Journal of Nursing Education

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Nurses' Knowledge and Perceptions Related to Foot Care for Older Persons

Margaret A Pierson, MSN, RN

Abstract

ABSTRACT

The purpose of this study was to examine nurses' knowledge and perceptions related to foot care of older persons. Nurses representing hospital, home health, and extended care settings were surveyed. Data were collected using a Foot Care Survey, with questions related to the nurse's role with foot care of older adults, importance of various components of patient teaching content, and knowledge about foot care.

Only half of the sample reported having content related to the mechanics of foot care in their nursing program. Ninety-five percent of the sample indicated that there is an unmet need of the elderly for assistance with foot care and that provision of this service is a nursing function. There was disagreement between practice setting as to whether the nurse needs a physician's order to do foot care. Nurses employed in home health and extended care settings indicated more independence in performing these functions. The mean score on the knowledge portion of the tool was 9.47 (possible score = 10). The data suggest that nurses possess the knowledge but have not had the opportunity to acquire the associated foot care skills. Implications for nursing education and service were discussed.

Abstract

ABSTRACT

The purpose of this study was to examine nurses' knowledge and perceptions related to foot care of older persons. Nurses representing hospital, home health, and extended care settings were surveyed. Data were collected using a Foot Care Survey, with questions related to the nurse's role with foot care of older adults, importance of various components of patient teaching content, and knowledge about foot care.

Only half of the sample reported having content related to the mechanics of foot care in their nursing program. Ninety-five percent of the sample indicated that there is an unmet need of the elderly for assistance with foot care and that provision of this service is a nursing function. There was disagreement between practice setting as to whether the nurse needs a physician's order to do foot care. Nurses employed in home health and extended care settings indicated more independence in performing these functions. The mean score on the knowledge portion of the tool was 9.47 (possible score = 10). The data suggest that nurses possess the knowledge but have not had the opportunity to acquire the associated foot care skills. Implications for nursing education and service were discussed.

Introduction

Nurses, whether in teaching or clinical positions, must challenge themselves to prepare new nurses to meet the needs of the growing number of older adults, particularly related to preventive health practices. It has been demonstrated that foot care for older persons is one appropriate area for preventive health practices (King, 1978; Schaefer, 1982). The literature describes structural, functional, and traumatic stresses to the aged foot which create deterrents to mobility. The pain and dependence which result contribute to social isolation and psychological consequences (Brown, Boosinger, Black, Gaspar & Sather, 1982; Conrad, 1977; Fowler, 1974; King, 1980; Shank, 1977). Even as early as 1961, the Second White House Conference on Aging concluded that prophylactic foot care was conducive to total well-being. Albert (1987) noted that feet have received less attention than other parts of the anatomy, perhaps because foot disorders are rarely the cause of mortality; however, foot disorders can cause significant disability and thereby compromise independence and quality of life (Chung, 1983).

Many elderly persons are unable to safely perform foot care (cleansing, inspecting, trimming of nails, and care of corns, calluses or other lesions) due to reduced dexterity or vision (Shank, 1977). The literature describes the role of the nurse in preventive foot care working independently (Garlinghouse & Haviland, 1986; King, 1980; Shank, 1977), assisting the podiatrist (Conrad, 1977), or under the direction of a physician (Brown et al., 1982). In these settings, the nurse uses a systematic assessment process; provides for hygiene and triniming of nails; provides education concerning hygiene, safety and prevention of disability related to foot disorders; and makes referral to physicians or podiatrists according to established protocols. Garlinghouse and Haviland (1986) developed a manual to guide registered nurses in the provision of care to the feet of persons unable to do so for themselves. In addition to the above described activities, this protocol includes filing of corns and calluses while the foot is wet using a pumice stone or specially designed file.

Informal discussion with nurse colleagues revealed that only rarely did nurses trim patients' toenails; typically referral was made to a podiatrist for such services.

