The results of the present study showed a significant association between foot care knowledge and practices among both nurses and care workers. The purpose of this study was to explore the strengths and weaknesses of both professions with regard to the provision of foot care and to develop strategies that improve the level of care within this area. One of features of the present study was the inclusion of care workers among the study participants. Care workers working in in-home service providers have countless opportunities to assess and come in contact with the client. Thus, statements like “he/she is not as usual” by non-nurses should be taken seriously and require follow-up .
Our results showed that both nurses and care workers were interested in learning about foot care and observing clients’ foot problems despite having low confidence, insufficient time, and limited foot care education. Indeed, 57 (92%) nurses and 165 (97%) care workers had cared for a mean of 7.9 and 9.5 clients with foot problems a month before the survey.
In contrast to our hypothesis, a significant correlation between working experience and practice scores had been observed, with full-time participants having higher mean scores. Moreover, working experience was significantly associated with practice scores among care workers. This is consistent with results presented in previous studies .and could perrhaps be attributed to increased chances for foot care practice with greater working hours.
Higher accuracy differences in the early detection of foot problems had been observed between both groups in contrast to our hypothesis. Despite nurses having received more in-depth anatomy and physiology education compared to care workers, only slight differences had been expected given the lack of foot care education in both professions. Previous studies indicated nursing assistant’ detection of early signs of symptom contribute to health care [15, 17]. Older people with low risk of foot problems might be undiagnosed and overlooked; therefore, they need medical help  and with high risk may develop worse conditions [24, 25].
Early detection and reporting of foot problems by care workers may lead to early treatment, which could potentially be life-saving. Therefore, enhancing knowledge on early detection among care workers should be emphasized.
The present study found that knowledge on shoes and socks had been lacking among both professions given the lower accuracy rates of related answers. Despite having more opportunities to observe the client’s foot when assisting with the wearing of shoes and socks or bathing, care workers were less aware of foot arches compared to nurses. Inappropriate shoes can cause calluses or corns, as well as toe and arch deformity [26, 27]. This is significant considering that the arch of the foot plays a vital role in balancing or walking. Although the effect of inappropriate footwear on the structure of foot has been extensively studied in other countries [27–32], limited research on the same has been available in Japan.
Nurse and care workers were aware of the protective effects of moisturizers on the skin barrier; however, the 25.5% knowledge difference between both groups regarding skin tears should be emphasized in future foot education programs. Considering the decreased elasticity, dryness, and fragility of older people’ skin, identifying factors that trigger skin tears on their arms and feet can prevent further skin problems. Accordingly, Serra R et al. had reported risk factors for skin tears among frail populations . Notably, small stones or objects inside the shoes may lead to skin breakage on the foot. Observing for signs on skin from improper footwear is imperative  Assessment of the skin between the toes and on the heel has also been poor among Japanese studies, unlike those in other countries [35–37]. Skin maceration between the toes may increase the risk for developing cellulitis from fungal infections. Indeed, a hospital based-study in Japan reported fungal infections among older people individuals , with another study on older people living at home and in nursing homes also showing the same . Hence, assessing the skin between the toes should be included in a health care provider’s daily routine.
The present study found that more nurses than care workers practiced nail care. However, nurses had the lowest scores for ingrown nail care among the items on nail care practice. Admittedly, foot nail care, particularly nail cutting, among older people individuals can be challenging for both of nurses and care workers. Changes in nail characteristics may be normal and related to the natural aging process. However, nail disorders, including thickened, elongated, and ingrown nails, can be painful and disabling . The MHLW in Japan provided a guideline to inform nurses and care workers on foot care based on qualifications . Such information would be beneficial for the safe and regulated practice of foot care among nurses and care workers. Learning to use a grinder and toenail clipper requires time and knowledge. Care providers may also learn to use a nail file for reducing nail thickness to some degree or shape the nail edge. Nail disorder not only caused cosmetic problems but also showed negative effects on health related quality of life and psychological problems [13, 42]. Thus, nail care among older people individuals greatly contributes toward maintaining and improving quality of life.
