Charismatic authority in modern healthcare: the case of the 'diabetes specialist podiatrist'

The role of podiatry in the early identification and prevention of lower limb venous disease: an ethnographic study

BACKGROUND

Lower limb venous disease can cause significant pain, loss of mobility, and can be detrimental to an individual's quality of life. Manifestations of venous disease often pose a substantially negative impact on patients and place a high demand on finite healthcare resources. Whilst this problem is internationally recognised, most research and discourse has predominantly focussed on treatment of leg ulceration and prevention of recurrence. Prevention of lower limb venous disease progression to the first ulceration has received far less attention. Overall, the care of this condition appears to rest in the domain of medicine and nursing yet podiatry, a profession with responsibility for the lower limb and foot, is conspicuous by its absence from the literature.  METHODS: An ethnographic approach was used to gather data from 26 participants through observation, semi-structured interviews, and a focus group interview. Qualitative analysis was conducted using the framework approach.

RESULTS

The findings revealed an identity crisis within the podiatry profession. Evidence emerged of ritual and routine practices that did not include lower limb venous disease. External control over practice limited the professional autonomy of podiatrists determining their own activities. Inter-professional relationships with nursing, and perceptions of boundaries that venous disease was a nursing role were also found to be limiting factors.

CONCLUSIONS

This research revealed that podiatry does not occupy a substantive role in contributing to the early identification and prevention of lower limb venous disease. Policy, education, research and practice changes are all required to enhance the contribution of podiatry to reduce the burden of this disease.

Perceived Barriers, Benefits, Facilitators, and Attitudes of Health Professionals Towards Multidisciplinary Team Care in Type 2 Diabetes Management: A Systematic Review

BACKGROUND

The need for a multidisciplinary team approach to provide physical exercise, diet, behavioral change, and insulin therapy in type 2 diabetes mellitus (T2DM) treatment has long been recognized. However, often patients with T2DM do not have access to a multidisciplinary team.

INTRODUCTION

In developing countries, most patients with T2DM receive their diabetes care in the office of an internist or family practice physician or in a primary level health center with a general practitioner. Knowledge of healthcare professionals regarding the perceived barriers, attitudes, facilitators, and benefits of a multidisciplinary team approach in T2DM treatment can help facilitate the implementation of multidisciplinary care in T2DM.

METHODS

A systematic search strategy was performed in six databases (PubMed, Web of Science, CINAHL, EMBASE, MEDLINE, and Cochrane) using different keyword combinations to identify studies describing the healthcare professionals' views of multidisciplinary team care in T2DM. A textual narrative synthesis was used to analyze data. The Critical Appraisals Skills Programme (CASP) tool for qualitative studies was used to assess the risk of bias and transferability.

RESULTS

The views of health professionals about multidisciplinary team care in T2DM were categorized into six major factors, namely working collaboratively to foster supportive relationships; strong committed organizational and team leadership; diversity in expertise, with team members tailored to local circumstances; shared goals and approaches to ensure consistency of message; clear and open communication with the team and with patients; and the patient at the center of decision- making.

CONCLUSION

There is a huge gap in shared roles among health professionals in T2DM therapy. Hence, there is a need for allied health professionals such as physiotherapists, dieticians, and psychologists with expertise in diabetes to explore primary healthcare, barriers and facilitators to the successful integration of multidisciplinary team, seamlessly distributedinto three hierarchal levels, namely health management, health professionals, and diabetic patients.

The changing landscape of professional practice in podiatry, lessons to be learned from other professions about the barriers to change - a narrative review

BACKGROUND

The delivery of healthcare is changing and aligned with this, the podiatry profession continues to change with evidence informed practice and extending roles. As change is now a constant, this gives clinicians the opportunity to take ownership to drive that change forward. In some cases, practitioners and their teams have done so, where others have been reluctant to embrace change. It is not clear to what extent good practice is being shared, whether interventions to bring about change have been successful, or what barriers exist that have prevented change from occurring. The aim of this article is to explore the barriers to changing professional practice and what lessons podiatry can learn from other health care professions.

MAIN BODY

A literature search was carried out which informed a narrative review of the findings. Eligible papers had to (1) examine the barriers to change strategies, (2) explore knowledge, attitudes and roles during change interventions, (3) explore how the patients/service users contribute to the change process (4) include studies from predominantly primary care in developed countries.Ninety-two papers were included in the final review. Four papers included change interventions involving podiatrists. The barriers influencing change were synthesised into three themes (1) the organisational context, (2) the awareness, knowledge and attitudes of the professional, (3) the patient as a service user and consumer.

