Knowledge of Diabetic Foot Among Nurses at a Tertiary Hospital in Saudi Arabia.

Background: Diabetic foot is the leading cause of hospitalization among patients with diabetes mellitus (DM). Nurses have a significant role in helping diabetic foot patients by educating them about their condition. Therefore, assessing the knowledge of diabetic foot among nurses will help provide better healthcare services to these patients. Objective: This study aimed to assess the knowledge of diabetic foot care among the nursing staff at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia.
Methods: This cross-sectional study was conducted at King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia, from March to May 2020. A total of 172 nurses from different departments of the hospital were randomly selected. A validated questionnaire including 68 yes-or-no questions about diabetic foot management was used for the assessment.
Results: The average total score of the entire questionnaire was 59 (standard deviation, ±7). During our study, the nursing school curriculum was found to be the major source of knowledge for nurses. Statistical significance (p=0.031) was found for the association between educational background and answers to the risk factor questions. According to our results, most nurses indicated that they believed that reporting any changes to the feet and toes and signs of infection to the physician was the best way to prevent the development of DM foot.
Conclusion: Specialized training programs beyond basic nursing education will reinforce knowledge and skills, resulting in an expected lower risk of amputation for DM patients.

BACKGROUND

Diabetes mellitus (DM) is a common disease that results in patient morbidity and mortality. It occurs with either inadequate insulin secretion or resistance to insulin at the receptor level (1). Obesity, sedentary lifestyle, and family history are considered risk factors for DM development (1). Stroke, ischemic heart disease (coronary artery disease), peripheral arterial disease, and chronic kidney disease are known as chronic complications resulting from DM. Furthermore, retinopathy, neuropathy, and nephropathy are acute complications of DM (2, 3).

In 2019, 500 million individuals globally were diagnosed with DM (4). Moreover, it has been estimated that by 2030, a total of 578 million individuals will have DM (4). Saudi Arabia is considered to have the most prevalent cases of diabetes, with 7 million individuals with diabetes and 3 million individuals with prediabetes, thus ranking first in the Arabian Gulf region and second in the Middle East for diabetes (5).

Uncontrolled and poorly managed DM and a history of peripheral arterial disease result in a higher risk of microvascular complications, including diabetic foot (6, 7). Diabetic foot is considered the leading cause of hospitalization for patients with DM (6). It results from complex pathogenesis related to increased plantar pressure and impaired cellular wound healing, eventually resulting in chronic foot lesions, and is commonly observed in patients with polyneuropathy and angiopathy (6). The risk of diabetic foot is 2.5% per year for DM patients, and the majority of these individuals will require amputation within 4 years of the initial diagnosis (7). A recent study conducted in Saudi Arabia found that 3.3% of patients had diabetic foot (8).

The preoperative role of nurses in the management of diabetic foot involves providing patients with information about proper nutrition to strengthen their immunity. Intraoperatively, their role is to prepare the sterilized equipment needed to perform any procedures. Postoperatively, their role is to prevent the wound from becoming infected (9, 10). Additionally, nurses who manage diabetic foot cases help control the progression of disease and select the appropriate dressing that will help treat the ulcer or wound (11).

Nurses can educate patients before they leave the hospital by providing them with information about controlling their condition, for example, by teaching them how to change the wound dressing and the appropriate way to use their medications (10, 12). Because nurses have a significant role in helping diabetic foot patients by educating them about their condition, assessing their knowledge about this disease will help us provide better healthcare services to these patients (13). Although similar studies have been conducted, none has been performed in Saudi Arabia.

OBJECTIVE

Therefore, this study aimed to assess the knowledge of diabetic foot care among the nursing staff at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia.

METHODS

This was a cross-sectional study involving nurses at KAUH in Jeddah, Saudi Arabia, that was conducted from March to May 2020. Jeddah is one of the largest cities in the western region of Saudi Arabia (near the Red Sea) and has a population of 3.5 million. With a capacity of 800 beds, KAUH is one of the largest tertiary referral and teaching centers in the western region of the country. Our sample consisted of 172 nurses randomly selected from different departments of the hospital.