Nurses and care workers had close mean scores for Movement and Toe Exercise. The present study included prevention of sedentary behavior and toe exercises in the general definition of foot care. A wide range of studies outside Japan have shown that sitting for long durations without standing every hour may cause adverse effects on the body [43–45]. Hence, monitoring sedentary time and promoting hourly standing among older people individuals should theoretically be promoted. However, this becomes challenging for nurses and care workers due to time constraints and the need for careful observation relate to safety.
The current study identified several challenges for future programs. Firstly, time constraints continue to be a universal issue for the nursing profession. Evidence has clearly shown that workload and access to equipment are among the challenges nurses and care workers face, which could lead to insufficient time allotted toward caring for clients [46, 47], most of whom are vulnerable. When caring for several clients at one time, nurses and care workers observe them carefully and assist with walking or bathing, taking extreme caution due to the risk for falls. To account for this situation, efficient and comprehensive “hands-on” foot care tools, which can be learned and implemented quickly during regular working hours, can be developed for nurses and care workers. Previous studies can also be used as reference [35, 47, 48].
Secondly, the lack of foot care education in the school curriculum as well as in the work field has hindered foot care practice in Japan. According to one study, 78.7% (48) of nurses and 75.7% of care workers (128) stated that foot care manuals are necessary. Moreover, the results presented herein showed that foot care knowledge came from various sources, with some care providers not even knowing the source (Table 3). Hence, a certain structured system for foot care education should be incorporated into the current academic curriculum. Detecting foot problems or providing foot care for particular foot problems among older people individuals has remained challenging. Stolt et al. stressed the necessity of having regular, organized continuing education for all professional nurses engaged in clinical practice .
Gaining knowledge and practical experience through education or training sessions has been shown to foster confidence. Lack of confidence may affect the delivery of care . Self-efficacy and confidence has often been associated with self-care behavior among patients with diabetes . Nurse and care worker confidence may supplement foot self-care insufficiency among older people due to aging. Coping with nail thickness or reducing edema, however, may require further foot care education and training.
Thirdly, the lack of foot care specialists has hindered appropriate treatment of foot problems in Japan. Accordingly, Japan does not provide a national license for foot care specialists or foot care doctors equivalent to a podiatrist or pomologist. Moreover, the present study suggested that the current consultation system is lacking due to an absence of podiatry referral system in Japan compared to other countries [51–53]. While the incorporation of referral recommendations may be influenced by many factors , communication channels represent the strength of an organization. Considering that nurses and care workers in in-home service providers do not immediately receive orders from doctors, unlike those in the hospital, they may have more autonomy over decisions regarding further referral after observing or assessing the foot problem.
The present study has explored the requirements for future foot care programs targeting nurses and care workers. Given the various current limitations, new approaches toward enhancing knowledge and practice among nurses and care workers need to be developed and exercised in the future. Additional large-scale studies on nurses and care workers in in-home service providers will be essential. However, researchers need to formulate strategies that address potential participation bias with the current Japanese working situation.
The participants included herein were collected using cluster sampling. Thus, once a field manager of a service center expressed willingness to respond to this study, nurses and care workers were more likely to cooperate with the study. Nonetheless, we need to accumulate evidence and provide reasons for the achieved response rates. Although 530 participants were initially targeted, this number could not be met due to time and budget constraints. Nonetheless, the final sample size was determined to be statistically appropriate. Non-certified care workers had several different types of certificates, the differences in which could not be analyzed due to the small number of participants. Moreover, some nurses worked as home care providers, which allowed them more time to assess the skin and toes of their clients. The time allocated for foot care might differ depending on provider types and their roles. To properly account for and analyze potential differences, future studies need to include a large enough sample from each type of provider. The present study obtained Cronbach’s alpha values of 0.63–0.73 for all subscales on practice, which could have been attributed to the number of items included in each subscale.