Action research assessment tool

Several authors recommend a staged approach to developing an assessment tool and this was utilized during the process, [ 12 — 14 ]. To guide the development process, a list of prerequisites was created from the results of the action planning phase of the action research cycle in which the clinicians had participated and is reported in a previous paper [ 5 ].

This list of prerequisites highlights the standards that the participants feel any subsequent tool should achieve. The list can be viewed in the results section. A list of items were presented to participants in Round 1, relating to factors associated with diabetes foot complications, and these were generated from a focused search of the literature that used a thematic framework approach to identify content cross referenced with a review of clinical guidelines. The literature search identified articles, of which were excluded.

Thirty-six studies were included in the final qualitative synthesis and were cross-referenced with national and local UK guidelines. In the context of the diabetic foot, validity refers to the degree to which the assessment measures the risk factors presenting in the lower limb. Face validity is the lowest level of validity and based upon the personal opinions of the observer.

Content validity is determined by theoretical reasoning that a foot health assessment tool adequately measures selected foot health variables. When a foot health assessment tool is believed to include the domains that are required to adequately assess the foot its content is considered valid content validity. We achieved consensus on the items to be included in the tool as well as the phrasing of such items and this process also enhanced the ownership of the assessment tool.

The assessment tool created by the clinicians Salford Indian Foot Health Assessment Tool SIFT was piloted to begin the process of assessing consistency, to achieve construct validity and to allow clinicians to test local implementation of their own solution. This process will continue following completion of the Delphi and will be reported in a follow up paper.

An overview of the Delphi process can be seen in Fig. The authors recruited to the Delphi panel those participants who had taken part in the first phase of the action research model [ 5 ], as it would be these clinicians who would be embedding the evidence base into clinical practice.

This provided continuity through the subsequent action and implementation phases. Although not experts in the assessment and triage of foot health, this was not necessary, since they were all experts within their chosen disciplines and in the Indian health care context. Information about the aim of their participation, the methods used and invitation to be part of the change process was sent to the participants. The researchers sent the initial list of possible risk factors for inclusion in the foot health assessment tool to the participants.

This was the list derived from the initial literature search and the information participants had already reported as list of criteria they would deem important in a foot assessment tool from a previous focus group [ 5 ]. This provided early ownership of the knowledge to be discussed, free from the influence of peers and the dynamics of group discussions. To help the decision making process the authors also included a summary of the evidence that supported each risk factor.

Participants were asked to rate the importance of inclusion of each risk factor using a Likert scale 5 being essential to include and 1 being essential to remove.

The authors also gave participants the opportunity to comment on any of the risk factors included in the tool. Responses were accumulated to devise an agreed criteria list, which was then sent out for comments and amendments in round 2. For round 2 the participants were asked to review the comments or amendments made to the risk factors in round 1 and re-evaluate any of those risks.

Again panel members were given the opportunity to provide comments and additionally participants were asked: Would you like to see a number of key Risk factors highlighted on the final assessment tool?

And do you endorse the Delphi procedure so far? If no please give details of the aspects of the procedure which you do not support and list any suggestions you have for improvement.

This latter question challenged participants to acknowledge their participation in a group exercise and reaffirm their belief in its progress. The results of round 2 were used to select the final risk factors, tests and assessments for inclusion in the final tool. Items that remained rated as 3 or had been re-rated as 2 or 1 were excluded.

This third round asked the panelists to review the inclusion and exclusion results for both items and to indicate whether they thought that an item should be included or excluded. Participants were also asked to comment on any item that they would like to rephrase or whether they wished to add an item to the tool and to provide suggestions of such changes. The results of round 3 were used to select any rephrased or additional items to be included in the foot health assessment tool.

This provided a new level of contribution by participants, such as rewording specific items, and thus provided ownership of the precise details and language used. The clinicians who had been part of the process were asked to pilot the tool over a 4-week period on patients presenting with foot health problems within their own specific disciplines.

This brought to life their own efforts in practical terms, in front of their colleagues and patients, and thus reinforced the productivity of the exercise in which they had participated. Additionally participants were asked to record any further items they would like to have considered for inclusion in the tool following the pilot. These were recorded as a list and distributed to the participants. This modification allowed the researchers to see the tool being used in a clinical setting in order to influence the development stages thereby improving face validity and overcoming the potential interpretation difficulties.