CONCLUSIONS

Minimal evidence exists about the barriers to changing professional practice in podiatry. However, there is substantial literature on barriers and implementation strategies aimed at changing professional practices in other health professions. Change in practice is often resisted at an organisational, professional or service user level. The limited literature about change in podiatry, a rapidly changing healthcare workforce and the wide range of contexts that podiatrists work, highlights the need to improve the ways in which podiatrists can share successful attempts to change practice.

Sociology of the professions: what it means for podiatry

Background

The health professions have progressed and evolved considerably over the last few decades in response to demographic, technological, societal and political changes. They continue to do so as the volume and complexity of population health needs steadily increase. Role boundary expansion is among the key changes to the health professions, including podiatry to meet demand. Nonetheless podiatry’s role boundary expansion has not been achieved swiftly or without resistance from neighbouring and dominant professions. This paper seeks to explain the nature of this resistance with respect to the sociology of the professions literature and to shed light on some of the factors and processes at play when role boundary changes arise in health care.

Discussion

Six of the most contemporaneously relevant sociology of the professions theories are summarised: Taxonomic, Marxian, Bourdieusian, Foucauldian, Boundary Work and Neo-Weberian paradigms.

Conclusion

This review highlights that some paradigms are more relevant than others in the current socio-political landscape. It also illustrates that there is a common theme underlying each approach to defining the professions and their boundaries: competition. This may help health professionals, including podiatrists, to understand and manage the challenges and resistance experienced when professions attempt to expand role boundaries to meet increasing and changing population health needs.

UK podiatrists' experiences of podiatry services for people living with arthritis: a qualitative investigation

Background

Provision of podiatry services, like other therapies in the UK, is an area that lacks guidance by the National Institute for Health and Care Excellence. Many individuals living with arthritis in the UK are not eligible to access NHS podiatry services. The primary aim of this investigation was to understand the views of podiatry clinicians on their experiences of referral, access, provision and treatment for foot problems for patients who have arthritis.

Methods

Focus groups were undertaken to explore, in-depth, individual views of podiatrists working in the UK to gain feedback on experiences of barriers and facilitators to referral, access, provision and treatment for foot problems for individuals living with arthritis. A purposive sampling strategy was adopted and two, semi-structured, focus group interviews conducted, involving 12 podiatrists from both NHS and independent sectors. To account for geographical variations one focus group took place in each of 2 predetermined ‘zones’ of the UK; Yorkshire and Hampshire. Thematic analysis was employed to identify key meanings and report patterns within the data.

Results

The key themes derived from the podiatry clinician focus groups suggest a variety of factors influencing demand for, and burden of, foot pain within the UK. Participants expressed frustration on having a service that accepts and treats patients according to their condition, rather than their complaint. Additionally, concern was conveyed over variations in the understanding of stakeholders’ views of what podiatry is and what podiatrists aim to achieve for patients.

Conclusion

Podiatrists interviewed believed that many individuals living with arthritis in the UK are not eligible to access NHS podiatry services and that this may be, in part, due to confusion over what is known about podiatry and access criteria. Essentially, podiatrists interviewed called for a timely renaissance of current systems, to newer models of care that meet the foot care needs of individual patients’ circumstances and incorporate national multi-disciplinary guidance. Through this project, we have formulated key recommendations that are directed towards improving what other stakeholders (including GPs, commissioners and users of podiatry services) know about the effectiveness of podiatry and also to futureproof the profession of podiatry.

Patients’ experiences of lupus-related foot problems: a qualitative investigation

Background

Systemic lupus erythematosus (SLE) can present with a variety of symptoms. Previous research has shown there is a high prevalence of lower limb and foot problems in patients with SLE associated with the musculoskeletal, vascular and neurological changes. Furthermore, there is a high prevalence of infections affecting the feet and a range of common skin and nail problems. However, it is not known how these foot problems impact upon people’s lives. Therefore, we aimed to explore this using a qualitative approach.

Method

Following ethical approval, 12 participants were recruited who had a diagnosis of SLE, current and/or past experience of foot problems and were over 18 years in age. Following consent, interviews were carried out with an interpretivist phenomenological approach to both data collection and analysis.

Results

Seven themes provide insight into: foot problems and symptoms; the impact of these foot problems and symptoms on activities; disclosure and diagnosis of foot problems; treatment of foot problems and symptoms; perceived barriers to professional footcare; unanswered questions about feet and footcare; and identification of the need for professional footcare and footcare advice.

