​Introduction
 
Registered nurses as leaders in assessment and care planning are in a position to make a substantial difference to the health, wellbeing, and safety of patients.  Elderly and/or disabled patients often present with foot conditions which they find difficult to manage and may initially look to primary healthcare services for information regarding how best to care for their feet. The purpose of this article is to raise awareness for registered nurses regarding the importance of foot health, and to showcase a nurse entrepreneur.
 
Challenges: Why foot care may be difficult to manage
 
“Foot Care is a very important part of Personal Care, especially for those who are unable to care for their own feet due to comorbidity such as diabetes, or advanced age.” (Waitemata District Heath Board, 2018). Anyone who has damaged their own toe will agree, there’s no doubt that foot hygiene and health is important for a sense of well-being and has a significant impact on comfort and mobility. 
 
Research supports the fact that 80% of people over the age of 80 years find managing their nails difficult (Harvey, Frankel, Marks, Shalom & Morgan, 1997).  This may be due to poor eyesight, poor balance, reduced flexibility, arthritis, obesity, shortness of breath, pain, tremor, weak hand muscles, dizziness or other chronic health conditions such as diabetes (Daly et. al., 2014) or rheumatoid arthritis (Rome, Gow, Dalbeth & Chapman, 2009).
 
As a result, there may be problems with the feet such as overlapping toes, tenderness, or open areas.  Nails may also present problems with shape, thickness, fungal infection, or edges that are prone to in-grow.  Previous injury to feet, toes, or nails can also make them difficult to manage.   Nail care is an important part of personal care, and registered nurses are in a pivotal position (Daly et. al., 2014) to help meet challenges that increasing demand for assistance with personal care and support care for our aging population presents (University of Auckland, 2017).
 
Risk related to unidentified need for assistance with foot care:
 
Pain: The patient may be suffering pain from long nails dragging on sheets, carpet, socks, or shoes. Long toenails may be digging into the toes in various ways.  Corn or calluses may be present on the toes or soles, making each step a challenge.
 
Reduced mobility: this pain can result in reduced or unstable mobility, which can negatively affect quality of life, independence, exercise, concentration, demeanour, and mood.
 
Injury: long toenails can cut either the underside of the toe if they curl under, or the side of an adjacent toe.
 
Accidental injury: People accidentally cut their toes when they are trying to cut their toenails, unfortunately these injuries can become infected, or in the case of patients with diabetes (Daly et. al., 2014) extremely difficult to heal. Keller-Senn, Probst, Imhof, and Imhof (2015) note that any changes in feet, nail and skin of patients can become established if circulation to the feet and toes is compromised, resulting in amputations that could have been avoided.

​Practicalities: What you can do to help

There are a number of simple, practical ways to assist with foot care. Number one is regular assessment of the feet of people with diabetes (Keller-Senn et. al., 2015), or patients who complain about painful feet, nails, or other related issues. This is a significantly important part of patient assessment. Nurses are then able to provide these assessments and then plan care, monitoring and guidance regarding foot care. This may include advocating regular professional foot care or referral to a specialist provider.
 
As part of the holistic care you provide, you should often ask elderly and disabled patients how they manage their foot and nail care, undertake a general assessment and discuss ongoing management options with them.
 
Process: Access to Foot Care Providers:
 
There are a variety of foot care services in the general community, including podiatry clinics, community foot care clinics, beauty therapy clinics, and visiting registered nurses providing basic foot care in the home. Clients may need assistance from a GP or practice nurse (Keller-Senn et. al., 2015) to access the services.
 
Procedure:
Any initial registered nurse assessment (Rome et. al., 2009) of feet and nails should include, contact details, clinical history and expectations. Examine skin, feet, toes and legs for colour, oedema, inflammation, deformity, pain, thickness, brittleness, shape, contour, and infection. A plan of care is discussed with the client regarding the immediate needs and ongoing care of their feet and nails.
 
