A Textbook Example: An Interview with Foot Canada Training’s Julie Gauthier

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When was the last time you thought about the importance of your feet? 

If you answered “often,” well done — you are one of very few. And according to Foot Canada Training’s Executive Director Julie Gauthier, even medical professionals can overlook the literal foundation of the body when providing care.

Julie and her team at Foot Canada Training have been on a thirty-year mission to change that by bringing the foot to the fore. Established in 1993 by Julie’s mother, Cindy Lazenby RN, Foot Canada Training has grown from one go-getting nurse’s passion project into an advocacy organization that has provided medical foot care training to over 5,000 nurses in Canada. Their impact has helped Canada become a global leader in foot care, whose teaching and instruction is contributing to positive change all over the world.

One of the primary tools Foot Canada Training uses to affect global change is the Art & Science of Foot Care textbook. Starting as a spiral-bound printout shared and sold at conferences in the early ’90s, their flagship resource is now a nearly 300-page guidebook for nurses. The book represents a lifetime of Cindy’s learnings and teachings as a pioneering care provider and allows her work to be consumed and implemented on a wide scale. Art & Science of Foot Care’s second edition was self-published in partnership with FriesenPress in 2015, with a third edition coming soon.

As part of our 15-year celebration, we spoke with Julie about how a textbook — which must adhere to the highest standards of accuracy, clarity, and timeliness — comes together, what its continued success means to her mother’s legacy, and why print on demand is such a perfect fit for academia-minded authors whose books need to stay current.

What’s Foot Canada Training’s origin story? How did you all get started in this field?

Foot Canada Training has been around since 1993, so this is our thirtieth year. We really started out with one nurse in Kingston, Ontario — Cindy Lazenby, my mom — opening a foot clinic.

She was a nurse in many different areas (ER, long-term care, palliative care, hospice) and saw the need. One thing she noticed was the lack of consistent foot care and how important it was to the patient’s overall health. Preventative foot care and preventative knowledge of foot health had many benefits; it could really help reduce amputation rates, improve overall health, improve mobility, which also improves independence, and that means it decreases the reliance on long-term care homes.

Cindy was quite the go-getter; she went out and got as much education as she could so she could start providing foot care services, which she did in some long-term care homes before she opened her first foot care clinic in Kingston, Ontario, and that was hugely successful.

She realized that she needed to share that knowledge so there could be more nurses doing what she was doing, so she developed her own course. This was back in the early ’90s — nothing was online. Everything was spiral bound and printed at Staples; she made herself a book. It wasn’t until 2015 that we published it as a professionally bound book — the first “good copy.” And then we published the second edition with [FriesenPress].

Today, we have 17 educators across Canada. We teach our theory course and a whole bunch of other mini theory courses online, as well as a 6-day clinical course and hands-on workshops on campuses all across Canada.

How does the foot care provided by nurses differ from other “foot focused” health professions that people might know about, like podiatrists?

The foot care nurses provide is the routine maintenance of the skin, nails, and health of your feet. They also can screen for many lower-limb complications, dress and treat wounds, and create padding and orthosis to help protect the skin, support the foot, or aid in wound healing. All of this, when addressed regularly, also helps to prevent complications or reduce the severeness of certain conditions, and improves overall health and wellness.

While chiropodists and podiatrists (and the numerous other foot health professionals) are a very integral part of the foot health team and provide long-term and specialized care, it is the foot care nurse who will see the patient more regularly and help them maintain healthy feet in between appointments with those professionals (or will refer to those professionals when their expertise is required).

What does your role as Executive Director at Foot Canada Training entail? Can you speak about your involvement in this book’s creation?

I’ve actually been working with Foot Canada Training since 1993. I don’t really look like I’m old enough to do that, but because it was my mom who was [the founder], I’ve been helping her out in her clinic since I was a kid. Her background is in nursing and my background is education. My specific skills lent really well to what she was trying to do. I helped her take her ideas for what needed to be taught and put it into a course format that made sense so that there was actual learning happening. I helped to edit all of her documents, policies, procedures, and the very first textbook. I’ve been there since the very beginning, starting off as an editor and later as a course writer. And then I started to do content on my own.

There are parts of the textbook that were written by me, and a lot of the background of the courses are now written by me. As my mom is slowly reducing her hours — she’ll probably never retire — she’s slowing down on how much work she wants to put in. I took on more and more of a leadership role, and I actually purchased the business from her last year. Now our roles are able to reverse; I own and run the business and use her as my expert. She’s still on the team as an educational advisor, and she’s still the lead author of the textbook.

