Performing personal care is an activity of daily living that individuals usually do independently; however, trimming toenails is often one of the first activities of daily living that individuals have difficulty performing as they age.1 Should an individual have a health condition such as peripheral vascular disease, diabetes, or neuropathy, in combination with onychomycosis or other nail disease, scrupulous nail care by a health care professional is optimal to decrease the risk of complications. Lower extremity amputation is one such complication.2 In addition, increased morbidity, mortality, and diminished quality of life can also be sequelae of neglected care of the feet. Such care may qualify for Medicare coverage by a participating provider; however, the majority of routine foot care services are not covered, making the cost of foot care prohibitive for many older adults.3 The increase in the number of individuals unable to perform nail and foot self-care and the lack of third-party reimbursement for routine services make nail care performed by nurses a desirable service and is within the scope and standards of nursing practice.
Many nursing specialty groups have an interest in foot care including gerontology nurses, diabetes educators, orthopedic nurses, those working in wound care, etc. The Wound Ostomy Continence Nurse Certification Board (WOCNCB) offered the first certification exam in Foot Care Nursing (CFCN) in the United States in 2005.4 The development of a nursing certification exam in foot care expanded the need for foot care education programs specific for nurses. Educational criteria to be eligible for certification have evolved over time. The initial criteria of 5 hours of education and 6 clinical hours endorsed by the WOCNCB expanded to 24 education hours and 40 clinical hours in 2015. The expanded certification requirements, in turn, created an opportunity for educational programs to consider expanding their programs to address the needs of nurses who wish to validate their specialized knowledge, skills, and expertise with certification recognition.
Our program has been offering continuing education in foot and nail care nursing since 2000, educating hundreds of participants. The initial continuing education program included 7 hours of didactic instruction, followed by 8 clinical hours over a 2-day period. An optional 3-hour program on innovation and business development was offered in the evening of the first day. The program attracts a national audience due to its longevity and consistency, allowing participants to plan far in advance.
As the number of participants increased, so did the need for individuals for whom the participants would provide foot and nail care in the clinical component of the program. The clinical component is a free service offered to numerous individuals in our clinic located in a church basement with handicapped accessibility and ample parking. A number of methods for soliciting individuals in need of foot and nail care have been employed over the years. Advertisements run in the local newspaper, and flyers targeting older individuals, those with developmental or other disabilities, or individuals who are unable to afford foot care have been placed in local clinics, shelters, apartments for older individuals, social service agencies, and church newsletters.
The course had been offered as often as 4 times per year. Course participants have a variety of educational backgrounds such as licensed practice nurses (LPNs) and advanced practice nurses, and some hold doctoral degrees. Occasionally, physician assistants and physical therapists have also participated. Enrollment peaked just prior to the change in eligibility criteria in January 2015 for the CFCN to RN with minimum of a bachelor's degree.
We surmised that expanding education and clinical hours for this long-established education model to meet the newer certification requirements would cost more to develop and, in turn, raise the cost for course participants. Some past participants expressed frustration in not being able to find additional appropriate continuing education offerings and clinical opportunities required by the new certification requirements. Yet, many other participants were unaware of the value of obtaining certification and were not planning to pursue, as evident per end-of-course evaluations. We were concerned that a longer, more costly program may deter these participants from attending our program. Thus, our program faculty and staff considered the following questions: Should the program be adapted to meet the criteria of the certification board or does the program continue offering content as has been done historically? Would our participants be willing to make the additional investment? Should we offer better equipment/supplies for conducting foot and nail care, which, in turn, would increase the cost to participants? Would there be enough interest to offer the course more often? Expanding a very successful and long-running continuing education program includes inherent risks such as being cost prohibitive for some and could result in lower enrollment. To address our concerns, we queried our former participants to gather information on whether it would be beneficial to expand the education and clinical hours to meet certification requirements. We believed this information would aid in performing a more in-depth analysis to determine whether expanding our program would continue to attract participants.5
Continuing education faculty and staff conferred to develop a brief survey delivered via SurveyMonkey.com to query past participants about their interest in expanding educational opportunities in foot and nail care. Our group was also very interested in the tool kits supplied in the course and whether to provide a higher-quality rotary file device, which would further increase the cost of the program. Program evaluation procedures were reviewed by University of Wisconsin–Eau Claire Continuing Education and deemed exempt from human subjects research.
