Referral on Chiropody and Podiatry Professions (HPRAC)
Dear Health Professional Regulatory Advisory Council,
The Registered Nurses' Association of Ontario (RNAO) is the professional body representing registered nurses (RNs) and nurse practitioners (NPs) working in all practice settings in the province of Ontario. We are pleased to respond to HPRAC’s initial consultation request on the current model of foot care in Ontario. This submission was informed by consultation with four of RNAO's expert interest groups: 1) Diabetes Nursing Interest Group, 2) Ontario Family Practice Nurses, 3) Community Health Nurses' Initiatives Group, and 4) Independent Practice Nurses Interest Group. We were also informed by dialogue with the Canadian Association of Foot Care Nurses (CAFCN). The purpose of this submission is to convey the important role of RNs and NPs in delivering foot care and the major issues facing patients, practitioners and the health system.
A. Registered Nurses' and Nurse Practitioners' Involvement in Foot Care
RNs and NPs in the province of Ontario deliver expert foot care in a variety of settings. The level of care provided depends on an individual nurse's role and practice setting, as well as her/his knowledge, skill and experience in the area of foot care. This care may range from assessment, education and referral to specialized foot and wound care provided by RNs, NPs and other Advanced Practice Nurses with expanded education and training, as well as other health professionals (i.e., chiropodist, podiatrist or physician).
Nurses may provide foot care in a publically funded context or in private practice. Independent practice nurses who specialize in foot care provide autonomous foot care. Nurses working in the community provide direct foot care to clients in diverse settings, including clients' homes, foot care clinics, primary care settings and outreach clinics. A foot care nurse carries out foot risk assessments, develops an individualized care plan, and provides treatment, health teaching and referrals to other interdisciplinary team members as needed.
Working in a unique setting, street outreach nurses look after some of society's most vulnerable people. Many factors contribute to an increased prevalence of foot problems among homeless individuals, including exposure to moisture, trauma, prolonged standing and walking, improper footwear and poor living conditions. Nurses working with homeless individuals provide preventative foot care which is important in order to prevent disease and reduce complications. For example, street outreach nurses provide foot care at drop-in clinics and partner with other community agencies to provide this essential care. Simple interventions, such as preventative foot care, providing proper foot wear or an orthotic, can help to prevent more serious complications, such as infection and ulceration. The marginalized population served by street nurses may have difficulty accessing other types of foot care services due to lack of proper identification, precarious and often transient living circumstances, and lack of ability to pay for private foot care.
Home care nurses are well-placed to assess foot health and provide preventative measures. Nurses assess a client's feet, provide preventative care and education, promote self-care measures, and refer clients to another foot care clinician, such as a chiropodist, podiatrist or physician, when further care is needed. Home care nurses provide foot care for clients, many of which are older adults, with a range of foot problems, including skin and nail problems, foot wounds and ulcers. Many otherwise healthy older adults have foot problems, not just those with chronic diseases, such as diabetes. Foot problems increase the risk of falls in older adults. RNs in home care are integral in helping their clients maintain foot health in order to promote the safety, mobility, and independence of older adults.
The Canadian Diabetes Association recommends regular foot assessment and care for all people with diabetes for the prevention and early detection of foot problems. Complications of diabetes, such as neuropathy and peripheral arterial disease, can cause foot problems including diabetic foot ulceration, infection and amputation, which are a major cause of disability and even death for persons with diabetes. Treatment of diabetic foot ulceration contributes to significant costs to the health care system. It is estimated that lower extremity ulcer care in Ontario costs an annual $511 million dollars due to prolonged hospitalization, rehabilitation, home care nursing hours, specialist care, and amputation. The societal cost is also significant in terms of decreased productivity, job loss and impaired quality of life.
Nurses know the value of prevention, not only in terms of client outcomes, but also in cost savings to the health system. Health promotion and client education are essential to nursing practice. Preventative measures, such as education, access to foot care and footwear, are a cost-effective means of decreasing the incidence of foot ulcers. Nurses in many practice settings, including hospitals, long-term care facilities, primary care and clients' homes, are key members of the health care team providing client education and assessment of potential foot problems. For example, an RN working at a Community Health Centre as a Certified Diabetes Educator provides education about the importance of foot care to clients with diabetes. This may occur in a diabetes education class or in a one-on-one appointment. S/he may also assess a client's feet for sensation, blood flow, wounds or infection and for any other problems that might be concerning. If a problem is identified s/he would refer the client to a team member that has more specialized training in foot care. The foot care nurse, for example, will perform a more thorough assessment to categorize the client's risk, provide foot care, and work with the interdisciplinary team to facilitate referrals as needed.
Once a wound or ulcer occurs, treatment by expert foot care providers, including RNs and NPs, is vital in order to prevent further complications. Given the complexity of treating foot ulcers in people with diabetes and the societal costs, a systematic team approach is needed. The RNAO is a leader in evidence-based practice and has published two Best Practice Guidelines relevant to diabetes and foot care: Assessment and Management of Foot Ulcers for People with Diabetes and Reducing Foot Complications for People with Diabetes. One of these guidelines was cited in a 2012 report by the Council of the Federation's Working Group on Health Care Innovation and was recommended by the Council for widespread adoption. The RNAO sees the Council of the Federation's national uptake of this Best Practice Guideline as an important first step in recognizing the personal and system burden of foot ulcers in people with diabetes, and the potential to prevent the human suffering and budgetary costs related to preventable amputations. This is also a welcome step in the transformation of our country's health system to be grounded in evidence to improve patient care.
