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Theses and Graduate Projects
4-29-2016 Essential nursing care for the sole Teresa A. Miller Augsburg College
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Essential Nursing Care for the Sole
Teresa A. Miller
Submitted in partial fulfillment of
the requirement for the degree of
Doctor of Nursing Practice
AUGSBURG COLLEGE MINNEAPOLIS, MINNESOTA
APRIL 2016 Augsbu¡g Coltggg I)epartment of Nursing I)octor of Nursing Practice Program Scholarly Project Approval Form
This is to certify that Teresa Miller has successfully defended her Graduate Project entitled "Essential Nursing Care for the Sole" and fulfilled the requirements for the Doctor of Nursing Practice degree.
Date of Oral defense April 29,2016.
Committee member signatures:
Advisor: V*ghn rlrcrhtt tñP fuJ Date
Reader 1: <¡-M Dut. 1-ùr, z-f; àc, X*2",,** So-,u-€qi\,- À¡rÞ T I 16,
i¡'1 .t tt.r tJ Reader 2 {- tÅ. li';Åt-i l'^i Date /þ ESSENTIAL NURSING CARE FOR THE SOLE lll
Presentations
January, ll,2016 Sigma Theta Tau International, Kappa Mu, Professional lnterconnectedness Rochester, Minnesota with live video streaming from'Winona and Rochester, Minnesota to Chicago, Illinois
Publications
Essential Connections: Holistic Nursing Sole Care Submitted December 27, 2015 AHNA Beginnings, A Publication of the American Holistic Nurses Association Greensboro, North Carolina ESSENTIAL NURSING CARE FOR THE SOLE IV
Dedication
This work is dedicated toLiz Miller, mother, artist, historian, author, inspiration. The path, not always visible, brings us closer to who we truly are meant to be than who we believe of ourselves. Thank you for sharing the journey. ESSENTIAL NURSING CARE FOR THE SOLE V
Acknowledgements
I wish to thank everyone who has contributed to the culmination of this final project of years of work as a doctoral nursing practice scholar. This endeavor was in pursuit of learning and exploring interconnections between transcultural health and essential foot health correlating to the health of nations.
To Drs. Kris McHale and Joyce Miller, for your invaluable encouragement, support, and mentoring onto a path unseen throughout this journey of forgotten ways assembled anew.
To nursing instructors Drs. Katherine Baumgartner, Deborah Schuhmacher, and Cheryl Leuning, vital to my integration of praxis and wisdom into this doctoral education experience, and especially to Ruth Enestvedt, thank you for your unwavering inspiration.
To Nurse Pochardt, thank you for listening to the experience of the journey, providing valuable insight, perspective, and feedback as a respected colleague.
And to Dr. Joyce Perkins, who inspired finding my path in this learning track to a new world vision and interconnectedness of nursing to the universe.
I thank all of you for these gifts of learning and growing as a nurse, and as a person free in the universe of life. ESSENTIAL NURSING CARE FOR THE SOLE VI
Abstract
This paper illuminates the transformational journey experienced while exploring nursing practice involvement in essential holistic foot care as a Doctor of Nursing -
Transcultural Nursing (DNP-TCN) practice project. The underlying theoretical framework is based on the relational caring complexity theory by Marilyn A. Ray and
Marian C. Turkel, depicting model complexity concepts essential to holistic health and wellness nursing foot cares. As an advanced practice nurse, this practice shift is an assertion of health and wellness essentials in the model of holistic nursing, as foot health is tied to the health of the physical body and spiritual soul of the living.
Individual foot care propels complex choices arising from intricately interconnected patterns forming the foundation of our lives as our feet transport us from one moment and one experience to the next. This final practice project aspires to convey the significance of essential holistic nursing foot care, within the culture of nursing, in facilitating a healthy, multidimensional life of an individual. Our feet form the foundation of what transport us from one experience, one paradigm, to the next.
'When we lose any fragment of meaning our feet provide, this influences and confounds every facet of our lives. As aspects of the relational caring complexity theory of Ray and Turkel, outcomes of this journey go beyond basic holistic nursing foot care, shaping the character of this nurse's transition from DNP student into participatory practitioner and novice author.
Keywords.' foot care, holistic nursing, essential foot care ESSENTIAL NURSING CARE FOR THE SOLE vll
TABLE OF CONTENTS
PRESENTATIONS, PUBLICATIONS . DEDICATION...... ACKNOV/LEDGEMENTS ..... 48STR4CT...... LIST OF FIGURES LIST OF TABLES....
CHAPTER ONE: INTRODUCTION Introduction...... l Project Background...... 1 Practice Project Context Occurrence .1 Project Purpose .Ja Population Benefited.. .4 Project Significance ...... 6 Importance to Society .6 Contributions to Nursing Knowledge and Practice .. Transcultural Leadership Practice Advances ...... Nursing Theoretical Foundation ...... Nursing Theoretical Framework and Concepts Guiding Theoretical Concepts ...
CHAPTER TWO: REVIEV/ OF RELEVANT LITERATURE Introduction...... 18 Literature Support... .20 Major Concepts. .20 Holistic Nursing Practice .21 Foot Health Beliefs .22 Foot Care Relationships & Practices ...... 23 Foot Health Pattems. .30 Theoretical Concept Connections .... .31
CHAPTER THREE: ESSENTIAL NURSING CARE FOR THE SOLE Introduction...... 34 Practice Model/Project Description ...... 34 Project Description ..34 Project Process ..35 Project Implementation...... 38 Theoretical Framework...... 40 Application of Theory to Project ..... 40 Practice Project Conceptual Model.. 4T How Project Advances Nursing Practice 44 ESSENTIAL NURSING CARE FOR THE SOLE vlll
CHAPTER FOUR: PRACTICE PROJECT EVALUATION AND REFLECTION Introduction...... 48 Evaluation of Final Practice Project .48 Project Outcomes .50 Translation of Evidence into Practice .50 Reflective Learning and New Insights .51 Project View and Vision Changes ...... 54
CHAPTER FIVE: CONCLUSIONS, IMPLICATIONS, FUTURE PLANS Introduction...... Project Next Steps, New Considerations... Advanced Nursing Findings Meanings to Practice Project Impact
REFERENCES 59
APPENDICES: Appendix A. Grid/Matrix for Summ anzing Literature Review ..... 16 Appendix B. Nursing Care for the Sole article ...... 87 Appendix C. Consent to Participate in a Pilot Research Study...... 99 Appendix D. Basic Nursing Foot Assessment Too1...... 103 Appendix E. Final Practice Project Presentation ...... 108 ESSENTIAL NURSING CARE FOR THE SOLE lx
LIST OF FIGURES: Figure 1: The Essential Holistic Nursing Foot Care model ..73 Figure 2: Nursing and Foot Care poster...... 74 Figure 3: Complexity of Foot Care Culture poster ..75 ESSENTIAL NURSING CARE FOR THE SOLE x
LIST OF TABLES: Table 1: Foot Health Condition Risk... ESSENTIAL NURSING CARE FOR THE SOLE 1
CHAPTER ONE: INTRODUCTION
Nursing's awareness and involvement on providing holistic foot care is essential. It is within the context of this Doctor of Nursing Practice (DNP) -
Transcultural Nursing (TCN) practice project and the transformational journey of this advanced practice holistic nurse to explore foot care within the practice culture of nursing that illuminates a variety of advanced holistic nursing explorations, experiences, and changes. Chapter one will describe the project background, significance and theoretical framework of this DNP final practice project. The original personal practice exposures and the familial unhealthy foot condition experiences embody the broader evolution of this DNP practice project, which started from a methodical evidence-based practice (EBP) investigation and led to the development of a nursing practice model and the enrichment of self-reflection techniques. This was an exceptional journey of lessons learned regarding foot cares.
Entitled as sole care, this course of nursing care interconnectedness is intimately affected by the spirit of our souls to the health of our feet. Significant facets of this nurse's awareness and involvement in essential holistic foot care are highlighted by defîning the importance of professional practice awareness, the evolution and impact of current nursing practice on world health, and an article submission to a national nursing publication as the culmination of this final practice project.
Project Background
Practice Project Context Occurrence
This project began during self-reflection as an advanced practice registered nurse (APRN) medical-surgical (med/surg) nurse, contemplating a variety of holistic ESSENTTAL NURSING CARE FOR THE SOLE 2 foot care aspects from multiple perspectives as a professional bedside nurse, family member, and doctoral practice nursing student. My initial professional nursing practice did not include foot care; specifically nail cutting which I understood throughout my nursing career as podiatrist managed. My preliminary inspiration occurred during a master's nursing course listening to a classmate's presentation on nursing foot care certification, and my subsequent attendance in a Certified Foot Care
Nurse (CFCN) course, followed by certification through the Wound, Ostomy, and
C ontinence Nursing Certificati on B oard (Vi O CNCB).
During the CFCN course, Beuscher (2012) presented content on nursing licensure practice allowed and often expected by state health boards. This responsibility through the Nurse Practice Act, to provide essential foot care includes cutting healthy toenails, and responsibility of referral to a certified foot care nurse or podiatrist for foot care issues beyond their skill set. Beuscher's (2012) CFCN program content established the historical trajectory of nursing away from foot care
with medicalizationand the advent of podiatry medical specialization in the early
1960's. It is only recently, with an ever increasing void in foot health needs, that
nursing is called back to essential foot care, particularly with the nursing focus of
holistic health and wellbeing.
In the course of this personal and professional transformation, my mother
stayed with me pre- and post-operatively during a total knee replacement surgery.
The night before surgery, she refused to go bed or to explain why' After much
encouragement and reassurance that I would help her with her concerns, she removed
her shoes and socks. I was shocked at the condition of her feet as the skin on her toes ESSENTIAL NURSING CARE FOR THE SOLE J and feet were covered with large patches of flaking skin. Her toenails, in a similar astonishing condition, were up to 2 inches long, thick, yellow, and curled. She stated she did not want to go to surgery with her feet looking as they did, and asked if I was able to clean them up. During the 90 minutes of foot care, I suggested she see a podiatrist or ask for medication from her primary care provider to rid the fungus. She emphatically stated she did not want to see anyone but me about the condition of her feet, nor did she want to take any additional pills. Although she has medical coverage for podiatry and primary care foot concerns, I continue to be the only professional she will allow to provide her with foot care years later. As a critical event, this experience became the inspiration for my objective to integrate holistic foot care into my own nursing practice. This profound reflection on current nursing foot cares was my labyrinth-like journey into personal transformation and my final DNP practice project.
Practice Project Purpose
The purpose of this DNP/TCN final practice project is to investigate and disseminate evidence-based best practice on holistic nursing foot care culture and practice. Dissemination is planned as a publication in a current peer-reviewed nursing publication. Emergent questions from DNP/TCN course work formulated my initial project direction beginning with a creative expression Haiku poem: "Global life equalization is, transforming opulent institutions into grassroots innovations, and the
sharing of knowledge, for all to envision", (Miller,2014) and evolved reflectively
from a personal foot care related experience between myself and my mother, into
DNP practice project questions: ESSENTIAL NURSING CARE FOR THE SOLE 4
How much did her foot health impact her life, independence, and
mobility? What must her soul, her spirit, be experiencing? What
could I do to alleviate her distress? What could I learn from this
experience? How many people share in this personal indignity? What
impact did this have on personal health and well-being? But the finer
insight of my nursing rituals was discovering what I needed to change
and what I might contribute to the realm of nursing to include the foot
in basic holistic nursing (Millea 2015,pp 2 - 3).
Learning about foot care as an APRN, carries the responsibility to share newly acquired awareness and practice skills with colleagues (Cumbie, Conley, & Burman,
2004). Within this responsibility exploring ways to divulge these pieces of information in an ethically professional manner carries additional facets of ethical standards (Saver, 2006). The purpose of this practice project is to share the nursing practice implications and recommendations regarding foot care learned throughout this DNP practice transformation.
Population Benefited
Essential holistic nursing foot care is vital in what doing nursing can and should do in role transforming global health which akeady burdened with. World health care needs are defined by V/orld Health Organization (V/HO) as "social determinants of health (SDH)" (WHO, 2016) and as the population increases, so do their needs. This process further deepens the complexity of foot cares and foot related morbidity as diminished resources dwindle further, intensifying the morbidity and mortality of millions around the globe. This complex human dilemma increases ESSENTTAL NURSING CARE FOR THE SOLE 5 the need for nursing awareness and involvement of transcultural foot health needs, where transcultural is defined as the ability to grasp specific cultural patterns, beliefs, and ideals important to the health and wellbeing of individuals from their lived experiences and practices (Doody & Doody, 20t2; Karabudak, Tas, & Basbakkal,
2013;Rajan, 1995).
Nursing, a nurturing professional practice, along with physicians, a medicalized professional practice continue to evolve their roles in the standard models of professional practice foot care. Once considered a fundamental nursing based practice, current professional EBP nursing foot care is sporadically practiced around the world (Abbas & Archibald,2007; Chikkaveerappa, Smout, Scurr, &
Benbow, 2014; Edmonds, 2006; Popoola, Jenkins & Griffin, 2005; Sheridan, 2012).
As a vital aspect of life, foot health impacts a signiflrcant amount of the human condition but is missing from much of nursing culture and literature (Popoola,
Jenkins & Griffin, 2005.
Essential nursing foot care is a fundamental concept of basic healthcare, affecting all populous, in all cultures. This culturally sensitive aspect of primary care includes special ethnic practices (Abu-Qamar,2012; Lovering, 2012). Many chronic diseases and disorders of the human body are apparent and affect lower legs and feet before the rest of the body. These maladies may range from malformations in rheumatoid arthritis first appearing as foot pain (Firth & Siddle, 2009; Williams,
Graham, 2012), to neurologic changes of sensation going unnoticed until causing injuries from foreign body incursion causing devastating wounds leading to amputation and death in diabetics (Soyupek, Ceceli, Suslu, & Yorgancioglu, 2007),to ESSENTIAL NURSING CARE FOR THE SOLE 6 a multitude of arterial and venous circulation conditions (Chikkaveerappa, Smout,
Scurr, & Benbow,2014).
Project Significance
Importance to Society
This project shares vital aspects of nursing care of the human condition about feet and imparts incalculable benefits of health and wellness. These issues, sporadically discussed within the context of nursing culture and literature, demonstrate indiscriminate EBP of nursing foot praxis. The holistic nature of this project, as a fundamental nursing practice, heightens the call for nursing involvement and global awareness of the infrequent practice of these transcultural foot health needs. Nursing knowledge and the inclusion of essential foot care are vital to global transformations in health and wellness. As the population of the world increases, the complexity of foot related care escalates morbidity and mortality outcomes which impact millions as resources diminish (Seyyedrasooli, Parvan, Valizadeh, Rahmani,
Zare, &.IzadLk, 2015), increasing the need for nursing awareness and involvement for transcultural foot-related health concerns. Once considered fundamental nursing practice (Hunt, 2013; Simko, 1967), current EBP of nursing foot care is arbitrary, and a vital aspect of life imparting so much of the human condition (Abbas & Archibald,
2007; Chikkaveerappa, Smout, Scurr, & Benbow,2014; Edmonds, 2006; Popoola,
Jenkins & Griffin, 2005: Sheridan, 2012).
Nursing praxis, following a holistic model, includes wellness attributes of body, mind, and spirit (Cumbie, Conley & Burman,2004). It is important to incorporate wellness aspects from all of these elements when examining patient care ESSENTTAL NURSING CARE FOR THE SOLE 7 needs. Leaving out one facet as important as feet may impair the well-being of any of the other. Through an extensive Cumulative Index to Nursing and Allied Health
Literature (CINAHL) article search, yielding 2,441articles on foot care, devastating statistical evidence of epidemic proportion exists for over 350 million diabetics.
Seyyedrasooli, Parvan,Yalizadeh, Rahmani, Zarc, &Ízadi (2015) underscore that no country is untouched by diabetes foot health related morbidity or mortality. A nurse- managed multi-disciplinary clinic in Kansas (Peterson & Virden, 2013), developed a comprehensive foot examination tool for assessment and intervention. In the expanded 2008 chronic disease (CD) Americans with Disabilities Act (ADA) report of healthcare burden and improvement CD quality of life (QOL) for complextype2 diabetic foot problems, millions are identified as underserved, suffering, and dying, while the WHO estimates yearly monetary health care costs of billions of United
States dollars on incapacitating foot health.
The professional nursing practice model of the 1990's, no longer included foot care as a practice expectation as it did in the 1960's (Hunt, 2013; Simko,1967), with nail care included as part of holistic patient comfort cares. This evolving practice has shifted from nursing to podiatry and currently back to nursing, with uninformed fears of nurses extending outside the nursing scope of practice
(Buchanan,2013).
Along this journey, during a foot care certification course, I learned about foot care falling under the legal practice model of nursing licensure. As a course participant, I was educated that sharp debridement with a blade is the only highlighted
activity outside the legal realm of nursing foot care. Additional course instruction ESSENTIAL NURSING CARE FOR THE SOLE 8 included nurse allowed healthy nail cutting and referrals for patient or client to a certified foot care nurse or podiatrist for unhealthy foot care concerns.
Before the 20th century, onychomycosis was arare nail fungal infection outside of Northern Australia, Southeast Asia,'West Africa, and Indonesia. With population mobility and international travel to West Africa, Indonesia, Northern
Australia, and Southeast Asia, combined with the wearing of occlusive foot attire,
onychomycosis is now estimated to occur in greater than30Yo of the world's population, and up to 50o/o for those over the age of 70 (Thomas, Jacobson,
Narkowicz, Peterson, Burnet, & Sharpe, 2010). Although often thought of as
cosmetic or even worse completely undetected through omission or overlook of foot health, onychomycosis frequently begins with tinea pedis followed by fungal
infection of the nails and feet. Fungi and yeasts are difficult to eradicate due to
organism cell structure while dermatophyte affinity for keratin with low medication permeability associated with low lipid level content of nail keratin and slow nail re-
growth of up to six months necessitate extended drug therapy. As nails become thick,
they are difficult to trim (Thomas, Jacobson, Narkowicz, Peterson, Burnet, & Sharpe,
2010), especially for anyone unable to reach their feet.
Drug interactions are concerning when trying to find the best practice drug
therapy, in particular for the elderly and others with chronic co-morbid conditions,
especially diabetics. Topical treatment, although a minimal risk for these
interactions, is a daily regime difficult, if not impossible to maintain for sufferers
(Bending,2002). ESSENTIAL NURSING CARE FOR THE SOLE 9
Somewhere along the trajectory of nursing versus medicalization, nurses have stepped back from foot care and only recently been requested to return to essential foot care, in particular with a focus on holistic health and wellness. [n Peterson &
Virden (2013), development of a comprehensive yearly foot assessment and intervention tool was trialed in a Kansas nurse-managed multi-disciplinary clinic.
The effort to improve chronic illness care and QOL while decreasing healthcare burden was outlined in a 2008 ADA report on complex type 2 diabetic foot problems.