Content related to foot care was predominately covered in their nursing programs under caring for the diabetic patient or peripheral vascular disease. Nurses had been instructed to refer all diabetics to a physician or podiatrist for trimming of toenails. Several nurses concluded that since this was the only "foot care education" they had received, perhaps their cautious posture had been generalized to all patients requiring foot care. The evidence suggested the need for formal inquiry of nurses' knowledge and perceptions related to care of the feet of older persons. Therefore, the purposes of this non-experimental descriptive study were to: (a) describe nurses' perceptions of their role in foot care of older persons, (b) identify those components of foot care which nurses perceive should be included in a patient teaching program, (c) assess nurses' knowledge of appropriate interventions for foot care of older persons, (d) determine if practice setting influences nurses' perceptions of appropriate nursing actions for foot care and foot care education of the older person, and (e) determine if there is a difference in knowledge of proper foot care by practice setting.

Method

Setting and Sample

A stratified convenience sample of 180 registered nurses (RNs) equally representing hospital, home health (HH), and extended care facility (ECF) settings was done. The three settings were chosen to determine if differences in nurses' perceptions and knowledge existed across practice settings. The HH agencies were Medicare-certified, and the ECFs provided both intermediate and skilled levels of care and were Medicare-certified. No attempts were made at randomization of the sample due to management reluctance to distribute names of personnel. In the hospital setting, nurses practicing in medical-surgical nursing (excluding critical care units) were surveyed because those nurses would most likely be caring for patients who would require foot care.

Overall response rate to the survey was 52%, representing a return of 94 completed surveys. The response rate was 58% for the hospitals, 47% for the HH setting, and 52% for the ECFs.

Procedure

Distribution of the questionnaires was done by the director of nursing in each of the practice settings. Participants were assured anonymity by the method of distribution of the tools. The tool was prefaced by the statement that "return of the completed questionnaire will demonstrate consent to be included in this study". Completed questionnaires were returned to the respective director of nursing.

Instruments

The Foot Care Survey (FCS) is a 25-item questionnaire developed by the author for purposes of this study. The tool consists of three major sections. Section I consists of 8 questions related to perception of nursed role with foot care of the elderly. The eight perception questions were coded on a scale of 1 to 4 with "1" indicating strongly disagree and "4" indicating strongly agree. Section II has seven teaching items and participants were asked to rate how important an item was in relation to a teaching plan for foot care of the elderly. Items were coded on a 4-point Likert-type scale with "1" indicating unimportant and "4" representing very, very important. Space was allowed for respondents to comment on other information that should be included in patient teaching. The 10 knowledge questions (Section III) were answered true or false. Content validity of the tool was established by a review of the literature and a panel of six experts consisting of two College of Nursing faculty members, a jointly appointed director of nursing of an ECF/nursing faculty member, a geriatric clinical speciahst, a diabetic clinical specialist, and a physician specializing in internal medicine. Only minor changes were made from their review of the instrument.

Reliability coefficients were computed on Section I and Section II of the tool using Cronbach's alpha. Alpha levels were computed to be .65 for Section I (role perception) of the tool and .91 for Section II (teaching content). An item analysis was conducted on the 10 knowledge questions.

In addition to the FCS, selected demographic variables were also obtained. The demographic characteristics selected for study were: educational preparation, time since graduation from a basic nursing program, age, full-time/parttime employment, shift usually worked, position, whether nursing education program specifically covered the mechanics of foot care for older persons, and how much involvement with foot care of older persons the nurse has had.

Data Analysis

Descriptive statistics were computed on each item on the tool and each of the demographic variables. To determine if there were differences between the groups on demographic characteristics, chi-square and analysis of variance (ANOVA) statistics were used. ANOVAs were employed to determine if there were differences between the groups on the role perception, teaching content, and knowledge portions of the tool. If statistically significant differences were found between the groups, a post-hoc Tukey procedure was used to determine where the differences were located.