Google Forms software was used to create the questionnaire, and Google Sheets software was used to distribute and collect data. After acquiring permission from the author of the questionnaire, it was adapted according to the study by Kaya et al. and used for our study (13) to examine the knowledge among nurses regarding diabetic foot. The questionnaire was self-administered, standardized, and confidential. To the best of our knowledge, this is the only questionnaire that tests the knowledge of diabetic foot management among healthcare practitioners. The questionnaire was divided into two sections. The first section collected the sociodemographic information and diabetes management-related knowledge of the nurses. The second section comprised 68 yes-or-no questions about diabetic foot management; these questions were divided into the following four subsections: risk factors, foot examination, foot complications, and footwear selection. The subsections contained 16, 10, 32, and 10 questions. A score of 1 was given for each correct answer, and each incorrect answer was given a score of 0, resulting in an overall score between 0 and 68. The higher the total score, the greater the nurse’s knowledge of diabetic foot management.

The validity and reliability of the questionnaire were tested using Cronbach’s α test, which indicated high reliability (0.89). The reliability coefficients for the subscales were 0.72 for the risk factors subscale, 0.64 for the foot examination subscale, 0.84 for the foot complications subscale, and 0.63 for the footwear selection subscale.

Data were analyzed using IBM SPSS Statistics for Windows (version 21). Demographic data and diabetic foot management practices of nurses were the independent variables, and the dependent variables were their knowledge of diabetic foot management based on their questionnaire scores. Descriptive statistics (means, standard deviations, frequencies, and percentages) were calculated for the demographic variables. Associations between background factors and the foot care knowledge test results were analyzed using a t-test for paired group comparisons; a one-way analysis of variance was performed to analyze more than two factors. The relationship between variables was examined using the Pearson chi-square test. Statistical significance was set at P<0.05. The internal consistency of the scale was tested using Cronbach’s α test.

This study was approved by the Research Committee of the KAUH Department of Biomedical Ethics. Participation in this study was voluntary. Participants were informed of the aim, purpose, and course of the study. Nurses were not offered any incentive to participate. Oral consent was obtained from each participant before data collection.

Results

Sociodemographic and Professional Characteristics of Nurses

Most of the nurses working at KAUH were female (86%), and the majority were married (74.4%). The mean age of the nurses participating in the study was 38 years (standard deviation [SD], ±9 years), 59.3% of the participants received their bachelor’s degree, 27.3% worked in the intensive care unit, and 87.8% were registered nurses. The mean duration of working as a nurse in their department was 74 months (SD, ±89 months) (Table 1).

Table 1.

Nurse Characteristics SD, standard deviation.

Characteristic		N	%
Average age, years	38 (SD, ±9; range, 22-61)
Average time working as a nurse, years	12.8 (SD, ±7.6; range, 0.3-30)
Average time working in the department, months	74 (SD, ±89; range, 1-400)
Sex	Male	24	14.0%
	Female	148	86.0%
Marital status	Single	40	23.3%
	Married	128	74.4%
	Divorced	2	1.2%
	Widowed	2	1.2%
Nationality	Saudi	28	16.4%
	Indian	80	46.8%
	Philippine	62	36.3%
	Jordan	1	0.6%
Education	Bachelor’s degree	102	59.3%
	Diploma	63	36.6%
	Master’s degree	7	4.1%
Department	Surgery	27	15.7%
	Mixed services	13	7.6%
	Operating room	7	4.1%
	Obstetrics and gynecology	2	1.2%
	Daycare unit	10	5.8%
	Dialysis	7	4.1%
	Medicine	35	20.3%
	Pediatrics	6	3.5%
	Intensive care	47	27.3%
	Wound care	13	7.6%
	Endoscopy	5	2.9%
Position	Student/intern	10	5.8%
	Registered nurse	151	87.8%
	Supervisor	11	6.4%

Characteristics of Nurses and Training to Perform Diabetic Foot Management

When evaluating the nurses’ training, we found that the majority received training as part of their nursing school curriculum (59.9%), whereas 15.7% relied on their in-service training program as their source of knowledge. Blood sugar was the most common topic discussed with the patients (77.3%), and applying initiatives to prevent diabetic foot was the main duty of KAUH nurses (70.3%) (Table 2).