Caring for millions of underserved, dying and suffering individuals cost billions of dollars yearly in the United States. In England, the Department of Health has nurses include essential foot care in their nursing practice (Howell, 2004).
Foot care faces challenges within the medical field of podiatry. A relatively new medical specialty formed in 1959 in Philadelphia, Pennsylvania occurred when the financial category of medical reimbursement became authorized within the
American medicalization system of Medicare (Social Security Act, Title XVII)
(Helfand, 2012; Helfand, 2013). Two American physicians observed the popularity of the specialty in England and touted it as an important facet of the overall health of the elderly. Official state licensing regulation occurred January 1, 1968. Reversing reimbursement of many aspects of foot care was written into Medicare rulings in
1967 for foot care, defined as routine. In 1984, toenail fungus, onychomycosis, was eliminated from podiatry-related Medicare reimbursement by classification as routine care (Helfand,2012).
One of our greatest global chronic health risks, diabetes, has reached epidemic levels, especially among indigenous peoples (Boulton, Vilekyte, Ragnarsan-Tennvall, ESSENTIAL NURSING CARE FOR THE SOLE 10
& Apelqvist, 2005). As a metabolism disorder, diabetes often requires complex foot
cares. When faced with non-healing diabetic wounds and foot sores, diabetics often
end up with amputations and related death. "Approximately half the persons receiving a diabetes-related amputation will not be alive in 5 years" (Armstrong,
Wrobel, & Robbins , 2007 , p. 286). This tragedy affects the quality of life of millions
of dying and suffering citizens, according to a 2008 ADA report, costing billions of
dollars yearly (Moulton, 2013).
In other chronic conditions, such as rheumatoid arthritis (RA), V/illiams &
Graham (2012) assert foot difficulties such as pain, the first symptom of RA, are
often ignored by primary care providers. In another study, patient complaints of foot related problems were often disregarded when reported to their primary care physicians (Williams, 2012), highlighting the importance of nursing involvement and
awareness. The impact of ignoring foot-related concerns speaks to the assessment
abilities of other caregivers regarding foot health and how indispensable nursing foot
care awareness is in this area.
The literature review also reveals an inadequate and inconsistent nursing
standard of foot health, deficient in reliable EBP nursing assessment tools (Stolt,
Suhonen, Puukka, Viitanen, Voutilainen, & Leino-Kilpi, 2013). The effect is a world
shortfall of population-based nursing foot care practice and devastating levels of foot related morbidity and mortality (Annersten Gershater, Pilhammar, & Alm Roijer
(2013). A qualitative analysis of foot ulcer prevention in diabetic in-home nursing patients study by Bakker, Apelqvist & Schaper (2012) demonstrates practical ESSENTIAL NURSING CARE FOR THE SOLE 11 guidelines on healthy and non-healthy foot assessments with recommendations for education, footwear, management, and prevention of the diabetic foot.
Contributions to Nursing Knowledge and Practice
Knowledge sharing of this practice project transpired with a variety of informal nursing course presentations, informal presentation feedback requests, and a formal educational presentation to members of a local Sigma Theta Tau International
(STTI), Kappa Mu chapter. Kappa Mu education officers declined the offer of nursing continuing education units (CEU) and formalized evaluation. The main focal point of this DNP practice project, a nursing EBP educational article, was submitted for publication to Beginnings, an international nursing magazine published through the American Holistic Nursing Association. Although not published in the month offered for, the editor received and accepted a request for future issue publication. As a first time submission by this author, this experience is encouraging for repeated
subject submissions.
The literature search identified inadequate and inconsistent holistic based nursing practice on foot care standards. The resulting world deficits of population- based foot care demonstrate devastating levels of foot related morbidity and mortality. Examination of current nursing practice reveals a deficiency in the cultural
consciousness of relationships between foot health and wellness. A behavior
assessment tool on foot care, developed by Senussi, Lincoln, Jeffcoate, & Thomas
(2011) for nurses in the United Kingdom, denotes a devastating impact on world health and wellbeing. In ameta-analysis study of elder nursing foot cares, Stolt,
Suhonen, Voutilainen, and Leino-Kilpi (2010), focused on nursing foot care role ESSENTIAL NURSING CARE FOR THE SOLE I2 responsibility, nursing practices demonstrating theoretical knowledge, and age-linked functional ability changes categorized into four general foot health problem areas: pain, skin, foot structure, and nails. This study showed nurses inability to demonstrate functional foot care skills or understand role responsibility in providing foot care. Recommendations included fuither research on elder foot care to show specific gaps in nursing practice and additional development of a nursing specific foot health evaluation tool.
lnTanzania, Abbas, Lutale, Bakker, Baker, and Archibald(2011) studied foot health issues in4787 patients from 14 districts to change the use of finite resources and reduce diabetic amputations foot complications in a train-the-trainer project of prevention education for doctor and nurse teams. Study outcomes one-year post project showed an increase in registered patients (11,583 - I4,716), a high-risk foot increase from 37 to 38%o, foot ulcers from 1 I to l4Yo, and lower limb amputations reduced from 9 to 6.50/o, with deaths rising from 4 to 4.7Yo. Physicians trained by trainers increased from 69 to 125, nurses trained expanded from 147 to 176, and patient educational sessions increased from163 to 563.
Illumination of current nursing practice culture is clarified in Table 1
(Beuscher, 2012) through avariety of nursing EBP resources, showing numerous conditions placing people at greatest potential risk for foot and nail care morbidity and mortality. As an essential aspect of the human condition, the foot is not omitted from the practice of holistic nursing. Potential risk factors, such as the brief listing of
Table I include impairments and alterations within nursing (Beuscher, 2012). ESSENTTAL NURSING CARE FOR THE SOLE 13
Inclusion of the foot as a focus on the health throughout the life cycle of the individual is caring holistically.
Table 1
Foot health condition risk
Condition Potential Risk Factor
Natural Aging Activity tolerance changes Diabetes Acute/chronic pain Rheumatoid Arthritis Alterations in peripheral neural function Raynaud's Disease Alterations in physical abilities Hansen's Disease Altered foot size and/or structure Coumadin Therapy Decreased foot pad tissue Alterations in selÊcare abilities Decreased vessel elasticity Acute loss of self-foot care abilities Disturbed sensory perception Pregnancy, injury, sickness Disturbed thought processes Hair and sebaceous secretion losses Impaired comfort Impaired individual resilience Impaired skin/tissue integrity Impaired social integration lneffective bathing/hygiene self-care Ineffective Health Maintenance Insulin resistance Loneliness Reduced lung oxygenation Risk for infection Self-care abilities Sensory perception alterations Social Isolation Undiagnosed pain factors Note. Adapted from Beuscher, T. (2012), Foot and nail care education for nurses, unpublished University of Wisconsin-Eau Claire continuing education/UW-Extension presentation.
Transcultural Leadership Practice Advances
Within the culture of nursing relationships between healthy feet, daily life, and the impact it poses on overall population health and wellbeing, searched EBP resources demonstrate a scarcity of awareness. In a Medline & CINAHL meta- analysis of 35 works published between 1980 - 2008 on nursing a\Mareness and a ESSENTIAL NURSING CARE FOR THE SOLE 14 practice model for elder foot cares Stolt, Suhonen, Voutilainen, and Leino-Kilpi,
(2010) observed that although nurses had good theoretical knowledge of foot care, they lacked functional foot care skills and role responsibility in providing those cares.
Nursing research is recommended to show exact gaps in nursing practice and for the development of a nursing foot health evaluation tool. In exploring ways of urging transformation in nurse involvement and awareness, Mertens (2009) recommends diverse community participation with cultural diversity and power arrangements to
address discriminatory and oppressive practices, as well as conversations between what the researchers see as the focus as compared with what the community
identifies.
Learning and incorporatingtraditional health practices into modern health
care belief models and current practices are like hiking to the top of Custer State Park
Harney Peak Mountain for the first time. One must understand the mental and physical complex demands of the journey, and dedicate oneself to the voyage
completion. Similarly, an advanced practice nurse must choose to make a difference
in the health of underserved Native Americans with poor clinical outcomes. APRN's
roles include understanding indigenous population complexity of health care and
dedication to working in collaboration with Native American people to find solutions
that they can incorporate into practice.
Essential foot care affects all populous, in all cultures. Nursing foot care is an
aspect of basic human care. The impact of complex health issues on Native
American's, including cultural, non-medical traditional practices may or may not
affect current health and wellness. This obstacle to navigation often distracts or ESSENTIAL NURSING CARE FOR THE SOLE l5 discourages use of healthy alternatives to these multifaceted issues. The role of an advanced practice nurse is to investigate and decide which of the available paths to take. One manner of accomplishment is through exploration of a variety of beliefs and practices of the Native American tribes. By co-determining which beliefs, practices, patterns, and relationships adversely affect health and which improve it, patients alter practices for continued wellness as a complex challenge all its own.
The invaluable joys and insights in finding individual solutions for the advanced practice nurse result from exploring possibilities and experiencing the journey.
Nursing Theoretical Foundation
Nursing Theoretical Framework and Concepts
The framework of this project is based on care complexity exemplified by Ray and Turkel (2014), of the nursing practice of combining and molding complex theories from other professions into nursing guiding frameworks and is applicable to the nursing praxis of today with a primary nursing foot care practice grounded in holistic nursing (Ray, 2015). Nursing theory guides my practice and definitive transformation as I embrace caring traditions (Lachman 2012) of holistic living and nursing practice (Ray, 2015) that includes safe patient care (Toth, 2011). The symmetry within complex systems of health and wellness (Ray & Turkel, 2012;
Turkel & Ray, 2001), arc reaLized through the utllization of basic medical-surgical nursing (Zimmerman,2005). Layered structures of health care relationships, caring, and health care expenditures provide a comprehensive interpretation of current essential foot care needs (Ray, 20151' Ray & Turkel, 20011' Ray & Turkel, 2012;
Turkel & Ray,2001). ESSENTIAL NURSING CARE FOR THE SOLE 16
The concept of essential nursing foot care embodies the humble process of caring. The culture surrounding these acts is full of complex, often unspoken rules inside diverse care provision communities. From a nursing theoretical perspective, this complexity of caring is best described by nursing theorists Ray & Turkel (2012), in the formulation of nursing practice standards while working within the economic realities of providing patient care. lncluded within this complexity Turkel & Ray
(2001) enumerate practice contradictions between nursing and medical practice resulting in a lack of nursing awareness in areas, such as essential foot care. As a complex health issue, today's foot care is manageable only through a care complexity lens (Cooper & Geyer,2009). As within managed care, cost containment, practice efficiency, management accountability and practice pressures, nurses are strongly encouraged to meet economic circumstances, organizational intricacies, ever- increasing medicalization, and patient expectations by researching, accepting, and affirming their ever-changing role in the world.
Guiding Theoretical Concepts
Core concepts of essential nursing foot care include holistic nursing foot care,
foot health patterns, foot care beliefs, foot care relationships, foot health practices. In maintaining a stable existence, holistic foot care management includes aspects of
economics, self-care, education, and prevention (Pattillo,2004). For purposes of this project, holistic nursing is deflrned as direct nursing care while considering the psychological, spiritual, cultural, and physical needs of the individual (Popoola,
Jenkins & Griffin, 2005). ESSENTIAL NURSING CARE FOR THE SOLE t7
Chapter One introduces this DNP project background investigation, significance, transcultural leadership practice advances, and nursing theory foundation. Necessary elements of a healthy existence related to one's feet are discussed as an essential nursing foot care model guides the reader through the complexities of health and wellness while depicting the holistic nursing role. Patterns of health and wellness emerge through concept understanding of foot health beliefs, practices, and relationships guided by a holistic nursing foot care practice. This chapter introduces the practice project to the reader, highlighting the importance and lack of essential holistic foot care to people around the globe. In chapter two, these areas will be further developed from the literature support into major project concepts and theoretical connections. ESSENTIAL NURSING CARE FOR THE SOLE 18
CHAPTER TWO: REVIEV/ OF RELEVANT LITERATURE
This chapter will review the practice project EBP literature review conducted extensively on essential holistic nursing foot care concepts of foot health beliefs, patterns, practices, and foot care relationships. This review enlightens, guides, and functions as the primary source of information and concept formulation. An initial key word search was implemented, using CINAHL Complete through Augsburg
College. Key words included: foot care, footcare, nursing foot care, and holistic nursing. Articles unavailable through Augsburg College access were either obtained by web searches and use of PubMed, or discarded from review. Article reference lists were also reviewed for relevant EBP not apparent or readily available in key word searches. EBP articles utilized for a practice project course are reviewed in Chapter
2 and listed as Appendix A, Grid/Matrixfor Summarizing Literature Review (Miller,
2015). A literature review ofessential holistic nursing foot care practices uncovered current evolving practices and complex foot health patterns intertwined with health beliefs form the major concepts of this project's practice model.
Early in the literature search, a foot care tool study was noted in the
Nottingham Assessment of Functional Footcare (NAFF). Senussi, Lincoln, Jeffcoate,
& Thomas (2011) observed behavior practices of individuals not altered solely on medical recommendations. According to Felzmann (2012), personal recognition of foot health needs is necessary to create change through patient self-accountability and through relinquishment of the compliance model by health care practitioners.
Behaviors, practices, and patterns of health that negatively impact a person's health related outcomes are dealt with by learning practitioner models of behavior change. ESSENTTAL NURSING CARE FOR THE SOLE T9
Currently medical and nursing practice change model concepts include adherence, compliance, and concordance (Felzmann,2012). The change model of adherence, has negative practice connotations involving aggressive tactics of coercion and ethical dimensions. The compliance change model of behavior is viewed as a practitioner paternalistic manner, directing rather than eliciting patient preferences. This model leaves the practitioner responsible for the patient's behavior, not the patient. The current recommended practice model of concordance, includes the facet of ethical, informed consent. Concordance is also the disclosure of important facts needed by an individual to make appropriate health care decisions. It also includes rationale for health practitioner sharing of relevant known care complexities and the opportunity for valuable personal choices (Felzmann, 2012).
ln Yumang, Hammond, Filteau, & Purden (2009), a qualitative descriptive study of perceptions of risk for foot problems and foot care practices, examined adults with end-stage renal disease on hemodialysis with lower limbs intact, without acute psychological illness. This study done in a large university hospital system explained the risk of foot problems and the performance of foot cares. All participants engaged in foot cares lacked foot risk awareness and judged foot problems only occurring with a diabetes diagnosis. Defining foot problems and confidence in appropriate treatments varied among participants. The authors ascertain dialysis holistic nursing practice offers essential foot care education and assessment opportunities worth exploring, as well as nursing referrals for professional foot care providers. ESSENTIAL NURSING CARE FOR THE SOLE 20
Literature Support
Major Concepts
The project conceptual complexity model (Figure 1,p.73), illustrates the principles of holistic nursing practice goals of health and wellness through the existential interconnectedness of life. The background of the model, a blue sky with brilliantly lighted clouds represents our interconnections with life around us. The colored circles surrounding a person suspended within these clouds represent not only our small individual spheres of interconnections within the universe. In addition to the important personal aspects needed to achieve foot related health and wellness in each of us and the foot health beliefs and relationships leading to practices and pattems of health and wellness guided by holistic nursing foot care.
Problematic diabetic foot care is a significant world health and wellness challenge. Cuaderes, Lamb, Khan, & Lawrence (2009) found a relationship between foot sole skin hardness and pressure exerted during weight-bearing activity, with and without foot sensation, leading to diabetic foot sores in a diabetic foot ulcer convenience sample study of Native Americans, with diabetic type I or II diagnosis, age 18 to 99, no history of diabetic foot ulcer, and able to walk on both feet without assistive devices. Also found, athletic running shoes protect non-deformed at-risk feet, while custom-made shoes protect deformed at-risk feet, and multi-layered socks increase foot protection better than simple, single-layered socks. Straightforward, economical and available for routine foot ulcer assessment, study instruments show specific risk areas of foot ulcer development. ESSENTIAL NURSING CARE FOR THE SOLE 2I
Health, as defined by the WHO (2015) is "a state of complete physical, mental and social well-being; not merely the absence of disease or infirmity" (Who are
Indigenous Peoples section, para. 5). According to Eriksson (1997), "Being healthy means being whole; and ...in its deepest sense an experience of holiness, reverence for one's life, as someone unique"(p. 70). Wellness, defined by McMahon, O'Shea,
Tapsell, & Williams (2014) is both a sense of how a person feels about themselves and their life, as well as how they view their physical attributes and abilities in meeting preferred life outcomes and overall fulfillment. The importance of relationships of health and wellness, so fragile and breakable, are not easily rendered unless relationships of the spirit are based or at least understood to be based on an understanding of the spiritual beliefs of the patient.
Holistic Nursing Practice
Nursing practice from a holistic perspective distinctively defines the living of each person from a universal viewpoint (Slater, 2005; Cowling, 2007). Holistic nursing, as a sacred transformational practice of therapeutic partnering alongside an individual, is a benevolently shared journey of economic self-care, prevention, and learning towards health and wellness (Kinchen,2015).
As a crucial facet of the human condition, essential holistic foot care is exemplified through a biblical parable (Luke 7:36-50, New Century Version) of a woman washing the feet of Jesus. This parable illustrates the underlying support of holistic nursing foot care described theoretically by Margaret Newman's three nursing paradigms (Newman, Sime, & Corcoran-Perry, 1991). Particulate-deterministic is the physical aspect of a homeless woman who revered, washed, and anointed Jesus' feet ESSENTIAL NURSING CARE FOR THE SOLE 22 with scented herbal oils, and was much more of an experience than a mere foot washing. The sharp distinction between this multifaceted unitary-transformative process of a homeless individual offering all she is and all she has to offer compared to a single interactive-integrative offering by the Pharisee, who had invited Jesus into his home but did not see the fuIl extent of Jesus freely sharing himself on the unitary- transformative paradigm level. It is this whole transformative experience a holistic practicing nurse brings to essential foot health. Our lives are much more complicated than a basic foot wash and a meal. Healthy, caring relationships are complex, multifaceted associations described by the relational caring complexity theory of Ray
& Turkel (2012; Turkel & Ray, 2001) which is the framework of the nursing model for this project.
Foot Health Beliefs
For the aim of this caring complexity based project, belief is defined as individual perceived vulnerabilities that guide behavioral responses altering lived experiences (Poss, 2001). Not a predictor of behavior (Perrin, Swerissen & Payne,
2009), according to Hjelm and Beebwa (2013), "Our beliefs are ideas about what something is like, based on the knowledge we have" (p.I2a). 'Witmer & Sweeney (1992) developed a health and wellness theory building model focused opposite to the medical model of illness and dysfunction. As a wheel shaped model, this theory concentrates on wholeness aspects that make us uniquely human: "mind, body, spirit, and community" (rWitmer & Sweeney,1992, p. 1a0).
Spirituality, the model center, is defined as a "life-enhancing belief' (p. 141), of the ESSENTIAL NURSING CARE FOR THE SOLE 23 right to live, a value for life, and self-respect. Beliefs defined as the personal perception of the lived aspects of reality determine actual health and wellness.
