Key challenges in nurse-led foot care education for persons with diabetes: an international survey across six countries.

backgroundDiabetic foot ulcers affect approximately one-third of people with diabetes during their lifetime and are a major cause of disability, amputation, and premature death. Preventing foot ulcers requires effective patient education. International guidelines have highlighted the central role of nurses in teaching routine foot care practices. However, nurse-led education varies considerably across healthcare systems, and it remains unclear which educational elements are consistently neglected internationally. This study aimed to identify common challenges in nurses’ self-reported implementation of foot care education for persons with diabetes across six countries.

methodsA cross-national survey was conducted with 412 nurses in China, Japan, Kazakhstan, Lithuania, Nigeria, and Trinidad and Tobago, recruited via non-probability convenience sampling. Using the 15-item Diabetic Foot Care Education Scale nurse version, nurses rated how often they delivered each item on a five-point scale. Responses of 1–2 (“never/rarely”) were classified as low implementation. The item-specific pooled benchmark for low implementation was calculated, and items exceeding the benchmark in ≥ 2 countries were identified as common challenges. Cross-country differences were examined using chi-square tests with Holm–Bonferroni adjustment.

resultsMost participants were female (95.1%), with a median age of 43 years (IQR 35–51); 63.6% had more than 10 years of clinical nursing experience, and 73.8% had at least 3 years of diabetes care experience. Nine of the 15 items consistently identified low implementation across countries. In particular, footwear inspection and sock-fitting education differed significantly across countries (all p_holm < 0.05, Cramér’s V ranged from 0.20 to 0.33). These findings indicate that key preventive elements of foot care, such as footwear inspection and appropriate sock selection, were not sufficiently addressed in nurse-led education for persons with diabetes.

conclusionsThis multi-country study identified both substantial variability among countries as well as shared international gaps in nurses’ implementation of foot care education. These findings indicate the importance of strengthening the implementation of commonly under-addressed educational elements while considering local contexts. By providing comparative evidence across diverse settings, this study may help inform context-sensitive educational strategies and support efforts to prevent diabetic foot ulcers.