Original Article

Experiences of nurses within a nurse‑led

multidisciplinary approach in providing care for patients
with diabetic foot ulcer
Nahid Dehghan Nayeri1, Nasrin Samadi2,3, Nasrin Mehrnoush2,
Irandokht Allahyari4,5, Fatemeh Bezaatpour2, Mansour NaseriAsl6
1
Department of Nursing, School of Nursing and Midwifery, Nursing and Midwifery Care Research Center, Tehran University of
Medical Sciences, Tehran, 2Department of Nursing, School of Nursing and Midwifery, Ardabil University of Medical Sciences,
Ardabil, 3School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, 4Department of Nursing, Khalkhal
University of Medical Sciences, Khalkhal, 5School of Nursing and Midwifery, Ardabil University of Medical Sciences, Ardabil,
6
Department of Health Care Management, Ardabil University of Medical Sciences, Ardabil, Iran

A bstract
Background and Aims: Diabetic foot ulcers require special attention due to their complex and chronic nature and special care and
the Nurse‑led approach has emerged in the current situation in response to the increasing need for health care as a way to treat
chronic patients and provide them with ongoing care. Providing this specialized duty in nursing can be promoted and enhanced
the professional independence of nurses and presents challenges. This study has been conducted to make an understanding
of the nurses’ experiences about their participation in a nurse‑led multidisciplinary team to providing care for patients with
Diabetic Foot Ulcer. Methods: This was a qualitative, phenomenological research, carried out with the participation of 8 nurses
of Shariaty Hospital of Tehran. Data collection was done through in‑depth and semi structured interview. Dieklemann method
was used for data analysis. Results: 2 themes and 4 categories emerged during data analysis: antecedents (background and
nursing skills) and manifestation of multidisciplinary function (from despair to tranquility, professional worthiness, promotion
of self‑confidence, preference of multidisciplinary approach). Conclusion: The findings of this study, which were the lived
experiences of the participants, indicated that most of them had experienced positive effect of nurse‑led multidisciplinary
team care, training and development, appropriate skill mix, quality and outcome of care. Therefore, despite working on a
multidisciplinary team is complex and demanding, management attributions and communication strategies is well situated to
meet the challenge.

Keywords: Diabetic foot ulcer, nurse‑led, nursing, phenomenology

Introduction
The disease of diabetes is one of the important problems of the
world and the number of patients suffering from it, is growing
Address for correspondence: : Dr. Nasrin Samadi,
Department of Nursing, School of Nursing and Midwifery, Ardabil
day by day. Statistics show that rising diabetes in the world is
University of Medical Sciences, Ardabil, and School of Nursing and also on the rise and every 10 seconds, 2 people get diabetes.
Midwifery, Tehran University of Medical Sciences, Tehran, Iran. The World Health Organization (WHO) estimates that the
E‑mail: [email protected]

Received: 14‑11‑2019 Revised: 20‑11‑2019

Accepted: 01-01-2020 Published: 02‑06‑2020 This is an open access journal, and articles are distributed under the terms of the Creative
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How to cite this article: Nayeri ND, Samadi N, Mehrnoush N, Allahyari I,

DOI: Bezaatpour F, NaseriAsl M. Experiences of nurses within a nurse-led
10.4103/jfmpc.jfmpc_1008_19 multidisciplinary approach in providing care for patients with diabetic foot
ulcer. J Family Med Prim Care 2020;9:3136-41.

© 2020 Journal of Family Medicine and Primary Care | Published by Wolters Kluwer ‑ Medknow 3136
 Dehghan Nayeri, et al.: A nurse led multidisciplinary approach in patients with diabetic foot ulcer

