The first part of the fellowship was focused on developing a solid understanding of the development and management of diabetic foot ulcers, and the impact of infection once an ulcer exists. The second half focused on applying this new information within clinical placements in order to increase the fellow’s knowledge and skills and comfort level in providing education to the client, colleagues, and facilitating the most appropriate plan of care. The bi-weekly meetings continued throughout the fellowship and were extremely beneficial in discussing key learnings, identifying additional opportunities, and for reflection.

The fellow has had significant new learning throughout the fellowship and achieved all three objectives:

Objective : To enhance knowledge of diabetic foot ulcers and the impact wound infection has on the client living with a DFU in the community

The fellow successfully completed a comprehensive review of existing literature and external resources and tools. Learnings included a more detailed understanding of best practices related to the diabetic foot, offloading options, types of infection most often responsible for diabetic foot ulcer infections, and the management of same, and was able to include this new knowledge and contribute to discussions when working with mentors during clinical placements. The fellow did an extensive literature search initially, and mentors also highlighted some additional articles of interest as the fellowship progressed through the clinical placements.

The fellow successfully completed a theoretical workshop, and the practical components necessary to become certified in conservative sharp wound debridement. This new knowledge and skills has improved care for our clients in the community through more timely access to debridement of callus and necrotic tissue which impedes healing. The online blog that the fellow continually maintained throughout the fellowship provided detailed information on assessment, management, best practices learned through from literature and placements, and reflection, to facilitate learning of colleagues, accessible by all nurses at Saint Elizabeth across the province.

Objective: To increase knowledge and skills related to the prevention of infection in diabetic foot ulcers
The fellow was able to complete most of the clinical placements identified in the learning plan. There were some challenges that required some amendment to the original plan, mainly due to competing priorities of the originally identified clinicians. An interesting reflection was the ability to understand why some of those contacted to seek replacement did not feel that they had anything to contribute to the fellows learning experience e.g. a number of chiropodists and a diabetes education program. The primary mentor and fellow worked diligently to identify replacements and were successful apart from the diabetes education program, however the fellow was able to attend an event sponsored by the Canadian Diabetes Association which provided much of the education covered in the education program.

During the placements with the ET nurse at Saint Elizabeth the fellow was able to impart the knowledge learned as a result of the fellowship to other wound etiologies, in terms of strategies to reduce the risk of infection.

Objective: To improve my ability to recognize and use infection prevention strategies to better prevent wound infections in clients with diabetic foot ulcers receiving service from Saint Elizabeth wound care program
Toward the latter part of the fellowship the fellow worked with her supervisor, primary mentor, and ET nurse to complete the required education to become a wound resource nurse for Saint Elizabeth. Nurses use a set of referral criteria to identify clients requiring additional support with their wound care plan. Clients with diabetic foot ulcers are referred to the wound team for a more comprehensive assessment and plan including callus debridement. The fellow created a very thorough presentation based on her learning throughout the fellowship and provided sessions to colleagues. The feedback was extremely positive and she was able to further facilitate the knowledge to practice translation for some of her peers. Identifying infection was one of the key learning opportunities given the more subtle signs demonstrated by those living with diabetes. Just recently the fellow also presented the education at the RNAO student best practice champions workshop with very positive feedback, and at that time also shared the client education pamphlet that was created.

During the fellowship it was identified that although there are resources available for clients with diabetes in terms of foot care there was a lack of resources that provided information from checking feet right through to what to do if an ulcer exists and how to minimize infection risk. In collaboration with the primary mentor the fellow created a pamphlet to reflect this which is being trialed with some of her clients, and so far the feedback has been positive. Based on the feedback there is a plan to create other pamphlets in this same format related to other wound types.

In collaboration with the primary mentor the fellow has been involved in testing, and providing feedback on, a wound infection surveillance program. There have been some challenges identified, primarily based on the method that we currently have of capturing electronic data, but there continues to be revisions, and ongoing PDSA cycles in an attempt to identify the method that provides us with the most accurate data. The fellow will be involved in a chart audit in the near future to determine the congruence between the information in the chart compared to the electronic data obtained.