An individual who perceives that aparticular life choice will lead to a spiritual goal fulfillment will choose spiritual over physical health and wellness. Unhealthy choices are often self-directed choices led by inappropriate maladaptive beliefs. The key in identifying health and wellness is a holistic nursing foot care assessment
(Kitson, Muntlin-Athlin, & Conroy, 2014; Poss, 2001). Taught as a practical skill, based from nursing theory, assessment skills are vital in nursing recognition of patient health and wellness needs and prioriti es (Zambas,2011). Nurse educators, in the advanced nursing role, are the key link to this paradigm of theory to practice, of questioning sacred practices and building the role identity of a new professional nurse with a holistic perspective of health and wellness crucial to the health of nations.
Foot Care Relationships & Practices
Nursing significance within foot care has evolved over time within a very complex system of life arising from relationships and practices between systems of culture, medicine, and social systems. 'Without connections within our universe, we do not exist. Connections are the foundation of human life, shape our wellness, and link us to all that makes us healthy. Caringrelationships are complex interconnections between persons, nurses, administrators and the organization (Reis,
Collins & Berscheid,2000; Turkel & Ray,2000).
As a time-related behavior, defining features of relationships are complex
actions from one relationship influencing the interactions between others. ESSENTIAL NURSING CARE FOR THE SOLE 24
Interactions are a response to needs and a reaction to actions from relationships (Reis,
Collins, & Berscheid, 2000).
A logical approach to diabetic foot ulceration treatment, Armstrong, Lavery,
& Wunderlich (199S) point out risk factors for essential foot assessment during health examinations by primary care providers, including details of time and performance factors necessary for a health care provider to perform an essential foot exam. An excellent descriptive article of risk factors affecting foot health; this detailed description traces possible causes of foot damage. ln Abbas and Archibald (2007), a feature piece of African diabetic foot care related to morbidity and mortality explains the major underlying causes: lack of monies, relevant education, and infection control issues. Study strengths include recommendations for infection prevention and medical treatment delays related to customary practices and homeopathic treatments.
Abbas and Archibald (2007) clarify major underlying causes of foot care related morbidity and mortality in Afric a, ranging from diabetic infection issues to financial
and educational deficiencies, and recommend cultural, homeopathic, and medical practice changes.
In Japan, Fujiwara, Kishida, Terao, Takahara, Matsuhisa, Funahashi, & ..'
Shimizu (2011), focused a two-year controlled analysis on the historical
epidemiology of diabetic foot complications and related nursing cares, which
revealed essential nursing foot care assessments and interventions. This piece is an
excellent demonstration of how early nursing intervention prevents long-term foot
related morbidity and mortality. ESSENTIAL NURSING CARE FOR THE SOLE 25
As part of a health and wellness system targeted at the foot health of chronic diabetic patients and primary care relationships in England, a basic diabetic foot assessment at every health provider visit, is regarded as an essential piece of this program (Baker & Kenny, 2014). [n another study at a Chicago university, health and wellness considerations of social support and health beließ were found to have a beneficial influence on diabetic self-management (Nundy, Mishra, Hogan, Lee,
Solomon, & Peek, 2014). Nursing cell phone reminder interventions based on belief and self-worth support, improved diabetes related health and wellness outcomes.
This mixed method cohort in a university based health plan, included concepts of denial, foot cares, attitude, knowledge, self-care, and ownership.
Other studies linked the nursing role to foot care, as in a longitudinal prospective study conducted at a Geneva rehabilitation and geriatric university care system. Pataky, Golay, Rieker, Grandjean, Schiesari & Vuagnat (2007), utilized an an at-risk foot education and assessment questionnaire (pre N:236 & post N:172), for an educational provider program targeted at foot complication prevention. Health care provider groups included physicians, nursing, nursing aids, physiotherapists, a psychologist, as well as occupational and speech-language therapists. Study outcomes determined that an operational group of foot care providers is crucial in the prevention of foot problems for at-risk patients. Requests for protective shoes doubled (2I to 41). Increased nursing assessment independence and potentially harmful practices were observed by the trained nursing staff. All groups, except physicians (76%) improved questionnaire responses after the l2-month learning program. Nurses increased from 47 to 85.7%o correct, nursing aids from 29 to 72.2o/o, ESSENTIAL NURSING CARE FOR THE SOLE 26 and the rest of group from 62 to 85.7Yo. The study also showed an overall improved awareness offoot care providers and professional foot care practices, especially in nursing staff. Further studies to evaluate long-term benefits of the program were recommended. In an analysis of diabetic foot care prevention, Foster and Bentley
(2008) summarized nursing's legal responsibility in long-term care. Main strategies for prevention of serious secondary diabetic foot related conditions included guidance on diabetic foot care controls, a two-minute foot assessment/interventional tool, and a monofilament based sensation check.
In another portrayal ofnursing foot care practices, Flood (2009) studied differences between home health and acute care nurses impact on nurse/patient interactions. This descriptive, correlational study (42:N) of 22 acute care and20 home care nurses in a rural Midwestern state health care organization, established that a home health care setting allows for an increased number of nursing interactions, support, education, and outcome management. An extensive literature review revealed how nurses and patients interrelate through a defining framework of the
Interaction Client Health Behavior model. This quality study outlines nursing education deficits from American Diabetes Association standards. Recommendations to change educational outcomes are related to increasing interactions and not to nursing education. Study limitations include lack of tool validity construct and repeating study with a larger sample at an alternative location for observing more nursing interactions.
In a nurse managed, foot health and wellness clinic, Pattillo (2004) discusses the function of a holistic foot care clinic in assisting independent self-care abilities ESSENTIAL NURSING CARE FOR THE SOLE 27 and the benefits of an elder systematic foot care program. This clinic, in a separate converted apartment in an assisted living center, was open 4 hours every other week, with a $10.00 fee for 30 to 45-minute appointments for healthy elders. The study demonstrated that education increased participant awareness in gait strength, balance, and exercise significance. Foot assessment and educational skills were enhanced by the addition of experienced, geriatric nurses, whose practice of foot care was considered within the scope of geriatric nursing as it met comfort and self-sufficiency needs. Study strengths included information sharing that led to both additional staff and patients. Limitations were expressed that the clinic had not started as a revenue generating business.
In rural Idaho, a model to increase annual foot examinations by Beem,
Machala, Holman, Wraalstad, and Bybee (2004) was conducted by observing the number of people participating in a health care prevention program targeted at diabetes care assessments. Strengths include the discussion of the development of a
2-minute diabetes foot examination curiculum physician and nursing training in CD-
ROM format, offering the curriculum in the local college nursing program, offering free foot screening clinics to targeted populations, and conducting public education and outreach.
In another study, Fletcher (2006), discusses the importance of including a basic foot assessment by health care providers every time a patient is seen, especially for at-risk diabetic patients. Emphasis is placed on good self-foot care and prompt wound care deemed vital during patient education sessions in averting ulcers and amputations. This is a good international article that references British guideline ESSENTIAL NURSTNG CARE FOR THE SOLE 28 practice standards and gives standard nursing practice foot and nail patient education recommendations.
In a needs assessment study, Howell and Thirlaway (2004) incorporated a nursing staff education program with an admission foot care plan and referral by integrating foot care into the everyday clinical practice of nurses at a26-bed acute medical unit. The aim was to reduce podiatry referrals and determine nursing ability in meeting patient foot care assessment and interventions needs. This resulted in increased nursing foot care capabilities and increased inter-professional relationships, and timely podiatry expertise utilization. Complex care needs were detected sooner resulting in less wait time for podiatry services and were identified and documented on admission to the hospital, allowing a structured foot care plan.
In a Kansas multi-disciplinary nurse-managed safety-net clinic discussed in a study by Peterson and Virden (2013), a comprehensive foot tool was developed for yearly assessment and interventions. The tool was designed to improve complex type
2 diabetic foot cares in accordance with the ADA chronic illness outcome recommendations of 2008, a report directed at chronic illness care to decrease healthcare burden and improve chronic disease quality of life. The article identified diabetic foot problems in millions of underserved, dying and suffering individuals costing billions of U. S. dollars yearly. Peterson and Virden (2013) utilized this six- month pilot study and a comprehensive diabetic foot health program in a nurse run clinic to reduce diabetic foot emergency hospitalizations. This quality improvement nursing assessment tool was developed from data chart reviews of 184 patients.
Study findings resulted in improveed strategies of proactive chronic foot care needs ESSENTTAL NURSING CARE FOR THE SOLE 29 from utilizing essential health care designs. Nursing foot and nail care tool development included utilization of concurrent interventions such as social and educational assessments. This comprehensive diabetic foot care nursing program reduced diabetic foot care complication hospitalizations and influenced positive, healthy outcomes. Study limitations included tool completion obstacles such as confusing foot assessment documentation, lack of skin or nail related foot care training, and no coverage for needs of uninsured patients.
In a quasi-experimental, feasibility study for patients admitted to an acute care hospital in Hong Kong, Chan, Lee, Leung, Man, Lai, Leung, and Vy'ong (2012) began with a foot and nail care system that was unclear, obscured by medical and podiatry routines, and absent from nursing routines. The study included adding a nursing protocol for foot and toenail cares to shape elder foot health. Authors defined foot health as a basic nursing process, with nursing assessments and interventions as vital aspects in the provision of health care. The nursing protocol was found to be a way to capture basic health care needs and develop foot care relationships. Patient foot health, wellness issues, and improved nursing awareness occurred when this nursing admission protocol was implemented. Additional study strengths included protocol foot health education resulting in increased nursing and patient foot health awareness.
Other results included observation of changes in self-care abilities from the normal aging processes, noted as an important factor in foot self-cares. Limitations of the protocol study found that short lengths of hospital stay limited the long-term effects of improving foot health outcomes (Chan, et al., 2012). ESSENTTAL NURSING CARE FOR THE SOLE 30
Essential to fundamental relationships are relational ethics, as Felzmann
(2012) outlines complex affiliations occurring between humans. Bonds exist in simple to complex interactions, ranging from private moments and traditions to intricate shared experiences (Anderson, 2013). It is the need for caring negotiations framed through collaboration between caregiver and patient. Foot health relationships, a fragile partnership of the human condition, garners many aspects close to the human spirit.
Foot Health Patterns
Personal life processes charactenzedby meaning, pattern, and continuing development, are fraught with chaos, randomness, and quantum physics patterns of matter and energy with observers as co-determinates of events (Newman,I99I;
2002). In these paradoxes between caring, economics, ethical choices, and challenges of organizational practice patterns, importance is often placed on data pattern analysis instead of the unitary character of human life within the universe and affiliation patterns of nurse-patient relationships found in holistic based nursing care (Popoola,
Jenkins, & Griffin, 2005).
From an extensive CINAHL article search, yielding 2,44I articles on foot care, diabetes-related foot health patterns ofdevastating statistical evidence exist in epidemic proportions within the current 366 million diabetics (Seyyedrasooli, Parvan,
Yalizadeh, Rahmani, Zare, &Izadi,2015). No country is unscathed by diabetes- related morbidity or mortality. In this educational outcome study affecting self-cares, soft tissue injuries related to peripheral vascular disease and sensation loss are most ESSENTIAL NURSING CARE FOR THE SOLE 31
often reported as debilitating diabetic foot health pattems by the World Health
Organization (WHO).
Walking the labyrinth, I begin to understand and recognize patterns Newman
(2000; 2002) discusses historically within nursing, from obeying of physician orders,
to the current consequence of comprehensive factors related to the intricacy of
individual wellness. This same complexity discussed by Boreaud (1974), is a genuine
implication of labyrinth walking, not only a useful method of pattern reflection and
recognition, but a transformational journey, in and out of the mind, leaving behind
opinions as you traverse back over old views (Wade, 1998).
In self-organizingpattems of behavior, everything settles into a new routine,
some changes, additions, and deletions, but new patterns nonetheless. Translational
science, the turning ideas and epiphany's into interventions, clarifies principles of
change behavior, concordance, adherence, and compliance (Felzman, 2012).
Concordance, as relational caring ethics of human existence, is a system of relationships where the caregiver must respond to needs with professional caring for the formulation of health patterns into wellness. Adherence and compliance lack respect to these requirements and patients do not take responsibility for self, but let the professionals lead them, so to speak, to their poor outcomes (Felzman,2012).
Theoretical Concept Connections
Everything in the universe is interconnected (Ray & Turkel,2014). This nursing theory of relational caring science within complex systems is centered on dyramic relationships of caring and healing intertwined within holistic nursing ESSENTIAL NURSING CARE FOR THE SOLE 32 practice incorporating ethical, spiritual, and social aspects of individual health and wellness.
Defining a nursing foot care conceptual model to incorporate into current nursing health care models is a demanding journey of devotion, discovery, and imagination, where you must first comprehend, conceive, and develop the conceptual model, while understanding complex nursing relationships needed to develop a change in practice embracing foot care. This project includes a redefining of the current nursing cultural and behavioral model to include practice aberrant to many nurses practice. Nursing is at the core of human dignity and health care of humanity, a basic realm of human healthcare (Beuscher, 2012). Disregarding foot care often results in a variety ofacute and chronic related disorders, diseases, and possible loss of limb and life for some. Without good foot care self-respect is lost, triggering devastating damage to the spiritual facet of health and wellness.
A working conceptual model consists of understanding the advanced nursing theory, history, and development obtained through concept investigation and model development. These are embraced by defining concepts around essential nursing foot care as a basic health care necessity. This critical process is broken down into conceptual ideations of primary human survival factors and distinguished through beliefs, practices, relationships, and patterns. In discerningthat holistic nursing included the foot in the provision of nursing care, nurses can appreciate their role in health and wellness related requirements. Approaching these concepts from a professional nursing position lends creation to the vital missing link in the world today, the indispensable working process of nursing care plan assessments, ESSENTIAL NURSING CARE FOR THE SOLE JJ recommendations, and interventions for our feet. The next chapter delves into the practical aspects of the project from ideation to implementation, while examining how the theoretical framework supports the conceptual model and implications for advanced nursing practice. ESSENTIAL NURSING CARE FOR THE SOLE 34
CHAPTER THREE: ESSENTIAL NURSING CARE FOR THE SOLE
The holistic approach to healthcare management views healing as a lifelong joumey, where prevention and understanding of the social, economic, cultural, psychological, and spiritual aspects of health and illness, in addition to the physical aspects, are key in maintaining a balanced lifestyle (American Holistic Nurses
Association,2015; Berg, Hedelin, Sarvimäki,2005). According to Dossey & Keegan
(2009) healing is about balancing the entire personal process of living, not just about removing disease, but an active human process of being whole, with the possibility of needing to reformulate the meaning of whole based on current circumstances and possible changes (V/endler, 1996).
Nursing is a practice focused at the core of human dignity and health care of humanity. Disregarding foot caÍe can result in a variety of acute and chronic related disorders, diseases, and possible loss of limb and life for some. Without good foot care, we lose self-respect. This DNP project conceptual model includes defining current nursing culture and behavior models as how to incorporate foot care within the model of nursing practice. Developing a conceptual model also includes understanding related nursing theory, its history and development and exploring the process of model development, including basic defining concepts indicating that foot care is a basic health care need.
Practice Model/Proj ect Description
Project Description
The purpose of this DNP practice project is to share my transformational journey of holistic nursing foot care within the practice culture of nursing through ESSENTIAL NURSING CARE FOR THE SOLE 35 publication in a nursing journal. I hope to add my voice to the transforming journey nursing culture is facing, not seeing it as a change in practice, but a change in how we view holistic health and the interconnectedness of our entire existence that is intimately affected by the health of our feet.
Project Process
Prior to starting this DNP program, I became interested in learning more about foot care after a classmate in my master of science nursing clinical nurse specialist presented a project on nursing involvement in foot care. I decided to investigate it more, as many of my medical-surgical patients often asked about foot care in the hospital. It was this ongoing interest in foot cares that led me to a pre-certifïcation nursing foot care course, and achieve nursing foot care certification, CFCN through the WOCNCB. Composition design began with a systematic CINAHL database nursing literature review. A basic nursing foot care article published in a peer- reviewed nursing journal is the project focus. The heart of the article is to get in touch with nursing culture and shift the nurses to visualize a holistic nursing foot care practice through education and awareness. A variety of basic nursing foot care annotated literature reviews, an basic nursing foot assessment tool, and a publication focused article were completed as part of my educational DNP program experiences.
The following items were developed: Basic nursing foot care annotated bibliography
(Miller, 2014), Complementary foot care annotated bibliography (Miller, 2014), How to write a nursing journal article annotated bibliography (Miller, 2014), Basic nursing foot assessment tool (Miller, 2014), and NursingCare for the Sole article, Appendix
B (Miller, 2015). The Basic nursing foot assessment tool, still in the creation stages ESSENTIAL NURSING CARE FOR THE SOLE 36 of development, is not available for public viewing at this time, but will be used for a future EBP foot care project that can be piloted, tested, and revised with nursing and client participants.
As part of this DNP program, immersion experiences embodied many of the transforming joumeys which lead to a change in this nurses professional and personal reflective practices, in addition to wellness practices. The beginning of the program and the first immersion journey included travel to Sylvan Lake, South Dakota, in the
Black Hills. In learning about Native American traditions, we learned of their name for the area around Sylvan Lake as, Okawita Paha, translated to gathering place in
English (Brademeyer,20l5). Part of the time was spent on an all-day reflective focused hike to the top of this magical place, sacred land-healing resources information, spiritual blessings, and a captivating journey into Native American
Culture with Dr. Little Finger, Lakota Elder, and Mr. Broken Nose, Lakota Medicine
Man.
Three of my immersion destinations included Southern England. The first immersion English experience had a focus of transcultural nursing through the eyes of cosmologies, ancient healing practices, and contemporary connotations through a nursing lens of theory research, and practice. Ancient myths, legends, ruins, holy wells, druid healing practices, essence making, earth energies, and dowsing are studied first hand. The second immersion was focused on alternative foot cares, with the third focus on advanced nursing reflective practices useful in educating nurses on essential holistic methods of foot care. ESSENTIAL NURSING CARE FOR THE SOLE 37
An additional immersion occurred as an encounter with an American Old
OrderAmish population in Central Wisconsin. This encounter involved a nursing foot care focus viewed through the complexities of daily life and healthcare. Other observations through the advanced nursing lens included how 16th-century Protestant beliefs shape homeopathic practices where life is based on immediate community, family, work, natural living. Onychomycosis is present here as well, as noted during health and wellness discussions with population-based small groups.
Learning and practicing a variety of transformational, reflective practices were mixed throughout this DNP/TCN practice project, ranging from reflective journaling to the meditative technique of Transcendental Meditation @ (TMO), and labyrinth walking. Reflective journaling during immersion experiences lent insight into self- evaluation of essential holistic nursing foot care relevant to DNP/TCN practice project. As in the Amish immersion, holistic foot care questions came from members of the Amish community that were similar to foot care needs of any other population.
Journaling during the England immersion on alternative nursing foot cares revealed widespread use of herbalistic and reflexology practices.