number of people with diabetes will double by 2030.[1] Patients accomplished through qualitative researches. Searching for valid
who have poor control of the disease have acute metabolic internal and external databases such as PubMed, Science direct,
complications such as ketoacidosis and chronic complications SID, up to date in the field nurses’ experience of multidisciplinary
such as retinopathy, nephropathy, neuropathy, delayed healing and team care were not achieved. Therefore, present study as more
ulcers.[2] However all the above mentioned complications lead than one article, is intended to examine the experiences of nurses
to many problems for diabetic patients, but diabetic foot ulcers in this particular case.
require special attention due to their complex and chronic nature
and special care.[3] The spread of diabetic foot ulcers results in Methods
foot infections, decreased quality of life, more time and cost for
treatment and eventually amputation and disability.[4] Statistics The present study is a qualitative research carried out in the
show that one out of every 5 diabetic patients admitted to the context of the nurses’ experiences about their participated
hospital had foot problems and it is estimated that 4‑10% of in a nurse‑led multidisciplinary team to providing care for
diabetics develop foot ulcers. The results of Iranian studies Patients with Diabetic Foot Ulcer. Hermeneutic interpretive
also show that 20% of hospitalized diabetic patients have foot phenomenology, based on Heideggerian philosophy,[12,13] is
problems.[5] a qualitative research methodology used when the research
question asks for meanings of a phenomenon with the purpose
The primary approach to reducing the incidence of diabetic foot of understanding the human experience.[14] This method is
and its complications is its timely prevention and diagnosis and it accepted as a method of careful research and regular study
is clear that careful attention to foot care and rapid management of important phenomena in nursing. Omry is one of the first
of minor foot injuries is key to this prevention.[6] In many prominent nursing researchers to introduce this method. In his
countries, specific guidelines for the prevention and screening of introduction to phenomenology he writes: the phenomenological
patients with diabetes have been developed and it is done with the approach is a descriptive and inductive research method whose
participation of the health system staff of physicians and nurses.[7] task is to deeply and comprehensively describe all phenomena,
including the description of human experiences as they appear.[15]
Indeed Multidisciplinary team work is a complex process in
which different types of staff work together to share expertise, This study focuses on understanding the nurses’ experiences of
knowledge and skills to impact on patient care. Despite increasing being involved in the care of patients with diabetic foot ulcers
emphasis on interdisciplinary teamwork over the past decade,[8] as a team. Regarding the nurses’ first time participation in the
there is little evidence as to the most effective way of delivering team approach, and due to have a unique characteristics and
interdisciplinary team work.[9] This difficulty is compounded by different understanding of the experience, phenomenological
the multifactorial nature of team work, which comprises the skill research is the best way to understand these experiences and to
mix, setting of care, service organization, individual relationships describe their meaning in the language of the study participants.
and management structures. This is why diabetic foot ulcer is
a disease that affects all physical, mental, psychological and In this study, a purposive sampling method was used to select
social aspects.[10] Optimal control of the disease is one of the study participants. During one year (2018‑2019), 9 nurses were
important goals of health care interventions performed by interviewed with a bachelor’s and master’s degree working in
nurses and the medical team. The experience of diabetic foot Tehran’s Shariaty Hospital. Written consent and willingness to
ulcer (DFU) is an unfamiliar and stressful for the patients and participate in the study were at least 5 years of experience with
nurses as multidisciplinary team member who providing care for the inclusion criteria. The participants consisted of 2 men and
this patients. It is essential for medical team to inter to in to this 6 women. In‑depth and semi‑structured face‑to‑face interviews
experienced world during the hospitalization period. It is almost were used as the main method of data collection. The process of
impossible to propose an affective and desirable nursing care, the interview was that after identifying the qualified nurses, the
without analyses and studying this experiences. So the first step participants were initially given an explanation of the purpose
in caring and treatment is to know this phenomenon and this will of the study and the method of doing the research and they
happened only by getting closer to the patients and their nurses, were invited. After the participants agreed on the timing and
discovery of their experienced world, analyze of their situation, location of the interview, agreement was reached. In this case,
and then proposing useful caring suggestions, according to this the viewpoints of the study participants were more important.
situation. Various studies have focused on the care of patients All the interviews were conducted. The interview sessions
with diabetic foot ulcers over time. Based on the results of lasted between 1‑2 minutes. At the beginning of each session,
these studies, providing nursing care as multidisciplinary team an explanation was given about the recording of the interview
has been reported useful and the need for a coherent structured and its purpose, and the researcher was obliged to stop recording
intervention in foot care has been demonstrated.[11] But there is the conversation, if requested, by the nurse in each part of the
no study in Iran in this field. Also, it must also be noted that the interview. To begin the interview and to gain a comprehensive
value of knowledge in creativity has to do with its relevance to understanding of the participants’ view of the phenomenon
human understanding. In order to gain understanding, nursing of team care for diabetic foot ulcer patients, they were asked to
is looking for ways to enable these experiences, and this can be describe their experiences at the end of the study.

