis seeking to explore qualitative studies living with chronic illness.52,53 examining individuals’ experiences of diabetes and depression. The metasynthesis study result reflects the complexity of diabetes Bird et al54 explore the role of storytelling and the challenges of as a disease. The researchers discuss that the impact of diabetes conducting cross-cultural research with indigenous Inuit peoples symptoms was ‘‘associated with varied psychological reactions, using interviews, thematic analysis, open coding, and structured not all of which are negative, and the concept of depression only narrative analysis. The narrative study highlights persons’ expecapture aspects of the experience [yet] depression and other psyriences of coping and negotiating social support while living chological states were significant barriers to effective coping.’’57 with diabetes. This study is important because the prevalence of diabetes among the ‘‘Inuit and Alaska Natives... has substantially This is an important study approach in diabetes because it synincreased and is now comparable with the general Canadian thesizes smaller important qualitative studies into useable data population.’’14 for clinicians assessing for depression in individuals living with diabetes or diabetic foot ulcers. Bird et al54 state the importance of the following in individuals living with diabetes: having support and sharing diabetes knowledge among friends and family, managing stress while CONCLUSION living with the disease, accepting support from family members, This article has highlighted a few of the qualitative approaches and having help to make nutrition choices and changes to one’s used in health research to increase understanding of diabetes, diet. Storytellers in this study also discussed the importance of diabetic foot ulcers, and amputation. As diabetes increases worlddiabetes education; one storyteller narrative included a discuswide and the costs to the healthcare system and the individual sion on the need to ‘‘watch your feet’’ and to ‘‘get checked’’ and living with the disease increase, understanding the disease get ‘‘your eyes’’ checked when you have diabetes because there from the perspective of the individual is crucial. The goal is to are consequences if you do not care for yourself.53 The study share with clinicians the strengths of qualitative approaches as a means to gain understanding of DM and its complications. findings help healthcare professionals understand some of the Sandelowski48 states: aspects of the Inuit culture when planning, providing, and evaluating diabetes outcomes; the researchers emphasize the impor‘‘Qualitative health research is an inductive research tance of taking time to appreciate the complexities of providing approach used for exploring health and illness. It considappropriate culturally sensitive education. ered the perspective of the people themselves, rather than the researcher’s perspective [it is used] to elicit emotions and perspectives, beliefs and values, and actions and behaviors for the purpose of understanding the participants’ responses METASYNTHESIS to health and illness, the meanings they construct about the Metasynthesis is a combining of qualitative studies on a specific experience, and their subsequent actions.’’ topic to produce a new integrative interpretation of findings; As the prevalence of diabetes and related complications inthrough integration, a more functional result may emerge than creases, understanding the perspectives of individuals, families, from single investigations.55 These studies are a useful way to ADVANCES IN SKIN & WOUND CARE & VOL. 27 NO. 4
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19. American Diabetes Association. Economic costs of diabetes in the U.S. in 2012: Scientific statement. Diabetes Care. 2013; doi: 10.2337/dc12-262513. 20. Schaper NC, Apelqvist J, Bakker K. Reducing lower leg amputation in diabetes: A challenge for patient, healthcare providers and the healthcare system. Diabetologia 2012; 55:1869-72. 21. Goeree R, Lim ME, Hopkins R, et al. Prevalence, total and excess costs of diabetes and related complications in Ontario, Canada. Can J Diabetes 2009;33(1):35-45. 22. Ohinmaa A, Jacobs P, Simpson S, Johnson JA. The projection of prevalence and cost of diabetes in Canada: 2000-2016. Can J Diabetes 2004;28(2):1-8. 23. Brod M. Quality of life issues in patients with diabetes and lower extremity ulcers: patients and caregivers. Qual Life Res 1998;7:365-72. 24. Carrington AL, Mawdsley SK, Morley M, Kincey J, Boulton AJ. Psychological status of diabetic people with or without limb disability. Diabetes Res Clin Pract 1996;32:19-25. 25. Goodridge D, Trepman E, Embil JM. Health-related quality of life in diabetic patients with foot ulcers. J Wound Ostomy Continence Nurs 2005;32:368-77. 26. Meijer JWG, Trip J, Jaegers SM, et al. Quality of life in patients with diabetic foot ulcers. Disabil Rehabil 2001;23:336-40. 