Healing Through Empowerment and Active Listening: Experience-Based Co-Design of a Nurse-Led Personalised Self-Care Support Intervention for Primary Care Patients With Diabetic Foot Ulcers

Abstract

Background: The rising prevalence of diabetic foot ulcers (DFUs) highlights the need for effective self-care interventions. Despite strong evidence supporting their effectiveness, patient engagement, uptake, and integration into routine care remain limited. Co-design approaches can enhance the relevance and adoption of interventions but are underutilized in DFU management.

Objectives: This study outlines the development of Healing through Empowerment and Active Listening (HEALing), a self-care intervention for patients with DFU, grounded in Self-Determination Theory and Motivational Interviewing, and developed using an experience-based co-design approach.

Design, setting and participants: The 27‐month co‐design process consisted of three phases involving patients, caregivers, and healthcare professionals (HCPs) from across a primary care cluster in Singapore. Phase 1 (16 months) included qualitative interviews with patients (N = 27), caregivers (N = 5), and HCPs (N = 8), analyzed via reflexive thematic analysis, alongside a quantitative survey (N = 186), analyzed using structural equation modelling to identify intervention determinants. Phase 2 (9 months) involved co-design workshops with patients (N = 10) and wound care nurses (N = 6) to define the intervention's content and delivery approach. In Phase 3 (2 months), iterative meetings refined the intervention's procedures, tools, and materials. Qualitative data from Phases 2 and 3 were thematically analyzed.

Results: Key barriers to DFU self-care included limited control over ulceration and treatment, low confidence, negative emotions, and misperceptions about the condition. Personalised care and clinician-facilitated motivation emerged as key enablers. HEALing targets five core self-care components: (1) wound care, (2) foot care and footwear, (3) diabetes care, (4) treatment seeking, and (5) managing worries and concerns. The personalised components are delivered using a card-sorting tool during clinic-integrated sessions by trained wound care nurses. The HEALing delivery pathway comprises three 30-min sessions at 2-week intervals. During workshops, participants perceived HEALing as supporting patient- and clinician-endorsed person-centred care and collaborative planning, while also identifying potential implementation challenges, including training needs and structural barriers.

Conclusions: HEALing positions patients as experts by experience, addressing the psychological and behavioural complexities of DFU care. This nurse-led and stakeholder-endorsed intervention is currently undergoing feasibility evaluation.

Patient and public involvement: Individuals with DFUs, their caregivers, and those in with post‐healing remission, and wound care nurses contributed to the co‐design of HEALing by identifying intervention targets and informing the intervention's content and delivery.

Keywords: codesign; diabetic foot ulcer; empowerment; personalised; primary care; self‐care.

Figure 1

Intervention development process: The cycle includes three phases (inspired and adapted from the Guidance on How to Develop Complex Interventions to Improve Health and Healthcare Communication [38] and prior work in other populations. The green rectangular boxes indicate the phases and steps of the experience‐based co‐design cycle/process (adapted from prior co‐design work in other populations [37, 39, 40]. [Color figure can be viewed at wileyonlinelibrary.com]

Figure 2

The HEALing logic model illustrates the complementary approaches of MI and SDT that can elicit adaptive behaviour change for better health outcomes and behavioural adoption, in which MI strategies provide support to satisfy the psychological needs for competence, autonomy, and relatedness. DFU, diabetic foot ulcer; HCP, healthcare professional; MI, motivational interviewing; SDT, self‐determination theory. [Color figure can be viewed at wileyonlinelibrary.com]

Figure 3

Overview of the co‐design process for HEALing intervention to support self‐care behaviours for primary care patients with diabetic foot ulcers, focusing on Phase 2 – experience‐based co‐design (EBCD). [Color figure can be viewed at wileyonlinelibrary.com]