The results of round 4 were used to select the content of the final foot health assessment tool. The researchers spent one week with participants in order to provide support and to identify any specific training needs.

Eight of the eleven clinicians invited to take part consented to participate in the Delphi procedure. The specialties of the clinicians are listed in Table 1.

The researchers and participants of the focus group in the problem identification and action planning stages decided that the foot health assessment tool should have the following prerequisites Fig. List of prerequisites to be met by a foot health assessment tool designed for this locality. The result of this study was the design of a foot health assessment tool SIFT developed by those who would use it in clinical practice.

This was achieved using a modified Delphi method embedded in an action research process, which aims to facilitate change through ownership. All eight of the participants who agreed to take part in the procedure returned completed questionnaires. Of the eight practitioners involved with the process seven returned completed questionnaires. The eighth member of the panel had reported being too busy this time to take part, but still wished to be part of further rounds. Following the results of this round, the ten risk factors selected for inclusion were not challenged and would therefore be included in the final tool.

The eight risk factors removed from the tool were all agreed and therefore excluded from the process. The two risk factors where consensus had not been reached had been rerated, one to be included in the final tool and the other to be amended, and then added to the final tool Table 3.

In this round six of the seven participants were in favor of seeing a number of key risk factors highlighted on the final assessment tool.

At this stage all seven of the panel members reported that they endorsed the Delphi procedure so far and were happy to continue with the process. All eight of the practitioners involved with the process returned completed questionnaires. The additional results in this round report those items that the panel wished to rephrase or add.

Panel members were also asked in this round if they agreed with the procedure of being asked whether they would support the instructions issued in round 4 and whether they would be willing to comment on any changes. All eight panel members agreed to this process. Field trials to assess consistency and construct validity are ongoing, as at this stage we have not undertaken any formal quantitative analysis. The first stages of the validation process have begun by piloting the tool in clinical practice.

All eight of the practitioners involved with the process returned completed questionnaires and took part in the pilot of the tool over a four week period, on patients presenting with foot health problems within their own specific disciplines, where they were asked to consider the practicalities of the tool in a clinical setting. Following the results of the completed questionnaires the eight risk factors chosen and where rephrased were not challenged and therefore included in the pilot tool.

No alternatives were suggested for any of the current items Table 6. It was further felt that the recording of skin and nail conditions should also be done by circling yes or no, and that location of lesions should be recorded on pictures of both a left and right foot.

Other lesions to be recorded here include amputations and current ulcers. The panelists also suggested that a number of sections be added to the final assessment tool which had not been considered until the tool had been used in practice Table 8.

At this stage all eight of the panel members reported that they endorsed the Delphi procedure following a review of the aims and purpose. Additionally all eight panel members reported use of the evidence provided and the feedback from the previous rounds. Two members stated that although they had read the evidence initially they used the feedback predominantly to inform and support their decisions as the evidence document took time to read in what were already busy clinics for them to manage.

All eight of the practitioners involved with the process agreed to being observed using the tool within their own departments. At this stage the panel members used the tool and the researchers observed it in use for one week within the hospital.

Six of the items proposed for additional inclusion were accepted by all of the panel members and therefore added to the final tool.

It was argued that as the tool collects multiple pieces of data it would also produce many possible diagnoses, which would be, prioritized differently depending on the specialist using the tool. It was further expressed that this was not required as the additional classification category provided enough information about risk, to guide the management steps appropriately. The tool is structured as a list of thirteen sections made up of the risk factors identified during this investigation.

Each of those sections contains subsections made up of the relevant tests, assessment methods and visual checks used to identify foot pathologies. Participants requested that these items were highlighted on the tool with a capital letter R.

The final tool is presented in Additional file 1. The clinical content of tool itself is not greatly dissimilar to foot health assessment tools developed in the West, this however is not surprising as the guidelines on which SIFT was based were mostly developed in the West. More importantly the opportunity for the clinicians to be participatory in the process has developed a tool where the structure and format are born out of the Indian health care system and subsequent adoption has taken place as a result of the participation in its development.

A more detailed description of each section together with the corresponding evidence base were issued to the participants to support implementation and to act as a reference once the researchers had withdrawn from the location on completion. The guidelines and use of the tool in round 5 identified possible training needs for the participants and potentially for others who may also wish to use the tool at this site.