27. Ribu L, Hanestad BR, Moum T, Birkeland K, Rusteon T. Health-related quality of life among patients with diabetes and foot ulcers: association with demographic and clinical characteristics. J Diabetes Complications 2007;21:227-36. 28. Ribu L, Birkeland K, Hanestad BR, Moun T, Rustoen T. A longitudinal study of patients with diabetes and foot ulcers and their health-related quality of life: wound health and quality-of-life changes. J Diabetes Complications 2008;22:400-7. 29. Salome GM, de souza Pellegrino DM, Blanes L, Ferreira LM. Self-esteem in patients with diabetes mellitus and foot ulcers. J Tissue Viability 2011;20:100-6. 30. Tennvall GR, Apelqvist J. Health-related quality of life in patients with diabetes mellitus and foot ulcers. J Diabetes Complications 2000;14:235-41. 31. Vedhara K, Miles JMV, Wetherell MA, et al. Coping style and depression influence the health of diabetic foot ulcers: observational and mechanistic evidence. Diabetologia. 2010;53: 1590-8. 32. Waters N, Holloway S. Personal perceptions of the impact of diabetic foot disease on employment. Diabet Foot J 2009;12(3):119-31. 33. Munhall PL. A phenomenological method. In: Munhall PH, ed. Nursing Research: A Qualitative Perspective. Sudbury, MA: Jones and Bartlett; 2007:145-210. 34. Creswell JW. Qualitative Inquiry and Research Design. 2nd ed. Thousand Oaks, CA: Sage Publications; 2007. 35. Struthers R, Hodge FS, Geishirt-Cantrell B, De Cora L. Participant experience of Talking Circles on type 2 diabetes in two Northern Plains American Indian Tribes. Qual Health Res 2003;13: 1094-115. 36. Ontario. Circle TraditionsVTalking Circle. Aboriginal Perspectives: The Teacher’s Toolkit. Ontario, Canada: Queen’s Printer for Ontario; 2009. www.edu.gov.on.ca/eng/aboriginal/ strategygr01lancircle.pdf. Last accessed February 27, 2014. 37. Beitz JM, Goldberg E. The lived experience of having a chronic wound: a phenomenologic study. Medsurg Nurs 2005;14(1):51-82. 38. Goldberg E, Beitz JM. The lived experience of diverse elders with chronic wounds. Ostomy Wound Manage 2010;56(11):36-46. 39. Charmaz K. Constructing Grounded Theory: A Practical Guide through Qualitative Analysis. Thousand Oaks, CA: Sage Publications; 2006. 40. Wuest J. Grounded theory: the method. In Munhall PH, ed. Nursing Research: A Qualitative Perspective. Toronto, Canada: Jones & Bartlett Publishers; 2007:239-71. 41. Public Health Agency of Canada. Report from the National Diabetes Surveillance System: Diabetes in Canada 2009. http://www.ndss.gc.ca. Last accessed February 7, 2014. 42. Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health perspective. 2011. http://www.phac-aspc.gc.ca/cd-mc/diabetes-diabete/index-eng.php. Last accessed February 7, 2014. 43. Livingstone W, van de Mortel TF, Taylor B. A path of perpetual resilience: exploring the experience of a diabetes-related amputation through grounded theory. Contemp Nurse 2011; 39(1):20-30. 44. Saldana J. Fundamentals of Qualitative Research. New York, NY: Oxford University Press; 2011. 45. De Vera N. Perspective on healing foot ulcers by Yaquis with diabetes. J Transcult Nurs 2003;14(1):39-47. 46. Zapata J, Shipee-Rice R. The use of folk healing and healers by six Latinos living in New England: a preliminary study. J Transcult Nurs 1999;10:136-42. 47. Flyvberg B. Five misunderstandings about case-study research. Qual Inq 2006;12:219-45. 48. Sandelowski M. ‘‘Casing’’ the research case study. Res Nurs Health 2011;34:153-9.
and caregivers is essential to help guide clinicians’ assessment, planning, and evaluation of health outcomes.
PRACTICE PEARLS & Qualitative research approaches support exploring the complexities of diabetic foot ulcers from the client and family perspective. & Qualitative health research findings are the ‘‘grounded theories, ethnographies, phenomenologies, and other integrated descriptions or explanations produced from the analysis of data obtained from interviews, observations, documents, and artifacts.’’2 & Provision of holistic care includes listening to the clients’ perspective and creating care plans with mutually agreed elements. & Nontraumatic lower limb amputations are 10 fold higher in persons living with diabetes , according to the World Health Organization.
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49. Coates V. Research and diabetes nursing. Part 5: reviews, case studies and audit. J Diabetes Nurs 2011;15(50):178-82. http://www.thejournalofdiabetesnursing.co.uk/.../pdf/ jdn15-5_178-182.pdf. 50. Zucker DM. How to do case study research. School of Nursing Faculty Publication Series; 2009: Paper 2. http://scholarworks.umass.edu/nursing_faculty_pubs/2. Last accessed February 7, 2014. 51. Tian M, Wang X, Xiao Y, Lu S, Jiang Y. A rare case of diabetic hand ulcer caused by Streptococcus agalactiae. Int J Low Extrem Wounds 2012;11:174-6. 52. Bailey PH, Montgomery P, Mossey S. Narrative inquiry. In: Beck C, ed. Routledge International Handbook of Qualitative Nursing Research. London, UK: Routledge. 2013.