Learning TM@ was a life altering experience as a research participant, which enabled insight into the role of the participant during a 4 month study entitled: The
Lived Experience of Graduate Nursing Students Practicing the TM@ Technique
(Perkins, 2016). This experience included professional TMO instruction, twice daily meditations, and daily reflective journaling on the practice of TM@ as a graduate nursing student. Included as Appendix C, Consent to participate in a pilot research study, outlines the study details. ESSENTIAL NURSING CARE FOR THE SOLE 38
The reflective practice of labyrinth walking began as a DNP/TCN practice project writing assignment: Labyrinth Walking: A Practice Reflection of a Direct
Experience (Miller, 2015) of exploring a direct reflective experience centered on a project relevant nursing theory. The practice of labyrinth walking, so successfully integrated into methods of personal and professional problem solving, led to my building a small backyard labyrinth. As an ancient practice used by a variety of ancient cultures, labyrinths are still found as relics on remote islands around the world utilized by Native Americans to Russians and Northern Europeans. Labyrinths, still in use, are growing in popularity in current culture and are found in city parks, private lands, hospitals, churches, and prisons (Diaconis, 2010; Harris, 2014; Munro, 2010;
Zucker & Sharma, 2012). Labyrinths continue to be used in our ever evolving quest for health and wellness practices as spiritual-physical beings (Bigard, 2009; Carnes,
2001; Padro,20LI).
Project Implementation
After learning how to write a for a nursing journal and completing an independent study, an outcome was the development of an article entitled: Nursing
Carefor the Sole (Miller, 2015). I began to search for an appropriate nursing publication for a basic informational holistic nursing article that would consider foot care as apart of holistic care. The AHNA, Beginnings magazine was chosen, and contact was made with the editor. After careful review and implementation of article guidelines, the article was reformatted into publication format and submitted to the editor with requested permissions and authorizations. After initial submission, editor confirmation of article review submission acceptance was received. Before the issue ESSENTIAL NURSING CARE FOR THE SOLE 39 publication date, arequest from the editor to maintain the article for publication in future issue was sought, along with notice of editorial choice of other articles for submitted issue. This author sent permission for the maintenance of the article and promised to notify the editor if published elsewhere before their use of the article.
Concurrent with work on article submission, a fellow nurse, during conversation, requested a presentation at a local educational meeting of the STTI,
Kappa Mu chapter on interconnectedness within nursing foot care. A presentation was officially requested by the chapter educational meeting officer. The offer was extended for educational credit with post-test on meeting presentation objectives of the following: impact of nursing in foot health, interconnectedness, and wellness; identification of fundamental elements of Ray and Turkel's theory of RelationalCare
Complexity; description of professional relationships essential to individual healthy feet and wellness; and definition of key terms related to essential foot health and wellness. Educational credits and post-test were declined. The presentation occurred with numerous members Skyping into the meeting through computer cameras and interactive internet programs around the state with one member present via computer from the Chicago, Illinois area. Discussions on the topic were lengthy with questions
asked throughout the presentation. Audience participation included a discussion on how many were interested in holistic nursing foot care and how to meet those needs.
Instructor participants offered how their nursing programs were interested in incorporating foot cares into their programs as well. ESSENTTAL NURSING CARE FOR THE SOLE 40
Theoretical Framework
Application of Theory to Project
Essential holistic nursing foot care is a therapeutic partnering joumey of economic self-care, education, and prevention with a focus on an individual's foot health needs. Optimal health and wellness may be achieved by integrating compassion and healing with a self-care focus utllizing concordance instead of adherence or compliance concepts of partnering as caring with nursing as a sacred practice (Kinchen, 2015).
The Essential Nursing Foot Care Model resulted from exploring the mutual caring complexity theory by Turkel and Ray (2001) of data analysis patterns, expenditures, caring, and affiliation patterns of the nurse-patient relationship and holistic based nursing foot care. Foot health and wellness is very complex
(Gallagher,2012).
For this project, health is defined as meeting the individual social, physical, spiritual, and psychological needs (Lovering, 2012). Holistic nursing is defined as social, spiritual, physical, and psychological consideration of the entire person, integrating Margaret Newman's (2000) theory of health as expanding consciousness within three nursing paradigms of particulate-deterministic, interactive-integrative, and unitary-transformative which shape the praxis of transformational nurses providing holistic foot care.
The holistic approach to healthcare management views healing as a lifelong journey, where prevention and understanding of the social, economic, cultural, psychological, and spiritual aspects of health and illness, in addition to the physical ESSENTIAL NURSING CARE FOR THE SOLE 4T aspects, are key in maintaining a balanced lifestyle (American Holistic Nurses
Association,2015; Berg, Hedelin, Sarvimäki, 2005). According to Dossey and
Keegan (2009), healing is about balancing the entire personal process of living, not just about removing disease, but an active human process of being whole, with the possibility of needing to reformulate the meaning of whole based on current circumstances and possible changes (Wendler, 1996).
Practice Project Conceptual Model
The Essential Holistic Nursing Foot Care conceptual model (Figure 1) was developed for foot health nursing care and health related concerns. These model concepts split into four major foot health and wellness themes: beliefs, pattems, relationships, and practices. As an ancient belief espoused by Socrates, healing rifts within the soul comes before healing wounds of the body. As such, foot care is tied to the souls of every living being, assessing the spiritual nature of foot care needs, a holistic approach to health. (American Holistic Nurses Association, 2015). Foot health beliefs are the underlying thought process an individual has acquired that directs their patterns, relationships, and practices. Do they believe in soaking their feet because "that's what my mother taught me and what I've always done"? Do they believe in seeking out medicalizedpractitioners or do they believe in homeopathic practitioners?
Foot health patterns are response behaviors formed over time through individual experiences related to foot health. Patterns such as healthy or unhealthy, depending upon how well an individual can maintain self-care abilities, often result in physical trauma such as foot ulcers or infected foot ulcers (Dobrina, Tenze, & Palese ESSENTIAL NURSING CARE FOR THE SOLE 42
(2014). Pattern, defined by Reed (2010) is an individual's evolving intellectual and physical expression ofexperiences ofself. Foot care practices consist ofprocesses and abilities an individual utilizes to maintain foot health, influenced by their beliefs.
What and how does one perform practices, such as cleanliness, cutting of toenails, washing or maintaining necessary foot moisturizing?
While advocating the use of the grounded theory, Turkel and Ray (2001) searched for data analysis patterns and found expenditure, caring, and affiliation patterns in their research on the nurse-patient relationship. Further developing their theory of complex cairng, Ray and Turkel (2012) found a balance between expenditures and caring, with an additional pattern of relational complexity. This pattern of relational complexity emerged as nursing continues to find balance ethically and choose among what can and should be done within available, limited, diminishing resources.
In a study by Chan, Lee, Leung, Man, Lai, Leung and Wong (2012) on the effects of a nursing protocol on elder foot health, in an acute care hospital in Hong
Kong, of essential foot and toenail cares for health and wellbeing of older adults was developed. It was noted that foot health of essential foot and nail care as a basic nursing process was missing from their nursing practice, ambiguous within healthcare, and overshadowed by medical lpodiatry practices. In addition, elder adults endure diverse foot and toenail difficulties, ranging from adequate to inadequate foot health, and regarded them as ordinary agingwith nursing avoiding this area of the human health care paradigm. This protocol included foot health education, which increased patient and nursing practice awareness. ESSENTIAL NURSING CARE FOR THE SOLE 43
Foot care relationships are interactions learned and utilized by an individual to maintain their foot health, such as foot care nursing, podiatry, or by family caregivers
(Dobrina, Tenze, & Palese, 2014). Does one seek out additional assistance by formalized practitioners such as a certified foot care nurse to maintain foot health? Is anyone else involved in providing foot cares? In Thornton (2014) and Klebanoff
(2013) holistic nursing recognizes interrelationships of a whole person, including physical, spiritual, cultural, and thought processing dimensions within community interactions. Holistic nursing is a way of being that incorporates the multidimensional aspects of living (Popoola et a1.,2005). Meeting foot care related needs is compounded further when a chronic condition, such as type II diabetes, results in neurologic changes, foot ulcers, and lower limb amputations (Broersma,
2004).
Developing the conceptual model includes a redefining of the current nursing cultural and behavioral model to include feet as a primary focus, not something hidden beneath shoes and socks. Nursing is at the core of human dignity and health care. This essential realm of human healthcare has been relegated to the annals of neglect and disgrace far too long. Core concepts of essential holistic nursing foot care includes the nursing role in foot care, foot health patterns, foot care beliefs, foot care relationships, and caregiver practices. Disregarding foot care can result in a variety of acute and chronic related disorders, diseases, and loss of limb and life for some. V/ithout good foot care, humans lose important aspects of our self-respect
(Hjelm & Beebwa,2013). Defining an essential holistic nursing foot care conceptual model to incorporate into current nursing health care models is a voyage of ESSENTIAL NURSING CARE FOR THE SOLE 44 dedication, exploration, reflection, and imagination. One must first comprehend, conceive, and develop what the conceptual model is while understanding the complex cultural nursing relationships needed to develop a change in practice to embrace foot
care. Application of theory to the conceptual model has been a transformational journey of complexity and a shift of thinking from learning how to perform foot care, to how to shift the culture of nursing to include a holistic pattern of wellness that
starts with the feet and does not omit them from observation. This includes thinking beyond time constraints as a bedside nurse about checking to see if toenails need
cutting, how patient beliefs complicate the process of foot health, checking feet so see
if they are in fact healthy, or to include and encourage referrals, if needed.
Nursing assessments and interventions are a vital aspect in the provision of health care among the populous and needs to include foot health in nursing practice.
An essential nursing foot health protocol for patients is a means of capturing a vital
aspect ofessential health care needs. A transcultural nursing change occurred in
Finland. In a study for a comprehensive nursing foot care assessment tool
implementation, Stolt et al. (2012) found older persons sought help with foot care in
the home for independent related needs. A tool was developed around the compound nature of providing a comprehensive nursing foot care assessment, this study was published in an English evidence-based practice nursing journal.
How Project Advances Nursing Practice
This project recognizes and conveys development of basic standards of practical nursing foot cares within a cate complexity framework needed to develop provider expertise, as recommended in Cooper & Geyer (2009) and Diabetes UK: put ESSENTIAL NURSING CARE FOR THE SOLE 45 feet first (2012). Developing nursing awareness and intentionality of providing essential foot care requires encouragement and recognition of the impact of nursing practice on foot care. Nursing relevance is exemplified through current foot related health suffering. Health and wellbeing, elusive and failing, is discussed by Boulton,
Vileikyte, Ragnarson-Tennvall, & Apelqvist (2005). They describe diabetes-related foot disease facing epidemic numbers of every population in the world.
Advanced practice nurses are situated to provide direction and support where nursing is amiss in this area of the human health care paradigm. Foot health is a basic nursing process. Nursing assessments and interventions are a vital aspect in the provision of health care among the populous, and the need exists to include foot health in nursing practice. Several studies connect the role of nursing in foot care in an advanced practice role. Muirhead, Roberson, and Secrest (2011) stress the importance advance practice nurses play in providing complex health care needs for homeless individuals regarding essential foot assessments and cares.
Etnyre, Zarate-Abbott, Roehrick, and Farmer (2011) discuss the role of the certified foot and nail care nurse to include the education of lower limb amputation, a preventable outcome for most people. These authors also talk about the scope of nursing foot care practice determined by nurse practice acts of individual states, which include skin, nail, musculoskeletal, and foot related sensation assessments, interventions, and education.
According to Tuhiwai Smith (2012) small, neighborhood community stories of positive transformation are the stories needing to be told. Foot care begins with one person, one community, and passes this knowledge onto the next nurse and the ESSENTIAL NURSING CARE FOR THE SOLE 46 next family. Nursing foot and nail care practice requires shared standards among
disciplines such as podiatry, primary care, registered dietician, wound care center,
and social services.
Finding ways to urge nurse involvement, awareness, and to be
transformational, according to Mertens (2009) means diverse community
involvement including cultural diversity, power arrangements, discriminatory and
oppressive practices addressed, with conversations between what focus researchers
see and what the community sees. Advanced practice nursing can make a difference
as seen in the health of underserved such as Native Americans with diabetic foot
cares to be high on the list of poor health outcomes (Cuaderes et a1.,2009). V/ith
diabetes of epidemic proportions among Native Americans, the complexity of
indigenous population health care means dedication at the advanced level is necessary
to finding solutions that a group will practice. Complex health care issues, such as
learning non-medical and traditional health practices, applied across any continuum
of cultural care throughout the advance holistic nursing foot care model.
This chapter described methods of personal reflection and project evaluation,
covering insights, vision changes, learning's, and a look at areas to alter, expand, or
reevaluate in future projects. Disregarding foot care is a serious quandary that faces
millions of people around the world. This project explores the nursing culture and
behavior models, while investigating techniques ofjournal writing. Utilized
throughout the project to add a personal view of foot care back into the model of
nursing praxis, reflexivity judiciously incorporates insight of the human experience of
foot care acumens of the mind, body, and spirit. This use of theory based on wellness ESSENTIAL NURSING CARE FOR THE SOLE 47 and development of the project conceptual model is a crucial implication in the provision of nursing foot care for patients. Chapter three focused on the experiences of this DNP practice project and how it became a transformational journey. Chapter four will expand the reflective processes of the project utilized throughout, highlighting new insights, project appraisal processes, and how the evidence translates into practice. ESSENTIAL NURSING CARE FOR THE SOLE 48
CHAPTER FOUR: PRACTICE PROJECT EVALUATION AND REFLECTION
This DNP practice project is a complex investigation of methods useful in
shifting nursing culture and practice with a focus on learning methods of exploring dissemination to groups of nurses. A look towards the future, a funded EBP pilot project, with measurable goals and outcomes might be set up according to research
standards and practices.
This chapter discusses evaluation and reflection processes of this project which occurred on a personal level, reflective in nature, measurable by professional and personal practice changes. What began with an awe-inspiring moment of personal discovery and problem awareness, evolved into obtaining nursing foot care certification, final DNP practice project choice, and culminating in a nursing foot care awareness article submission to the AHNA with international membership.
Additional verbal feedback on this model was obtained from professional nursing peers during the Sigma Theta Tau Intemational, Kappa Mu presentation.
Evaluation of Final Practice Project
This unique, original DNP final practice project, underscored in Rolfe (2006), incorp orate s conceptual terminolo gy of trustworthy, trans ferability, and conf,rrmability which rely on peer-reviewed, scientific integrated evidence, as presented in the project significance and background. Reliability and validity outcomes, described by Darawsheh (2014), stress use of reflexivity, researcher self- awareness through reflective practices, a tool of research rigor in qualitative work to improve study quality and awareness of personal researcher influences. Reflexivity, a self-awareness practice and valuable empowerment tool of APRN analysis especially ESSENTIAL NURSING CARE FOR THE SOLE 49 for profound or questionable practice relevant implications and inter-connectedness, are a vital piece of this DNP practice project.
Immersions, EBP literature research, project reflections, and outcome analysis are focused reflexivity practices cultivated during this doctorate project direction and completion. Reflective immersion journaling, along with advanced reflexivity practices of TM@ and labyrinth walking brought this APRN unexpected outcome foci such as peace of mind, decreased blood pressure, enhanced sleeping patterns, and other facets of self-awareness previously unfulfilled to the author.
A practice project query highlighted during this reflectivity was: would leaving out reflective practice while exploring EBP essential holistic nursing foot care issues result in similar project outcomes? Immersions developed in-depth reflective, leadership and relationship development skills. Relationship skills are useful in high- stress situations, where quick responses are often necessary due to the nature of travel, with limited resources, such as lack of adequate sleep, high-stress situations, new situations, demanding schedules, and demands from group members, with group members needing individual responses for individual needs. Relationships are avital aspect of human interactions; immersion experiences highlight those needs and demonstrate the importance of relationships in maintaining health and wellness during lived experiences, experiences not available in classroom situations.
Experiences are necessary to fully comprehend deep-seated emotional needs when participating in a group.
Corroborating qualitative and quantitative studies rely on the archetype of truth, which is useful in measuring repeatability of projects when conceptualized ESSENTIAL NURSING CARE FOR THE SOLE 50 through the qualitative lens. Do similar outcomes result from a replicated practice project using similar techniques, the essence of reliability (Golafshani, 2003)? rWithout including as many of the features as possible involved in health and wellness of holistic nursing, outcomes are inaccessible voids of empty data, a DNP practice change project beginning as an epiphany moment is a truth unexplored. The project itself is the needed exploration which first must occur as a self-awareness and deliberate process of change occurring through the lived experiences of the project.
Project Outcomes
The strength of a qualitative type practice project is comparable to intricacies and outcomes of lived experiences. Additional evaluation processes for this project includes journal editor review of an article submission, as outlined in the American
Association of Colleges of Nursing (AACN) (2015) and recommendation for
evaluation components of the project. A request by the journal editor was also made
and granted for editor copy in a possible future AHNA, Beginnings magazine, March
20t6.
Another outcome was the STTI, Kappa Mu chapter foot care educational
meeting presentation: Essential Nursing Carefor the Sole & Professional
Interconnections. Based on discussions and reflective questioning throughout the
presentation, the presentation length was extended to an additional 30 minutes.
Translation of Evidence into Practice
Putting together an article for publication in a nursing publication is a method
of translating the evidence available on the subject through CINAHL. Other evidence
into practice was the nursing foot care consultation requests from nurses who work at ESSENTIAL NURSING CARE FOR THE SOLE 51 the Health Commons, Augsburg College, Minneapolis, Minnesota; the Health Fair at
Bethel Church, in Rochester, Minnesota by the community health BSN class, Foot
Care Program; and use of evidence for a change in this author's own nursing foot care practices, and the variety of integrated changes in reflective practices
Reflective Learning and New Insights
Reflection on the experiences of this practice project is an insight into what to expand on and what to omit. A new insight would be to narrow the practice project intent, skip the broad scope this project took and limit the project to a professional nursing journal article on the need for a holistic nursing perspective on essential foot cares. The extra insight gained from complementary and alternative foot care practices is also an additional direction best suited for a project of its own as these practices include two widely distinct paths: a historical perspective, and current day practices.
The immersion experiences exposed personal relationship dynamics open to modification and enhancement of relationship interactions, such as responses to moments of mental and physical fatigue causing like-minded responses. If a reactionary retort is given during an interaction, this APRN has observed that a like- minded response enflames the message sender; while an honest, thoughtful response informs and defuses the inflammatory emotional state of the initial speaker.
Working on the essential holistic nursing foot care tool brought deeper insight into patient needs and nursing foot care practices (Miller, 2015). Nurses are often unaware of nursing practice importance and their impact on world health. V/ith foot ESSENTIAL NURSING CARE FOR THE SOLE 52 care impacting many health concerns/issues, nursing has a greater role in future practice affecting world health.
