title: Guidelines for the management of people with foot health problems related to rheumatoid arthritis: a survey of their use in podiatry practice.
abstract: BACKGROUND
  In the last decade there has been a significant expansion in the body of knowledge on the effects of rheumatoid arthritis (RA) on the foot and the management of these problems. Aligned with this has been the development of specialist clinical roles for podiatrists. However, despite being recommended by national guidelines, specialist podiatrists are scarce. In order to inform non-specialist podiatrists of the appropriate interventions for these foot problems, management guidelines have been developed and disseminated by a group of specialist podiatrists. The aim of this survey was to investigate the use of these guidelines in clinical practice.
  
  
  METHODS
  Following ethical approval an online questionnaire survey was carried out. The questions were formulated from a focus group and comprised fixed response and open response questions. The survey underwent cognitive testing with two podiatrists before being finalised. An inductive approach using thematic analysis was used with the qualitative data.
  
  
  RESULTS
  245 questionnaires were completed (128-non-specialist working in the private sector, 101 non-specialists working in the NHS and 16 specialist podiatrists). Overall, 97% of the non-specialists (n = 222) had not heard of the guidelines. The non-specialists identified other influences on their management of people with RA, such as their undergraduate training and professional body branch meetings. Three main themes emerged from the qualitative data: (i) the benefits of the foot health management guidelines, (ii) the barriers to the use of guidelines generally and (iii) the features of useable clinical guidelines.
  
  
  CONCLUSIONS
  This study has revealed some crucial information about podiatrists' level of engagement with the foot health management guidelines and the use of guidelines in general. Specifically, the non-specialist podiatrists were less likely to use the foot health management guidelines than the specialist podiatrists. The positive aspects were that for the specialist practitioners, the guidelines helped them to identify their professional development needs and for the few non-specialists that did use them, they enabled appropriate referral to the rheumatology team for foot health management. The barriers to their use included a lack of understanding of the risk associated with managing people with RA and that guidelines can be too long and detailed for use in clinical practice. Suggestions are made for improving the implementation of foot health guidelines.
authors.affiliation: Directorate of Prosthetics, Orthotics and Podiatry, University of Salford, PO29 Brian Blatchford Building, Salford, M6 6PU, UK. a.e.williams1@salford.ac.uk.
authors.forename: Anita E
authors.initials: AE
authors.lastname: Williams
authors.forename: Andrea S
authors.initials: AS
authors.lastname: Graham
authors.forename: Samantha
authors.initials: S
authors.lastname: Davies
authors.forename: Catherine J
authors.initials: CJ
authors.lastname: Bowen