Results

Demographic Characteristics

There were no significant differences (p<.05) between groups on the demographic characteristics: educational preparation, extent of involvement with foot care of older persons, or feeling that his/her nursing program specifically covered the mechanics for foot care of older persons. However, there were significant differences between groups on age F (2,90) = 7.97, p<.001 and time since graduation F (2,89) = 6.82,p<.01. A post-hoc Tukey test indicated that the ECF and the HH nurses were significantly older (p<.05) than were the hospital nurses, with mean ages of 35.65, 39.36 and 29.83 years respectively. Additionally, a Post-hoc Tukey indicated that HH nurses had graduated from their basic program significantly longer ago (p<.05) than had either the ECF or hospital nurses, with means of 16.85, 13.03, and 7.58 years respectively.

Table

TABLE 1Percent, Mean, and Standard Deviation of Nurses' Perceptions Related to Role in Foot Care (N =94)

TABLE 1

Percent, Mean, and Standard Deviation of Nurses' Perceptions Related to Role in Foot Care (N =94)

When comparisons were made between settings using chi-square statistics, significantly fewer nurses in the HH setting were employed full-time (x2[2,92] = 16.06, p<.001); however, significantly more HH nurses worked the day shift while significantly more hospital nurses rotated shifts or worked "off shifts" (x2[2,93] = 20.39, p<.001). There were also significantly more staff nurses than nurses from other positions (i.e., middle and upper level management positions) in the hospital setting who completed the survey (x2[6,93]=21.73,p<.005).

Overall, only 51% of the sample agreed or strongly agreed that their nursing program specifically covered the mechanics of foot care for older persons. Slightly over half of the sample (62%) reported having had moderate to extensive involvement with foot care of older persons.

Role Perception

The possible range of scores for this section of the tool was 8 to 32. Lower scores on this section of the tool are suggestive of less independent functioning within the nursing role related to foot care, with independent/interdependent being defined as relative degree of rebanee upon physician direction in performance of role. The actual range of scores was 16 to 32 (M = 22.7). The majority of nurses disagreed or strongly disagreed with the statements that: (a) it was appropriate for them to file their patients' corns and calluses (52%), and (b) it was not necessary to consult a physician before trimming toenails (63%) or filing corns and calluses (73%). The majority of nurses agreed or strongly agreed with the remainder of the items related to role. This included the perception that there is an unmet need of the elderly for assistance with foot care (95%) and provision of foot care for older persons is a nursing function (95%). Table 1 illustrates the percentage of responses, mean and standard deviation for each item on this portion of the tool.

An ANOVA was performed using the total score on the role perception portion of the tool as the dependent variable and work setting as the independent variable. Role perception scores differed significantly between the three groups, F (2,93)= 11.21, p<.0001. A post-hoc Tukey test indicated that nurses employed in the hospital setting had significantly lower mean role perception scores (p< .05) than did nurses employed in HH or ECF settings.

Open-ended comments related to this portion of the tool included: (a) 12 comments about nurses not trimming toenails of diabetics, (b) five comments related to trimming of toenails only if no contraindications existed (e.g., thick nails or diminished circulation), and (c) four remarks that this was a "gray area" and appropriate nursing action was dependent upon the situation.

Table

TABLE 2Percent, Mean, and Standard Deviation of Nurses' Perceptions Concerning Importance of Components of Patient Teaching Related to Foot Care (N = 94)

TABLE 2

Percent, Mean, and Standard Deviation of Nurses' Perceptions Concerning Importance of Components of Patient Teaching Related to Foot Care (N = 94)

Patient Teaching Content

The majority of nurses rated all seven items as very important to very, very important. The possible range of scores for this portion of the tool was 7 to 28, with higher scores indicating nurses' perception of greater importance of the identified teaching items and the need to provide more extensive information in patient teaching related to foot care. The actual range of scores for this group of nurses was 15 to 28 (M = 23.7). All items were considered important components of teaching related to foot care. The importance of inspecting feet regularly had the highest mean rating (3.52) and appropriate types of products to use for dry skin or excessive perspiration of the feet had the lowest score (2.99). The frequency of responses concerning importance of components in a patient teaching program related to foot care are displayed in Table 2.