New insights added during this practice project experience during the use of self-reflection practices include self-reflection as an on-going skill that must be practiced consistently and mindfully to be useful. Learning T.M.O has enhanced my meditation, reflexivity, and self-transcendence skills immeasurably to where I find them more beneficial as a form of meditation than any of the many other types of meditation I have used in the past (Darawsheh,20l4; Haugan, Hanssen, & Moksnes,
2013). I can reflect on work, handle stressful situations by stepping back and objectively examining what is causing the stress, and make changes to lower the anxiety of involvement. V/hile on a recent immersion, when someone snapped verbally at me, my initial response was to snap back. This made me feel anxious and defensive in the situation. I decided not to snap back the next time someone snapped at me, which I was able to do later that same day, as immersions caffy much anxiety in all of the new situations participants are involved in. Time is limited, and group activities are mandatory, leaving little time to process all the new learning, so tempers are short, and people snap. lnstead of snapping, I responded with an honest answer in a cheerful manner to the snapping demand directed my way. I sensed this surprised the person directing their anxiety my way, as they repeated the snapping demand
again. The snap demand was repeated, with me responding in the same honest, cheerful manner. Only this time, the anxiety I initially felt disappeared and I joined the group without a feeling of anger or anxiety, something that surprised me. A pleasantly unexpected and healthier feeling! ESSENTIAL NURSING CARE FOR THE SOLE 53
The on-going skill of self-reflection assists in focusing on the complexities of maintaining my health and wellbeing, on foot health and how complex it may be for anyone. Patterns of chaos and complexity cause ripples throughout the difficulty of maintaining health and wellbeing as a highly educated advance practice nurse.
Harmony within my life comes from simple patterns of behavior of walking and focusing on a path representative ofphysical care to interpersonal processes and integrative approaches to a unitary perspective.
Learning the practice of labyrinth walking is a transformative, self-healing technique of altering chaotic mental, spiritual, and physical routines into harmonious praxis (Sandor & Froman, 2006). Purpose within praxis and labyrinth walking are required to develop and adjust spiritual proficiency within the context of outside undermining forces (Ugarnza,2002), while focus, a useful method of praxis reflection, is determined by the labyrinth walker outside the labyrinth entrance
(Miller, 2015). Then by the use of refocusing and sifting through alternative problem
solutions of reorganization throughout the labyrinth walk, a pattern of steps may
evolve, leading to a shift in praxis and possibly a shift in spiritual, physical and mental practices, and patterns.
Another change I now reaLize is how important nursing is to the world health
and wellness paradigm. Current worldwide foot related health issues deepen my
outlook and feelings that foot health is not sound without holistic nursing
involvement from the whole perspective of an individual, such as the culture they live
in, the beliefs they have, and the experiences that make up their lives, which is a
complex scenario, as expressed by Ray (2015). I view nursing as an art with nurses ESSENTIAL NURSING CARE FOR THE SOLE 54 able to recognizing astute events, and acting to resolve issues within their power to resolve (Newman, 2002). I view nursing more than a profession or art. I see it as a profound connection where our choices as a group can alter unhealthy pathways into healthy patterns of wellness fitting in with ourselves and our surroundings.
Project View and Vision Changes
With regard to what would be done differently, I advocate a focus on learning peer-reviewed journal writing skills prior to the beginning of project or at the same time instead of waiting until well into practice project. Additionally, I urge a narrowing of the project intent to a specific outcome, such as article submission or focused EBP research on apafüc;'tlar topic within foot care, such as alternative nursing foot care modalities, or creating and piloting an essential nursing foot care tool assessment tool. I also support that a practice project author develop a tool reliability and validity assessment survey of their own.
I have learned much from this process, such as relationships in newly formed groups on immersions are a learning experience all their orwn, as new relationships are formed as situations arise with continuous relationship alterations which highlights complex conceptual definitions. Unfamiliar places, situations, long hours, unfamiliar cultural practices, and unfamiliar food and drink choices, all situations people face as patients.
Learning new ways of being mindful brings about personal and worldview
changes. Nursing culture is largely unaware of their importance and impact
capabilities in world foot related health and wellness. Many health concerns are in
flux. The role of nursing is just beginning to modiff how the world views health and ESSENTIAL NURSING CARE FOR THE SOLE 55 wellness. Learning through immersions is an important method of exploring concepts in real time and real world interactions. Essential conceptual relationship frameworks of relationships, found out while studying ancient energy and healing practices support a reflective based practice.
Reflecting back, this project evolved from a health and wellness perspective into an important portrait of foot health that I was not aware of before. A cultural change in nursing assessment begins at the feet and lower legs, not top down, as formerly learned throughout the nursing career of this nurse. This change focuses assessment on the entire body, not just what stands out, as feet are often overlooked in assessments provided today. An initial focus on the foot is directed towards a culture change surrounding foot health from negative to positive health outcomes. In this transformational journey about my own personal and professional practices and beließ, I have learned important self-reflective techniques. This chapter accentuates a variety of processes and techniques I was unfamiliar with as ways of learning about myself and the universe around me. Becoming more in tune with the universe is an important perspective of a healthy life. Chapter five will review project conclusions, practice implications, and future practice plans brought about by the experiences of this journey. ESSENTIAL NURSING CARE FOR THE SOLE 56
CHAPTER V: CONCLUSION, IMPLICATIONS, FUTURE PLANS
Chapter 5 reviews reflective planning of continuation of practice project expansion, through continued nursing awareness and article submissions to professional nursing journals, exploration to a creative nursing publication, as well as additional speaking, and./or poster presentations. This chapter also discusses these practice project conclusions such as the impact sharing of this project has within the nursing community, and implications for advanced practice nursing.
Project Next Steps, New Considerations
Next steps to consider include exploring the essential nursing foot care tool as an underutllized example that may be shared and studied for tool validity and reliability, through exploration of appropriate test settings such as alarge,
Midwestem hospital medical/surgical setting or through a clinic setting supporting homeless citizens :utilizing free clinic services for essential foot cares. Additional project areas might include integrating foot care into nursing practice such as including foot care in basic nursing education or a pilot project of incorporating a basic nursing foot care tool into hospital practice. Future research needed is awareness of the impact and importance of nursing foot care on world health.
Possible areas for continuation ofthis practice project could be through project expansion into a nursing foot care tool implementation as a pilot project in a community nursing foot care program or teaching hospital, as well as continued nursing awareness and article submission to additional professional nursing journals.
This continuation might include exploration to a creative nursing publication, ESSENTIAL NURSING CARE FOR THE SOLE 57 additional speaking presentations and professional nursing organization poster presentations.
Advanced Nursing Findings
Meanings to Practice
Both nursing praxis and labyrinth walking require intention, a concept lJgarnza (2002) describes as a determining factor in human development discernible as a response to outside forces. Ugarnza (2002) also illustrates Newman's nursing paradigms in levels of intentionality: with the particulate-deterministic as situation purposeful, reactionary and predictable; the interactive-integrative as variable relationships driven by goal choices; and the unitary-transformative as unpredictable, complex, self-awareness determined by goal choices. The concept of intent for labyrinth walking is determined by the participant, depending on their needs and proficiency of contemplation, at the onset of the walk outside the entrance and changes as the walker progresses through.
Labyrinth walking, as a physical to metaphysical connection, is useful in developing proficiency in adjusting one's spiritual essence, ability vital to insight within the nursing process. Labyrinth walking parallels physical, psychological and spiritual nursing praxis essentials (Sandor & Froman, 2006) of learning how to self- heal through the transformation of chaotic practices into harmonic human sustenance
Just as APRN roles provide access to healthy patient outcomes, sorting out, refocusing, and prioritizing the whole person physically, psychologically, and spiritually leads to a new perspective at the journey's end. ESSENTIAL NURSING CARE FOR THE SOLE 58
Project Impact
Developing advanced practice insight into theory and concepts related to essential holistic nursing foot care, enables the APRN to share insights with patients as they explore their foot health related needs and determine what health-related changes they are capable of integrating into their practices and beliefs in their own ever-evolving health (Vandemark,2006). Learning methods of meditation such as
TMO and labyrinth walking, brings a deeper understanding of expanding consciousness and how we are all interconnected in all of our lives experiences. It is through an advanced awareness of consciousness that APRN's can explore complex patterns of foot health needs with patients in need (Newman, 1994).
The purpose of this DNP practice project was to share this transformational journey of incorporating reflective, holistic nursing foot care, with others within the practicing culture of nursing through publication in a nursing journal. There were invaluable joys and insights in this journey of immersion experiences, learning of new reflective techniques, and building of collegial relationships. There also were unforeseen obstacles to overcome just as there are for the advanced practice nurse in making the effort to learn about essential holistic foot care for their patients and families. I hope my voice of the transforming journey nursing culture faces, is not
seen as a change in practice, but as a change in the vision of holistic health and the interconnectedness of our lives that are ultimately affected by the health of our feet.
Chapter five emphasized practice project findings, outcomes, and the impact an
essential holistic nursing practice has on foot care. Chapter five is not an end to a project. It is a passage into a new way of seeing and being within the world. ESSENTIAL NURSING CARE FOR THE SOLE 59
References
Abbas, 2., & Archibald, L. (2007). Challenges for management of the diabetic foot in
Africa: doing more with less. International Wound Journal, 4(4), 3 05-3 1 3.
Abbas, Z.,Lutale, J. K., Bakker, K., Baker, N., & Archibald, L. (2011). The'step by
step'diabetic foot project inTanzania: a model for improving patient
outcomes in less-developed countries. International Wound Journal, 8(2),
I 69 -17 5 . doi : 1 0. 1 I I I Ij.l7 42-481X.20 10.007 64.
Abu-Qamar, M. A. (2012). Qualitative content analysis of complementary topical
therapies used to manage diabetic foot in Jordan. African Journal Of
Traditional, Compl ement ary & Alternative Medicines, 9(3), 440-448.
American Association of Colleges of Nursing. (2015). The Doctor of Nursing
Practice: Current Issues and Clorifiing Recommendations. Retrieved from:
htp ://www.aacn.nche.edu/aacn-publications/white-papers/DNP-
Implementation-TF-Report- 8 - 1 5.pdf
American Holistic Nurses Association. (2015). For consumers. Retrieved from:
htç ://www .ahna.or glHome/For-Consumers
Anderson, I. (2013). How to... Ten top tips on compliance, concordance, and
adherence. l(ounds International, 4(2), 9-12
Annersten Gershater, M., Pilhammar, E., & Alm Roijer, C. (2013). Prevention of foot
ulcers in patients with diabetes in home nursing: a qualitative interview study.
European Diabetes Nursing, l0(2), 52-57 . doi: 10. I002ledn.227 ESSENTIAL NURSING CARE FOR THE SOLE 60
Armstrong, D., Lavery,L., & Wunderlich, R. (1998). Risk factors for diabetic foot
ulceration: a logical approach to treatment. Journal Of lYound, Ostomy &
Continence Nursing, 2 5 (3), 123 -I28.
Armstrong, D., Wrobel, J., 8. Robbins, J. (2007). Guest editorial: are diabetes-related
wounds and amputations worse than cancer?. International Wound Journal,
4(4),286-287
Baker, N., & Kenny, C. (2014). Prevention, screening and referral of the diabetic foot
in primary care. Diabetes & Primary Care, 16(6),307-316
Bakker, K., Apelqvist, J., & Schaper, N. C. (2012). Practical guidelines on healthy
and non-healthy foot assessments with recommendations for education, foot
wear, management and prevention of the diabetic foot 201 1.
D iabetes /Metabo lism Res earch & Reviews, 2 8225 -23 l.
doi: 1 0. I 0021 dmrr.2253.
Beem, S., Machala, M., Holman, C.,'Wraalstad, R., & Bybee, A. (2004). Aiming at
"de feet" and diabetes: a rural model to increase annual foot examinations.
American Journal Of Publ ic Health, 9 4(10), 1664-1666.
doi: 1 0.2 I 05/AJPH.94 .10.1664
Bending, A. (2002). Fungal nail infections: far more than an aesthetic problem.
Britis h Journal Of C ommunity Nurs ing, 7 (5), 25 4-259
Berg, G., Hedelin,B., & Sarvimäki, A. (2005). A holistic approach to the promotion
of older hospital patients'health. International Nursing Review,52(I),73-80 ESSENTIAL NURSING CARE FOR THE SOLE 6l
Beuscher, T. (2012). Foot and nail care education for nurses. Unpublished
University of Wisconsin-Eau Claire continuing educatiorVUW-Extension
presentation.
Bigard, M. F. (2009). Walking the Labyrinth: An Innovative Approach to Counseling
Center Outreach. Journal Of College Counseling, l2(2),I31-I48.
Boreaud, P. (1974). The open entrance to the closed palace of the king: the Greek
labyrinth in context. History of Religions. 14(1), 1-27. Retrieved from :
http ://www j stor.org/stable/ 1 06 I 890.
Boulton,4., Vileikyte, L., Ragnarson-Tennvall, G., & Apelqvist, J. (2005). The
global burden of diabetic foot disease. Lancet,366 North American Edition
(9498), 17t9-r724.
Brademeyer, B. (2015). Use traditional Lakota name for Harney Peak. Friends of the
Norbeck Members blog. Retrieved from: http://friends-oÊ
norbeck.ning.com/profiles/b1ogs/use-traditional-lakota-name-for-harney-peak
Broersma, A. (2004). Preventing amputations in patients with diabetes and chronic
kidney disease. Nephrology Nursing Journal, 31(l), 53-64
Buchanan, L. (2013). Expectations and practicalities of nursing collide in nail care.
Nurs ing Standard, 2 7 (32), 32-32
Carnes, V. (2001). Not-for-profit report. Walking the labyrinth to peace. Nursing
Homes : Long Term Care Management, 5 0(10), 4l-42.
Chan, H.Y., Lee, D. T., Leung, E.M., Man, C.., Lai, K., Leung., M., & Wong, I. K.
(2012). The Effects of a Foot and Toenail Care Protocol for Older Adults.
G er iatr ic Nurs in g, 3 3 (6), 446-453 . doi : I 0. 1 0 I 6/j . gerinurse.2O I 2. 04. 003 ESSENTTAL NURSING CARE FOR THE SOLE 62
Chan, H.Y., Lee, D. T., Leung, E.M., Man, C.., Lai, K., Leung., M., & V/ong, [. K.
(2012). The Effects of a Foot and Toenail Care Protocol for Older Adults.
Geri atr ic Nurs ing, 3 3 (6), 446-453 . doi : 1 0. I 0 1 6/j . gerinurse .20 12.04.003
Chikkaveerappa, K., Smout, J., Scurr, J. R., & Benbow, S. J. (2014). Critical limb
ischaemia: an update for the generalist. Practical Diabetes,3l(l),32-36a lp.
doi:10.1002lpdi.l825Cowling, W. R., III. (2007). What makes a manuscript
holistic? Journal of Holistic Nursing, 25, 215-216.
Cuaderes, E., Lamb, L., Khan, M., & Lawrence, G. (2009). V/eight-bearing activity
and foot parameters in Native Americans with diabetes with and without foot
sensation. Journal Of Cultural Diversity, I6(l),10-20. '
Cumbie, S., Conley, V., & Burman, M. (2004). Advanced practice nursing model for
comprehensive care with chronic illness model for promoting process
engagement. Advances In Nursing Science, 27(l),70-80
Darawsheh,W. (2014). Reflexivity in research: Promoting rigour, reliability and
validity in qualitative research. International Journal Of Therapy &
Rehabilitation, 2 I (12), 560-568
Diabetes UK: put feet first. (2012). Practice Nursing, 23(3),ll2-Il2
Diaconis, L. (2010). The labyrinth: a transformative path for RN to BSN education.
International Journal For Human Caring, 14(3),43-48.
Dobrina, R., Tenze, M., & Palese, A. (2014). An overview of hospice and palliative
care nursing models and theories. International Journal Of Palliative Nursing,
20(2),75-8 I ESSENTIAL NURSING CARE FOR THE SOLE 63
Edmonds, M., & Edmonds, A. (2009). Caring for the diabetic foot: recognition and
management. Nursing & Residential Care, I1(5),235-238.
Eriksson, K. (1997). Caring, spirituality and suffering. In M.S. Roach (Ed.), Caring
from the heart: The convergence of caring and spirituality (pp. 68-84). New
York, NY: Paulist Press.
Etnyre, A.,Zarate-Abbott, P., Roehrick, L., & Farmer, S. (2011). The role of certified
foot and nail care nurses in the prevention of lower extremity amputation.
Journal of Wound, Ostomy and Continence Nursing, 38(3),242 -25t.
Felzmann, H. (2012). Adherence, compliance, and concordance: an ethical
perspective . Nurs e Pres crib ing, I 0(8), 406-41 |
Firth, J., & Siddle, H. (2009). Management of foot ulceration in patients with
rheumatoid arthritis. Nursing Standard, 23(24),62-68 Fletcher, J. (2006). Full
nursing assessment of patients at risk of diabetic foot ulcers. British Journal
Of Nursing, 15(15), S18.
Flood, L. S. (2009). Nurse-patient interactions related to diabetes foot care. Medsurg
Nursing. 1 8(6), 361-368.
Fujiwara, Y., Kishida, K., Terao, M., Takahata,M., Matsuhisa, M., Funahashi, T., &
... Shimizu,Y . (2011). Beneficial effects of foot care nursing for people with
diabetes mellitus: an uncontrolled before and after intervention study. Journal
Of Advanced Nurs ing, 67 (9), 19 52-19 62. doi: 1 0. n I U j.1 3 65 -
2648.20r 1.05640. ESSENTIAL NURSING CARE FOR THE SOLE 64
Gallagher, D. (2012). The certified foot care nurse and the importance of
comprehensive foot assessments. Journal of Wound, Ostomy and Continence
Nursing, 39(2),194 - 196
Golafshani, N. (2003). Understanding reliability and validity in qualitative research.
The Qualitative Report, 8(4), 597 - 607. Retrieved from:
htç : //www.nova. edu/ssss/QR/QR8 -4lgolafshani.pdf.
Harris, P. A. (2014). Tracing the Cretan Labyrinth: Mythology, Archaeology,
Topology, Phenomenology. Kronos cope, I 4(2), I33 -l 49.
doi : 1 0. I 163 I I 5 685241 -123 41301
Haugan, G., Hanssetr, 8., & Moksnes, U. K. (2013). Self-transcendence, nurse-patient
interaction and the outcome of multidimensional well-being in cognitively
intact nursing home patients. Scandinavian Journal Of Caring Sciences,
27(4), 882-893 l2p. doi: 10.1 1 I l/scs.12000
Helfand, A.E. (2012). When Routine Foot Care Should Not Be "Routine"-Part 1.
Podiatry Management, 3 I (8), 163 -17 3.
Helfand, A. E. (2013). When routine foot care should not be "routine"-part 2.
Podiatry Management, 3 2 (l ), I 89- I 98.
