A non-equivalent control group study was conducted by Chan, et al (2012) exploring the effects of a foot and toenail care protocol for older adult in the context of hospitals. A non-equivalent control group is a type of quasi-experimental studies in which a minimum of two groups with similar characteristics are non-randomly allocated and it has a 2.d evidence level as per Joanna Briggs Institute levels of evidence-effectiveness (Briggs, 2014). In this study, a total of 160 participants were recruited from a geriatric ward in a general hospital in Hong Kong of which 150 completed the study. Because of the extended period of time in which Hong Kong was a British colony (156 years), the health care system has similar features to the public health system in UK (Kong et al, 2015). Therefore, we can asseverate that this research study is relevant to the purpose of this essay. Moreover, foot problems are common in elderly population in all races, as the feet get wider and flatter and create deformities as we age (Muchna et al, 2018).
In this particular study, the participants were men and women over 65 with a mean age of 78.9 who were allocated into two groups. All participant in both groups had an initial assessment for which nurses and HCA’s were trained in a 2-hour workshop. However, only the intervention group received foot and toenail care as per the care protocol developed. The protocol was developed using literature review and with the expertise of a panel of a multidisciplinary team specialised in geriatric care which included podiatrists, nurses, geriatricians and academics. The result of this study concluded that after the training, the nurses were able to identify that 89.3% of the participants had foot problem, that the 52% had nail problems and that 10% of the patients that wear shoes did not meet the criteria for shoe fit selection that were not identified before. In addition, after day 6 the intervention group agreed that there was a significant increase of foot health (Chan, et al 2012). The research study proves that education programs for nurses increases the knowledge on foot care and toenail care that would benefit especially the quality of life of the elderly and it supported by Fijii, et al (2020), Pataky, et al (2017), Christesen, et al (1990) and Mikkola, et al (2019) among others.
Similarly, Fijii, et al (2020) conducted a study in a non-randomised control trial of 87 participants in Japan. In this case, the study is focus in nurses and care workers in the context of community nursing. A control trial is a quantitative study that seek to compare and measure outcomes and assess the effectiveness of an intervention (Kendall, 2003). Participant were non randomly selected because that was what the providers wanted due to short of staffing or personal circumstances; however, the bias was partly avoided because nurses did not know each other, they did not know the type of intervention they would receive, and because one of the inclusion criteria was that they had never received intervention program before (Kumar and Yale, 2016). The aim of the study was to assess first the level of knowledge of both group (control and intervention group) and, second, the difference before and after the education program in the intervention group. The education program consisted on PowerPoint presentation, 10 minutes motion picture material, foot-care booklet, foot care assessment sheet and nail fail and foot file. The intervention lasted 2 months and concluded that educational program resulted in an improvement in foot care knowledge and practices, especially in early detection in a 79% and an 88.4% increased their knowledge in nail care.
Another quantitative interventional research was conducted in Switzerland to evaluate the effectiveness of an educational program to prevent foot complications (Pataky et al, 2007). 128 nurses and 67 HCAs took part in the study. The educational program consisted in a combination of theory -leaflets and posters- and practice -in which the nurses and HCAs would attend the specialist consultation with the patient during a twelve-month period-. The study shows that the initial baseline in foot care knowledge of nurses was 47% and of HCAs was 29%. After the twelve-month intervention, the knowledge improved to an 85.7% and 72.2% respectively. However, transfer bias has been detected in this research that could have affected the result of the research. In this case, the number of participants that responded to the questionnaire after the intervention period decreased from 128 to 84 in nurses and from 67 to 54 for HCAs. Transfer bias occur when participants are lost during the follow-up, it can be avoided by having different way of contacting the participant to facilitate the response of the questionnaire (Pannuci and Wilkins, 2010).
The effectiveness of foot programs was the focus of another interventional paper research (Christensen et al, 1990) in USA. In this case, the intervention consisted in assessment tool workshops and guidelines for treatment of different conditions. 23 nurses attended a foot an education program. The baseline knowledge were assessed before and it showed a 65% of correct answers. Two months after the intervention program, the knowledge in foot care increased a 10%. 91% of nurses reported that they had improved their knowledge and that they feel more confident in foot related problems and especially in the care of the toenail.
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One common outcome of two of the research papers is that nurses would like to have more training in the future (Fijii, et al, 2020a; ). Continuing education is essential in nursing to give a safe and effective care to our patients and its part of our professional responsibility (NMC, 2014) but protocol and guidelines on foot care and nailcare for our elderly has to be offered in our workplace and this is not happening. Several studies has assessed the knowledge of nurses and HCAs in foot care and the conclusion is that nurses have a poor understanding on foot care and they recognise the need of having a training program and well design protocol in this matter.
Fujii, et al (2020b) conducted a cross-sectional study using a random cluster sample aiming to explore the foot care knowledge of nurses and care workers in the context of community in Japan. Cross-sectional study is a type of observational study that assess the prevalence of an outcome in a specific time (Setia, 2016). As it is randomised, the level of evidence is 4.b as per Joanna Briggs Institute levels of evidence-effectiveness (Briggs, 2014). 232 nurses and care workers participated in the survey which included questions about foot care knowledge, foot care practice and perception about foot care. The nurses and care workers were divided into two groups. The study concluded that 53.2% of nurses and 78.2% of care workers considered that the foot education they receive is insufficient, only 4.8% and 0.6% of the participants had confidence in foot care practices which included nailcare proving that nailcare is challenging for both groups. In addition, 78.7% of nurses and 75.7% of care workers agree that a foot care protocol were necessary.
Similarly, nurses’ knowledge in toenail care was also assessed by Tuner and Quine (1996). 100 people participated in this cross-sectional study in Australia of which 49 were nurses and 51 HCAs. Of those, an 87% of the participants didn’t have any previous training in foot care or toenail care. They were showed photographs of nails and asked to assess the nail, whether they will cut the nails and the actions they will take. The result showed that 25% of the nurses and HCAs told they were not confident of cutting the nails because of lack of knowledge or experience. This study also shows lack of assessment skills in 18% of nurses sending patients with no conditions to podiatrist and only 9% were able to recognise fungal infections. Conclude also that nurses need to be taught basic nail care including toe cutting.
In contrast, in Finland the knowledge of foot care of community nurses show a slightly different result. This cross-sectional survey was conducted by Stolt, et al (2015) in Finland. In this case 651 community nurses participated in a study aimed to assess the knowledge of foot care of nurses. The results showed a higher number of correct answers, a 68.5%. Probably due to the fact that only nurses participated in the research and, of those, a 71% occasionally received some kind of foot training. Nevertheless, 39% considered that the foot care education they receive is insufficient in the workplace.
Another interesting outcome of the research paper is that nurses realises that with educational foot programs they can focus in prevention not just in treating a problem (Christensesn, et al, 2007). Pataky, et al (2007) also mentioned that prevention reduces complications and, therefore, is cost benefit for the healthcare system and Fijii, et al (2020) highlighted that due to the increase of the aging population, foot care prevention would help to alleviate the elevated cost of medical care.
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