To determine if there was a significant difference in perception of components of patient teaching between practice settings, an ANOYA was conducted. No significant difference was found F (2,91) = 2.65, p = .07; however, this difference did approach statistical significance. Mean scores for hospital, HH, and ECF nurses were 22.66, 24.14, and 24.35 respectively.

Nurses' recommendations for additional information to be included in patient teaching consisted of content which appeared in other portions of the tool, with the exception of suggestions to inform patients under what circumstances to contact a physician or podiatrist (seven comments) and informing the patient of the role of exercise and of accupressure in foot care (one comment each).

Knowledge

The range of correct scores for the knowledge portion of the tool was 6 to 10 (maximum possible score = 10) with a mean of 9.47 correct responses. Item analysis revealed that 17 nurses responded incorrectly to the question concerning perspiration of feet in leather or canvas shoes. Ninety percent or greater of the respondents correctly answered the remainder of the knowledge items. A summary of the responses to those items appears in Table 3.

ANOVA was computed to determine if there was a difference in knowledge scores between practice settings. There was not a significant difference between groups. Mean knowledge scores for hospital, HH, and ECF were 9.49, 9.35, and 9.57 respectively.

Discussion

The HH and ECF nurses were significantly older than the hospital nurses, and the HH nurses had graduated from their nursing program significantly longer ago than had the hospital or ECF nurses. The remaining significant differences between groups in relation to shift worked, full-time/part-time status and proportion of staff nurses to first- and second-level management, may in part be explained by the differing purposes, staffing patterns, and organizational structure between settings. Almost one half (49%) of the nurses surveyed disagreed or strongly disagreed that foot care content was covered in their educational preparation.

Table

TABLE 3Item Analysis: Nurses' Knowledge Related to Foot Care and Foot Care Education (N = 94)

TABLE 3

Item Analysis: Nurses' Knowledge Related to Foot Care and Foot Care Education (N = 94)

The majority of nurses in this study indicated that they were comfortable performing hygiene and assessment functions related to foot care. While still a majority, a somewhat smaller percentage were comfortable trimming patients' toenails. A majority of the nurses also indicated that they did not perceive it was within their role to trim patients' toenails without a physician's order, or to file corns or calluses with or without a physician's order. The results indicated that hospital nurses were significantly less independent within this nursing role than were nurses in ECF or HH settings. This finding is consistent with what one might expect. Patient acuity is greater in the hospital setting and nursing activities are directed more toward curative measures. In addition, physicians are more accessible within the hospital setting than in either of the other settings studied, and thus might be more easily consulted as needed. It is the consensus of nurses across settings that there is a need of the elderly for assistance with foot care and that this is a nursing function. There is, however, some disagreement as to whether this is an independent, a dependent, or an interdependent nursing function. This lack of agreement is consistent with the varying descriptions of nursing practice related to foot care which are found in the literature (Brown et al., 1982; Conrad, 1977; Garlinghouse, 1986; King, 1978; Shank, 1977). Comments related to not trimming toenails of diabetics or those with compromised circulation support the suspicions raised by nurse colleagues. Many nurses have been taught to refer all diabetics to physicians or podiatrists for toenail care, and perhaps this cautious posture has carried over to the care of all patients' feet.

Overall agreement with items which the literature identified as important components of patient teaching related to foot care was observed. The component felt to be least important was information related to appropriate products to use for dry skin or excessive perspiration of the feet. Nurses suggested adding information concerning when patients should be instructed to seek assistance from a physician or podiatrist. This is certainly appropriate content for inclusion in patient teaching, especially for those patients at greater risk for need of more extensive care (e.g., those persons with compromised circulation, open skin lesions, fungal infection, ingrown toenails). Practice setting did not account for significant differences in perception of important components of teaching content related to foot care. Knowledge level of nurses related to foot care and foot care teaching was observed to be very good. Overall, 94.7% of all responses on the knowledge portion of the tool were answered correctly. The level of knowledge did not differ significantly by practice setting.