Hjelm, K., & Beebwa, E. (2013). The Influence of Beliefs About Health and Illness
on Foot Care in Ugandan Persons with Diabetic Foot Ulcers. The Open
Nur s in g J ournal, 7, | 23-I 32. htþ : //doi. or gl | 0 .2 17 4 I | 87 443 460 13 07 0 I 0 123
Howell, M., & Thirlaway, S. (2004). Foot care. Integrating foot care into the
everyday clinical practice of nurses. British Journal Of Nursing, 13(8), 470-
473. ESSENTIAL NURSING CARE FOR THE SOLE 65
Hunt, J. (2013). Hand and foot care, including nail cutting, is part of our job. Nursing
Standard, 2 7 (30), 30-3 I
Jain, P. K. (2012). Knowledge & Attitude of Diabetic Patients Regarding Diabetic
diet, Exercise and Foot care. International Journal Of Nursing Education,
4(2), r41-t4s.
Karabudak, S. S., Tas, F., & Basbakkal,Z. (2013). Giger and Davidhizar's
Transcultural Assessment Model: A Case Study in Turkey. Health Science
Journal, 7(4),342-345
Kinchen, E. (2015). Development of a Quantitative Measure of Holistic Nursing
Care. J Holist Nurs,33(3)238-246
Kitson, A. L., MuntlinAthlin, Å., & Conroy, T. (2014). Anything but Basic: Nursing's
Challenge in Meeting Patients'Fundamental Care Needs. Journal Of Nursing
Scholars hip, 4 6(5), 33 | -339 . doi: 1 0. 1 I 1 1 /jnu. I 208 I
Klebanofi, N. 4., & Hess, D. (2013). Holistic nursing: Focusing on the whole person.
American Nurse Today, S(10), 9.
Lovering, S. (2012). The Crescent of Care: a nursing model to guide the care ofArab
Muslim patients. Diversity & Equality In Health & Care,9(3),Ill-178.
McGeorge, N. (2010). The science of holistic nursing. Journal Of Community
Nursing, 24(5),32-34.
McMahon, A. T., O'Shea, J., Tapsell, L., & V/illiams, P. (2014). V/hat do the terms
wellness and wellbeing mean in dietary practice: an exploratory qualitative
study examining women's perceptions. Journal Of Human Nutrition &
Dietetics, 2 7 (4), 40 I -410 1 0p. doi : 1 0. 1 1 1 | I jhnJ2l 65 ESSENTIAL NURSING CARE FOR THE SOLE 66
Mertens, D. M., (2009). Transþrmative research and evaluation. New York, NY:
Guilford Press.
Miller, T. A. (2014). Basic nursing foot care annotated bibliography. Unpublished
manuscript.
Miller, T. A. (2014). Basic nursing foot assessment tool. Unpublished manuscript.
Miller, T. A. (2014). Complementary foot care annotated literature review.
Unpublished manuscript.
Miller, T. A. (2014). Creative expression - a Haiku poem. Unpublished manuscript.
Miller, T. A. (2014). How to write a submittable nursing journal article, annotated
literature review. Unpublished manuscript.
Miller, T. A. (2014). Nursing care for the sole. Unpublished manuscript.
Miller, T. A. (2015). Grid/Matrix for summarizing literature review. Unpublished
manuscript.
Miller, T. A. (2015). Labyrinth walking: a practice reflection of a direct experience.
Unpublished manuscript.
Moulton, C. (2013). Diabetic footcare: part I Avoiding amputations. Practice Nurse,
43(s),30-32.
Muirhead, L., Roberson, A. J., & Secrest, J. (2011).Utilization of foot care services
among homeless adults: Implications for advanced practice nurses. Journal Of
The American Academy Of Nurs e Practitioners, 2 3 (4), 209 -2t 5 .
doi: 1 0. 1 I I I lj.I7 45 -7 599.2011 .00598
Munro, C. (2010). Running the maze and walking the labyrinth. American Journal Of
C rit ic al C ar e, I 9(3), 208 -2 10. doi : 1 0.403 7 I ajcc2\ 10638 ESSENTIAL NURSING CARE FOR THE SOLE 67
Newman, M. (2002). The pattern that connects. Advances In Nursing Science,24(3),
l-7.
Newman, M. A. (2000). Health as expandizg consciousness. Sudbury, MA: Jones
and Bartlett.
Newman, M.4., Sime, A.M., & Corcoran-Perry, S. A. (1991). The focus of the
discipline of nursing. Advances in Nursing Science, I4(l),1-6.
Newman, M.A. (1994). Theory for nursing practice. Nursing science quarterly,T(4),
I 53.
Nundy, S., Mishra,4., Hogan, P., Lee, S.M., Solomon, M.C., & Peek, M. E. (2014).
How do mobile phone diabetes programs drive behavior change?: evidence
from a mixed methods observational cohort study. The Diabetes Educator,
40(6), 806-819. doi:10.1 177 10145721714551992
Padro, J. (2011). Labyrinth walking: a journey of the body, mind, and soul. Alive:
C anada's Natural Health & Wellnes s Magazine, (3 42), 97 -t0I.
Pataky, 2, Golay,A., Rieker, 4., Grandjean, R., Schiesari, L., Vuagnat, H. (2007). A
first evaluation of an educational program for health care providers in a long-
term care facility to prevent foot complications. The International Journal of
Lower Extremity Wounds, 6(2), 69-7 5.
Pattillo, M. (2004). Therapeutic and healing foot care: a healthy feet clinic for older
adults. Journal Of G erontolo gical Nurs ing, 3 0(12), 25.
Perkins, J. B. (2016). The Lived Experience of Graduate Nursing Students
Practicing the Transcendental Meditation @ TM@ Technique. Unpublished
manuscript. ESSENTIAL NURSING CARE FOR THE SOLE 68
Perrin, B. M., Swerissen, H., Payne, C. (2009). The association between foot-care
self eff,rcacy beliefs and actual foot-care behaviour in people with peripheral
neuropathy: a cross-sectional study. Journal of Foot andAnkle Research,
(2):3. DOI :I0.1186l 17 s7 -1146-2-3
Peterson, J. M., & Virden, M. D. (2013). Improving diabetic foot care in a nurse-
managed safety-net clinic. Journal Of The American Association Of Nurse
P ract it ioners, 2 5 (5), 263 -21 I . doi : 1 0. I I I I Ij.I7 45 -7 599 .20 12.007 86
Popoola, M., Jenkins, L., & Griffin, O. (2005). Caring for the foot mobile: holistic
foot and nail management. Holistic Nursing Practice, 19(5),222-227.
Poss, J. (2001). Developing a new model for cross-cultural research: synthesizing the
Health Belief Model and the Theory of Reasoned Action. Advances In
Nursing Science, 2 3 (4), I -I5.
Rajan, M. (1995). Transcultural nursing: a perspective derived from Jean-Paul Sartre.
Journal Of Adv anc ed Nurs in g, 2 2 (3), 45 0 -45 5 6p. doi : 10. 1046 Ij.1,3 65 -
2648.1995.22030450.x
Ray, M. A. (2015). Rootedness in Holistic Nursing: The Ontologic Mystery and
Structure of Caring. Beginnings, 35(2),12-14.
Ray, M. 4., & Turkel, M. C. (2012). A Transtheoretical Evolution of Caring Science
within Complex Systems. International Journal For Human Caring, 16(2),
28-49.
Ray, M. 4., & Turkel, M. C. (2014). Caring as Emancipatory Nursing Praxis.
Advances In Nursing Science, 37(2),132-146.
doi: 1 0. 1 097/4NS.0000000000000024 ESSENTIAL NURSING CARE FOR THE SOLE 69
Rolfe, G. (2006). Validity, trustworthiness and rigour: quality and the idea of
qualitative research. Journal Of Advanced Nursing, 53(3), 304-310 7p.
doi : I 0. 1 | | | Ij.l3 65 -2648.2006.037 27 .x
Saver, C. (2006).Guest series: writing for publication. Legal and ethical aspects of
publishing [corrected] [published erratum appears in AORN J 2006
Dec; 84(6) : 9 501. AORN Journal, I 4(4), 57 I -57 5 .
Senussi, M., Lincolo, N., Jeffcoate, V/., & Thomas, D. (2011). Psychometric
properties of the Nottingham Assessment of Functional Footcare
(NAFF)...including commentary by Thomas D.International Journal Of
Therapy & Rehabilitation, I 8(6), 330-334.
Seyyedrasooli,4., Parvan, K.,Yalizadeh, L., Rahmani, A.,Zare, M., & Izadi,T.
(2015). Self-Efhcacy in Foot-Care and Effect of Training: A Single-Blinded
Randomized Controlled Clinical Trial. International Journal Of Community
Bas ed Nursing & Midwifery, 3 (2), l4I -149.
Sheridan, S. (2012). The Need for a Comprehensive Foot Care Model. Nephrology
Nursing Journal, 3 9(5), 397 -400.
Simko, M. V. (1967). Foot welfare. The American Journal o/Nursing,67(9),1895 -
1 897. Retrieved from: http ://www j stor. org/st ablel3 420488.
Slater, V. (2005). Holistic nursing practice. Journal of Holistic Nursing, 23(3),261
- 263. DOI: 10. I 17710898010105278885
Soyupek, F., Ceceli, E., Suslu, F., & Yorgancioglu, R. (2007). Neurologic and
radiologic abnormalities of the foot in diabetic patients. Journal Of Back &
Mu s cu I o s ke I et al Rehab i I i t at io n, 2 0(2 I 3), 5 5 -60. ESSENTIAL NURSING CARE FOR THE SOLE 70
Stolt, M., Suhonen, R., Puukka, P., Viitanen, M., Voutilainen,P., & Leino-Kilpi, H.
(2013). Development process and psychometric testing of foot health
assessment instrument . Journal Of Cl inical Nurs ing, 2 2 (9 I I0), 13 10-1321
12p. doi: 10. 1 1 1 Iljocn.I2078
Stolt, M., Suhonen, R., Puukka, P., Viitanen, M., Voutilainen,P., & Leino-Kilpi, H.
(2012). Foot health and self-care activities of older people in home care.
Journal Of C I inical Nurs ing, 2 I (21 I 22), 3082-3095 1 4p. doi: 1 0. 1 I 1 I Ij.1365 -
2702.20t2.04223
Stolt, M., Suhonen, R., Voutilainen, P., & Leino-Kilpi, H. (2010). Foot health in older
people and the nurses'role in foot health care--a review of literature.
Scandinavian Journal Of Caring Sciences, 2 4(I), 194-20I.
doi: 1 0. 1 nl ü.147 I -67 12.2009.00700
Thomas, J., Jacobsor, G., Narkowicz, C., Peterson, G., Burnet, H., & Sharpe, C.
(2010). Toenail onychomycosis: an important global disease burden. Journal Of
Clinical Pharmacy & Therapeutics, 3 5(5), 497 -519 23p. doi: 10.1 llllj.1365-
2710.2009.01107.x
Toth, J. (2011). Development of the Basic Knowledge Assessment Tool for Medical-
Surgical Nursing (MED-SURG BKAT) @ and Implications for In-Service
Educators and Manag ers. Nurs ing Forum, 4 6(2), 1 1 0- 1 1 6.
doi: 1 0. 1 n U j.I7 44-6198.2011 .002 I 6
Vandemark,L. (2006). Awareness of self and expanding consciousness: using
nursing theories to prepare nurse-therapists. lsszes In Mental Health Nursing,
27(6),605-615. ESSENTIAL NURSING CARE FOR THE SOLE 7I
Wallace, S. (2013). The importance of holistic assessment -- A nursing student
perspective . Nuritinga, (I2), 24-30.
Wendler, M. (1996). Understanding healing: a conceptual analysis. Journal Of
Adv anc ed Nurs ing, 2 4 (4), 83 6-842. doi : 1 0. I 04 6 I j.l3 6 5 -2648.199 6.26 123
Williams, A. E., Graham, A. S. (2012). 'My feet visible but ignored . . .' qualitative
study of foot care for people with rheumatoid arthritis. Clin Rehabil.26(10),
952-9. doi: I 0. 1 177 10269215511434995
Witmer, J. M., & Sweeney, T. J. (1992). A Holistic Model for Wellness and
Prevention Over the Life Span. Journal Of Counseling & Development, 71(2),
1,40-148.
World Health Organization. (2007), Health of indigenous peoples. Fact sheet N'326.
World Health Organization. (2016). Social determinants of health. Programmes. Retrieved
from: http : //www.who. int/social determinants/en/
Wound, Ostomy, and Continence Nursing Certification Board. (2014). Foot care
certification. Retrieved from: https://www.wocncb.org/certification/foot-
care-certif,rcation.
Yumang, M., Hammond, L., Filteau, N., & Purden, M. (2009). Perceptions of risk for
foot problems and foot care practices of patients on hemodialysis. Nephrology
Nursing Journal, 36(5),509-5 16.
Zambas, S. (2010). Purpose of the systematic physical assessment in everyday
practice: critique of a "sacred cow". Journal Of Nursing Educotion,49(6),
305-3 I 0. doi : 10.3928 I 0l 48483 4-20100224-03 ESSENTTAL NURSING CARE FOR THE SOLE 72
Zimmerman, L. (2005). Integrating holistic nursing practice into your medical-
surgical nursing career. Med-Surg Matters, 14(4),l-I4.
Ztcker, D.M., & Sharma, A. (2012). Labyrinth Walking in Corrections. Journal Of
Addictions Nursing (Taylor & Francis Ltd),23(l),47-54.
doi : I 0.3 1 09/ 1 08846 02.201 | .645253 ESSENTIAL NURSING CARE FOR THE SOLE 73
Figure 1. The Essential Holistic Nursing Foot Care model ESSENTTAL NURSING CARE FOR THE SOLE 74
Nursing and Foot Care Teri Miller, MS, RN,ACN$BC, CùISRN, CFCN
lnroduction Project Description Findings Practice Implications
. Foot problems ofien ignored . Systematic nursing . Basic nursing practice model . Develop basic standards of even when reported by literature review of nursing does not include of foot care practical nursing foot cares patients to primary care foot cares . Nursing culture globally . Develop methods of physicians, (Williams, 2012, . Development of basic defìcient in basic nursing disseminating importance p. 954). nursing education module foot cares of nursing including foot . Nursing awareness and . . Nursing foot cares - an care as a basic portion of inclusion of basic foot care is Systematic literature review expected standard of nursing health care vital in global transformational of complimentary nursing practice throughout the world health. foot cares . Encourage recognition of . Nursing is theoretically . Change in nursing culture to . lnformation sharing through impact nursing has on the knowledgeable of foot care include a basic foot care peer reviewed nursing health of the world through but lack practical application foot care recommendation by oublications Department of Health in . Express need for nursing p. 2001, (Howell, 2004, 47 0l foot care involvement
Project Goals References . Expand awareness ofvoid HoSL M, & Iìid&ay S (zru) Fd dß foot care in nursing ldo06ti.ng l6t €re inb ho ærydry dtu pdb ot toß ôdI$ úüml 0rilüniu, . Alert nursing culture to r3(8),470{73 Shll,M.tuh(M,R,\tûdh¡En,P,8tdm-Kilpi,H health care needs relating (2010) Fod h6lh in oü¿r ppb Bil tu nus' 0lo h hslù øH Hk d to foot care in nursing. tuÊMo bdiÈvbr'@t ,hwl ü ùin Stuc 2{(1),1Sæ1 doil0 111111471- . Develop basic nursing foot 6712mi07m Wtiåß,4 E,Gråhm,A s (2012) 'ilyfætviùlo care tool(s) bulþmrod' quaftdiwqdyolldø for @h rih rtþumld åùilb É . Ror¡åòf. â110), 9Í-q d: To develop basic nursing 10.1117nm215511434N5 education module
Figure 2. Nursing and Foot Care poster ESSENTIAL NURSING CARE FOR THE SOLE 75
Complexity of Foot Care Cutture
Arffi illc tnrfltctfnnt
NunsIxG cULTURE Mmrc¡l cuLTiiRE
Cnrunr OF BASIC HEALTH CARE
Figure 3. Complexity of Foot Care Culture poster ESSENTTAL NURSING CARE FOR THE SOLE 76
Appendix A Grid/Matrix for Summ aúzing Literature Reviw
AuthorÆitle/ Year Findings Published Practice
1. Stolt, Literature Literature Older people Strengths - Further Suhonen, review to review meta have variety Studies come research Voutilainen, describe foot analysis, offoot from a variety of needed on & Leino- health in Medline & problems cultures. nursing Kilpi,20l0. older people CINAHL that impact Limitations - involvement Foot health in and what foot databases 1980 functional Limit to chronic with elder older people cares nufses - 2008, 35 abilities of disease foot care and the know about articles. life, nurses generalizability, issues to nurses'role in and exhibit a those with show exact foot health complete. good rheumatoid gaps in care--a theoretical arth¡itis and nursing review of knowledge, diabetes not practice and literature. have no foot included. for a nursing care practice specific foot abilities and health uncertain of evaluation role in tool. providing foot care. ESSENTIAL NURSING CARE FOR THE SOLE 77
Study Author/Title/ Purpose/ Appraisal: Design, Strengths/ Year Problem/ Findings Worth to Sample & Limitations Published Aims Practice Setting
2. Cuaderes, Assess Descriptive Age and Strengths - Study Study tools Lamb, Khan, relationships feasibility sensory instruments show straight & Lawrence, of Native study. A neuropathies specific diabetic forward, 2009. Americans converuence linked. No risk areas offoot economical Weight- (diabetics/no sample of 80 relationship ulcer and available bearing n-diabetics) Native between development. for routine activity and on how hard Americans, weight Limitations - foot ulcer foot the skin on diabetic type I bearing Inadequate, assessments. parameters rn the soles of or II diagnosis, activities and homogenous Native their feet is to age 18 to 99, foot sensory sample size. Americans pressure no history of perception. Measurement with diabetes exerted while diabetic foot Athletic tools and with and walking ulcer, fluent in running techniques have without foot leading to English (speak, shoes protect limited sensation. diabetic foot read, write), non- sensitivities, sores. able to walk on deformed at- including self- Decide both feet risk feet. reporting whether or without Custom- measures by not to expand assistive made shoes participants. the study to device. From 2 protect include more Native deformed at- Native American risk feet. Americans. southwestern Multi- U.S. health layered clinics. socks increase foot protection better than simple, single layered. Plantar pressures linked to individual specific sites of weight bearing activities and skin hardiness. ESSENTIAL NURSING CARE FOR THE SOLE 78
Study AuthorÆitle/ Purpose/ Appraisal: Design, Strengths/ Yea¡ Problem/ Findings rWorth to Sample & Limitations Published Airns 'Sefinng Pr¡ctice
3. Abbas, & Finding ways Extensive staff Outcomes I Strengths - Diabetic Archibald, of utilizing lower limb year post Reduced related lower 2007. finite evaluation, project morbidity and limb Challenges resources treatment train initiation: mortality proven amputations for lacking the trainer increase in through and related management medical project, starting registered education/prevent foot care of the diabetic services to with paired patients ion. complication foot in Africa: reduce teams of 11,583 - Limitations - s can be doing more diabetic foot doctor/nurse 14,716:high requires drastically with less. complication (15) from 14 risk foot healthcare enhanced s and lower Tanzanian went from provider through limb regions. 37 to38Yo, commitment to education for amputations. Educate both foot ulcers the project. practitioners, staff and ll to l4%io, patients, patients. 4787 lower limb their patients amputations relatives and identified with 9 to 6.5o/o, friends. foot health deaths 4 to complications. 4.7yo, physicians trained by trainers 69 to 125, nurses îained 147 to 176, patrents educational sessions 163 to 563. ESSENTIAL NURSING CARE FOR THE SOLE 79
Study Author/Title/ Purpose/ Appraisal Design, Strengths/ Year Problem/ Findings Worth to Sample & Limitations Published Aims Practice Setting
4. Yumang, Expand Qualitative All Strengths - Foot Dialysis Hammond, insight into descriptive hemodialysis care nurse nursing Filteau, & hemodialysis semi-structured participants acceptance by practice Purden,2009. related foot interviews. engaged in dialysis offers Perceptions problems. Nine foot cares of population opportunity ofrisk for How do individuals, varymg possible. Future for patient foot problems dialysis >18, English benefit or study areas - foot care and foot care patients fluent possible incorporate assessment, practices of perceive their (conversation, harm. End reasons why interest, and patients on risk of foot reading), stage renal participants with education. hemodialysis. problems and without acute disease not foot problems what foot psych illness or seen by disinclined study cares are they both legs hemodialysis involvement. currently amputated patients as Limitations - performing. diagnosed with risk for Sample small, end stage renal developing homogenous. disease and foot receiving problems hemodialysis unless they patient, from also had a large, Quebec, diabetes university diagnosis. hospital Foot system. problem definitions and appropriate treatments varied amongst participants. Lack offoot risk awareness. ESSENTIAL NURSING CARE FOR THE SOLE 80
