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, healthcare professionals(HCPs), and researchers from across primary care 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 with post-healing in remission, and wound care nurses as service users contributed to co-design HEALing by identifying intervention targets and shaping the intervention's content and delivery.