Conclusion

These participants tend to “self-treat” rather than disclose that they may need professional footcare. A lack of focus upon foot health within a medical consultation is attributed to the participant’s belief that it is not within the doctor’s role, even though it is noted to contribute to reduced daily activity. There is a need for feet to be included as a part of patient monitoring and for foot health management to be made accessible for people with SLE.

Charisma and the clinic

Here we argue that 'charisma', a concept widely taken up within geography and the environmental humanities, is of utility to the social studies of medicine. Charisma, we suggest, draws attention to the affective dimensions of medical work, the ways in which these affective relations are structured, and the manner in which they are intimately tied to particular material-discursive contexts. The paper differentiates this notion of charisma from Weber's analyses of the 'charismatic leader' before detailing three forms of charisma - ecological (which relates to the affordances an entity has), corporeal (related to bodily interaction) and aesthetic (pertaining to an entity's initial visual and emotional impact). Drawing on interview data, we then show how this framework can be used to understand the manner in which psychologists and neuroscientists have come to see and act on autism. We conclude the article by suggesting that examining charisma within healthcare settings furthers the concept, in particular by drawing attention to the discursive features of ecologies and the 'non-innocence' of charisma.

Nurses', physicians' and radiographers' perceptions of the safety of a nurse prescribing of ionising radiation initiative: A cross-sectional survey

BACKGROUND

A new initiative was introduced in Ireland following legislative changes that allowed nurses with special training to prescribe ionising radiation (X-ray) for the first time. A small number of studies on nurse prescribing of ionising radiation in other contexts have found it to be broadly as safe as ionising radiation prescribing by physicians. Sociological literature on perceptions of safety indicates that these tend to be shaped by the ideological position of the professional rather than based on objective evidence.

OBJECTIVES

To describe, compare and analyse perceptions of the safety of a nurse prescribing of ionising radiation initiative across three occupational groups: nursing, radiography and medicine.

DESIGN

A cross-sectional survey design.

SETTINGS

Participants were drawn from a range of clinical settings in Ireland.

PARTICIPANTS

Respondents were 167 health professionals comprised of 49 nurses, 91 radiographers, and 27 physicians out of a total of 300 who were invited to participate. Non-probability sampling was employed and the survey was targeted specifically at health professionals with a specific interest in, or involvement with, the development of the nurse prescribing of ionising radiation initiative in Ireland.

METHODS

Comparisons of perspectives on the safety of nurse prescribing of ionising radiation across the three occupational groups captured by questionnaire were analysed using the Kruskal-Wallis H test. Pairwise post hoc tests were conducted using the Mann-Whitney U test.

RESULTS

While the majority of respondents from all three groups perceived nurse prescribing of ionising radiation to be safe, the extent to which this view was held varied. A higher proportion of nurses was found to display confidence in the safety of nurse prescribing of ionising radiation compared to physicians and radiographers with differences between nurses' perceptions and those of the other two groups being statistically significant.

CONCLUSION

That an occupational patterning emerged suggests that perceptions about safety and risk of nurse prescribing of ionising radiation are socially constructed according to the vantage point of the professional and may not reflect objective measures of safety. These findings need to be considered more broadly in the context of ideological barriers to expanding the role of nurses.

Specialisation versus special interest - the Australian podiatry experience

Background

Ensuring efficient and effective delivery of health care to an ageing population has been a major driver for a review of the health workforce in Australia. As part of this process a National Registration and Accreditation Scheme (NRAS) has evolved with one goal being to improve workforce flexibility within a nationally consistent model of governance. In addition to increased flexibility, there have been discussions about maintaining standards and the role of specialisation. This study aims to explore the association between practitioners’ self-perceptions about their special interest in musculoskeletal, diabetes related and podopaediatric foot care and the actual podiatry services they deliver in Australia.

Methods

A cross sectional on-line survey was administered on behalf of the Australasian Podiatry Council and its’ state based member associations. Self-reported data were collected over a 3-week interval and captured information about the practitioners by gender, years of clinical experience, area of work by state, work setting, and location. For those participants that identified with an area of special interest or specialty, further questions were asked regarding support for the area of special interest through education, and activities performed in treating patients in the week prior to survey completion. Queensland University of Technology Human Research Ethics approval was sought and confirmed exemption from review.

Results

218 podiatrists participated in the survey. Participants were predominately female and worked in private practices.