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Koch argues that the question provides a context for study tape‑recordings. Having the right to stop participating in the study
participants to provide a broad and long description of their at any time was among the ethical principles that were followed.
experience.[16] Subsequent questions were asked according to the
descriptions provided by the nurse and in order to deepen them Results
by using the speculation technique. The following questions are
an example of these questions: The participants in the present study included 8 individuals. All
participants at hospitals affiliated with one of the universities of
Can you explain more about this? medical sciences were those who worked there. Most research
What do you mean by that? participates (%29.5) aged from 35‑58 years old. Among them,
How would you describe your perception of this? 58.8% were female and 82.4% were married. The first nurse who
What do you think this experience means? had the inclusion criteria was selected. According to the results of
the interviews, nurses who provide diabetic foot care as a member
At the end of the meeting, participants were asked to write in of multidisciplinary team face with different factors during their
full, if possible, a written description of their diabetic foot care experience. Thus, do a series of actions which could worsen or
team participation days and deliver it to the researcher. In total, 5 improve quality of care and disease management which is itself
submitted their written submissions. At the end of each interview related to continuation of care. The analysis of the participant
session and at the earliest opportunity, the researcher personally interviews resulted in the extraction of 2 themes and 4 categories
transcribed the recorded conversations verbatim. consisting of: Antecedents (Background and Nursing skills) and
Manifestation of multidisciplinary function (From despair to
Dieklemann method was used for data analysis. Thus, the text
tranquility, professional worthiness, promotion of self‑confidence,
of all interviews was read several times in order to gain a general
preference of multidisciplinary Approach) [see Table 1]. Each
understanding of the phenomenon in question. After reaching a
describes a particular aspect of team‑based nursing care.
general understanding and feeling of being overwhelmed with the
data, the second phase of the analysis began. At this stage, each
of the interviews was examined using the textual interpretation Antecedents
method. Explicit and hidden meanings were extracted in the The main categories of patient experiences were nurse‑led
participants’ descriptions. Each interview was then extracted multidisciplinary care, and participants described it as a risk factor
according to the meanings and coded to determine the initial theme. for foot ulcers and the need for a care team, and subcategories of
“disease background, inadequate knowledge/lack of knowledge,
In the third step, the coded texts were discussed and analyzed clinical beliefs and skills of nurses” has resulted. It was inferred
by the research team. The main goal of the researcher was to from participants’ experiences that factors such as neuropathy,
reach a common understanding of the descriptions provided by wearing inappropriate shoes, diet and medication adherence,
the study participants. In the fourth step, the inconsistencies in family history of diabetes, and diabetes‑induced blurred vision
the interpretation provided by the research team were clarified were the causes and causes of foot ulcers. In this case, a 4‑year‑old
and resolved. During the fifth stage, the codes were determined nurse states the reason for the wound in the patient under his care:
and described using the comparison method. The outcome of
this step was 5 categories and 2 themes that were extracted from
Table 1: Themes extracted from the experiences of study
the participants’ experiences to explain the different dimensions
participants
of multidisciplinary team care. Next, the study findings were
Theme Categories Subcategories
reviewed by the research team, and the final outline of the
Antecedents Context Disease precursors
findings was presented in the form of a main theme consisting
Lack of awareness
of professional worthiness, promotion of self‑confidence, Beliefs
autonomy, preference of multidisciplinary Approach. As to Nursing skills History of Diabetic Foot Ulcer Care
the validity and reliability of the present study, as interpretive Provide expert care
phenomenology was considered, confirmation of the findings of Manifestation From despair to Stress due to weakness in disease
the research, which is a result of the merging of the researcher’s of tranquility management
and the participant’s views, was not considered. Therefore, multidisciplinary Hope to healing
function Peace of mind
attempted to provide the reader with an interpretation of the
data. Also, long‑term contact with participants was a frequent professional Nurse Dominance
worthiness Efficiency
review of interviews. The team’s interpretation of the data also
promotion of Autonomy
added to the validity of the research. self‑confidence Empowerment of Nurses
Challenges of Conflict in role
Ethical considerations Implementing a Accuracy and follow‑up
We followed all the principles for confidentiality of the data multidisciplinary Coordination interdisciplinary
team Care
and getting the conscious consent for the interviews and