Impact of Fellowship
Throughout this experience, this fellow has grown significantly in her nursing practice, and continues to move forward along the novice to expert clinical competency continuum. During the fellowship she was able to make many new observations and ‘aha’ moments from reviewing the literature including:

• Prevention is everything. Once deformities start, ulceration is very likely, and amputation may follow close behind, severely impacting a patient’s mortality, mobility, and quality of life. The best way to avoid infection is to prevent the preceding complications

The clinical placements have further exposed the fellow to many new client situations which have strengthened her fellowship experience and knowledge translation. These include:

• Effective team-building and communication strategies for clients with DFUs in the community. It became evident after working at an Interprofessional diabetic foot care clinic in another area in Ontario how the close collaboration was critical to the management of DFUs and prevention/management of infection. Although each of the Interprofessional team members exist in the local area and may see the client, they are not working collaboratively. The fellow identified this as a real problem and is currently working on solutions to address the disconnect.
• Although the fellow understood the importance of offloading in management she did not understand fully how this is optimized and how styles differ to address various deformities
• The faster a wound is healed the more significantly the incidence of infection is reduced. The Interprofessional team must be involved from the outset to optimize the plan of care to facilitate healing in a timely manner
• Clients are often not taught when they should no longer be providing their own foot care and what tools should be avoided. This was included in the educational pamphlet created by the fellow
• A greater understanding of the chiropodists role and how extensive the foot care received is. The fellow determined that there were not as many clients with diabetic foot ulcers attending the chiropodist for Footcare as there potentially should be and on reflection determined that a possible cause could be the cost as this is not covered by OHIP. If ulcers and infection related to amputation are to be prevented in future there must be an opportunity for this to be reviewed. The attendance at the Canadian Diabetes Association event did reveal a reduced price Footcare service in the area which the fellow is now able to share with clients and colleagues
• Time spent with the pedorthotist resulted in the fellow performing some additional literature reviews to determine best practices. It was evident that many of the clients seen by the fellow during the clinical placements were not only wearing inappropriate shoes, but were in footwear that was creating damage. Reflection and discussions revealed that many of the clients cannot afford to have this specialty footwear fitted.
• Clinical placement with the vascular surgeon provided great insight into the association between the vascular system and the healing/increased infection risk in clients with DFU
• The greatest learning opportunity was found with the infections specialist at the diabetic foot clinic, learning amongst other things about the prevention, identification, and management of soft tissue infections including teaching related to the IDSA guidelines. This increased the fellows understanding of why certain medications are prescribed in which situations, and also the impact that such medications may have on the clients health. She was also able to observe a specialty boot (CROW walker) for charcot foot being made and the intricate work required to perfectly create footwear that will prevent further complication. This learning can be used when discussing prevention strategies with the client. The holistic and Interprofessional approach observed at the clinic inspired the fellow to try to evolve the local teams to work in a similar manner

Opportunities and Challenges
As previously mentioned there were some challenges with some of the clinical placements. The primary mentor and fellow were able to reach out to other clinicians and eventually find replacements, one of which resulted in one of the best clinical learning experiences the fellow has had.

The opportunity to practice in the role of wound resource nurse has enabled the fellow to even more effectively implement some of the initiatives identified as necessary based on her new knowledge. The result is more timely access to clients with DFUs due to the expertise that she now has in DFU management and infection prevention, and her understanding of the need for a truly Interprofessional approach and collaboration, which at present remains a challenge in the local area. She continues to support her colleagues to provide the same approach.

The opportunity to speak about her fellowship at the RNAO Student best practice champions workshop provided a great learning opportunity to speak in front of a larger audience, and present her experience and how it has helped shape her practice, both now and in the future. The presentation was met with positive feedback and resulted in further discussion with some of the delegates after the workshop.

The challenges faced with the lack of a centralized, interprofessional clinic that can provide the necessary collaborative care approach for clients with DFU has inspired the fellow to take her education one step further and has applied for the Nurse Practitioner program with the vision of creating such a resource for clients with diabetes and foot ulcers, to optimize healing and prevention infections that may eventually result in amputation, and de-compartmentalize the current health care approach.

Sustainability Plan
Since the fellowship began the fellow has become a wound resource nurse for Saint Elizabeth’s Erie St Clair service delivery centre, and is in a better position to be able to utilize her new knowledge and skills to provide assessment and education for our clients with diabetic foot ulcers, helping to reduce the risk of infection and promote healing/manage concerns ongoing.

The education that was delivered to the local nursing team will be provided to all new nurses during orientation, but will also be provided as a refresher session to nurses at intervals. The content will be made available to the other sites across the province.

The ability to electronically track clients with infections associated with DFU will be optimized across the organization, resulting in greater capacity to report, and to utilize an audit and feedback process to revisit practice and available resources. Education will continue to move forward along with practice resources to encourage an interprofessional approach, which includes addressing financial concerns and barriers. The primary mentor will continue to work with the fellow to maintain collaboration related to the infection tracking elements at the local service delivery centre.

The diabetic foot education pamphlet for clients at Saint Elizabeth that addresses not only prevention of ulcers, but what to do if a wound develops and how to prevent infection will be made available to all nurses across our organization with the requirement that clients are either presented with the paper format, or the link to access the on-line content. The utilization of these pamphlets will be audited after a 3 month period and follow-up with each site will be made based on outcome. The online content is available to the public and not just clients of Saint Elizabeth with the hope that this information will reach far further than those that we can immediately impact.