Basic foot care includes: trimming and filing of toenails, reduction of corns and calluses, cleaning and dressing of any open areas and sanitiser with moisturiser is applied to the feet and toes. Cream may be massaged into dry skin. Fingernails may be cut and filed at the same time that Food Care is provided, if requested by the client and/or offered by the service provider.
 
Ongoing care a follow-up appointment may be made at either a 4-6-8 or 12 week intervals, dependent upon client requirements, or a client may be directed to a Mobile Foot Care Community Clinic if they wish to explore that option.
 
Cost:
The cost of footcare may range from $45 to $105 per visit or $25 at a Community Clinic. 
Clients with Diabetes can access some free foot care from a Podiatrist via a GP referral.
WINZ may reimburse foot care costs using the Disability Allowance via receipt.
ACC: http://www.acc.co.nz/im-injured/injuries-we-cover/treatment-we-pay-for/ and
Veterans Affairs: http://www.veterans.gc.ca/eng/about-us/policy/document/1239/ will provide free Foot Care with GP referral.
 
Clinical Example:
Mobility community foot care clinic: Registered Nurse provider.
 
I am a registered nurse based in the Canterbury region. Requests for affordable foot care for people unable to travel to clinics were received from GPs and practice nurses were made directly to me. This section describes my journey in setting up and managing “Mobile Foot Care”.
 
I initially had to invest time and finances to prepare for the role by working as a Foot Care Assistant with a Podiatrist for a year. During this time, I learned basic foot care, including care of nails, corns, and calluses. The training Podiatrist was enthusiastic and supportive about a registered nurse providing a low cost, mobile, domiciliary foot care service, because he could see the need for it and believed that Podiatrists would not be interested in providing such a service. I would refer clients needing advanced care back to him.
 
There is certainly benefit in a registered nurse providing this service, and combining nursing knowledge, assessment skills and nursing philosophy within a Foot Care Service. As a registered nurse I can also assess, plan, evaluate and understand specific, unusual or challenging needs or behaviours related to disabilities such as physical, psychiatric, neurological, sensory, intellectual disability or dementia.
 
At the time of my preparation, I also completed a Person-Centred Counselling Diploma at Christchurch Polytech which fine-tuned my ability to listen and respond effectively during the inevitable conversations which arise during home visits (New Zealand Nursing Review, 2014). Broader health related questions often arise, providing the opportunity for health educations and if required, referral to a GP or other Health Service.
 
The home visit by a friendly, professional registered nurse is often as valued by the client as much as the foot care. Patients have reported a feeling of total wellbeing following the consultation, not just the fact that their feet feel much better.
 
Community Foot Care Clinics:
At the request of a rural GP, I established community Foot Care Clinics in Kaiapoi and Christchurch, which I run one day per month. In this service, which is a minimal charge, toenails and fingernails are cut and filed, and feet receive basic foot care. 
 
Collaborative approach:
Foot care involves liaison between many health professionals. Including GP’s, practice nurses, district nursing, hospitals, occupational health, palliative care, ACC, aged and residential care facilities, podiatrists, chemists, carers, beauty therapists, emergency care workers, diabetes centre, elderly day care centre staff, and social services. Nurses retain a pivotal role in helping to coordinate and plan (Keller-Senn et. al., 2015).
 
Foot care services are currently being reviewed in other regions of the country (Waitemata District Heath Board, 2018), though not using Registered Nurses. 
 
Education for registered nurses in basic and advanced foot care:
The Ontario College of Health Studies in Canada has a well-stablished Foot Care Nurse System and offers online education (College of Health Studies, 2018) to registered nurses and nurse practitioners worldwide.
 
Profile:
Heather Woods is a Registered Nurse clinical nurse specialist who has been operating Mobile Foot Care for 28 years, it is a private business based in North Canterbury.
 