Study Author/Title/ Purpose/ Appraisal: Design, Strengths/ Year Problem/ Findings Worth to Sample & Limitations Published Aims Practice Setting 5. Pataky, To develop Longitudinal All groups, Strengths - Operational Golay, and evaluate l2-month except Instructive course group ofat- Rieker, a program for prospectlve physicians improved risk foot Grandjean, foot problem study. (76%) theoretical providers Schiesari, & risk At-risk foot improved awareness of crucial in Vuagnat, assessment assessment questionnair health care prevention 2007. A first abilities and questionnaire e responses providers and of foot evaluation of differences (pre N:236 & afterthe 12 professional problems for an between post N:172) month practices, patients at educational health care and education leaming especially in risk. Further program for providers. for all program. nursing staff. studies to health care (physician, Nurses Limitations - evaluate providers in a nurse, nurslng increased Closed end long term long-term aid, from 47 to questions only. benefits of care facility physiotherapist 85.7% progfam. to prevent , occupational correct, foot therapist, nursing aids complications speech- from 29 to language 72.2Yo, rest therapist, and ofgroup psychologist) from 62 to health care 85.7%. providers at Requests for Geneva protective rehabilitation shoes and geriatric doubled (2 I umverslty care to 4l). system. Increased assessment independenc e and potentially harmful practices by nursing staff observed. ESSENTIAL NURSING CARE FOR THE SOLE 81
Study AuthorÆitle/ Purpose/ Appraisal: Design, Strengths/ Year Problern/ Findings Worth to Sample & Limitations -Prúlisheé -'-4ims - Prqnfi¡e Setting
6. Nundy, Examine Mixed method Intervention Strengths - Low Need studies Mishra, interactive observational led to cost applications on how cell Hogan, Lee, cellular cohort study. increased widely available phone Solomon, & phone 67 (s0% participant for those with cell interventions Peek,2014. application African adherence to phone services. actually How do use for American selÊ healthy Cell phone change mobile phone improving acknowledged) behavìors interventions able behavior. diabetes patient ,> 19 - 70, through cell to interact in real Future programs adherence of enrolled in a phone time, more often, studies could drive nursing Midwestern, reminders. and more focused include those behavior health university Participants on individual currently change?: interventions. hospital system described issues than other without cell evidence Qualified health plan, lower levels computer based phone from a mixed nursing staff diagnosed with ofadherence intervention resources as methods monitor and type I or 2 anxiety and applications. possible observational available for diabetes. increased Limitations - diabetic cohort study. diabetic self-cares Interventions not adherence related and diabetes individually tool. application related tailored. requests and vulnerability Diabetics responses. a'wareness. continue to have diffrculties with adherence to healthy behaviors. ESSENTIAL NURSING CARE FOR THE SOLE 82
Study AuthorÆitle/ Purpose/ Appraisal: Design, Strengths/ Year Problem/ Findings Worth to Sample & Limitations Published Aims Practice Setting
7. Anita E. Investigation Qualitative, Reported Strengths - Impact of Williams, & into interpretive foot uncovered ignoring Graham, rheumatoid phenomenologi problems participants patients' foot 2012.'N[y arthritis cal study. ignored by experiences related feet visible patients foot 22 adults, >18, health care Limitations - concems but ignored . problem English fluent providers. small speaks to the .'qualitative expenences. with foot Empathy homogenous assessment study offoot problems, skills sample. Possible abilities of care for diagnosed with deficient sample biases. other people with rheumatoid from health providers rheumatoid arthritis. care throughout arth¡itis. providers. the health care field and how indispensabl e nursing is in this area of expertise. 8. Panillo, Establish A nurse Increased Strengths - Foot care 2004. elder managed, foot participant Information directly Therapeutic systematic health and awareness rn sharing led to within scope and healing foot care wellness clinic gait strength, additional of foot care: a programs rn a separate balance, and staff/patients. professional healthy feet benefits. converted exercise Foot assessment practlce clinic for Discuss apartment ln an significance. and educational model of older adults. function of a assisted living skills enhanced gerontologic holistic foot center, open 4 under added al nursing care clinic in hours every experienced, under elder assisting other week, gerontological comfort, individual $10.00 fee for nurse. functional independent 30 to 45 Limitations - and self-care minute Clinic not started independenc abilities.. appolntments as a revenue e needs. for healthy generatrng elders. business. ESSENTTAL NURSING CARE FOR THE SOLE 83
AuthorÆitle/ Yea¡ Findings D,,t"ti.t"-,{ Dr-^+:^á ùçrLurË,
9. Howell & Identification A 26-bed acute Inter- Strengths - Foot care Thirlaway, of admission metabolic/gene professional Complex care needs are 2004. foot care ral medical unit relationships needs met sooner, identified Integrating needs and action plan to improved less wait time for and foot care into foot care reduce with chiropody documented the everyday referral chiropody enhanced services. on admission clinical needs. referrals and nursing foot Improved inter- to hospital, practice of Education to meet patient care abilities. professional allowing a nurses. improve foot care Specialist relationships. structured patient foot assessment and chiropody Included in foot care care seryices. interventions expertise hospital student plan. needs by unit more nursing program. Incorporate Nl¡rSES. suitably into nursing employed. staff educational progmms. ESSENTIAL NURSING CARE FOR THE SOLE 84
Study AuthorÆitle/ Purpose/ Year Problern/ Findings n_ùl!-i- ^ I a:-- Seftñg 10. Flood, To portray Descriptive, Home health Limitations - Nwses need 2009. Nurse- nurse-patient correlational care practice Repeat in practice patient foot care study of42 setting additional region related interactions practices of registered allows for for additional RN diabetes related to both home nurses in a increased interaction education, as diabetes foot health and rural diabetic examination. outlined in care. acute care Midwestern patient Tool construct American nursing and state health interactions, validity not Diabetes how practice ca.re support, established, need Association diflerences organization. teaching, and larger sample. recommende and 22 fromacule decision d practice nurse/patient care practice management standards. interactions and 20 from influence home care Educational outcomes. practice. outcomes directly related to increased interactions not to nursing educational levels. ESSENTIAL NURSING CARE FOR THE SOLE 85
Study Author/Title/ Purpose/ Appraisal: Design, Strengths/ Year Problem/ Findings Worth to Sample & Limitations Published Aims Practice Setting
ll. Peterson. A nurse- Health center Diabetic foot Strengths - The & Virden, managed quality crisis Proactive chronic comprehen- 2013. multi- improvement hospitalizati foot care needs sive diabetic Improving disciplinary nursing ons can be framework by foot care diabetic foot clinic in assessment tool drastically identification of nurslng care in a Kansas development. decreased essential health program nurse- developed a Pilot tool with a nurse care design and reduces managed comprehensi testing over a 6 run clinic improvement diabetic foot safety-net ve foot month period. with a strategies. care clinic. examination comprehen- Limitations - 3 complication tool for a Tool training. sive diabetic risk assessment hospitalizati yearly foot health and foot care ons and program. influences assessment Chart reviews obstacles and Vital nursing identified: positive of I 84 patients. intervention assessment confusing foot healthy tool and assgssment outcomes. identihed in interventiona documentation 2OO8 ADA I (education tool, no skin and report and social) nail related foot parameters needs are care training, lack for complex meet while ofcoverage of type 2 providing uninsured patient diabetic foot foot and nail needs. problems/Mil care lions of interventions underserved, dying and suffering individuals costlng billions of dollars yearly in the U.S. / To improve chronic illness care decreasing healthcare burden and lmprove chronic disease quality of life. ESSENTIAL NURSING CARE FOR THE SOLE 86
Study Author/Title/ Purposei Appraisal Design, Strengthsi Year Problem/ Findings Worth to Sample & Limitations Published Aims Practice Setting
12.Chan, To formulate Quasi- Elder adults Strengths - Foot health Lee, Leung, a nurslng experimental, endure Protocol included is a basic Man, Lai, protocol convenience diverse foot foot health nurslng Leung, & highlighting sampling and toenail education, which process. Wong,2012. essential foot feasibility. diffrculties, in turn inçreases Nursing The Effects of and toenail Ase >65 regarding awareness in both assessments a Foot and cares patients them as patient and and Toenail Care essential for admitted to an ordinary nursing practice. interventions Protocol for health and acute care aging and Limitations - are a vital Older Adults. wellbeing of hospital in ranging from short length of aspect in the older Hong Kong, adequate to stays limit long- provision of adults./Basic control group inadequate term protocol health care foot and nail of 72, foot health. improved foot amongst the care is absent intervention Nursing health effects. populous in current group of78. neglects this and need to nurslng area ofthe include foot practice and human health in ambiguous health care nurslng within paradigm. practice. A healthcare, basic nursing overshadowe foot health dbv protocol for medical/podi patients is a aÏrY means of practices./Th capturing a e aim is to vital aspect study effects of basic this protocol health care has on elder needs. foot health. ESSENTIAL NURSING CARE FOR THE SOLE 87
Appendix B
NURSING CARE FOR THE SOLE Article
Teresa A Miller
Augsburg College ESSENTTAL NURSING CARE FOR THE SOLE 88
Nursing caÍe for the Sole
By Teresa Miller, MSN, RN ESSENTIAL NURSING CARE FOR THE SOLE 89
Reflection and learning guide my nursing rituals. Every so often an exceptional experience transforms them. Once such journey was so exceptional it transmuted my rituals to include certification as a foot care nurse, something I had been always been trained was outside the practice of nursing. And it all began when my elderly mother came to stay with me for her total knee replacement surgery.
The night before her surgery, it was getting late and we had an early rise for
surgery, but she wouldn't go to bed and I couldn't get her to tell me why. After about
an hour and a half, after a range of reassurances and offers of respectful assistance,
she sat down and took off her shoes. Which, thinking back, gave me such an odd
feeling of wondering what could her feelings be that made it so hard to share with her
daughter, an experienced, highly educated, medical/surgical (med/surg) nurse. But,
once her socks came off, it all made sense. I was stunned when I saw long, distorted,
thickened, yellow nails extending up to an inch beyond her toes. Some were curled
and bent; a few had embedded themselves into the neighboring toes. But what was
more heartbreaking was the look and feelings I saw expressed throughout her affect
and body language, of all that had been too embarrassing to share with anyone.
How much did her foot health impact her life, independence, and mobility?
What must her soul, her spirit, be experiencing? What could I do to alleviate her
distress? What could I learn from this experience? How many people share in this
personal indignity? What impact did this have on personal health and well-being?
But the finer insight of my nursing rituals was discovering what I needed to change
and what I might contribute to the realm of nursing to include the foot in basic
holistic nursing. ESSENTTAL NURSING CARE FOR THE SOLE 90
Table I
Foot care nursing diagnosis
Nursing Care Reflections Related Nursing Diagnosis I could not fathom her powerless to share Risk for spiritual distress her health care needs with anyone. 'What Impaired social interaction must her soul, her spirit, be experiencing? Intemrpted family processes Ineffective role performance Readiness for enhanced coping Anxiety Fear
How much did her foot health impact her Self-care abilities life, independence, and mobilitY? Risk for infection Impaired walking Impaired comfort Acute/chronic pain Social Isolation Impaired social isolation Activity Intolerance Disturbed sensory perception Risk for loneliness
What impact did this have on personal Ineffective Health Maintenance health and well-being? Impaired individual resilience Disturbed thought proces ses Impaired skin/tissue integrity Ineffective bathing/hygiene self-care Disturbed sensory perception
Note. Adapted from Dyson, Cobb, & Forman, (1997), Kralik, (2002), Smanioto, do Carmo Femandez Lourenço Haddad, & Rossaneis, (2014), Eggert, (2010), Soares Novaes, Morbin Torres, & Vilcinski Oliva, (2015), and Svedberg, Jormfeldt, Fridlund, & Arvidsson, (2004). ESSENTIAL NURSING CARE FOR THE SOLE 9l
The framework of fundamental nursing foot care is grounded within holistic nursing practice (Wallace, 2013; Klebanoff & Hess, 2013; McGeorge,2010:'
Castledine, 2001), and completed through Ray andTurkel's (2014), complexity of cares framework (Hess & Markee, 2014). This layered framework between health care relationships, caring, and related health care expenditures provides the comprehensive interpretation of essential foot care needs of today (Wallace, 2013;
McGeorge,2010).
Nursing assessment of the feet play a vital role in identifying aspects of health and well-being of their patients (Kitson, MuntlinAthlin, & Conroy 2014; Zambas,
20ll). The core of basic med/surg nursing includes foot care as a practice expectation (Toth, 2011). Beneficence and non-maleficence, core foundations of competent nursing practice, support the human condition as one entity (Toth, 20ll;
Lachman, 2012). The needs of 21st century healthcare calls us back, as nurses fundamentally trained to provide holistic care, in providing for the basic needs and care of our nations' health (Hess et al., 2014; McCurdy, 2014), as evidenced in the health of our feet. ESSENTTAL NURSING CARE FOR THE SOLE 92
Table2
Basic nursingfoot care assessment
Nursing Assessment Category Outside Normal Parameters (ONP's) Assessment - Referral - Integumentary Podiatrist or Certified Foot Care Skin & Nail Tissue Nurse (RN, CFCN)
Color redness, paleness, lighter or darker than patient's normal skin tones changes in nail bed bruising
Pain where, size, type Intermittent cramping with movement/exercise
Temperature palpable temperature tissue differences
Hyperkeratosis - corn increased pressure callous forming risk
Foot malformations bunions, hammer toes, claw toes, abnormal biomechanics Charcot foot Rheumatoid arthritis Neurologic disorders & diseases Musculoskeletal disorders & diseases
Wound Integumentary damage beyond superficial scratch or scrape
Moisture clammy moisture between toes anhidrosis hyperhidrosis macerated tissues interdigital mycosis ESSENTIAL NURSING CARE FOR THE SOLE 93
Nursing Assessment Category Outside Normal Parameters (ONP's) Assessment - Referral - Integumentary Podiatrist or Certified Foot Care Skin & Nail Tissue Nurse (RN, CFCN)
Neurologic Increased risk to total Methods of assessment: changes loss of sensation I) 128-Hz tuning fork (Big toe vibratory sensation, initial neurologic loss detection) 2) I0- g monofilament (Secondary indication) 3) Inability to detect sensations (Final indication)
Pulses Dorsalis pedis thready Posterior tibial bounding absent
Patient self-care Physical abilities unable to visualize nail & foot care abilities: bottom- needs of-the-foot, unable to reach lower limbs & feet or between-the-toes utilize foot care instruments inspection Ineffective improperly trimmed nails bathing/hygiene self- Ingrown toenails care deficit
Foot Care knowledge peripheral neuropathy, Ineffective Health peripheral vascular disease, Maintenance p eripheral arterial dis eas e history of foot ulcers, lower limb amputation
Comfort improperly fitting footwear "That's the size I've always worn"
Spiritual Ideations Foot Care practices and unhealthy foot health practices beliefs
Note. Adapted from Baker., & Kenny, (201Ð, Helfand, (2013); Moulton, (2013); Newton & Roberts, (2013); Rudy, (2007); Shapiro, Koshimune, & Moellmer, (2013); Sibbald, Ayello, Alavi, Ostrow, Lowe, Botros, & ... Smart, (2012); Smanioto, Carmo Fernandez Lourenço Haddad, & Rossaneis, Qll\; Eggert, (2010); Sund-Levander, &Grodzinsky, (2013); Williams, & Graham, (2012;Yen- Fan, Jersey, Woan-Shyuan, Brend Ray-Sea, & Tzu-Ting, (2014). ESSENTIAL NURSING CARE FOR THE SOLE 94
References:
Baker, N., & Kenny, C. (2014). Prevention, screening and referral of the diabetic foot
in primary care. Diabetes & Primary Care, 16(6),307-316.
'W., Bellah, R., Madsen, R. Sullivan, Swidler, A., & Tipton, M. (1992). The Good
Society. New York: NY, Vintage Books.
Boggatz, T., & Dassen, T. (2011). Why older persons seek nursing care: towards a
conceptual model. Nursing Inquiry, I8(3),216-225 10p. doi: 10.1 1 1 llj.l440-
1800.201 1 .00563
Castledine, G. (2001). Castledine column. Is nursing care losing its holistic focus?.
British Journal Of Nursing, 10(16),1091.
Dyson, J., Cobb, M., & Forman, D. (1997). The meaning of spirituality: a literature
review. Journal Of Advanced Nurs ing, 2 6(6), I I 83- 1 1 88. doi: 10.1046 I j.1365 -
2648.1997 .00446.x 1 0. I I I t Ij.l3 6s -2648.1 997.tb008 I I .
Eggert, S. (2010). Psychosocial factors affecting employees' abilities to return to
work. AAOHN Journal, 5 8(2), 5 I -5 5. doi:103928 I 089 l0I 62-20 1 00 1 1 8-0 1 .
Etnyre, A, Zarate-Abbott, P., Roehrick,L., 8. Farmer, S. (2011). The role of certified
foot and nail care nurses in the prevention of lower extremity amputation.
Journal of Wound, Ostomy and Continence Nursing, 38(3),242 - 251.
Griffin, M. & Weiss Block, J., Editors. (2013). In the company of the poor:
Conversations with Dr. Paul Farmer and Fr. Gustavo Gutiérrez. New York:
NY, Orbis Books. ESSENTTAL NURSING CARE FOR THE SOLE 95
Helfand, A. E. (2013). When routine foot care should not be "routine"-part 2.