This survey comprised 8 questions and was distributed to participants who attended the course from 2013 to 2018, as these e-mail addresses were readily accessible.
The questions were related to the following topics:
- Application and integration of material learned
- Tool kit containing a mechanical rotary file
- Expanded education and clinical time and timing of course offerings
- Open-ended question for additional comments
Data were analyzed by frequency counts/percentages, and yes/no responses. Open-ended questions were tallied for common themes.
Application/Integration of Material Learned
The majority (88%; n = 87) of nurses who participated in the program were actively practicing foot care. It is not known with this particular sample how many nurses were practicing in the foot and nail care specialty prior to attending the program. Anecdotally, some nurses attend to obtain continuing education hours, refine their skills, and learn new information, with already having practical experience in foot and nail care. For others, they attend to acquire these new skills. Our participants had a range of foot care and general nursing experience as well as educational preparation.
Over time, increasing numbers of nurses are attending this course at the request of their employers who are financing their attendance. It is fitting that the largest portion of nurses who have incorporated foot care into their practice (43%; n = 43) are doing so through their employer.
Starting a side business for the practice of foot care was reported by 22% (n = 22) of respondents. Many nurses report verbally, during or at the end of the course, that they are financing the cost of the course independently. They see a need in the community and would like to offer this service for direct remuneration, taking incremental steps into developing a private practice. Working in an independent nursing practice is foreign to most nurses across the country, although that trend is increasing.6
A small, yet significant, number of nurses (17%; n = 17) are finding ways to provide foot care on a volunteer basis. Volunteer opportunities at free health clinics, faith-based communities, international mission trips, senior centers, and homeless shelters are a few of the many locations and populations where nurses have the opportunity to offer foot care services. In addition, many nurses find themselves caring for family members and neighbors.
Twelve respondents (12%) indicated on the survey they were not currently providing foot care. This group may have had a change of employer or chose not to do foot care. For some, they might have found it was not the right time to provide this service in the area in which they live. Anecdotally, there have been past participants who have returned to take the course again as they did not immediately put the skills into practice and felt the need for a refresher. This is one reason why we provided tool kits in the course. Participants would use their kits in the clinical portion of the program and have those same kits to take home and begin using immediately in their practices.
We provided a tool kit to each participant that comprised a basic mechanical rotary file and burr used to debride thick toenails. The tool kit also contained a nail nipper, a curette, solution for high-level disinfection, lotion, and a manual coarse nail file. Additional disposable supplies are provided including gloves, N-95 masks, baby wipes to clean feet, alcohol wipes, gauze pads, bandages, and antibiotic ointment.
About one-third of respondents (35%; n = 27) answered that they were using a different rotary tool from that which we provided that they either purchased or was purchased by their employer. Many different types and brands of these files, sometimes referred to as devices or drills, were mentioned by those who were utilizing a file that was different from the basic model we provided. There was no clear preference for one particular model.
In reviewing the open-ended responses, some of the respondents were not using any type of rotary file as they made referrals to other health care providers for more advanced care when nails were highly dystrophic or the file was not permitted to be used in their particular practice setting. We were unaware of how many respondents were unable to utilize a rotary file, as that question was not directly asked on the survey. Files for the purpose of nail debridement generate particulate matter that can remain in the air after the procedure is complete.7 Appropriate infection control measures are essential when utilizing this method of debridement and are reviewed thoroughly in the course (ie, use of mask, sterilization of burrs).