The SIFT was subsequently adopted by the hospital and used in practice. To date the tool has been used 2, times. Through the action research approach researchers facilitated the process whereby clinicians took local ownership of a clinical problem, developed their own solution i. Through this approach researchers identified the knowledge and skills of the adopters, made the research evidence accessible and using Delphi ensured the adopters actively participated in reaching professional consensus on how that research evidence was embraced and embedded into practice [ 18 ].

This is the first time an action research approach has been used to drive change in Indian foot health care services. The Delphi process has been a useful method for both data collection and to achieve consensus with the participants [ 19 , 20 ]. Delphi was employed as a tool embedded within the ethos of action research. Active participation of the adopters in this process has proven to be effective as a vehicle to embed evidence into practice, facilitate ownership of the solutions thereby sustaining change within their clinical practice [ 21 ].

In the west, podiatrists are considered the experts in the care of foot problems [ 3 , 11 ] but in India there are no locally trained podiatrists within its healthcare system. However, although the participants were not experts in the area of foot health assessment they were experts in how foot health problems present in their clinics and in India on a daily basis.

Critically, it was this expertise, not expertise in best practice of foot health, that was needed to drive creation of shared solutions for the foot assessment tool [ 22 — 25 ].

The Delphi has the further advantage of offering anonymity [ 26 ]. This helped prevent domination of some over others due to caste, gender, authority or personality.

It is recognized that this culture and environment may influence the success of a change management process [ 27 ]. According to the institutional theory [ 27 ], the institutional environment can be defined by its structure and culture.

Hofstede [ 28 ] also identified that gender inequality influences the culture of an institution and in India the male gender is viewed as superior with the role of decision makers [ 30 , 31 , 32 ]. Hence, we considered the anonymity of the Delphi method would overcome some of these influences in order to achieve completion of the action research cycle. There are limitations to the use of the Delphi method [ 33 ].

There is no reported standard for the size and selection of panel members, with studies using a range of 4— experts, [ 34 — 36 ]. Additionally, there is no evidence of reliability of the method and as a result it cannot be certain that if the same task were given to two or more different panels, would the same results be obtained.

Furthermore the lack of opportunity to clarify responses can create interpretation difficulties for both the researchers and participants [ 37 ], especially when working with participants whose first language is not English. The Delphi method has been used successfully to develop data collection tools previously [ 38 — 43 ] but to date, this is the first time that a delphi has been used within an action research approach to bring about local ownership of a clinical problem and produce a solution which was the development of the Salford Indian Foot health assessment.

However, the SIFT is not without its limitations and clearly focuses on the medical and podiatric presentations of patients following a biomedical model of health care. Although it collects some data in relation to alcohol, tobacco use and footwear practices, the wider bio psychosocial aspects [ 44 , 45 ] are absent.

It is important to handle the three together, as literature suggests that patient perceptions of health, threat of disease and barriers to good health in a patient's social or cultural environment influences the likelihood that they will engage in good health behaviors [ 46 ]. The dominance of the biomedical model may reflect wider cultural approaches to health care. Use of the tool in clinical practice to assess consistency and construct validity are ongoing, as at this stage we have not undertaken any formal quantitative analysis of the SIFT.

However, the first stages of the validation process have included a pilot of the tool in clinical practice. This has shown variation among some clinicians where there is subjectivity in the assessment decision which is similar to what Thompson et al. The pilot also identified that there was a training need for objective clinical testing.

It has also been reported that the opportunity to make modifications based upon reflections in practice can be useful in improving validity and reliability when generalists use structured screening tools [ 51 ].

Further testing is required to measure the reliability of the instrument and thereby determine the degree of consistency between the scores obtained at two or more independent times of testing by measuring inter rater reliability [ 52 ]. The participants reflected on the final tool and it components and this highlighted the need for training to support its use [ 53 , 54 ].

Hence, as well as the tool being the vehicle for assessing foot health, it aided identification of training needs in foot health assessment and management including an increased awareness of the importance of simple lesions, the importance of regular screening including vascular, neurological, wound and offloading principles in the high risk foot.