The largest area of personal interest by the podiatrists was related to the field of musculoskeletal podiatry (n = 65), followed closely by diabetes foot care (n = 61), and a third area identified was in the management of podopaediatric conditions (n = 26).

Conclusions

Health workforce reform in Australia is in part being managed by the federal government with a goal to meet the health care needs of Australians into the future. The recognition of a specialty registration of podiatric surgery and endorsement for scheduled medicines was established with this workforce reform in mind. Addition of new subspecialties may be indicated based on professional development, to maintain high standards and meet community expectations.

Electronic supplementary material

The online version of this article (doi:10.1186/s13047-015-0127-0) contains supplementary material, which is available to authorized users.

Reducing length of stay for acute diabetic foot episodes: employing an extended scope of practice podiatric high-risk foot coordinator in an acute foundation trust hospital

BACKGROUND

To enhance the acute management of people with diabetic foot disease requiring admission, an extended scope of practice, podiatric high-risk foot coordinator position, was established at the Great Western Hospital, Swindon in 2010. The focus of this new role was to facilitate more efficient and timely management of people with complex diabetic foot disease. The aim of this project was to investigate the impact of the podiatric high-risk foot coordinator role on length of stay, rate of re-admission and bed cost.

METHOD

This study evaluated the difference in length of stay and rate of re-admission between an 11- month pre-pilot period (November 2008 to October 2009) and a 10-month pilot period (August 2010 to June 2011). The estimated difference in bed cost between the pre-pilot and pilot audits was also calculated. Inclusion criteria were restricted to inpatients admitted with a diabetic foot ulcer, gangrene, cellulitis or infection as the primary cause for admission. Eligible records were retrieved using ICD-10 (V9) coding via the hospital clinical audit department for the pre-pilot period and a unique database was used to source records for the pilot phase.

RESULTS

Following the introduction of the podiatric high-risk foot coordinator, the average length of stay reduced from 33.7 days to 23.3 days (mean difference 10.4 days, 95% CI 0.0 to 20.8, p = 0.050). There was no statistically significant difference in re-admission rate between the two study periods, 17.2% (95% CI 12.2% to 23.9%) in the pre-pilot phase and 15.4% (95% CI 12.0% to 19.5%) in the pilot phase (p = 0.820). The extrapolated annual cost saving following the implementation of the new coordinator role was calculated to be £234,000 for the 2010/2011 year.

CONCLUSIONS

This audit found that the extended scope of practice coordinator role may have a positive impact on reducing length of stay for diabetic foot admissions. This paper advocates the role of a podiatric high-risk foot coordinator utilising an extended scope of practice model, although further research is needed.

Guidelines for the management of people with foot health problems related to rheumatoid arthritis: a survey of their use in podiatry practice

Background

In the last decade there has been a significant expansion in the body of knowledge on the effects of rheumatoid arthritis (RA) on the foot and the management of these problems. Aligned with this has been the development of specialist clinical roles for podiatrists. However, despite being recommended by national guidelines, specialist podiatrists are scarce. In order to inform non-specialist podiatrists of the appropriate interventions for these foot problems, management guidelines have been developed and disseminated by a group of specialist podiatrists. The aim of this survey was to investigate the use of these guidelines in clinical practice.

Method

Following ethical approval an online questionnaire survey was carried out. The questions were formulated from a focus group and comprised fixed response and open response questions. The survey underwent cognitive testing with two podiatrists before being finalised. An inductive approach using thematic analysis was used with the qualitative data.

Results

245 questionnaires were completed (128–non-specialist working in the private sector, 101 non–specialists working in the NHS and 16 specialist podiatrists). Overall, 97% of the non-specialists (n = 222) had not heard of the guidelines. The non-specialists identified other influences on their management of people with RA, such as their undergraduate training and professional body branch meetings. Three main themes emerged from the qualitative data: (i) the benefits of the foot health management guidelines, (ii) the barriers to the use of guidelines generally and (iii) the features of useable clinical guidelines.

Conclusions

This study has revealed some crucial information about podiatrists’ level of engagement with the foot health management guidelines and the use of guidelines in general. Specifically, the non-specialist podiatrists were less likely to use the foot health management guidelines than the specialist podiatrists. The positive aspects were that for the specialist practitioners, the guidelines helped them to identify their professional development needs and for the few non-specialists that did use them, they enabled appropriate referral to the rheumatology team for foot health management. The barriers to their use included a lack of understanding of the risk associated with managing people with RA and that guidelines can be too long and detailed for use in clinical practice. Suggestions are made for improving the implementation of foot health guidelines.