53. Bailey PH, Tilley S. Storytelling and the interpretation of meaning in qualitative research. J Adv Nurs 2002;38:574-83. 54. Bird S, Wiles JL, Okalik L, Kilabuk J, Egeland GM. Methodological consideration of storytelling in qualitative research involving indigenous peoples. Glob Health Promot 2009;16(4): 16-26. 55. Downe S. Metasynthesis: A guide to knitting smoke. Evid Based Midwifery. 2008;6(1):4-8. 56. Sandelowski M, Barroso J. Handbook for Synthesizing Qualitative Research. New York, NY: Springer Publishing Co Inc; 2007. 57. Gask L, Macdonald W, Bower P. What is the relationship between diabetes and depression? A qualitative meta-synthesis of patient experience of co-morbidity. Chronic Illn 2011;7:239-52.
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The Role of Qualitative Research in Understanding Diabetic Foot Ulcers and Amputation C M E 1 AMA PRA Category 1 CreditTM
ANCC 2.3 Contact Hours
Janet L. Kuhnke, RN, BA, BScN, MS & Enterostomal Therapist & Faculty & BScN Collaborative Program & St. Lawrence College/Laurentian University & Cornwall, Ontario, Canada Patricia Hill Bailey, RN, BN, MHSc, PhD & Professor & School of Nursing & Laurentian University & Sudbury, Ontario, Canada M. Gail Woodbury, BScPT, MSc, PhD & Assistant Professor, Adjunct Faculty & School of Rehabilitation Therapy & Queen’s University & Kingston, Ontario, Canada Mona Burrows, RN(EC), BScN, MScN, NP-PHC & Faculty & BScN Collaborative Program & St. Lawrence/Laurentian University & Cornwall, Ontario, Canada All authors, staff and planners, including spouses/partners (if any), in any position to control the content of this CME activity have disclosed that they have no financial relationships with, or financial interests in, any commercial companies pertaining to this educational activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least 13 of the 18 questions correctly. This continuing educational activity will expire for physicians on April 30, 2015.
PURPOSE: To enhance the learner’s competence with knowledge about using qualitative methodologies to understand diabetic foot ulcers and amputations. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to: 1. Analyze qualitative research methodologies. 2. Summarize how conclusions from qualitative research relate to diabetes mellitus and its complications.
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ABSTRACT
individuals to share their personal stories, researchers ‘‘choose people [purposive samples] who are willing to describe [articulate] their experience [and] who can adequately reflect on their experience and verbally describe it.’’6 Although qualitative methods are not without drawbacks, challenges, and limitations, 7,8 they do offer a depth of understanding of the experience of living with or experiencing a diabetic foot ulcer that other research approaches may not offer. As cited in Sandelowski,2 Selikoff states ‘‘qualitative findings are said to show the tears that statistical accounts wipe off.’’ The language within qualitative research studies, however, may not always make the research process transparent for the uninitiated.9 Nevertheless, ‘‘the researcher’s goal within all qualitative models, regardless of the differing approaches and methods, is to ‘interpret’ and or ‘reconstruct’ subjective meaning.’’10 Within this inquiry paradigm, researchers need to be clear on the philosophical foundation and methodological approach they are using and clearly outline this for the reader. Qualitative studies may be conducted as part of a larger study, to initially explore an issue where little research exits, and/or in partnership with a quantitative study. Qualitative studies contribute greatly to the understanding of an individual’s experience with diabetes, diabetic foot ulcers, and amputations.
Persons living with diabetes are at high risk for foot complications, lower extremity trauma, injury, ulceration, infection, and potential amputation. Qualitative health research helps to explore and understand more fully the complexities of diabetes. Qualitative health research seeks to understand what is happening and going on for the individual and his/her support persons. In addition, qualitative health research enables clinicians to appreciate how different qualitative research approaches can explore illness from the perspective of the individual living with the disease. KEYWORDS: diabetic foot ulcers, qualitative research, diabetes complications ADV SKIN WOUND CARE 2014;27:182–8
INTRODUCTION Qualitative health research is used by interdisciplinary teams to explore states of health, maintenance, and illness from the perspective of the individual, family member, caregiver, or clinician, rather than reporting only the researchers’ perspective. Qualitative research seeks to ‘‘elicit emotions and perspectives,’’ beliefs and values, and actions and behaviors for the purpose of understanding the participants’ responses to health and illness, the meanings they construct about the experience, and their subsequent actions.’’1 Qualitative health research findings are the ‘‘grounded theories, ethnographies, phenomenologies, and other integrated descriptions or explanation produced from the analysis of data obtained from interviews, observations, documents, and artifacts.’’2 In qualitative research, the building of new knowledge occurs when one develops a research question asking ‘‘what is happening or going on?’’ Then, the methodology is chosen that best supports answering the research area of interest.3 This article highlights several key qualitative methodologies seen in studies seeking to understand diabetes and related diabetic foot complications, ulcerations, and potential amputations. In recent years, new and thoughtful qualitative methodologies have emerged to answer specific research questions.4,5 Research approaches are ‘‘developed in different disciplines [of practice], different traditions, and on the basis of different ideas of science.’’6 Overall, these approaches and methods emphasize the collection of individual and group firsthand accounts or self-report of life experiences and events through interviews and/or observations. Interview data, observations, and narratives are recorded, typed, or transcribed into texts, narrative data sets, or accounts to be further studied by the researcher. When recruiting and selecting WWW.WOUNDCAREJOURNAL.COM