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“A 63‑year‑old man referred with a DFU and said I was upset to tell the the wound and observation of the healing process, response
my children to go out and change our minds. I wanted to get warm by the to treatment and care they expressed happiness and hope,
fire. I wouldn’t have cared for the hot charcoal. The bottom of my left foot recognizing the importance of self‑care, follow‑up treatment
was burnt with charcoal. I didn’t feel it at all. ” and prevention. Hopes for healing, satisfaction, and comfort
can be deduced from the participants’ conversations. One of
Participants stated that patients in their care had beliefs and the experienced nurses says:
beliefs regarding their circumstances, situations, cultures and
customs, and their religion (regardless of the positive and “When you talk to your patient and explain to him that your foot is healing,
negative impact of these beliefs on one’s lifestyle) which affects their eyes glow with joy. It is a good feeling to be the result of the care and
the healing or healing of diabetic ulcers. Also, nurses noted treatment of all colleagues when you find that the patient is satisfied that
that skill in caring for foot ulcers had an impact on patients’ the leg is not amputate.”
confidence in nurses. The 9‑year‑old nurse said of her experience
with dealing with the patient: Professional worthiness
Another category of themes that can influence the practice
“My patient told me while changing my dressing; I didn’t think the nurses of nurse‑led multidisciplinary care is professional worthiness,
would know the examination. Usually, doctors would examine and nurses which itself consists of subcategories “nurse dominance and
would wash. Well, it was interesting to see in this caring method that you efficiency”. The participants’ experiences indicated consistent,
examining, controlling, training and dressing and answer more of your sick comprehensive, coordinated, and regular care, with reported
questions. You said you are a nurse. It was very good.” dominance, seriousness, and nurse‑centered care. These
statements represent the whole spectrum of professionalization
Manifestation of multidisciplinary function in nursing, providing a good quality care to chronic patients such
as diabetic foot ulcers and consequently wound healing.
Other powerful classes emerging from participants’ experiences
of multidisciplinary care were outcomes such as increased
Because of the complexity of the role, nursing is a professional
knowledge and skills, enhanced self‑care, and a sense of activity that requires a great deal of responsibility and care.
independence and relief from helplessness. It was cited as Obviously, any deficiency in the education of this group will
improving the general mood, reducing stress, the importance affect the quantity and quality of care provided and will also
of self‑care and autonomy in nurses and appeared with the ultimately affect the health of individuals and society.
decrease in the size of the wound, the depth and degree of
the wound. Also lead to improve nurse‑patient relationship, The main mission of nursing education is to train competent
increase satisfaction with the quality of care provided too. This and competent nurses to have the knowledge and skills
category consists of four sub‑classes “From despair to tranquility, needed to provide quality nursing care, maintain and promote
professional worthiness, promotion of self‑confidence, community health. There are many factors that influence nursing
preference of multidisciplinary approach.” professionalism, including clinical experience, competence,
professional development, ethics and human values, and quality
From despair to tranquility assurance of patient care. When the nurse is presented to the
The nurses’ experience during the care of a team of patients patient as a nurse‑led, holistic view, responsible for overall
was anxious, fearful, hopeless, ashamed, and stressed because of coordination, management and continuity of care for a specific
poor management of the disease at the onset and diagnosis of part of treatment or intervention and this in turn can improve
the DFU, followed by delay in wound healing and the possibility patient‑nurse relationships, patient satisfaction with follow‑up
of amputation. These patients were extremely mentally fragile care, timely diagnose and treat patients’ problems and improve
and said they had been struggling with diabetes for many years. them faster. Examples of participants’ experiences include:
Whenever the possibility of amputation arose, frustration
and despair were evident in all their movements, actions, and “One patient told me; See this time the treatment and nursing and glucose
behaviors, and the slightest hope for healing was the least, and control and Pam examinations were done early. I no longer needed my
the least attention and listening to their heart was accompanied family to follow me. Something was done more consistently. The orthopedic
by a significant reduction in stress and anxiety. specialist visited my foot, then a surgeon. A physician came to explain and
give consent too. You also dress and scrape every day. Well it all means things
In this regard, a client, a 61‑year‑old woman with a 16‑year history are going well. Nothing left. I find myself wondering every time that I feel
of diabetes, stated: comfortable treating her well.”

“It’s so hard my daughter. It’s really hard. I always wish that no one would Promotion of self‑confidence
get diabetes and not get this. I think one can get cancer but not diabetes.” Participants’ experiences indicated that the multidisciplinary
care method had an impact on the wound healing process, as
Nursing experiences during the study revealed the mood of well as affecting their ability to help healing and lead to nurses’
patients. With each assessment, examination and dressing of independent and promotion of self‑confidence them. This