Limitations of this study include use of a convenience sample, a moderate response rate to the survey, comparison of groups that were significantly different in a number of demographic characteristics, and use of a newly developed tool which has not previously been used in research. The identified limitations of the study do limit generalizability of the findings.

Refinement of the data collection instrument would be advised if the instrument were to be used in the future. At the suggestion of several RNs, further study would include survey of licensed practical nurses (LPNs) as well as RNs because of the large numbers of LPNs employed in long-term care settings.

In conclusion, foot care has been documented as an appropriate area for preventive nursing intervention to promote the individual's hygiene and comfort in addition to ininimizing disability (Brown et al., 1982; Conrad, 1977; Fowler, 1974; King, 1978; King, 1980; Schaefer, 1982; Shank, 1977). It is of particular value and importance for those older persons who are unable to perform this task safely due to impaired dexterity and/or vision (Shank, 1977). The data gathered in this study demonstrated that many nurses in this geographic area are more comfortable providing foot care under the direction of a physician. Only half of the nurses working in areas with a high proportion of older patients reported having exposure to mechanics of foot care in their educational programs. Data gathered in this study demonstrated that nurses possess the knowledge, but have not had the opportunity to acquire the associated foot care skills.

Implications

Nurses involved in the care of older persons are in a position to work to improve the accessibility and quality of health care for this group. This nursing intervention (foot care) can positively impact comfort, mobility, and quality of life for the growing number of older adults.

If there is uncertainty concerning whether foot care constitutes an independent or an interdependent nursing function, we can assure delivery of this service by establishing collaborative relationships with physicians or podiatrists for provision of foot care. Collaborative relationships can take the form of: (a) development of physician-approved standardized protocols for foot care and criteria for physician referral, and (b) establishment of institutional credentialing of individuals qualified to perform foot care.

Nurses can affect improvements in relation to foot care in two other major ways: (a) by working cooperatively (clinical practice and academics) to include this content and clinical experience as a component in nursing education curriculum, and (b) through establishment of continuing education opportunities so that nurses involved in care of older adults can acquire foot care skills.

References

  • Albert, M. (1987). Health screening to promote health for the elderly. Nurse Practitioner, 12(b), 42-48.
  • Brown, M. M., Boosinger, J., Black, J., Gaspar, T, & Sather, L. (1982). Nursing innovation for dry skin care of the feet in the elderly: A demonstration project. Journal of Gerontological Nursing, 8, 393-395.
  • Chung, S. (1983). Foot care: A health maintenance program. Journal of Gerontological Nursing, 9, 213-215, 219,227.
  • Conrad, D. (1977). Foot education and screening programs for the elderly. Journal of Gerontological Nursing, 3(6), 11, 14-15.
  • Fowler, M. D. (1974). Behold the great right toe. American Journal of Nursing, 74, 1817-1819.
  • Garlinghouse, C, & Haviland, S. (1986). Foot care standards: Nursing assessment, intervention and patient education. Lansing, MI: Michigan Department of Health Promotion.
  • King, RA. (1978). Foot assessment of the elderly. Journal of Gerontological Nursing, 4(6), 47-52.
  • King, RA. (1980). Foot problems and assessment. Geriatric Nursing, (5), 182-186.
  • Schaefer, A.M. (1982). Nursing measures to maintain foot health. Geriatric Nursing, (3), 182-183.
  • Shank, M.J. (1977). A survey of the well-elderly: Their foot problems, practices, and needs. Journal of Gerontological Nursing, 3(6), 10, 12-13.

TABLE 1

Percent, Mean, and Standard Deviation of Nurses' Perceptions Related to Role in Foot Care (N =94)

TABLE 2

Percent, Mean, and Standard Deviation of Nurses' Perceptions Concerning Importance of Components of Patient Teaching Related to Foot Care (N = 94)

TABLE 3

Item Analysis: Nurses' Knowledge Related to Foot Care and Foot Care Education (N = 94)

10.3928/0148-4834-19910201-05

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