The Diabetes Challenge Worldwide As of 2013, the World Health Organization reports 347 million people worldwide have diabetes, creating a global epidemic.11 In developed countries, diabetes-related lower limb amputations are ‘‘at least 10 times more common in people with diabetes than in non-diabetic individuals.’’12 In 2011, the American Diabetes Association reported a prevalence of diabetes in adults and children at 8.3%; neuropathy was reported in about 60% to 70% of persons with diabetes. In addition, 60% of nontraumatic lower-limb amputations occur in this population.13 In Canada, the Canadian Diabetes Association estimated in 2012 that 9 million Canadians are living with diabetes and pre-diabetes adding to the diabetes issue globally.14 In its 2013 report, the Canadian Diabetes Association estimated that the number of Canadians living with diabetes will increase to 3.7 million by 2019 and emphasized that diabetes is the leading cause of ‘‘blindness, end stage renal disease and nontraumatic amputation in Canadian adults.’’14 With approximately 2.4 million Canadians living with diabetes, an estimated ‘‘345,000 will develop a foot ulcer.’’15 Therefore, understanding the disease and its complications from the perspective of the individual is essential for healthcare professionals providing holistic care. Diabetes mellitus (DM) may be type 1, type 2, or gestational in nature.14 One of the feared complications of diabetes is a diabetic foot ulcer.16 Diabetic foot ulcers are defined as ‘‘infection, ulcerations, and/or destruction of deep tissues associated with 183
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These are powerful practical insights neurologic abnormalities and varTo support individuals living with a chronic to be used when creating culturally ious degrees of peripheral vascular wound, findings suggest regular pain assessments sensitive programs.35 disease in the lower limb; approxand reassessments, mobility assessment imately 40%–60% of all lower exBeitz and Goldberg37 used pheand support access to devices, referring individuals tremity amputations are related nomenology to explore the meaning to diabetes mellitus.’’17 Research of the lived experience of individuals to support groups, and creation of living with a chronic wound (arterial, shows that at least ‘‘85% of lower partnerships with the individual and healthcare venous, diabetic, pressure, unknown). extremity amputation is preceded by professionals. Using interviews and field notes with a diabetic foot ulcer.’’18 16 white (retired) study participants, the researchers analyzed The cost of diabetes in the United States has increased from findings into 3 key cluster themes (physiological, psychological, $174 billion (in 2007 dollars) to $245 billion in 2012, a 41% inand social): ‘‘living with pain, changing eating patterns, losing crease. This is a significant issue for the healthcare system.19,20 In mobility, explaining causes of wounds, receiving care, healing Canada, the cost of diabetes is also significant. In the year 2000, it and recuperating, contending with chronic illness, adapting and was estimated that Canadian healthcare costs exceeded $4.6 billion maladapting, living and aging, dealing with wound treatments, (1996 CAD) and costs were predicted to rise to $8.1 billion by and experiencing altered sleeping habits.’’37 Some of the reported 2016.21 These costs are expected to continue to rise over time. For example, in the province of Ontario, costs are estimated to rise themes were described in other research studies, whereas changfrom $1.8 billion to $3.1 billion by 2016.22 ing eating patterns and living and aging were new findings from this study. Participants varied in their perspectives of how living As rates of diabetes increase, understanding diabetes from the with a wound affected their appetite; some experienced no change, individual’s perspective is essential because living with a diabetic whereas some experienced significant changes. Living (and aging) foot ulcer affects the quality of an individual’s life. Social wellwith a wound varied in the study findings. Residents in the study being, employment status, psychological welfare (self-esteem), relied on past knowledge and life experiences to remain optimistic mobility, physiological health, and overall health are all affected and hopeful and to appreciate the care they received. Some used by living with a foot ulcer.23–32 personal ‘‘self-talk’’ to feel better while living with a chronic wound. Goldberg and Beitz38 further explored the lived experience of PHENOMENOLOGY diverse older adults with chronic wounds (African American, Phenomenology is a philosophical perspective and a qualitative Hispanic; 7 men, 4 women) living in financially fragile circummethodology.7 Studies using a phenomenological focus aim to stances. Chronic wounds were described as wounds being predescribe the meaning of illness experiences from the individual’s sent for longer than 8 weeks. The researchers found that diverse perspective.33 Studies may use interviews, observations, docuolder adults experienced ‘‘tolerating pain, missing normal mobilments, and art to collect data for analysis; several individuals who ity, living with chronic illness, and explaining causes of wounds’’ ‘‘have shared the experience’’ (eg, a diabetic foot ulcer) of interest in the same way white older adults did in their 2005 study.37 are the focus of the study.34 35 Struthers et al use phenomenology to examine participants’ New study findings were ‘‘encountering losses, considering experiences of being part of a ‘‘Talking