Nursing specialty certification is a form of credentialing for individuals and is widely linked to improved quality of care and patient outcomes.8 Certification in the specialty of foot care nursing began with the WOCNCB initiating the exam in 2005.4 Our course began prior to a certification exam being offered. Since the inception of this specialty certification exam, an increasing number of participants take the course with the expressed purpose of preparing for certification. However, many participants learn about the availability of a certification while attending the program. Those seeking certification continue to be in the minority, with 38% (n = 35) of respondents having achieved certification in foot and nail care after course participation. Of those becoming certified, 52% (n = 17) were with the WOCNCB and 36% (n = 12) were certified through the American Foot Care Nurses Association (AFCNA). Four respondents (12%) noted that they were dually certified by both organizations.
Interview responses indicated that at least some participants were continuing to pursue certification. One respondent noted, “My work place changed their mind about having me do foot care but I still plan to get my certification for myself.”
Some respondents noted the need for additional education hours and clinical hours as well as apprehension about taking the exam acted as barriers to seeking certification following course attendance. They expressed a desire for additional study materials for exam preparation. When discussing certification in the course, learners were directed to either the WOCNCB or AFCNA Web site for further preparation materials.9,10 Comments made by respondents indicated there is an increasing interest in certification and the desire for more educational and exam study materials:
- LOVED the course ... have been “scared” to take the certification exam. Is there an additional booklet to study for certification?
- There also needs to be more information provided to prep for the certification tests.
- Would like continuing education to become a CFCN nurse.
- Need more continuing education for certification.
- I need more education CE hours on foot care and vascular disease for recertification.
Expanding Education and Clinical Time
The majority of respondents (77%; n = 75) were interested in additional clinical hours as part of this program. The number of hours desired ranged from 6 to 40. Of those interested in more clinical hours, many were interested in taking “enough for certification.”
It can be challenging to find suitable clinical placement in such a specialized area of nursing. Often, participants are interested in the education because of a perceived need and lack of availability of foot care in their communities, which translates into a lack of suitable preceptors and hands-on practice opportunities.
Our program has been offered over the past several years in spring and fall, corresponding to a typical college semester class schedule. We are mindful of unpredictable winter weather conditions in Wisconsin. The previous winter class offering was dropped after a record snow fall caused hazardous travel conditions for mostly elderly and disabled individuals who come to the clinic during the course. The number of course offerings and enrollment could be increased by adding a summer session. The majority of respondents (86%; n = 59) were more than willing to attend in the summer for the additional clinical practice hours. Many respondents (77%; n = 54) would be willing to bring their own equipment for the additional clinical hours.
When respondents were asked if they would be willing to pay more for the additional clinical hour component to cover an upgraded rotary file, more than two-thirds (69%; n = 58) were in favor of having a higher-quality file provided as part of the expanded clinical offering. About one-third of respondents preferred the entry-level tool to keep course costs reasonable. One respondent wrote, “I bought a podiatry drill and am still trying to get used to it. So, my original rotary file is still a hot item for me.” Another mentioned, “Perhaps I would pay more for an ‘upgraded file,’ but my budget is very tight, so I'd prefer to use the file currently provided first to see the difference before purchasing one.”
In addition to the question of upgraded rotary file, several individuals requested more information on different types of burrs and learning how to use them. Another comment indicated a need for more education: “The class needs to spend more time teaching about the various tools in the kit and how to properly use them.” This comments suggests a need for extended class and clinical time.
The final question on the survey asked for additional comments or suggestions for future trainings. Additional themes were identified as follows:
Scope of Practice Issues
This course was designed for RNs. The course draws many advanced practice nurses and occasionally other health care providers such as physician assistants and physical therapists. Licensed practical nurses have taken the course and are instructed about scope of practice and delegation. The following comment highlights the continued questions regarding scope issues: “I am a LPN I don't know if I am able to have the training with my license. I do foot care one day a week. Would this training allow me to work with a podiatrist or do more extensive care?”