This next edition is going to be her crowning achievement because it is, by far, way more work than we had originally planned. Textbooks need to be updated quickly; regulations in Canada and the field of nursing foot care have started to really take off so our textbook needs an update. [Cindy] took that on as her big final project. My role is to make sure that project comes to fruition and help her collaborate with so many other experts in the fields of wound care, diabetes, nursing foot care, and IPAC (infection prevention and control). All these experts have contributed to this textbook, whether co-authoring the chapters or as peer reviewers or by submitting resources. It’s been a really collaborative approach, which is going to lend well for it being a multidisciplinary textbook as opposed to just nursing foot care.

[Purchasing the business] was just such a natural progression for me. With the longevity of the business, I think it’s really important to be able to continue doing what we’ve been doing for thirty years, as opposed to completely changing direction with a new owner. It’s also nice that we’re all Canadian — and predominantly women, actually. I use women photographers and videographers, graphic designers, medical illustrators, web hosts and designers, and many people who worked on the book at FriesenPress have been women. We try to use women-led and Canadian-based businesses as much as possible, so we were really happy to work with FriesenPress for that reason.

I feel good carrying the torch on from what my mom started thirty years ago, while still keeping her in my back pocket because I need that thirty years of experience in nursing to help me make the right decisions.

How does a nursing textbook like Art & Science of Foot Care come together? What is the writing and editing process like? 

There are a lot of things that people wouldn’t take into consideration. The writing process is one thing, but the editing, the peer review, and the formatting is a whole other ballgame. 

For an academic textbook, there’s a timeliness to it. You want all of your resources and your references to be up-to-date. You don’t want to be spouting something and the only proof you can find is from a 1985 article. There’s a very specific test called the CRAAP test where you have to vet your own resources. You can’t just say it. You can’t just talk about a diagnosis or a technique and say that it’s the best; you have to say why, you have to prove it, and you have to look credible.

Not only does a reference need to be up to date, it should also be Canadian and a reputable source. Even by the time you finish writing, it’s possible that [some other research] has come out. If it’s something that’s controversial or emerging, you need to make sure that you’re saying so, or presenting two sides of an argument so that people know where to go and find more information as things change. 

Being pioneers in an industry makes it even harder. Where are we getting our resources? How do we know that this is the best? Well, because we’ve looked at all of the resources, put them together, and come up with our own conclusions. There are books on podiatry, chiropody, and diabetes, but nursing foot care as a discipline is new. Because there’s no provincial or federal accreditation or regulatory bodies, people need to take everything we’re saying with a grain of salt. We need to prove ourselves. We need to show how much work we’ve put into the background and the research, but then we also have to make it fundamentally obvious to everyone that it still is an opinion at the end of the day — until someone puts in a regulation and finds a way to hold nurses to it.

Health Canada, IPAC Canada, Wounds Canada, and the Canadian Standards Association all have regulations that refer to foot care tools or some procedures. We have to pull all that together and make it comprehensive and relatable. We reached out to the experts to make sure we were getting the most up-to-date information.

Once you’ve got a chapter that gives the information you’re trying to convey, the peer review process is really important. That involves sending out the chapter to other experts in the field that will read it from a different perspective or will have different expertise. They will be able to pick out where you haven’t done a good job at explaining a concept, or point out a brand new theory or philosophy on wound debridement (for example) that you’re missing. And though we find that process to be long, it enriches the content of our textbook because we know that the end result is going to be comprehensive and more useful to different disciplines and as up to date as humanly possible.

Then, we go through the same editing process as any other book, and then the rest of the process is about formatting. Because you want diagrams or images to go with certain parts of the textbook — including glossaries or references at the end of each chapter or the end of the book — that process is incredibly time-consuming. Right now we’re at the very end of writing the third edition. We have one chapter to rewrite because as we were writing the chapter of the new textbook, all the regulations changed. It’s mind-blowing how much it’s going to affect foot care in Canada.

Why did Foot Canada Training decide to self-publish the second edition of this academic book?

Print on demand was huge for us. Pre-printing and having [bulk] copies of a textbook that can go out of date is a terrible thing to do because then you’re stuck with out-of-date textbooks or you’re trying to sell them and get rid of them quickly. That’s the issue we had with our previous printer — a nice, local small business. But just like any other printer, they wanted a print run of 2,500 books. And when it came time to make edits to the textbook, we were stuck holding all this stock. We don’t sell in regular brick-and-mortar stores (apart from maybe a few). We were storing 2,500 books in our basement and in a couple of other places in Canada so the shipping would be cheaper. We couldn’t even update our courses; you can’t teach something new if the textbook doesn’t match.

Being able to go with FriesenPress made it so that we’re printing on demand. We really liked the idea of being able to get that content edited faster, and now we’re able to ship worldwide faster. We’re able to get to markets we couldn’t before. We’ve really seen a huge boom in sales that we never would’ve seen with the other printer. We also have better records of how many books we’ve sold.