Circle’’ for individuals costs, and changing social roles.’’38 Costs included spending perwith type 2 diabetes from the Northern Plains American Indian sonal savings on care to the point of being dependent on the state Tribes. The study’s objective was to understand the experience of programs (eg, Medicaid, Medicare). Chronic wounds often occur being part of a 12-week diabetes educational intervention. Talking when an individual is coping with other chronic illnesses, adding Circles represent ‘‘important principles in the Aboriginal worldstress and possible disruption to their already busy lives. To supview and belief systems, namely, interconnectedness, quality, and port individuals living with a chronic wound, findings suggest continuity.’’36 Through Talking Circles, researchers learned from regular pain assessments and reassessments, mobility assessment and support access to devices, referring individuals to support the participants that this was an effective, culturally appropriate groups, and creation of partnerships with the individual and means of providing information about type 2 diabetes in their healthcare professionals. community. Eight themes emerged from the study data, including how harmonizing western diabetes information with traditional indigenous methods could be achieved. One study participant GROUNDED THEORY shared how she and her husband were able to merge prayer, Grounded theory is an approach used to purposively develop a traditional medicine practitioners, dreams, traditional rituals, and a theory about a ‘‘dominant social process rather than to describe belief in the Creator to help heal her husband’s diabetic foot ulcer. a particular phenomenon.’’3 The goal of grounded theory is to ADVANCES IN SKIN & WOUND CARE & VOL. 27 NO. 4
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De Vera’s45 study emphasizes the generate or expand a theory that adNarrative research is one of the many research dresses problematic realities for inneed for healthcare professionals to approaches with the aim of providing insight dividuals facing healthcare challenges. learn and regard traditional healing into the lives of individuals by ‘‘transforming The method of grounded theory uses practices as part of the individual’s data from, by, and or about participants constant comparative analysis and belief system. These efforts assist in theoretical sampling, which enhances the integration of traditional healing into literary story formats.’’ engagement in data analysis.39 The methods with western biomedicine, promoting healthy outcomes.42 Taking time to listen to individproduct of a grounded theory study is the identification of patterns or process through the examination of the experiences of uals’ beliefs; encouraging the use of support groups; and learning those experiencing those realities.40 about specific cultural beliefs, perceptions, and healing practices may help with healing of diabetic foot ulcers.46 For example, for individuals living with DM the risk for developing a diabetic foot ulcer and experiencing an amputation is a CASE STUDY real personal fear, though preventable with proper daily foot care.41,42 To understand the individual’s experience, Livingstone Case study research involves the study of ‘‘one person, one group, et al43 used a grounded theory approach, exploring what the one event, one organization, and so on.’’44 The aim is to analyze ‘‘day-to-day life’’ is like for someone with diabetes after ampuand examine in-depth the setting or participants of interest to tation. Using unstructured interviews, grounded theory methods, uncover common and potentially unique transformative exemand data analysis, 3 key categories emerged from the study data: plars available in no other way.47–49 This approach involves use 43 ‘‘imposed powerlessness, adaptive functionality, and endurance.’’ of a case, multiple cases over time, observations, interviews, documents, or reports within a setting or context and examines an Individuals shared stories of moving from single-digit amputaissue not readily explored by other research approaches availtion to more complex procedures and amputations. They shared able.34 Case study approach can ‘‘be designed in a variety of ways what this was like for themselves and their caregivers to experience these events. This small study adds to the understanding and can involve quantitative, qualitative or both investigative apof the ‘‘path of perpetual resilience’’ that individuals experience. proaches.’’50 Zucker50 outlines the difference between a case reThe researchers recommend that clinical teams support an indiview and a case report that healthcare professionals may see in vidual’s psychological adaptation to life after amputation. This is educational formats. The case study differs in that key features ‘‘are important research because clients may experience more than 1 its scientific credentials and its evidence base for professional amputation in their journey living with diabetes.42 application [and it] often involves in-depth interviews with participants and key informants, review of the medical records, observation, and excerpts from patients’ personal writings and diaries.’’50 ETHNOGRAPHY Tian et al51 use a case study research approach to share the case Ethnography seeks to understand culture and human processes, of a 71-year-old woman with a diabetes-related ulcer on her hand; through prolonged engagement, using inside (emic) and outside one limitation of this study is that the individual’s personal per(etic) perspectives, gaining tacit knowledge (deeply embedded spective was not included. In the study, the researchers give the cultural experiences), and using the researcher as an instrument medical history and causes of a diabetic hand ulcer caused by to construct theory.44 Ethnography involves field work, collecting Streptococcus agalactiae and how the wound/amputation site observations, conducting interviews, and communication with closed during