Table 2.

Nurses’ Education and Training

Characteristic	Answer	N	%
Have You Received Any Training to Perform Diabetic Footcare?
Within the curriculum of nursing education	No	69	40.1%
	Yes	103	59.9%
Within an in-service training program	No	145	84.3%
	Yes	27	15.7%
I attended courses, seminars, and symposium programs related to performing diabetic footcare	No	127	73.8%
	Yes	45	26.2%
I received no training	No	154	89.5%
	Yes	18	10.5%
Do You Discuss the Following Topics With Diabetic Patients?
Blood sugar control	No	39	22.7%
	Yes	133	77.3%
Foot examination	No	88	51.2%
	Yes	84	48.8%
Footcare	No	63	36.6%
	Yes	109	63.4%
Footwear selection	No	104	60.5%
	Yes	68	39.5%
Amputation	No	148	86.0%
	Yes	24	14.0%
None	No	146	84.9%
	Yes	26	15.1%
Do You Perform the Following For Diabetic Patients in Your Department?
Provide information about diabetic foot risk factors and etiology	No	62	36.0%
	Yes	110	64.0%
Perform foot examinations	No	99	57.6%
	Yes	73	42.4%
Apply initiatives to prevent diabetic foot	No	51	29.7%
	Yes	121	70.3%
Help with footwear selection	No	101	58.7%
	Yes	71	41.3%

Nurses’ Knowledge Based on the Diabetic Foot Management Scores

The average total score for the entire questionnaire was 59 (SD, ±7). Table 3 shows the scores for the four subsections of the questionnaire (risk factors, foot examination, foot complications, and footwear selection).

Table 3.

Scores for the four subsections of the questionnaire, SD, standard deviation.

	Mean	SD	Lowest Score	Highest Score
Risk factors	14	2	8	16
Foot examination	9	1	5	10
Foot complications	27	4	14	31
Footwear selection	8	2	4	10
Total score	59	7	37	67

When examining each factor individually, we found that almost all the nurses (98.8%) considered glycemic control to be the most important risk factor affecting their patients. Regarding the foot examination, most nurses (99.4%) indicated that the factor they most commonly focused on was foot color (pale, red, cyanosed). All nurses indicated that reporting any changes to the feet and toes (color, temperature, or shape) and signs of infection to the physician was the best way to prevent DM foot development. Most nurses (98.3%) reported that recommending soft and comfortable shoes was the most beneficial advice provided to patients (Table 4).

Table 4.