References
 
College of Health Studies (2018). Basic and Advanced Nursing Foot care Competencies and Standards. Retrieved from http://www.collegeofhealthstudies.com/footcarenurseprogram/footcarenursestandards.html.
Daly, B., Arroll, B., Sheridan, N., Kenealy, T., Stewart, A., & Scragg, R. (2014). Foot examinations of diabetes patients by primary health care nurses in Auckland, New Zealand. Primary care diabetes, 8(2), 139-146.
Harvey, I., Frankel, S., Marks, R., Shalom, D., & Morgan, M. (1997). Foot morbidity and exposure to chiropody: population-based study. BMJ 315(7115), 1054-1055.
Keller-Senn, A., Probst, S., Imhof, R. M., & Imhof, L (2015). Nurse-led education programme enhancing foot care self-efficacy in high-risk diabetes population: pilot randomised controlled study. International Diabetes Nursing, 12(2), 74-78.
New Zealand Nursing Review. (2014). Faith, duty and foot pampering winds nurse QSM. New Zealand Nursing Review, 14(3), 15.
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 Practitioners, 25(5), 263-271.
Rome, K., Gow, P. J., Dalbeth, N., & Chapman, J. M. (2009). Clinical audit or foot problems in patients with rheumatoid arthritis treated at Counties Manukau District Health Board, Auckland, New Zealand. Journal of foot and ankle research, 2(1), 16.
Soliman, A., & Brogan, M. (2014). Foot assessment and care for older people. Nursing Times, 110(50), 12-15.
University of Auckland. (2017). Report finds our ageing population will need increased levels of care. Retrieved from http://www.auckland.ac.nz/en/about/news-events-and-notices/news/news-2017/04/aging-population-will-need-increased-care-levels.html
 
 

​​Falls are the most common and costly cause of injury in people aged 65 and older.
That may not be alarming to many but falls and fractures often result in loss of independence and wellbeing. These types of claims cost ACC $233 million per year and without proper interventions this is forecast to increase at least $460 million by 2035.
 
Whit the time lost in recovery, the potential downward slide of confidence and the sense of not being in control of something you take for granted, falls can have a huge impact on the wellbeing of older New Zealanders.

The importance of balance can help with basic and simple tasks such as navigating a trip to the toilet without falling, or when you’re out playing bowls with friends, heading to a social event or visiting the whanau.
 
To lower ACC claim numbers of falls in older people, there is a need for a shift in behaviour to see more older people taking part in regular strength and balance activities. A simple, free evidence-based training app is helping thousands continue to keep living the life they want to live.
 
ACC’s app Nymbl is a balance app that assists people in completing regular balance exercises, wherever they are and whenever they want. Since its launch on April 3, ACC has had over 10,000 older adults in New Zealand who have downloaded and are using the app.

​For as little as 10 minutes a day you can dramatically decrease the chance of a fall so you can take control of your wellness by incorporating balance exercises into your life style.
 
The app is specifically designed to cater for anyone over 50 to complete a few simple physical activities and have a little fun along the way by adding a few quiz questions into each session. Simple body exercises with Nymbl’s fun brain games help keep you sharp, balanced and steady on your feet.
 
ACC Injury Prevention leader James Whittaker is hopeful the app will provide another avenue of continue wellbeing.
 
‘The reasons why people are injured through slips, trips and from person to person. There are some factors that can increase risk of falls amongst older people though. As people age the muscle mass, and their eyesight and hearing may also start deteriorating”, Whittaker said.

“This can lead to reduced confidence and when people aren’t as confident, they become less active. People can reduce their risk of falling by increasing their strength and improving their balance. The strength and balance classes provided through the ACC supported Live Stronger for Longer programme can help people a lot and boost their confidence.” 
 
The programme takes a systemic approach to reduce the rate of falls and fractures in our older population, to help keep them well and independent so they can live the life they want to live.
 
Whittaker said what makes Nymbl different from a class is its convenience.