The RNAO is currently engaged in research to determine the outcome of the systematic implementation of best practice guidelines related to foot care. Through the Nursing Quality Indicators for Reporting and Evaluation (NQuIRE) system, the impact of implementing evidence-based care through Best Practice Guidelines is being measured. This ongoing evaluation will provide important information linking the implementation of best practices in nursing care of foot ulcers with client outcomes.16 In addition, the RNAO has partnered with the Canadian Association of Wound Care to launch a new eJournal titled Diabetic Foot Canada (http://www.diabeticfootcanadajournal.ca/).This publication addresses an interdisciplinary audience of health-care professionals who care for people with diabetes, to support their practice and to help improve client outcomes.
There are other areas of nursing practice where RNs and NPs provide foot care in addition to the practice settings profiled in this submission. Nurses play a robust role as active leaders in the provision of quality foot care to Ontarians.
B) Major Issues Facing Patients, Practitioners, and the Health System
1. Barriers to accessing publically funded foot care
As previously articulated, access to foot care is a critical preventative measure which leads to decreased suffering, improved health outcomes and overall savings to the health system. However, there are few options for receiving publicly funded foot care in Ontario. If Ontarians are not eligible for the limited foot care services provided under the provincial health plan and do not have private insurance, they may be unable afford necessary care. Marginalized populations, such as those living in poverty, are at greater risk of developing chronic diseases such as diabetes and resulting complications with their feet. Despite often being most in need, people experiencing economic and social marginalization often have difficulty accessing primary care and the health care system. Foot care clinics provided by outreach nurses fill a critical gap in providing essential foot care for this population, but the clinics are often stretched beyond capacity and face funding challenges as they must depend on charitable donations. Not being connected with a primary care provider or not having proper identification such as a health card is just one aspect of this problem. Many Ontarians who are living with low or moderate income are unable to access needed chiropodic or podiatric care as there is often a substantial fee associated with these services. Essential health care, including foot care, must be available to all Ontarians based on their need and not on their ability to pay.
i. Increase public funding to not-for-profit foot care - including proper footwear and orthotics - to prevent foot complications such as foot ulcers and amputations.
ii. Facilitate access to publically funded, interdisciplinary foot care for all Ontarians.
2. Lack of public awareness of the scope of practice and role of foot care nurses
There are many types of clinicians providing foot care in Ontario and their scopes of practice, while distinct, may overlap. RNAO believes that when regulated health professionals work to their full scope of practice, Ontarians will have more timely access to the care they need. Nurses provide expert foot and wound care with a unique focus on prevention, education, assessment, treatment and monitoring. There is a lack of awareness about the role of foot care nurses, both on the part of clinicians and the public, as well as lack of understanding of the respective roles of foot care providers. An opportunity exists for improved service co-ordination and collaboration among foot care providers in order to provide optimal care and improve outcomes for clients. System integration leads to increased connectivity among service providers, decreased waste and improved client outcomes and experience. For more information about RNAO's vision for the future of the health system and nursing in Ontario, please visit www.RNAO.ca/vision.
iii. Improve service co-ordination and collaboration among foot care providers in order to provide optimal care and improve outcomes for clients.
3. Lack of standardization in education and certification requirements for health professionals that practice foot care.
The Canadian Association of Foot Care Nurses is advocating for national guidelines for the practice of foot care nursing, as well as the development of education opportunities for foot care nurses. RNAO believes that standardizing the education of foot care for all health professionals who practice foot care would serve to improve access to foot care and improve outcomes for clients.
iv. Work towards standardization of education requirements for health professionals that practice foot care.
In summary, client education, access to interdisciplinary foot care, proper footwear and orthotics are known to help prevent foot complications, including diabetic ulcers yet without access to publicly funded foot care, many Ontarians will be forced to go without, leading to unnecessary complications and increased costs to the health system. A client who develops a foot wound will have access to costly wound care, specialist care, and, if necessary, surgery and hospitalization, all covered under the provincial health plan; in contrast, simple preventative measures are not publicly funded.
The focus of the system remains treatment rather than prevention and this approach comes at a high cost to individuals and to society. RNAO believes that it is imperative to increase access to publicly funded and not-for-profit foot care, including proper footwear and orthotics, so that Ontarians can receive the preventative care they need regardless of their ability to pay. By doing so we will improve the lives of Ontarians and decrease health care spending on preventable complications, including amputations.
Many thanks for the opportunity to provide information on the current model of foot care in Ontario. We are asking to continue to be engaged in these very important consultations.
Doris Grinspun, RN, MSN, PhD, LLD(hon), O.ONT.
Chief Executive Officer
Registered Nurses' Association of Ontario