Answers to the Four Subsections of the Questionnaire

		N	%
Do You Considering the Following as Risk Factors?
Poor glycemic control	No	2	1.2%
	Yes	170	98.8%
Presence of the sense of chill, pain, burning, tingling, and tenderness in the foot	No	28	16.3%
	Yes	144	83.7%
Neuropathic foot (loss of sensory motor function)	No	5	2.9%
	Yes	167	97.1%
Peripheral vascular disease	No	12	7.0%
	Yes	160	93.0%
Inadequate foot care and lack of hygiene	No	10	5.8%
	Yes	162	94.2%
Presence of foot edema	No	24	14.0%
	Yes	148	86.0%
Presence of foot callus	No	41	23.8%
	Yes	131	76.2%
Dry and cracked foot skin	No	31	18.0%
	Yes	141	82.0%
Diabetic foot history or diabetic ulcer on the opposite extremity	No	24	14.0%
	Yes	148	86.0%
Infection (redness, tenderness, and temperature increase of the foot)	No	10	5.8%
	Yes	162	94.2%
Trauma (barefoot walking, poor-quality shoes, accident, foreign body in the shoes)	No	12	7.0%
	Yes	160	93.0%
Foot deformity (mallet toes, claw toes, hallux valgus, amputation, Charcot deformity, low foot, etc.)	No	36	20.9%
	Yes	136	79.1%
Smoking	No	28	16.3%
	Yes	144	83.7%
Obesity	No	19	11.0%
	Yes	153	89.0%
Age 65 years or older	No	24	14.0%
	Yes	148	86.0%
Patients not trained to recognize or care for diabetic foot	No	13	7.6%
	Yes	159	92.4%
Do You Perform the Following During Foot Examinations?
Foot skin (color change, edema, atrophy, dryness, crack, callus, ulcer, etc.) is evaluated	No	1	0.6%
	Yes	171	99.4%
Color (pale, cyanosis, red) is evaluated	No	5	2.9%
	Yes	167	97.1%
Temperature (temperature, coldness) is evaluated	No	13	7.6%
	Yes	159	92.4%
Presence of foot neuropathy (pain, tingling, burning, tenderness, sensory loss) is evaluated	No	4	2.3%
	Yes	168	97.7%
Muscle functions (atrophy caused by motor damage in the muscles) are assessed	No	16	9.3%
	Yes	156	90.7%
Circulation (foot is pale and cyanosis) is evaluated	No	6	3.5%
	Yes	166	96.5%
Presence of foot ulcers (temperature increase, redness, edema, and tenderness of the foot) is evaluated	No	3	1.7%
	Yes	169	98.3%
Presence of deformity (hammer finger, claw, hallux valgus, amputation, Charcot deformity, low foot, etc.) is evaluated	No	22	12.8%
	Yes	150	87.2%
Toenails (thickening, ingrowth, and length of the nails) are evaluated	No	22	12.8%
	Yes	150	87.2%
Shoe suitability is assessed	No	9	5.2%
	Yes	163	94.8%
Do You Provide the Following Advice for Preventing Foot Complications?
Feet should be checked every day by the patient or a relative using the eyes, hands, and a mirror (callus, crack, redness, bulla, open wound, etc.)	No	1	0.6%
	Yes	171	99.4%
Feet should be washed with warm water every day	No	23	13.4%
	Yes	149	86.6%
The water temperature used for washing feet should be checked	No	9	5.2%
	Yes	163	94.8%
Feet, especially the spaces between the toes, should be dried very well after each wash	No	1	0.6%
	Yes	171	99.4%
Moisturizing cream should be applied to feet	No	12	7.0%
	Yes	160	93.0%
Moisturizing cream should be applied to the spaces between the toes	No	27	15.7%
	Yes	145	84.3%
Toes should be kept dry to prevent fungal growth	No	5	2.9%
	Yes	167	97.1%
Cutting tools and chemicals should not be used to remove calluses or hardened skin areas	No	11	6.4%