“A lot of older New Zealanders lead full, active lives and they’d enjoy being able to choose when and where they use Nymbl. Some people might not be able to make it to a strength and balance class and other people may prefer not to be surrounded by others while they’re working on their balance.”
 
Think watching a quiz show on TV and doing some balance activities during the ad breaks – it’s fun, easy and can be done from the comfort of your own home. The app tracks your activity and adapts as you go, becoming a personal training of the mind and the body.
 
Getting the mind to concentrate while also navigating a daily task can have huge benefits.
 
Nymbl helps with the concentration of balance while you go about the simple act of walking, therefore reducing the chance of a fall or accident. Its dual tasking feature, a combination of simple body movements and ‘brain games’ is scientifically proven to improve balance faster than just physical forms of exercise alone.
 
Adrian is an 83-year-old resident at the Evelyn Page Retirement Village in Orewa, Auckland who said he has seen first-hand the consequences of a fall. 
 
“I’ve seen people retreat into themselves and not want to leave home”. 
 
Whitin a week, Adrian, who has been using Nymbl for 10 minutes a day, found it easy to navigate and said the ability to change levels of physical and mental challenges was helpful. He said the questions were challenging in a fun way and he looked forward to improving his performance.
 
There was no jumping over a candlestick but in a quick response Adrian summed up the newest addition to the live stronger longer toolbox. 
 
“It was fun – I actually look forward to it,” Adrian said.
 
Watch the video above to see Adrian’s experience using Nymbl and what he thinks of the app: https://youtu.be/sdy6nbu3baU
 
Keep living the live you love and download the app to your device form the Apple app store or Google Play storeand begin taking part in the app-lead balance activity at no cost. 
 
 
Article created in partnership with ACC. Published at Newshub on 15/05/2023.
 
 
 

If you have an elderly family member or disabled child you care for at home and you need sometime off the Ministry of Health can help fund some support (Carer support) for you.
 
You may be able to use this support to fund some allied health services. Talk with your local DHB Needs Assessment and Service Coordination (NASC) services or Ministry of Health NASC Lifelinks in Christchurch.
 
Carer Support 
Carer support provides reimbursement of some of the costs of using a support person to care and support a disabled person. This means their carer can take some time out for themselves.
 
What Carer Support is 
Carer support is a subsidy that helps you take some time out for yourself. It provides reimbursement of some of the costs of care and support for a disabled person while you have a break.
 
Who can get Carer Support 
Carer support is available for full time carers - a full time carer is the person who provides more than four hours per day unpaid care to a disabled person, for example, the parent of a disabled child.
The number of hours or days that Carer Support is funded for depends on your needs and those of the person you are care for.
 
Who funds Carer Support 
Carer support for people with age-related support needs, mental health and long-term medical conditions is funded by district health boards.
Carer Support for people with disabilities is funded by the Ministry of Health.
 
Getting Carer Support 
You can be assessed by a Needs Assessment Service Coordination (NASC) organisation, or, undertake a review with you, usually after a year.
You can find out more about claiming at Carer Support Claims or by talking to your local NASC.
 
Tax Issues 
Carer Support payments may be subject to income tax. This will depend on your individual circumstances. You may wish to seek advice regarding tax issues from the Inland Revenue Department or, if you receive a benefit, from Work and Income New Zealand.
 
Carer Support – funded by the Ministry of Health 
The following information applies if you receive Carer Support from the Ministry of Health. Carer Support from DHB’s is not affected.
 
You must work within your current funding allocation.
 
You can continue to spend your Carer Support on any disability support/service/item that:

• helps you live your life or makes your life better, and
• gives you a break from caring for your family member with a disability, or to provide a breakfor the disabled person, and
• use of funding is reasonable and cost-effective, and
• not funded through other funding options such as Disability Allowance. You can find out about what is reasonable for you to buy and you can find out more information below.