Podiatry Management, 3 2 (l ), I 89- I 98.
Hess, D.,8. Markee, D. (2014). Holistic Nursing and the Patient Protection and
Affordable Health Care Act. New Mexico Nurse, 59(l),10-11.
Holmes, D., Perron, 4., O'Byrne, P. (2006). Understanding Disgust in Nursing:
Abjection, Self, and the Other. Research and Theory þr Nursing Practice: An
International Journal, 20(4), 305-3 I 5.
Kitson, A. L., MuntlinAthlin, Å., & Conroy, T. (2014). Anything but Basic: Nursing's
Challenge in Meeting Patients'Fundamental Care Needs. Journal Of Nursing
Schol ars hip, 4 6(5), 33 I -339. doi : 1 0. 1 1 I I /jnu. 1 208 1
Klebanoff, N. 4., & Hess, D. (2013). Holistic nursing: Focusing on the whole person.
American Nurse Today, S(10), 9.
Kralik, D. (2002). The quest for ordinariness: transition experienced by midlife
women living with chronic illness. Journal Of Advanced Nursing, 39(2),146-
1 54. doi : 10.1046 Ij.l3 65 -2648.2000.0225 4.
Lachman, V. D. (2012). Applying the Ethics of Care to Your Nursing Practice.
MEDSURG Nurs ing, 2 I (2), 112-116.
McCurdy, C. (2014). Foot Care Professionals Call for lncreased Investment in
Prevention. Retrieved from https://www.thelundreport.orglcontentlfoot-care-
professionals-call-increased-investment-prevention
McGeorge, N. (2010). The science of holistic nursing. Journal Of Community
Nursing, 24(5),32-34. ESSENTTAL NURSING CARE FOR THE SOLE 96
Moulton, C. (2013). Diabetic footcare: part 1 Avoiding amputations. Practice Nurse,
43(5),30-32.
Newton, V., & Roberts, P. (2013). Diabetic foot ulcers: your questions answered.
Nursing & Residential Care,15(1), 26-29.
Ray, M. 4., & Turkel, M. C. (2012). A Transtheoretical Evolution of Caring Science
within Complex Systems. International Journal For Human Caring, 16(2),
28-49 22
Rudy, S. (2007). Dermatology nursing essentials: core knowledge. Pediatric
dermatology: transient conditions, genodermatoses, dermatitis, and bacterial
infections. Dermatologt Nursing, I 9(4), 404.
Shapiro, J., Koshimune, D., & Moellmer, R. (2013). Diabetic foot ulcers - treatment and prevention, type 2 diabetes, Intech, DOI: 10.5772156400. Retrieved from:
htp://www.intechopen.com/booksltype-2-diabetes/diabetic-foot-ulcers-
treatment-and-prevention
Sibbald, R. G., Ayello, E.4., Alavi, A., Ostrow, B., Lowe, J., Botros, M., &... Smart,
H. (2012). Screening for the High-Risk Diabetic Foot: A 60-Second Tool
(2012)@. Advances In Skin & Wound Care,25(10),465-476.
Smanioto, F.N., do Carmo Fernandez Lourenço Haddad, M., &Rossaneis, M. A.
(2014). SelÊcare into the risk factors in diabetic foot ulceration: cross-
sectional study. Online Brazilian Journal Of Nursing, 13(3),343-352. Eggert,
S. (2010). Psychosocial factors affecting employees' abilities to return to
work. AAOHN Journal, 5 8(2), 5 1 -55. doi: 1 0.3928/089 1 0 1 62-20 1 00 1 I 8-0 I ESSENTIAL NURSING CARE FOR THE SOLE 97
Soares Novaes, 8., Morbin Torres, M., &Vilcinski Oliva, A. P. (2015). Nursing
diagnoses in surgical clinic. ActaP aulis ta D e Enfermagem, 2 8(I), 26-3 I .
doi: I 0. 1 5901 1982-019420 1 500006
Sund-Levander, M., &Grodzinsky, E. (2013). Assessment of body temperature
measurement options. Britis h Journal Of Nurs ing, 2 2(l 5), 880-8 8 8.
Svedberg, P., Jormfeldt, H., Fridlund, 8., &. Arvidsson, B. (2004). Perceptions of the
concept of health among patients in mental health nursing.
Toth, J. (2011). Development of the Basic Knowledge Assessment Tool for Medical-
Surgical Nursing (MED-SURG BKAT) @ and Implications for ln-Service
Educators and Manag ers. Nurs ing Forum, 4 6(2), 1 1 0- I 1 6.
doi: 1 0. 1 1 I 1/j. 17 44-6198.2011.00216
Trostle, J. (2005). Epidemiolog,, and Culture. New York: NY, Cambridge University
Press.
Tuhiwai Smith, L.T. (2012). Decolonizing Methodologies: Research and Indigenous
Peoples. London: UK, Zed Books.
Wallace, S. (2013). The importance of holistic assessment -- A nursing student
perspective . Nuritinga, (I2), 24-30 7
Williams, A. E., & Graham, A. S. (2012).'My feet - visible, but ignored . . .' A
qualitative study of foot care for people with rheumatoid arthritis. Clinical
Reh ab i I i t ati on, 2 6(1 0), 9 52-9 59 . doi : I 0. 1 17 7 I 026921 5 5 | | 43 499 5
Yen-Fan, C., Jersey, L., Woan-Shyuan, \ùy'., Brend Ray-Sea, H., & Tzu-Ting, H.
(2014). The role of foot self-care behavior on developing foot ulcers in ESSENTIAL NURSING CARE FOR THE SOLE 98
diabetic patients with peripheral neuropathy: A prospective study
International Journal Of Nursing Studies, 51(12), 1568-1574.
doi : I 0. I 0 I 6/j.ijnurstu.20 1 4.05.00 1
Zambas, S. (2010). Purpose of the systematic physical assessment in everyday
practice: critique of a "sacred cow". Journal Of Nursing Education,49(6),
30s-3 1 0. doi: 10.3 928101484834-20100224-03 ESSENTIAL NURSING CARE FOR THE SOLE 99
Appendix C ESSENTIAL NURSING CARE FOR THE SOLE 100 ESSENTIAL NURSING CARE FOR THE SOLE 101 ESSENTIAL NURSING CARE FOR THE SOLE t02
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Appendix D
Basic Nursing Foot Assessment Tool
Name: Date:
T¡me; Nurse lnitials:
tr Diabetes f, Lower Leg/Foot Wound(s), iJ rype z ü Type 1 tr Surgically induced I Right foot Ü night tr D Leftfoor D ü Amputation(s) lf wounds found, Refer D Primary ry tr Skin & Nail Care - Acceptable Nursing Clea nt Cares
I Do not soak feet, simple washing only lf washed in basin, provide disposable, unused device for each individual 2 Eaeh ¡:ersun to h¿vc sl.erili¿ed or lrew/ulrused 3. Use personal prolective equipmenl 4. Maintain infeclion control for skin related infectio ns Signs & Symptoms may include: drainage, ¡nflammat¡on, edema, odor 5. lnspect lower legs, feet, and nails for ce practice personnel cares, rroting below 6, Acceptable licensed nursing a Define free nail border debris) b Clipping, tr¡mm¡ng, a may be done No use of off of corns or calluses c, Perform cuticle d, Apply patent request Do in between toes
B Physical F¡rst not¡ced: O days below f weeks I f months fl years low F¡rst noticed: f Cognit¡ve lmpa¡rnìents, listed below fl days f Other lnrpairments, listed below U weeks fJ months D years ESSENTIAL NURSING CARE FOR THE SOLE 104
fl Footwear ând Socks/Stockings lnspected D rvtobility Aids tnspected E Mouility Aids lnspected tr Type D Type tr Aids tr Aids D A¡ds tr Aids D Need D Need tr Need tr Need
Sensation & circulation: (Pulses, blanching, capìllary refill, hyperkeratot¡c areas, tr 10 pa¡n, pitt¡n&/nonpin¡ng) numbness, t¡nBl¡n8, edema - tr Check box if any changes listed above are observed e8 tr R¡ght leg O R¡ght foot foot E Right leg E Right foot Left leg Skin temperature: E Normal O Xot ü Cold Lower leg hair condition: O Normal Q None t Sk¡n condit¡on:
Dnlgntfoot: Eblister(s) Ccalluses flcorns s fl fissures fl plaques Eulcers: f,lodor, f,lpen, Oseepi
D night leg: O blister(s) fl calluses dryflakes ll fissures f,l plaques , Dpen, flseeping, flslough
O left foot: E dry¡flakes Ofìssures f,l plaques , Dpen, I-lseeping, flslough
E teft leg: fl drylflakes fl fissures E plaques , flpen, Üseeping, flslough
ü ldentified above Bring copy of this to fl Primary Care your: D eodiatry fl Primary care fl other fl Podtatry D other D other i I D other
i ESSENTIAL NURSING CARE FOR THE SOLE 105
Refèrences:
Abbas, 2., Lutale, J. K., Bakker, K., Baker, N., & Archibald, L. (2011). The'step by step'
diabetic foot project in tanzania: a model for improving patient outcomes in þss-
developed countries. Internotional \found Journal, 8(2), 169-175. doi: l0' I I I lli.l742-
48rX.20r0.00764.
Annersten Gershater, M., Pilhammar, E., & Alm Roijer, C. (2013). P¡evention of loot ulcers in
patients with diabetes in home nursing: a qualitative interview study. European Diobeles
Nursing, I0(2), 52-57 . doi:10.1002/edn.227
Armstrong, D., Lavery, L., & lilunderlich, R. (1998). Risk F¿ctors for diabetic foot uberation: a
logical approach to treatment. Journal Of Wound, Oslonty & Conlinence Nursing, 25(3).
123-t28.
Baker, N. (201 l). Prevention, screening and referral ofthe diabetic foot in primary care.
Diabetes & Primory Care, I3(4)'225-234.
Bakker, K., Apelqvist, J., & Schaper, N. C. (2012). Practical guidelines on healthy and non-
healthy foot aasessments with recommendations for education, foot wear, management
and prevention ofthe diabetic foot 201 l. Diabe¡elMelabolism Research & Reviews,
2e225-23 1. doi: I 0. I 002dmrr.2253.
Bateman, Sharon. 20 l 4. "Principles of preventat¡ve foot care." British Journal OJ L'omnunily
ly'ursing 530-8. C I NA H L Compl e te, EBSCOåosl (accessed November I 0, 20 I 4).
Been¡ S., Machala, M., Holman, C., Wraalstad, R., & Bybee, A. (20M). Aiming at "de fleet" and
diabetes: a rural model to increase annual loot examinations. Americon Journal Of Public
Ilealth,94(to),1664-1666. doi: I 0.2105/AJPH.94. I 0' | 6ó4 ESSENTIAL NURSING CARE FOR THE SOLE 106
Bryant, J. L, & Beinlich, N. R. (2003). l-low to sta¡t a nurse-managed foot care clinic'
O rthopae dic Nursin g, 22(6), 4f7 44 I .
Chan, tl. L., Lee, D. F., Leung, E. F', Chui-wah, M., Kwok-man, L., Man-wai' L', & Wong, l' Y
(2012). The Eflects ola Foot and Toenail Care Protocol for Older Adulls. Geriatric
Nursing, 3l(6), 446-453, doi: I 0. I 0 I 6/j.gerinurse.20 I 2.04.003
Living: For The Clair, D. (20 I I ). Diabetic foot ulcers: Assessment and education. Long-Term
Cont inuing Carc Professional, 60(2), 20-22.
Delmas, L. (2006). Best practice in the assessment and management of diabetic loot ulcers.
Rc habi l i t at io n Nur.sing, 3 I (6), 228-234.
Edmonds, M., & Edmonds, A. (2009). Caring lor the diabetic foot: recognition and managemenl.
Nursing & Residential Corc, I I(5),235-238.
Etnyre, 4., Zarate-Abbott, P., Roehrick, L., & Farmer, S. (201l). The role of certified loot and
nail care nurses in the prevention of lower extremity amputation. Joumal of Wound,
Oslomy and Conlinence Nursing, 38(3)' 242 - 25 I
F'letcher, J. (2006). Full nursing assessment ofpatients at risk ofdiabetic loot ulcers. Briliså
Journal 0f Nur'ring, /J( l5)' S I 8.
Flood, L. S. (2009). Nurse-patient interactions related to diabetes foot care. Medsurg Nur.sing.
r 8(6), 36 I -368.
Formosa, C., Catt, A., & Chockalingam, N. (2012). The impolance of diabetes foot care
educalion in a primary care setting. Joumal of Díabeles Nursing,, /ó(10),410-414.
Helfand, A. E. (2012). When Routine l--oor care Should Not Be "Routine"-Pafl l. Podiotry
Manogement, J/(8), I 63- t 73. ESSENTIAL NURSING CARE FOR THE SOLE t07
Helfand. A. E. (201 3). When routine foot care should not be "routine"-pan 2. Podiatry
Management, 32( I ), I 89- I 98.
Holt, P. (2013). Assessment and management of patients with diabetic loot ulcers. Nursing
S! undard, 2 7(27 ), 49-55.
Howell, M., & Thirlaway, S. (200a). Foot c¿¡e. lntegrating foot care into the everyday clinical
practice of nurses. B ri I i s h Jo u rna I Of Nu rs i n g, 1 3(8), 47 M7 3.
McCurdy, C. (2014). Foot Care Professionals Call for lncreased Investment in Prevention.
Retrieved from https://www.thelundreport.org./contenUfoot-care-professionals-call-
increased-investme
Muirhead, L., Roberson, A. J., & Secrest, J. (201 l). Util'rzation of fuot care services among
homeless adults: lmplications for advanced practice nuræs. Joumal Of The Amcrican
Academy ofNurse Proctilioners,23(4),209-215. doi:10.1 lllli.l745-7599.201 l-00598.
Peterson, J. M., & Virden, M. D. (201 3). lmproving diabetic foot care in a nurse-managed
safety-net clinic. Jounol OlThe Anerican Association Of Nurce Praclitioners,25(5),
263 -27 I . doi : I 0. I I I I / i. t 7 45 -7 599.2o1 2.007 86. Shapiro, J., Koshimune, D., & Moellmer, R. (2013). Diabetic foot ulcers - treatment and prevention, type 2 diâbetes, lntech, Dol: 10.5772156400- Available fiom:
prevention
sheridan, s. (2012). The Need for a comprehensive Foot care Model. Nephrulogt tYursing
Journ a l, J 9(5), 397 -400. ESSENTIAL NURSING CARE FOR THE SOLE 108
Appendix E Final Practice Proj ect Presentation ESSENTIAL NURSING CARE FOR THE SOLE 109
. Disseminaþ EBP findings regarding nursing foot care: Relevant practice issues I - I - Nursirg presence - Best practices - Holistic insight in support of the human condition i!drÉ-- tüt k¡ È¡9, t61¡d;Þt DtU . Submitfinal project article to American Holistic Nursing Association (AHNA)
Project Significance
. Alteration of our basic health & wellness . Chronic disorder QOL . Global spread of Onychomycosis . (ön'i-ko-mi-ko'sis) . Diabetes incidence 11 . Podiatry medicalization
1.1..r¡.=- t'-: ::: Êtà E.:-' '¡r<: v:. lb:_ =- ?--¿ i 9Gr Ë=, ESSENTIAL NURSING CARE FOR THE SOLE 110
ÎqÎy Practice Epiphany
. ìilhen.. .
. Mother, t2
' C¡mc to st¡y
. Total knee replacement ESSENTIAL NURSING CARE FOR THE SOLE 111
Prelim inary Prcject Components "æi.?-- . lnspirational Project Que¡tlonc . AnnoEtsd tXte¡ature ReYiews * Trrnsfornutiru Reflcctive Practless
Thanrforming lournËys
o sylvan lake, S,D., Okawíta Paha, Sacred Black Hills ' Old Order Amish, Cêntral Wisconsin ESSENTIAL NURSING CARE FOR THE SOLE rt2
Modern lmplications Ancient myths & practices Alternatlve foot cares
cåfeforthe 9ote Ortru], E, b o \¡r¡tadt¡..t Foot Care Tool EEEE a EBP Poster EBP Article E lË ESSENTIAL NURSING CARE FOR THE SOLE 113
Theoretical Nurslng Fo'undstlon ' Carirg Sdrncr WEñh ComÞhx Spûrm: - Dynamk reldomhip of cadlg e heellng ' RcJaûional C¡rc Comphxfi - Ethical, splrltual, social - lMfltîÀ n.B rfl, r x-Ùrc ìfr.+ ni, ¡fl4
ËrrÈUrhr*t f ,l"u ESSENTIAL NURSING CARE FOR THE SOLE II4
ñlurclng Ift corct¡ml toun datlon . Translational Science: . ldeas& lnsþhts Generating lnterventions
o P¿radox between: . Caring . Economics . EthicalChoices . Organizational Practices lF¡r¡ A-urtci 2C1¿l
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. Our Routines o Dailyfoot practices - skin integrity - foot wash - footweaç socks - inspection ESSENTIAL NURSING CARE FOR THE SOLE 118
ì Foot C ar r
. Defining relation . lnflue . A unique i within the . tffi" related
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Scholarly Prolect Outcomes & Evaluatlon
. AHNA Beglnnings, Journal: - Essen trbl Co n n ect ¡o ns; Èlol{stlc lV u rs ln g SoþCore
. Sigma Theta Tau lnternstional, Kappa Mu Chapter Educational Presentation - Essentiøl Nursing Core for the þle & Pr ofe ssi onol I nte r conne cdons ESSENTIAL NURSING CARE FOR THE SOLE r22
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Augsburg Collcgc I)igital ¡\rchivcs [)cposit Agreemunt
tsy depositing this Content ("Contcnt") in thc Augsbur-g Collcge Digital Archives ("Digital r\rchives"), I agree that I am solely responsible for any conscquences of uploading this Content to the I)igital Ârchives and making it publicly availablc, and I represcnt and warrant that:
o I aln eilhcr thc solc crcator or tlre owner of the copyr.ights in the Content: ol., without <_rbtaining another's permission, I havc thc right t . _l agree to the above but I rvish to lestrict access ofthis Content to thc Augsburg Collegc Nctrvork only (sign tl). I. Work (s) to bc clepositcd 'titlc: e:: Author(s) of Work( s) t \\ \h,f Depositor's Name ( A. Sr,ì[q_,tr Author's Signature: Date:1{ I tta II. Work (s) to bc deposited (w'ith restriotions) Titlc Author(s) of Work(s): Dcpositor's Narnc (Plcasc Print): Author's Signaturc: Date lfthc Dcposit Agrccnrcnt is cxccutcd by thc Author's Rcplcscntative, the l{cpresentative shall scp¡rrately execute the Following representat¡on. I repÍesent that I arlì authoriz.cd by thc Authol to executc this Deposit Agreernent on the behal I of the author. Author' s l{epresentative Si guature: I)atc: