Nurse Training Shows Real Promise in Preventing Devastating Diabetic Foot Complications

Every twenty seconds, somewhere in the world, a person loses a limb to diabetes. Behind each of those amputations lies a cascade of missed opportunities: a foot examination that never happened, a pair of shoes that was never checked, a warning sign of nerve damage that went unnoticed. A new systematic review published in Health Science Reports suggests that one of the most powerful tools for breaking that cascade may be surprisingly simple—teaching nurses to recognize and prevent diabetic foot complications before they begin.

The scale of the problem is enormous. Recent global estimates indicate that 537 million adults were living with diabetes in 2021, a figure projected to climb to 783 million by 2045, with the steepest increases expected in low- and middle-income countries where healthcare infrastructure is often already stretched thin. Among the chronic complications of the disease, diabetic foot stands out as particularly devastating. Between 19 and 34 percent of people with diabetes will develop a foot ulcer during their lifetime, and the majority of lower limb amputations not caused by injuries are preceded by just such an ulcer. The International Working Group on the Diabetic Foot defines the condition broadly, encompassing infection, ulceration, or tissue damage in the feet of people with diabetes, typically accompanied by loss of protective sensation, foot deformities, or impaired blood flow—deficits that dramatically raise the risk of ulceration and slow healing once wounds appear.

What makes these figures so frustrating for clinicians is that diabetic foot complications are largely preventable. International guidelines consistently emphasize systematic foot examination, early identification of at-risk patients, appropriate footwear, prompt treatment of minor injuries, and structured patient education as the cornerstones of prevention. Yet translating that guidance into practice depends heavily on frontline healthcare workers—above all, nurses. In hospitals, outpatient diabetes clinics, primary care centers, and home care services, nurses are often the professionals with the most frequent and sustained contact with patients. They perform routine foot assessments, detect early signs of neuropathy and peripheral artery disease, counsel patients on self-care, and coordinate referrals to specialist services. Studies from multiple countries, however, have documented substantial gaps in nurses’ knowledge and clinical practice related to foot assessment, alongside limited access to structured training.

To determine whether educational programs can close those gaps, researchers conducted a systematic review of quasi-experimental studies published between 2015 and 2024, prospectively registered in PROSPERO and reported according to the PRISMA 2020 guidelines. The team searched Web of Science, the Cochrane Library, CINAHL via EBSCOhost, MEDLINE, and Scopus, screening 93 initial records down to nine studies that met their inclusion criteria. Each candidate study was appraised independently by two reviewers using the Joanna Briggs Institute critical appraisal checklist for quasi-experimental research, with studies scoring five or fewer points out of nine excluded. Sample sizes across the nine included trials ranged from 30 to 110 participants, and the settings spanned five continents—from university hospitals in Egypt and Iran to community health programs in Nigeria, Brazil, Pakistan, Japan, and Saudi Arabia.

The results were strikingly consistent. Every single one of the nine studies reported statistically significant improvements in nurses’ knowledge or clinical practice following structured education, regardless of country, setting, or teaching format. The magnitude of change was often dramatic. In one Egyptian study, nurses’ practical performance of neurovascular assessment—incorporating the standardized 10-gram monofilament test, tuning forks, and reflex hammers—improved from predominantly poor at baseline to good immediately after training, with total practical scores of 93.33 percent that remained at 90 percent one month later. In Brazil, a 20-hour theoretical and practical course for primary care nurses raised mean knowledge scores from 23.8 to 41.9, with the largest gains in neurological assessment techniques that had been weakest at the outset. A 16-week program in Pakistan lifted participating nurses from uniformly weak baseline knowledge to a position where more than half achieved good knowledge ratings, while an Egyptian geriatric-care study found that the proportion of nurses demonstrating good foot care practice surged from 14 percent before training to 100 percent one month afterward.

The review also offers practical clues about how best to teach these skills. The only head-to-head comparison of delivery formats, conducted among 80 nurses in Iran, pitted a five-module e-learning course against a face-to-face interactive workshop covering identical content. Both approaches improved knowledge significantly, but post-test scores were markedly higher in the workshop group, suggesting that active, participatory, hands-on formats hold an edge for acquiring technical assessment skills. At the same time, the authors note that e-learning remains more time- and cost-efficient and more flexible, raising the possibility that blended models combining online preparation with in-person practice could deliver both accessibility and effectiveness. A Japanese study further demonstrated that a multi-component package—PowerPoint materials, videos, booklets, picture cards, and on-site coaching delivered over three to five sessions across two months—could successfully improve foot care knowledge and practice among nurses and care workers in home care settings, extending the evidence beyond hospitals.

Yet the researchers are careful to temper enthusiasm with methodological caution. Applying the GRADE framework, they rated the overall certainty of evidence as very low for both knowledge and practice outcomes. All nine studies used quasi-experimental designs without randomization, most lacked concurrent control groups, and serious concerns about inconsistency and imprecision arose from heterogeneous interventions, varied measurement instruments, small samples, and short follow-up periods. Improvements measured immediately or one month after training cannot be assumed to persist, and none of the studies tracked whether better-trained nurses actually reduced ulcer incidence, amputation rates, or hospital admissions among their patients—arguably the outcomes that matter most.

The review also uncovers structural barriers that training alone cannot overcome. Even after completing education, nurses in many settings lacked access to basic diagnostic equipment such as monofilaments, tuning forks, and reflex hammers, forcing them to improvise with inappropriate tools or skip parts of the examination altogether. The authors argue that educational programs must therefore be paired with organizational support: adequate supplies, clinical protocols aligned with international guidelines, formal authorization for nurses to conduct regular foot examinations, and protected time for both training and systematic screening. They further recommend tailoring content to nurses’ prior experience, progressing from basic pathophysiology for novices to complex case management in specialized clinics, and extending training to community nurses, geriatric specialists, and home care workers as diabetes care increasingly shifts out of hospitals.

For researchers, the roadmap is clear. The authors call for randomized and cluster-randomized controlled trials comparing e-learning, workshops, blended learning, and mentoring models; longitudinal studies assessing skill retention at six to twelve months and beyond; standardized measurement instruments to enable meaningful comparisons across settings; and, critically, research linking nurse training to patient-level outcomes such as ulcer recurrence and amputation. Until such evidence accumulates, the review concludes that integrating competency-based diabetic foot care training into nursing professional development is a reasonable interim strategy—one supported by consistently positive, if methodologically limited, findings across five continents.

Subject of Research: Effectiveness of educational programs in improving nurses' knowledge and practice related to diabetic foot care

Article Title: Effectiveness of Educational Programmes on Knowledge and Practice Related to Diabetic Foot Care Among Nurses: A Systematic Review

Article References: Al‐Me'ani, M., Alqaisi, O., Dibas, M., Al‐Aaraj, H., & Rubbai, Y. (2026). Effectiveness of Educational Programmes on Knowledge and Practice Related to Diabetic Foot Care Among Nurses: A Systematic Review. Endocrinology, Diabetes & Metabolism, 9(5), Article e70324. https://doi.org/10.1002/edm2.70324

Image Credits: AI Generated

DOI: 10.1002/edm2.70324

Keywords: diabetic foot care, nursing education, systematic review, diabetes complications, foot ulcer prevention, quasi-experimental studies, GRADE assessment, monofilament testing, nurse training, health policy, patient safety, continuing professional development