 
You cannot use your Carer Support for the following:

• paying family carers who are either a family member living with a disabled person or a parent or spouse

• illegal activities, gambling or alcohol, or
• to pay for things that are not disability supports like rent/mortgage, food, personal debt, gifts, power, regular household items etc

What people can buy with Disability Funding: Ministry of Health Purchasing Guidelines 
 
Published online:
17 April 2018
 
This document describes what government disability support funding (funding) can be used to buy. It is for people using:

• Enhanced Individualised Funding (EIF)
• Individualised Funding (IF)
• Choice in Community Living (CiCL)
• Enabling Good Lives (EGL) hosted personal budgets
• Flexible Respite Budgets (IF Respite and Carer Support)
• Flexible Disability Supports (FDS).

 
Disabled people who can make choices about how they use their funding are more likely to buy goods and services that make their lives easier and/or better. This purchasing policy aims to give disabled people as much flexibility as possible over what they can buy with government funding.
 
A disability support (support) is a good or a service that helps a person overcome barriers that come with having an impairment within a disabling society.
 
Criteria 
There are four criteria that must be met to be able to use funding to help buy a disability support.

1. It helps people live their life or make their life better  
 
The support should help people live a good life.
Each person has a different idea about what a good life is. The person’s goals and aspirations for a good life should be written out in a personal plan. This can be done with help from their Needs Assessment and Service Coordination (NASC) organisation or Independent Facilitator. Personal plans should include goals such as:

• having good relationships
• maintaining or improving skills
• being able to do everyday activities at home or in the community
• the person’s family/whānau being supported to continue their caring roles
• being able to live in a home of the person’s own choice. 

 2. It is a disability support  
 
The support:

• is only needed because the person is disabled and/or
• costs more than would be the case if the person weren’t disabled and/or
• is in addition to, or complements, the goods and/or services the person would need if they didn’t experience disability.

 
3. It is reasonable and cost-effective  
 
Generally, the support should be ‘reasonable’. Here it means that the support should cost about the same as (or less than) the market price for comparable things.
‘Cost-effective’ here means the best available outcome for the money spent.
It might cost more than another type of support but will help the person more, it will last longer or mean that less is spent on some other support now or in the future.
 
4. It is not subject to a limit or exclusion  

A person should explore other funding options to help get a support. Examples of other options include:

• the Disability Allowance (from Work and Income)
• grants, charitable donations 
• equipment funding (either by the Ministry of Education or the Ministry of Health
• specialist services, (eg, the Ministry of Health’s Behaviour Support Services and Child Development Services)
• district health board funded therapies
• transport allowances (eg, the Total Mobility transport scheme).

 
In some cases, people can buy a support when funding for that support has been turned down by (or on behalf of) the responsible government agency or if waiting times are too long and the proposed support is expected to:

• achieve a person’s life goal that would not otherwise be achievable and/or
• reduce disability support costs over time and/or
• reduce the risk that disability support costs will increase in the future.

The funding cannot be used for:

• paying family carers who are either a family member living with the disabled person or a parent or a spouse unless they are delivering Home and Community Support services and the disabled person has been assessed by a NASC as having high or very high needs.
• illegal activities, gambling or alcohol
• things that are not disability supports, such as health services provided by ahospital or income support.

 
Further help 
For more help in understanding this policy, people can talk to their NASC organisation or their provider to work out if a support they want to buy meetings the criteria.
 
See Ministry of Health Purchasing Guidelines Processes Ministry ofHealth Purchasing Guidelines notes
 
A Guide for Carers - He Aratohu mā ngā Kaitiaki
Has a good summary of financial support available to carers
 
https://www.msd.govt.nz/what-we-can-do/community/carers/guide-for-carers/index.html
 
Reference:
 
See Ministry of Health Carer Support
https://www.health.govt.nz/your-health/services-and-support/disability-services/types-disability-support/respite/carer- support
​