These types of questions can be challenging with a national audience, as state practice acts differ. Scope-of-practice issues are reviewed in the course; participants were directed to the nurse practice act for the state in which they practice and are encouraged to contact their boards of nursing with questions that are not specified in the acts. Often, the legislative language in these documents is kept purposefully vague. Guidance documents promulgated by the board may exist to answer more specific questions and may be found on the board Web sites. Calling the board with specific questions is also an option.
Educational Content and Design
Participants offered a number of suggestions to expand course content:
- “Weekend class option”
- “I would like to learn more about the structure of the feet and problems that occur and what can we do to assist.”
- “Dealing with thick fungus toenails, what's the limit of care.”
- “Please provide information and training about painful callous treatment.”
- “Is there any update to the original material presented?”
- “I'm not sure about more education because I recently retired and I have more work than I planned to have in foot care. So, I doubt more education would be necessary but just love to know when there is new information!!”
One respondent asked for an update on Medicare charting requirements. This topic is touched on in the current class offering. Most RNs are not in a position to bill Medicare, and of all Medicare recipients, only a small percentage qualify. The billing rules are complex. Advanced practice nurses are in a position to obtain third-party reimbursement and directly utilize information obtained from such an offering. The RNs may benefit from enhanced knowledge of third-party reimbursement so that they can refer the client to the appropriate provider to utilize the insurance benefit.
Innovation and providing care on an independent basis are novel ideas for many participants in this course. A short companion program has been offered for many years on how to become an entrepreneur. This additional business class is offered as an optional program offering at the time of the initial training and focuses on how to write a business plan. It also introduces the participants to nurses who run their own successful independent foot care practice as a business. Several nurses who did not take advantage of this offering at the time commented that they wish they had taken it as noted by comments such as:
- “Would love to take the course now on providing foot care as a side business. I did not take the course when I went through the foot care training.”
- “I'd like to learn more about how to promote my business.”
- “I'm so busy, please let me know of anyone from this course who wants a job.”
Results of this survey suggest that respondents would like more education and clinical hours in order to meet certification requirements. In response, the program has initiated a longer course offering, which is now available online and its format follows the WOCNCB content outline for certification. This education model was developed in an asynchronous format to allow participants the flexibility to participate as their schedule permits. The clinical component has been expanded to 40 hours as required by the WOCNCB. Participants can choose the number of clinical hours from 8 to 40 to meet their needs. With the didactic portion held online, the clinical component can be done over the course of 5 days in the clinic affiliated with the program in the summer.
The expanded format meets the needs of participants seeking certification, yet many participants are not seeking certification. While we offer the didactic content online, there continues to be a need for a single-day course, followed by a 1-day clinical course for those who desire exposure to this content. We will continue to offer this “brick and mortar” format; however, how often the program will be offered is currently being explored (eg, adding an additional summer program).
The survey questions were directed to the foot and nail care program specifically; however, many of the respondent comments showed a desire for more business content. The companion offering on business development and entrepreneurial skills continues to be popular with program participants. At present, comments related to the business offering are being incorporated in revising those modules. We are considering expanding this offering in the future as more nurses are seeking nontraditional employment opportunities. To assist us with future program evaluation, we would include additional questions in subsequent surveys including participant demographics such as the number of years practicing in nursing, barriers to achieving expectations to start or expand businesses, and the number of participants using a rotary file or other devices.
Foot care nursing is an example of disruptive innovation11 where nurses are meeting customers' needs in nontraditional ways and represents a growing opportunity for entrepreneurial practice. As the specialty continues to grow, foot care positions are being advertised specifically for nurses and many employers are sending nurses to acquire knowledge and skill to practice in specialized positions.
There is a trend toward nurses obtaining certification as many health care organizations recognize the value of specialty nursing. Quality and patient safety are the 2 themes that are often cited as outcomes associated with certification. There is a great need for additional continuing education opportunities for foot care nurses to meet the need for certification and thereby enhance the confidence of nurses to practice independently within their scope of practice.