Aside from print on demand, why did you choose FriesenPress for this project? What brought you back for the third edition?

Beyond the fact that you are Canadian, which was really important to us, we needed that platform. We didn’t have a marketing platform. It was just Cindy selling courses to her friends and her colleagues via an email chain from nurse to nurse. We didn’t advertise, weren’t on Facebook. We did nothing.

We knew that if we wanted to grow as a business and get to our end goal, which was finding a standard for foot care in Canada, we needed to start marketing. We had the textbook and the knowledge and the drive, but we needed our courses to be available across Canada. Finding online solutions for our courses and having our textbook available for purchase — to be able to market through Amazon and get ourselves out to different markets — was the next step and FriesenPress helped with facilitating that. We got up on Amazon with your help, and that has been really fantastic because now anytime someone’s searching for a book on foot care (or even on “diabetes”), ours pops up as an option.

The visibility is a huge thing. It’s opened up such a different market for us. I get emails now all the time from people in different countries (and even different disciplines) who want to know more about the textbook or to order some copies. And with my “no marketing at all in Canada,” I never would’ve reached those people.

We wanted to partner with a company that was well enough established that they would be able to help us with that goal without us feeling like we were just a small fish. We wanted someone where we could call and they would give us service right away and treat our textbook as something special. Publishing companies wouldn’t even return our calls because we weren’t established. We weren’t in the nursing curriculum. We wanted a company that followed our same values. FriesenPress seemed to offer that because they had such a great team that worked so directly with authors to make sure that the textbook met their needs, not necessarily what was going to sell.

We were a unique book, and FriesenPress didn’t bat an eye. It’s been a great relationship from the very first day — super easy to work with and focused on making our textbook meet our needs as an author. Our online presence has improved. We hit your bestsellers list, we hit the Amazon bestsellers list. Print on demand, even through the slowdowns of COVID, was still relatively quick. Moving into the next edition of the textbook, it’s been seamless.

What are you and Foot Canada Training most proud of in relation to this book?

This textbook is a culmination of everything Cindy was working for and that we are still working towards. It’s not just a textbook, it’s a resource book. The proudest part of it is that we’re able to start those conversations in small communities, in colleges across Canada, and internationally. People are reading this book not just to learn about the foot — which is great! — but they’re reading it with that same end goal of improving their own knowledge and hopefully improving the standard of care wherever they’re working or wherever they’re studying. Whether they’re in a clinic or in a long-term care home, if they’re in a hospital or they’re part of a college nursing team, or they’re part of a government body that makes standards and regulations — we are proud that we’re keeping that conversation going and that it’s going in the right direction.

We’re proud to say, “Here’s all the wonderful research that everyone should know about, please use our textbook to further that conversation so that a real standard can be established and a change can be made.” Because standards in foot care means improved overall health. And a platform like a textbook allows us to get that message out faster.

We feel like we’re enabling that change because the nurses and the experts are now asking to collaborate with us. They want to be part of the research, the textbook, our courses, and even teach our courses. We’ve been approached by IPAC Canada, and we’re now doing a three series webinar on the very changes that are holding up the delivery of our next edition of the textbook, because they see us as having a platform and a voice that’s going to help enable that change.

There’s always a reason why you write a book. For us, that reason was furthering the conversation and enabling change. We’re definitely getting there. We feel that success. Every time I see another purchase, I wonder who’s reading this [book] and why. I wonder where they are, and what they’re going to change in their workplace because of this.

Thirty years ago, Cindy wanted to improve foot care and general patient health in Kingston, and now her knowledge and drive is spread out across the globe and everyone’s picking up her book because it’s got her name on it. They know what she stands for and what Foot Canada Training stands for. And the fact that our name is driving that through the textbook is a very proud moment.

We’re celebrating 15 years in the publishing industry, and look forward to at least 15 more. What do you hope the future brings for Foot Canada Training?

In the immediate future, I want that new textbook out, which is going to change the face of foot care. Then our courses can be updated so that we are pushing forward for everyone across Canada — regardless of the province — to be doing the absolute safest foot care possible.

Second step of that would be to finish what Cindy and the Canadian Association for Foot Care Nurses (which she co-founded thirty years ago) started: to see provincial regulations in foot care. We won’t feel like we’ve hit our goal or had true success until there’s an accreditation program for foot care education so that the actual programs are put through some regulatory process. 

I would like national foot care standards for practicing nurses to follow and a regulatory body to uphold them across Canada. Once that happens, I think Canada can continue in its role of being a leader in foot health internationally. It would be wonderful to see other countries use what Canada has been doing and pioneering to form international committees to make sure that foot health is no longer the last thing you think about.

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Art & Science of Foot Care is available now.
Visit footcanada.ca to learn more.
Follow Foot Canada Training on Facebook and LinkedIn.

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