This research has facilitated the action research cycle that initially identified the need for change [ 5 ]. Through the phases of action and implementation the authors have facilitated the development of a locally defined, context specific assessment tool to aid identification of foot problems and hence the implementation of appropriate and timely management for individual patients.

Further, the information gathered from this tool can be used to identify areas for service improvement. The action research process has given local ownership of the solution to practitioners and produced the first systematically developed evidence based foot health assessment tool to be used in India. The first step identified by the participating practitioners [ 5 ], as being pivotal to achieving better outcomes for patients. Engagement in the action research process has given practitioners the opportunity to reflect on current practice and bring about change within their service and individual clinical practice.

DOC kb. Learning points for foot health assessment and management training. DOC 33 kb. Competing interests. MHB was responsible for the study design, collection and analysis of the data and preparing the manuscript. MC participated in the delivery of the training programme identified by the study. CN and AW contributed to study design and preparing the manuscript.

All authors read and approved the final manuscript. National Center for Biotechnology Information , U. J Foot Ankle Res. Published online Sep Nester , and Anita E. Christopher J. Anita E. Author information Article notes Copyright and License information Disclaimer.

Michael Harrison-Blount, Email: ku. Corresponding author. Received Apr 17; Accepted Sep 3. Abstract Background India has a diabetes population that is growing and alongside this, the incidence of limb threatening foot problems is increasing. Methods Participants were facilitated through the action and implementation phases of the action research cycle by the researchers. Conclusion An action research approach has facilitated the development and implementation of a locally created and owned foot health assessment tool.

Electronic supplementary material The online version of this article doi Keywords: Diabetes, Action research, Foot health assessment. Background India is second only to China in terms of the size of its diabetes population Stage 1 — Preliminary conceptual decisions To guide the development process, a list of prerequisites was created from the results of the action planning phase of the action research cycle in which the clinicians had participated and is reported in a previous paper [ 5 ].

Stage 2 — Initial category and Item generation A list of items were presented to participants in Round 1, relating to factors associated with diabetes foot complications, and these were generated from a focused search of the literature that used a thematic framework approach to identify content cross referenced with a review of clinical guidelines.

Stage 3 — Assessment of face and content validity In the context of the diabetic foot, validity refers to the degree to which the assessment measures the risk factors presenting in the lower limb. Stage 4 — Field trials to assess consistency and construct validity The assessment tool created by the clinicians Salford Indian Foot Health Assessment Tool SIFT was piloted to begin the process of assessing consistency, to achieve construct validity and to allow clinicians to test local implementation of their own solution.

Open in a separate window. Selection of Delphi panel members The authors recruited to the Delphi panel those participants who had taken part in the first phase of the action research model [ 5 ], as it would be these clinicians who would be embedding the evidence base into clinical practice. Round 1 Information about the aim of their participation, the methods used and invitation to be part of the change process was sent to the participants.

Round 3 The results of round 2 were used to select the final risk factors, tests and assessments for inclusion in the final tool. Round 4 Pilot The results of round 3 were used to select any rephrased or additional items to be included in the foot health assessment tool.

Round 5 Visit modification of the Delphi procedure This modification allowed the researchers to see the tool being used in a clinical setting in order to influence the development stages thereby improving face validity and overcoming the potential interpretation difficulties.

Results Eight of the eleven clinicians invited to take part consented to participate in the Delphi procedure. Table 1 Participants involvement and clinical specialties. Preliminary conceptual decisions The researchers and participants of the focus group in the problem identification and action planning stages decided that the foot health assessment tool should have the following prerequisites Fig. Delphi rounds 1—3: Assessment of face and content validity The result of this study was the design of a foot health assessment tool SIFT developed by those who would use it in clinical practice.

Delphi Round 1 All eight of the participants who agreed to take part in the procedure returned completed questionnaires. Table 2 Delphi results: Round 1. Delphi round 2 Of the eight practitioners involved with the process seven returned completed questionnaires.

Delphi round 3 All eight of the practitioners involved with the process returned completed questionnaires. Table 4 Delphi results: Round 3. The total score on the ARAT ranges from , with a higher score indicating better performance. Search for:. Company About Blog Contact Us. Copyright Neurorehabdirectory. All Rights Reserved. Terms and Conditions Privacy Policy. Website by LunaseaMedia Productions.