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 Dehghan Nayeri, et al.: A nurse led multidisciplinary approach in patients with diabetic foot ulcer

category was extracted from two subcategories of “Autonomy patients with foot ulcers and three main themes of “disease
and Empowerment of Nurses”. management”, “disease experience”, and “continuous care”
are derived from the study. In the end, they acknowledged that
One contributor explains this: awareness of their patients’ experiences and how to deal with
these conditions in the face of foot ulcers can lead to better
“After the multidisciplinary team care was established at this hospital, decision‑making by the treatment team, quality care delivery and
nursing is not just about the therapeutic role and implementation of ordered consequently faster recovery for these patients.[18] The results of
medications. Nursing came up with its own concept. A nurse should use this qualitative study were similar, overlapping and confirming
her own knowledge and take full care, coordinate and act with the all the findings of the present study. Some countries have specific
the team members and physicians when it was necessary. In addition to guidelines for the prevention and screening of patients with
administering medication and therapeutic role, I had other nursing roles diabetes.
during this period too.”
This is done with the participation of health system staff
Challenges of Implementing a multidisciplinary consisting of physicians and nurses.[19] Bentley and colleagues
team care acknowledged that diabetic foot ulcers require specific
The hospital system’s unwillingness to implement team care management and. Diabetic foot ulcers require accurate
has, in many cases, produced adverse emotional reactions for and rapid assessment, diagnosis, treatment, and long‑term
participants. Conflicts, lack of collaboration, lack of teamwork, follow‑up in order to maintain the foot. This complex treatment
and lack of nurse‑centered team care were the most prominent cannot be managed by one individual and it should involve a
reactions experienced by almost all participants. These reactions multidisciplinary team to ensure that these complex wounds are
created challenges among team members. The following excerpts properly treated.[20] These teams can be coached by a member of
support this theme: the team. Most teams are guided by a nurse in which nurses play
a central role.[21] The role of nurses as nurse‑led and empowered
“Despite the usefulness and effectiveness of guided nurse care, it should leadership is not new, and Florence Nightingale noted this with
be noted that expanding the role of nurses in the field of care may pose her evolving skills in evidence‑based leadership and nursing
inter‑professional challenges.” care.[22,23] Julian and his colleagues in the United Kingdom (UK)
stated that real‑world evidence suggests that wound management
And: was largely successful in the Nurse‑led system. But the hospital
staff ’s cooperation and acceptance to implement this procedure
“Providing care in this way will increase with the increase of nurses’ led by nurses is not fully accepted and the environment is not
workload, which will require increasing the number of nurses. Managing ready. However, given the clinical benefits of using this care
these challenges requires time and skilled human resources.” approach, one can expect to modify care systems and increase
awareness of the impact of the nurse‑guided approach on wound
Overall, this is the authors’ final understanding of the participants’ management in patients.[24]
experiences in the study that however nurse‑led multidisciplinary
care has proven to be beneficial and its positive impact is clear, Therefore, providing a suitable program for nurses and physicians
but there is no proper context and working environment that can who can adapt the clinical environment to multi‑disciplinary
enhance the nursing profession and provide effective adaptation team practices seems to be of great importance. However,
of nurses and other staff to new conditions. endocrinology and diabetes clinics and staff training to care for
patients with foot ulcers are expected to be outpatient and even
Discussion hospitalized, and try to provide ongoing care to these patients
and prevent ulcers in diabetics. But these arrangements appear to
The findings of this study are the concrete experiences of be ineffective and do not provide the right environment for care.
the study participants, was found that many study participants Therefore, reviewing the current treatment and care plan for foot
were not prepared to provide multidisciplinary care for patients ulcers is suggested as the main recommendation of this study.
with diabetic foot ulcer. Reviewing and comparing the above Certainly, it is important to use the experiences of other countries,
findings with the results of other studies reveals similarities like England, which are implementing multidisciplinary team care.
and differences between the experiences of participants in the
present study and other studies. The qualitative study conducted Conclusions
by Pazargadi et al., Had similar results to the present study.
The findings of this study, which were the lived experiences of
In this study, “providing desirable and safe services” and “client the participants, indicated that most of them had experienced
satisfaction” are the main categories of study mentioned[17] that positive effect of nurse‑led multidisciplinary team care, training
confirm the qualitative results of the present study. Asgharpour and development, appropriate skill mix, quality and outcome
et al., in a qualitative study “The process of caring for patients of care. Therefore, despite working on a multidisciplinary
with diabetic foot ulcers” have studied the way of care for team is complex and demanding, management attributions and

Journal of Family Medicine and Primary Care 3140 Volume 9 : Issue 6 : June 2020
 Dehghan Nayeri, et al.: A nurse led multidisciplinary approach in patients with diabetic foot ulcer

communication strategies is well situated to meet the challenge. Metab Disord 2019;18:729‑31.
Furthermore policymakers should be aware that implementing 7. Guideline N. Diabetic foot problems: Prevention and
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8. Jennings A, McLoughlin K, Boyle S, Thackeray K, Quinn A,
experience of multidisciplinary team care, it is of an interpretive
O’Sullivan T, et al. Development and evaluation of a primary
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