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New Foot and Nail Care Section of the JWOCN

Journal of Wound, Ostomy and Continence Nursing (JWOCN ):

NEW Foot and Nail Care Section

TARA BUESCHER, DNP, RN-BC, GCNS-BC, ANP-BC, CWOCN, CFCN, NEA-BC

It is with great pleasure that I introduce myself as the new Foot and Nail Care Section Editor for the Journal. I am eager to start by sharing my background as a foot care nurse, talk about the purpose of this new JWOCN section and my vision for upcoming features. My background in foot care nursing started in 1991 after identifying a need for nail care among the older adults for whom I was providing care in both acute and home care settings. At that time, I was a Certified Enterostomal Therapy Nurse and a Gerontological Clinical Nurse Specialist (GCNS) working in a rural community for a home care agency and began consulting with home care nurses on complex or slow to heal wounds. I was amazed at the number of patients with lower extremity ulcers I saw who also had severely dystrophic nails. My desire to “do something to help these patients” began to grow. At the time, I knew no one who was providing such a nursing service. After searching for information on courses, conferences, or experts in the field, I found small pockets of nurses around the country providing similar care. I attended a course and developed my skills in assessment, nail and skin care, acquiring supplies, and made it my mission to provide foot care education for other nurses who care for patients no longer able to cut their own toenails and perform proper hygiene. My overall goal was to help improve function and mobility.

At the time I started providing and teaching foot care to RNs in home care, I was living in Northern Wisconsin where the population consisted of a high percentage of older adults. The local health care system purchased a group of communitybased residential facilities, small group homes for older adults, and assisted living facilities in our area. I observed a great need for nail care among the older adults living in these community settings. I addressed this need for nail care delivery in the community (partnering with the local community college) by writing a grant to develop community-based clinical sites for nursing students. The sites were located in local senior centers where I oversaw the foot care students provided and worked with them on their projects. Community-residing older adults would sign up for appointments, and the students would provide foot assessment and nail care. This system of care delivery also enabled students to enhance skills such as history taking and communication.

While I entered foot care nursing practice working with fairly healthy older adults in community senior centers and more frail elders in nursing homes, many other nurses work with individuals with complex vascular and other conditions in specialized vascular, wound, or orthopedic centers who require more advanced education.”

I taught my students that, over time, toenails can become thicker and difficult to cut (referred to as debriding in Foot and Nail Care specialty practice). As people age, their flexibility, dexterity, vision, and strength may decline, making it difficult to care for their feet. Nails affected by chronic conditions such as diabetes and fungal infections are outside the scope of beauty professionals; yet, many older people see this as their only option to get foot care. Salon care is suboptimal to manage the complex nail problems of these individuals, thus the need for nurses to be adequately prepared to provide this care.

As my skills developed, I developed a Foot and Nail Course for Nurses offered through the continuing education division of a local university in Wisconsin. Initially, this course was offered annually, increasing in frequency as demand for education grew. Foot and wound care and education became a full-time endeavor as I transitioned from the home care agency to our health system's advanced practice nurse (APN) group. I began consulting in nursing homes as a GCNS with prescriptive authority, providing both foot and wound care services. I saw patients in 10 nursing homes and 10 senior centers each month and worked 1 day per week in the ambulatory clinic providing foot, wound, and ostomy-based services. During this time, I worked with a talented and passionate billing specialist who was instrumental in supporting my quest to bill third party insurers for foot-related services. We worked with Medicare for 3 years and finally I secured privileges to independently bill foot care codes as an APN/clinical nurse specialist (not under another professional's name/number). This process occurred during a time when prescriptive authority, state practice act changes for APNs, and changes in federal programs rapidly evolved, allowing for third party billing.

Around this time, the Wound Ostomy Continence Nursing Certification Board (WOCNCB®) commissioned a group of nursing foot care experts to determine the feasibility of a foot care certification exam. This visionary work lead to the Foot Care Certification examination, first offered in 2005. Since the inception of the Foot Care Certification examination, the need for education has expanded; yet, continuing education can be difficult to find. While I entered foot care nursing practice working with fairly healthy older adults in community senior centers and more frail elders in nursing homes, many other nurses work with individuals with complex vascular and other conditions in specialized vascular, wound, or orthopedic centers who require more advanced education.

I continued to advance my education (earning my DNP) and career in a nurse practitioner role working with an interprofessional pain management group in a large multispecialty clinic and then developing a world-class wound care program at a university-based long-term acute care hospital. All the while I continued to instruct nurses in the arena of foot care. Over the past 28 years, I taught thousands of nurses how to assess feet, provide appropriate care within the scope of nursing practice, and refer to others when indicated. Most recently, I returned to where I started, back with older people, helping preserve mobility and prevent/identify early complications through an independent, full-time professional nursing foot care practice delivered in multiple care settings.

The field of nursing foot care is as old as time and yet so new. The impact of nurses providing foot care—conducting regular assessments, managing early conditions such as maceration or thickening toenails, and identifying clinical problems for which referral is warranted—in a wide variety of care settings is yet to be fully explored or documented. I know many of you who are providing this care might be doing so full-time in private practices or perhaps devoting a small portion of your time to your patients as needed. Regardless, I am confident that the impact of our care is recognized and appreciated by our patients and clients, but I am concerned that it is less well known in the wider health care community. The WOCNCB first supported this growing specialty with a certification exam. Now the WOCN Society and JWOCN will provide a platform for your excellent work and provide extensive continuing education options with each column. The purpose is to showcase peer-reviewed research, quality improvement projects, and clinical features focusing on foot care. The Foot Focus section will appear in every issue of the JWOCN, offering much needed continuing education related to foot and nail care. I look forward to working with you, as together we continue to shine light on and grow this very important area of specialty practice.

I hope you share in my vision to offer informative, practical, and relevant articles. I enthusiastically invite you to suggest topics and submit foot-focused papers to the Journal. A few of my thoughts for features include the following: Have you implemented a foot care program within your setting? What skills did you acquire as you started your own business? What teaching tools have you found useful with your patients? What are your continuing education needs? Have you conducted a quality improvement project or research study in the area of foot care? Do you have an idea for a best practice, for example, how best to debride a dystrophic toenail? Help us shine light on the intricacies of this service provided to seniors, veterans, developmentally disabled, homeless individuals, those with chronic illnesses, and other unique populations and care settings. I would enjoy hearing your thoughts, experiences, and educational needs and look forward to working with you to submit and publish your work in my new role as Foot and Nail Care Section Editor.

This article was originally published in the Journal of Wound, Ostomy and Continence Nursing (JWOCN). Beuscher, T. L. (2019). Commentary. Journal of Wound, Ostomy and Continence Nursing, 46(3), 246-247. doi:10.1097/won.0000000000000526