	Yes	161	93.6%
Callus and skin stiffness should be thinned with a pumice stone	No	40	23.3%
	Yes	132	76.7%
Exercise in the form of twisting and stretching the toes several times per day should be performed to prevent the formation of foot corns and calluses	No	27	15.7%
	Yes	145	84.3%
It is beneficial to use a callus band and plaster	No	45	26.2%
	Yes	127	73.8%
Only socks should be worn to warm feet	No	42	24.4%
	Yes	130	75.6%
Direct heat sources (radiators, hot water bottle, electrical appliances, etc.) should be used to warm feet	No	92	53.5%
	Yes	80	46.5%
Socks should not be torn, wrinkled, or oversized	No	16	9.3%
	Yes	156	90.7%
Socks should be checked for wetness and darkness	No	16	9.3%
	Yes	156	90.7%
Socks should be changed every day	No	7	4.1%
	Yes	165	95.9%
Rubber socks that restrict the circulation should not be worn	No	24	14.0%
	Yes	148	86.0%
Wool socks should be worn during winter and mercerized socks should be worn during summer	No	10	5.8%
	Yes	162	94.2%
You should not walk with bare feet	No	9	5.2%
	Yes	163	94.8%
Relieve foot pressure by not standing for long periods	No	9	5.2%
	Yes	163	94.8%
Legs should not be crossed when sitting	No	26	15.1%
	Yes	146	84.9%
If there is clawing of the toes, then massage should not be performed to prevent joint stiffness	No	50	29.1%
	Yes	122	70.9%
Toenails should be controlled in terms of thickening, ingrowth, and length	No	13	7.6%
	Yes	159	92.4%
Toenails should be cut flat	No	21	12.2%
	Yes	151	87.8%
Skin around the toenails should not be cut	No	20	11.6%
	Yes	152	88.4%
Thickened nails should be cut with a special scissors after they are softened in warm water	No	13	7.6%
	Yes	159	92.4%
Blind patients must never cut their own toenails	No	6	3.5%
	Yes	166	96.5%
Toenails should be rounded	No	49	28.5%
	Yes	123	71.5%
Any changes to the feet and toes (color, temperature, or shape) and signs of infection should be reported to the physician immediately	Yes	172	100.0%
Foot exercises should be performed every day to help circulation	No	4	2.3%
	Yes	168	97.7%
In case of any foot lesion, only shoes should be replaced to reduce the load on feet	No	53	30.8%
	Yes	119	69.2%
Smoking is strictly forbidden because it will reduce the amount of blood to the feet	No	7	4.1%
	Yes	165	95.9%
Do You Provide the Following Information About Footwear Selection?
Shoes should fit properly	No	8	4.7%
	Yes	164	95.3%
Soft and comfortable shoes are recommended	No	3	1.7%
	Yes	169	98.3%
Shoes should be checked for foreign bodies (such as nails, gravel, etc.) before each wear	No	7	4.1%
	Yes	165	95.9%
Shoes should be worn without socks	No	99	57.6%
	Yes	73	42.4%
If shoe insoles are worn away, then they should be replaced	No	5	2.9%
	Yes	167	97.1%
Shoes should not lose their exterior protection feature	No	4	2.3%
	Yes	168	97.7%
Shoes should be cleaned frequently	No	91	52.9%
	Yes	81	47.1%
Allow feet to get used to new shoes by wearing them	No	24	14.0%
	Yes	148	86.0%
High-heel shoes tapering forward are recommended	No	103	59.9%
	Yes	69	40.1%
If there is a foot deformity, then a physician should be consulted so that proper treatment and/or orthopedic shoes can be prescribed	No	9	5.2%
	Yes	163	94.8%

Nurses’ Sociodemographic, Professional, and Diabetic Foot Management Care Characteristics and Diabetic Foot Management Scores

Significant sociodemographic, professional, and diabetic foot management characteristics of the nurses involved in this study were compared to the total questionnaire scores. No statistically significant correlations were observed between the sex, marital status, duration of work in the department, training to educate patients about diabetic foot risk or problems, and training to perform foot examinations (p>0.05).

Additionally, there were no statistically significant differences between the subscale scores and training to perform DM foot care (all P<0.05). A further examination of the data revealed statistical significance only for marital status and footwear selection scores (8.13±1.59; p=0.009) and for educational background and risk factor scores (p=0.031) (Table 5).

Table 5.

Training and Subsection Scores, SD, standard deviation; SEM, standard error of the mean.

	Have You Received Diabetic Footcare Training	N	Mean	SD	SEM	p
Risk factors	Yes	102	14.18	2.245	0.222	0.823666
	No	70	14.10	2.181	0.261
Foot examination	Yes	102	9.47	1.031	0.102	0.421117
	No	70	9.33	1.271	0.152
Foot complications	Yes	102	27.12	3.936	0.390	0.764220
	No	70	26.93	4.223	0.505
Footwear selection	Yes	102	7.96	1.515	0.150	0.895414
	No	70	7.93	1.662	0.199
Total score	Yes	102	58.73	7.188	0.712	0.691543
	No	70	58.29	7.043	0.842

Discussion

Diabetic foot is a macrovascular complication of DM, and the majority of these patients will require amputation (14). Diabetic foot is considered the leading cause of hospitalization among individuals with DM (6). In addition to regular preventive care and treatment, a crucial aspect of diabetic foot prevention is the frequent education of all individuals with DM at every healthcare visit (15, 16). Diabetic foot management requires a multidisciplinary approach with an emphasis on the role of nurses because they are in direct communication with patients for long periods (13).

According to one study, education provided by nurses to patients at high risk for diabetic foot about proper foot care resulted in the prevention of foot ulcers and reduced amputations (17). Therefore, nurses must have sufficient knowledge and practical training to have an important role in the prevention of diabetic foot (18).

This study assessed the knowledge of several aspects of diabetic foot management among nurses at KAUH. Our results showed that most of the nurses received training regarding diabetic footcare through their school curriculum when they were nursing students. However, some nurses did not receive any training. Reinforcing that training to perform diabetic foot management as part of an in-service training program would compensate for any previous missed opportunities to receive training. One study mentioned that the low levels of knowledge of diabetic foot care were attributed to the lack of proper training and several other important factors, such as imprecise communication between different parties involved in the management plan and insufficient time allotted for each visit (19).

According to the International Diabetes Federation Report, the optimal management plan for the prevention and treatment of diabetic foot consists of regular foot evaluations, determination of the at-risk foot, education provided to the patients and healthcare staff, appropriate footwear, and early treatment of foot problems (20). Most of our participants reported that they educate their patients about blood sugar control and general footcare, perform diabetic foot risk factor assessments, and apply preventive initiatives. Other topics, such as the importance of regular foot examinations, footwear selection, and the risk of amputation, were not discussed with patients by the majority of nurses. Additionally, regular foot examinations were not performed by the nurses. Therefore, an optimum diabetic foot management plan was not implemented, as suggested previously.

Nurses were greatly concerned about poor glycemic control because it is a significant risk factor for diabetic foot; in one study, this concern led to a 1% decrease in glycated hemoglobin and can lead to a 35% reduction in diabetic complications (21). However, they were not as concerned with peripheral vascular disease, peripheral neuropathy, and infection, which are the three major factors for diabetic foot ulcers (22). The majority of nurses agreed that patients who are not educated about diabetic foot are at risk for its development. A systemic review concluded that patient education has an overall short-term positive impact on the foot care knowledge and behaviors of patients (23). However, it is uncertain whether patient education can prevent foot ulceration and amputation.

There was a significant relationship between the educational background of the nurses and their knowledge of the risk factors for diabetic foot. Most of the nurses had a high average questionnaire score compared to those reported by other studies (24–30). The majority of those studies attributed the poor knowledge and scores to the lack of formal educational and training programs because of limited access. The higher average score in our study could be attributed to the relatively better schools attended by the nurses and the fact that more than half of them had received a bachelor’s degree in nursing.

Appropriate education can prevent up to 85% of diabetic foot amputations (31). Additionally, it can reduce the burden of the disease and the respective costs of care (24). Consistent, intensive nursing education and interactive forms of training, such as workshops, regarding diabetic foot care are needed to further enhance the knowledge and assessment skills of nurses. Implementing a dedicated training program administered by a diabetic foot specialist with advanced training in this field is a feasible and inexpensive way to prevent foot ulcers and amputations in the long term, improve patient awareness and attitudes, and increase nurses’ confidence in managing diabetic foot ulcers (17, 32).

Conclusion

Nurses’ knowledge of diabetic foot is a crucial factor in the prevention of diabetic foot. The educational backgrounds of nurses reflect their knowledge of diabetic foot. Because nurses are in direct and frequent contact with patients, specialized training programs beyond basic nursing education will reinforce their knowledge and skills, resulting in an expected lower risk of amputation in the long term.