Nursing action.
The RNs agreed upon the necessity of appropriate footwear. However, according to the interviewed RNs, the responsibility to obtain shoes was put on the patient, next of kin, or HCAs. Few of the RNs mentioned shoes from the hospital’s orthopaedic shoe maker. Referring to the orthopaedic shoe maker was associated by the nurses with administrative paperwork and extra visits to the hospital for the patients, and therefore avoided. RN: ‘Protect the feet? Yes, but it is impor- tant that they have the right shoes, that they do not walk in too tight shoes.’ The RNs said that coordination of visits to the chiropodist was delegated to the HCAs. Patients in assisted living facilities received chiropody from vis- iting self-employed chiropodists, with different skills and education. Some reluctance towards them was stressed by the RNs as the chiropodists some- times caused foot ulcers by cutting the patient’s toes too deeply. The RNs interviewed did not cut toenails, and HCAs were not allowed to, because of the risk of causing foot ulcers in sensi- tive feet. RN: ‘And do you know what I think the chiropodists do? They cut a little too deep, it very easily becomes an ulcer.’ I: ‘By the chiropodist?’ RN: ‘Yes, that is my opinion. It is difficult to talk to them about it also. One intrudes into their space. So afterwards the patients come to us and we have to change dressings and fix things.’ One overarching nursing action described in the interviews was tokeep the patients mobilised, to avoid pressure ulcers. Off-loading in the bed with pillows was used as well, together with turning charts. The RNs stated that they had good access to other professionals such as phys- iotherapists and occupational thera- pists who provided the patients with wheelchairs and pressure-relieving mattresses. RN: ‘I get the HCAs to email the occupational therapist. I do not deal with those things, they do. And there are lambskins if one wants them. And there are off-loadings for the heels.’ Other actions mentioned were to maintain a good nutritional status and good metabolic control for the patients. A holistic view of the patients was emphasised, also for non-ulcer- ated patients with diabetes. RN: ‘When there are really high-risk patients one must inspect both feet even if there is not a hole in the contra lateral. But it is important with the feet even if there is no ulcer on them. One must see the whole picture.’