a 32-day period after surgery. The individual histhe cultural group to describe the emergent cultural themes.34 tory, laboratory values, surgical care, wound care treatment, and De Vera45 used ethnography to explore and describe perspecoutcomes are shared in the case study. The researchers reflect on tives on healing DM foot ulcers by Yaqui Native Americans the rarity of this case and what is known about ‘‘tropical diabetic (Arizona, United States).44 Eight cultural themes or domains of hand syndrome’’ and its relationship to long-term diabetes, poor meaning emerged from the 8-month data collection period. These blood glucose monitoring, and lack of attention to small wounds.51 included (1) the experience of having foot ulcers, (2) personal Overall, the case study approach used shares a ‘‘rare’’ case in a self-care beliefs and practices, (3) faith and strength (religion, professional format and reminds clinicians of the rapid treatment spirituality, and philosophy of life), (4) types of support (spiritual, required to support positive outcomes in these situations. family, and professional), (5) difficulties with diabetes complications, (6) prevention of foot ulcers through self-care measures, (7) ceremonies, (8) and cultural themes (prayer that gives power for healing, the Yaqui health way of life, foot ulcers as a modern illness, and supports to survive the difficult journey with diabetes). WWW.WOUNDCAREJOURNAL.COM
NARRATIVE RESEARCH Narrative research ‘‘is the study of stories.’’6,8 Narrative research (narrative inquiry) is one of the many research approaches with the 185
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access relevant literature on a topic in aim of providing insight into the As diabetes increases worldwide and the costs a timely and effective manner.49 This lives of individuals by ‘‘transformto the healthcare system and the individual ing data from, by, and or about parapproach is not without its critics at living with the disease increase, understanding ticipants into literary story formats.’’44 every step of the process.55,56 One risk the disease from the perspective of the is the inclusion of weaker studies, A study using narrative inquiry folindividual is crucial. which in turn may weaken the lows research structures that examine metasynthesis result. Researchers using either life stories or limited accounts the approach work closely together and set criteria for incluwithin the larger segments of interview data.48 To explore the sion of studies in the metasynthesis. This methodology offers individual’s life, researchers use interviews and documents to researchers an opportunity to synthesize data from ‘‘phenomehelp tell the story. Once data and stories are collected, the researcher nologies, ethnographies, grounded theories, and other coherent ‘‘stories’’ and ‘‘re-stories’’ the information through data analysis descriptions or explanations of phenomena, events, or cases.’’56 strategies with the goal of developing themes or ordering the data 34 into a chronological order. There are ongoing efforts to standardize this approach. Clinicians working with persons with diabetes assess and For patients, these stories provide access to subject reality, that discuss depression in an effort to understand how it influences is, their truth and the meanings of their experiences. These meanthe functioning and self-care activities by individuals. Gask et al57 ings constitute important personal truths, which are vitally important to understand and provide appropriate care of individuals conducted a metasynthesis seeking to explore qualitative studies living with chronic illness.52,53 examining individuals’ experiences of diabetes and depression. The metasynthesis study result reflects the complexity of diabetes Bird et al54 explore the role of storytelling and the challenges of as a disease. The researchers discuss that the impact of diabetes conducting cross-cultural research with indigenous Inuit peoples symptoms was ‘‘associated with varied psychological reactions, using interviews, thematic analysis, open coding, and structured not all of which are negative, and the concept of depression only narrative analysis. The narrative study highlights persons’ expecapture aspects of the experience [yet] depression and other psyriences of coping and negotiating social support while living chological states were significant barriers to effective coping.’’57 with diabetes. This study is important because the prevalence of diabetes among the ‘‘Inuit and Alaska Natives... has substantially This is an important study approach in diabetes because it synincreased and is now comparable with the general Canadian thesizes smaller important qualitative studies into useable data population.’’14 for clinicians assessing for depression in individuals living with diabetes or diabetic foot ulcers. Bird et al54 state the importance of the following in individuals living with diabetes: having support and sharing diabetes knowledge among friends and family, managing stress while CONCLUSION living with the disease, accepting support from family members, This article has highlighted a few of the qualitative approaches and having help to make nutrition choices and changes to one’s used in health research to increase understanding of diabetes, diet. Storytellers in this study also discussed the importance of diabetic foot ulcers, and amputation. As diabetes increases worlddiabetes education; one storyteller narrative included a discuswide and the costs to the healthcare system and the individual sion on the need to ‘‘watch your feet’’ and to ‘‘get checked’’ and living with the disease increase, understanding the disease get ‘‘your eyes’’ checked when you have diabetes because there from the perspective of the individual is crucial. The goal is to are consequences if you do not care for yourself.53 The study share with clinicians the strengths of qualitative approaches as a means to gain understanding of DM and its complications. findings help healthcare professionals understand some of the Sandelowski48 states: aspects of the Inuit culture when planning, providing, and evaluating diabetes outcomes; the researchers emphasize the impor‘‘Qualitative health research is an inductive research tance of taking time to appreciate the complexities of providing approach used for exploring health and illness. It considappropriate culturally sensitive education. ered the perspective of the people themselves, rather than the researcher’s perspective [it is used] to elicit emotions and perspectives, beliefs and values, and actions and behaviors for the purpose of understanding the participants’ responses METASYNTHESIS to health and illness, the meanings they construct about the Metasynthesis is a combining of qualitative studies on a specific experience, and their subsequent actions.’’ topic to produce a new integrative interpretation of findings; As the prevalence of diabetes and related complications inthrough integration, a more functional result may emerge than creases, understanding the perspectives of individuals, families, from single investigations.55 These studies are a useful way to ADVANCES IN SKIN & WOUND CARE & VOL. 27 NO. 4
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19. American Diabetes Association. Economic costs of diabetes in the U.S. in 2012: Scientific statement. Diabetes Care. 2013; doi: 10.2337/dc12-262513. 20. Schaper NC, Apelqvist J, Bakker K. Reducing lower leg amputation in diabetes: A challenge for patient, healthcare providers and the healthcare system. Diabetologia 2012; 55:1869-72. 21. Goeree R, Lim ME, Hopkins R, et al. Prevalence, total and excess costs of diabetes and related complications in Ontario, Canada. Can J Diabetes 2009;33(1):35-45. 22. Ohinmaa A, Jacobs P, Simpson S, Johnson JA. The projection of prevalence and cost of diabetes in Canada: 2000-2016. Can J Diabetes 2004;28(2):1-8. 23. Brod M. Quality of life issues in patients with diabetes and lower extremity ulcers: patients and caregivers. Qual Life Res 1998;7:365-72. 24. Carrington AL, Mawdsley SK, Morley M, Kincey J, Boulton AJ. Psychological status of diabetic people with or without limb disability. Diabetes Res Clin Pract 1996;32:19-25. 25. Goodridge D, Trepman E, Embil JM. Health-related quality of life in diabetic patients with foot ulcers. J Wound Ostomy Continence Nurs 2005;32:368-77. 26. Meijer JWG, Trip J, Jaegers SM, et al. Quality of life in patients with diabetic foot ulcers. Disabil Rehabil 2001;23:336-40. 27. Ribu L, Hanestad BR, Moum T, Birkeland K, Rusteon T. Health-related quality of life among patients with diabetes and foot ulcers: association with demographic and clinical characteristics. J Diabetes Complications 2007;21:227-36. 28. Ribu L, Birkeland K, Hanestad BR, Moun T, Rustoen T. A longitudinal study of patients with diabetes and foot ulcers and their health-related quality of life: wound health and quality-of-life changes. J Diabetes Complications 2008;22:400-7. 29. Salome GM, de souza Pellegrino DM, Blanes L, Ferreira LM. Self-esteem in patients with diabetes mellitus and foot ulcers. J Tissue Viability 2011;20:100-6. 30. Tennvall GR, Apelqvist J. Health-related quality of life in patients with diabetes mellitus and foot ulcers. J Diabetes Complications 2000;14:235-41. 31. Vedhara K, Miles JMV, Wetherell MA, et al. Coping style and depression influence the health of diabetic foot ulcers: observational and mechanistic evidence. Diabetologia. 2010;53: 1590-8. 32. Waters N, Holloway S. Personal perceptions of the impact of diabetic foot disease on employment. Diabet Foot J 2009;12(3):119-31. 33. Munhall PL. A phenomenological method. In: Munhall PH, ed. Nursing Research: A Qualitative Perspective. Sudbury, MA: Jones and Bartlett; 2007:145-210. 34. Creswell JW. Qualitative Inquiry and Research Design. 2nd ed. Thousand Oaks, CA: Sage Publications; 2007. 35. Struthers R, Hodge FS, Geishirt-Cantrell B, De Cora L. Participant experience of Talking Circles on type 2 diabetes in two Northern Plains American Indian Tribes. Qual Health Res 2003;13: 1094-115. 36. Ontario. Circle TraditionsVTalking Circle. Aboriginal Perspectives: The Teacher’s Toolkit. Ontario, Canada: Queen’s Printer for Ontario; 2009. www.edu.gov.on.ca/eng/aboriginal/ strategygr01lancircle.pdf. Last accessed February 27, 2014. 37. Beitz JM, Goldberg E. The lived experience of having a chronic wound: a phenomenologic study. Medsurg Nurs 2005;14(1):51-82. 38. Goldberg E, Beitz JM. The lived experience of diverse elders with chronic wounds. Ostomy Wound Manage 2010;56(11):36-46. 39. Charmaz K. Constructing Grounded Theory: A Practical Guide through Qualitative Analysis. Thousand Oaks, CA: Sage Publications; 2006. 40. Wuest J. Grounded theory: the method. In Munhall PH, ed. Nursing Research: A Qualitative Perspective. Toronto, Canada: Jones & Bartlett Publishers; 2007:239-71. 41. Public Health Agency of Canada. Report from the National Diabetes Surveillance System: Diabetes in Canada 2009. http://www.ndss.gc.ca. Last accessed February 7, 2014. 42. Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health perspective. 2011. http://www.phac-aspc.gc.ca/cd-mc/diabetes-diabete/index-eng.php. Last accessed February 7, 2014. 43. Livingstone W, van de Mortel TF, Taylor B. A path of perpetual resilience: exploring the experience of a diabetes-related amputation through grounded theory. Contemp Nurse 2011; 39(1):20-30. 44. Saldana J. Fundamentals of Qualitative Research. New York, NY: Oxford University Press; 2011. 45. De Vera N. Perspective on healing foot ulcers by Yaquis with diabetes. J Transcult Nurs 2003;14(1):39-47. 46. Zapata J, Shipee-Rice R. The use of folk healing and healers by six Latinos living in New England: a preliminary study. J Transcult Nurs 1999;10:136-42. 47. Flyvberg B. Five misunderstandings about case-study research. Qual Inq 2006;12:219-45. 48. Sandelowski M. ‘‘Casing’’ the research case study. Res Nurs Health 2011;34:153-9.
and caregivers is essential to help guide clinicians’ assessment, planning, and evaluation of health outcomes.
PRACTICE PEARLS & Qualitative research approaches support exploring the complexities of diabetic foot ulcers from the client and family perspective. & Qualitative health research findings are the ‘‘grounded theories, ethnographies, phenomenologies, and other integrated descriptions or explanations produced from the analysis of data obtained from interviews, observations, documents, and artifacts.’’2 & Provision of holistic care includes listening to the clients’ perspective and creating care plans with mutually agreed elements. & Nontraumatic lower limb amputations are 10 fold higher in persons living with diabetes , according to the World Health Organization.
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53. Bailey PH, Tilley S. Storytelling and the interpretation of meaning in qualitative research. J Adv Nurs 2002;38:574-83. 54. Bird S, Wiles JL, Okalik L, Kilabuk J, Egeland GM. Methodological consideration of storytelling in qualitative research involving indigenous peoples. Glob Health Promot 2009;16(4): 16-26. 55. Downe S. Metasynthesis: A guide to knitting smoke. Evid Based Midwifery. 2008;6(1):4-8. 56. Sandelowski M, Barroso J. Handbook for Synthesizing Qualitative Research. New York, NY: Springer Publishing Co Inc; 2007. 57. Gask L, Macdonald W, Bower P. What is the relationship between diabetes and depression? A qualitative meta-synthesis of patient experience of co-morbidity. Chronic Illn 2011;7:239-52.
For more than 110 additional continuing education articles related to skin and wound care topics, go to NursingCenter.com/CE.
CONTINUING MEDICAL EDUCATION INFORMATION FOR PHYSICIANS
CONTINUING EDUCATION INSTRUCTIONS
Lippincott Continuing Medical Education Institute, Inc. is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Lippincott Continuing Medical Education Institute, Inc. designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should only
& Read the article beginning on page 182. & Take the test, recording your answers in the test answers section (Section B) of the
claim credit commensurate with the extent of their participation in the activity.
CE Group, 74 Brick Blvd, Bldg 4 Suite 206, Brick, NJ 08723.
& Within 3 to 4 weeks after your CE enrollment form is received, you will be notified
PROVIDER ACCREDITATION INFORMATION FOR NURSES
of your test results.
Lippincott Williams & Wilkins, publisher of the Advances in Skin & Wound Care journal, will award 2.3 contact hours for this continuing nursing education activity. LWW is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 2.3 contact hours. LWW is also an approved provider by the District of Columbia and Florida CE Broker #50-1223. Your certificate is valid in all states. The ANCC’s accreditation status of Lippincott Williams & Wilkins Department of Continuing Education refers only to its continuing nursing education activities and does not imply Commission on Accreditation approval or endorsement of any commercial product.
OTHER HEALTH PROFESSIONALS This activity provides ANCC credit for nurses and AMA PRA Category 1 CreditTM for MDs and DOs only. All other healthcare professionals participating in this activity will receive a certificate of participation that may be useful to your individual profession’s
CE enrollment form. Each question has only one correct answer.
& Complete registration information (Section A) and course evaluation (Section C). & Mail completed test with registration fee to: Lippincott Williams & Wilkins, & If you pass, you will receive a certificate of earned contact hours and an answer key. Nurses
who fail have the option of taking the test again at no additional cost. Only the first entry sent by physicians will be accepted for credit.
& A passing score for this test is 13 correct answers. & Nurses: Need CE STAT? Visit http://www.nursingcenter.com for immediate results, other
CE activities, and your personalized CE planner tool. No Internet access? Call 1-800-787-8985 for other rush service options.
& Questions? Contact Lippincott Williams & Wilkins: 1-800-787-8985.
Registration Deadline: April 30, 2016 (nurses); April 30, 2015 (physicians).
PAYMENT AND DISCOUNTS
& The registration fee for this test is $21.95 for nurses; $22 for physicians. & Nurses: If you take two or more tests in any nursing journal published by LWW and send in
your CE enrollment forms together by mail, you may deduct $0.95 from the price of each test. We offer special discounts for as few as six tests and institutional bulk discounts for multiple tests. Call 1-800-787-8985 for more information.
CE requirements.
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