This was a descriptive cross-sectional analytical study using a self-administered questionnaire.

The study was conducted in public health centres within Sol Plaatje Municipality in the Frances Baard District, Northern Cape. Sol Plaatje sub-district comprises 14 clinics, namely: Galeshewe Community Health Centre, Ritchie, City Clinic, Beaconsfield, Floors Clinic, Betty Gaetsewe, Masakhane, Mapule Matsepane, Dr. Winston Torres, Platfontein, Madoyle Clinic, Phutanang, Greenpoint and Riverton Clinic. Northern Cape is the least populated province in South Africa, with an estimated population of 1 263 875 as of 2019. Approximately, 31% of the populace is younger than 15 years, 64% is between 15 years and 64 years and 5% is over 60 years. The province has the largest land area in the country, with a surface area of 372 889 km².²⁶

The study population consists of 128 individuals taken from the human resource database from the 14 clinics in the Sol Plaatje sub-district. The study included all nurses working in the 14 clinics. The targeted population comprises 104 professional nurses, 5 enrolled nurses and 19 auxiliary nurses.

Professional, enrolled or auxiliary nurses working in one of the 14 public clinics in Sol Plaatje District Municipality who consented were included in the study.

The intended sample for the study consisted of a maximum of 128 participants. Feedback was received from 105 participants – 92 professional nurses, 3 enrolled nurses, 9 auxiliary nurses and 1 unspecified participant, with a response rate of 82%. The remaining 18 of the sample could not be reached either because they were on annual leave or quarantine or isolation from coronavirus disease 2019 (COVID-19), thus absent during visits to their respective clinics. One was discarded for incorrectly filling the forms, and four declined to give consent. The study included everyone who satisfied the inclusion criteria; a power calculation to determine an adequate sample size was unnecessary.

Self-administered questionnaires were used to gather data from the participants. The questionnaire was designed based on information from the literature on diabetic foot care.^16,27,28 Further validation was done internally by the Department of Family Medicine at the University of the Free State.

The questionnaire consisted of four sub-sections designed to assess the following:

The pilot study was done at City Clinic in the last week of April 2020. Four professional nurses and one auxiliary nurse completed the questionnaires. No amendment was necessary, and data from the pilot study were not included.

The collected data were computed on an Microsoft Excel spreadsheet and analysed using SAS 9.4 software. Descriptive statistics were calculated, namely cumulative frequencies and percentages for categorical data and median. The results are presented in tables and graphs, and the association between variables was determined using appropriate statistical interpretations. Chi-square was used to determine the association between participants’ level of education and KAPs. The probability value (p-value) of less than 0.05 was accepted as statistically significant.

Ethical approval to conduct the study was obtained from the Health Sciences Research Ethics Committee (HSREC) of the University of the Free State with reference number UFS-HSD2019/1884/2104. Approval for data collection was also obtained from the Northern Cape Health Department identification number NC_2020SOL_001.

Number coding was used to ensure the confidentiality of the participants’ responses. No names or personal identifiers appeared on any research-related information or datasheet sent for statistical analysis. All paper-based records were kept in a secure location by the researcher and were only accessible to those involved in the study. All information was managed in a strictly professional and confidential manner.

A considerable number of the participants are unaware of the existence of the South African Diabetic Foot guideline, which is available online and may explain the sub-optimal level of knowledge among some of the participants in this study. An Australian study by Schoen et al. also found that the availability of diabetes foot care education brochures was low, particularly in rural settings.³⁰ There is, therefore, the need to increase nursing staff awareness of the guideline’s availability, with an emphasis on the importance of disseminating this information for improved diabetic foot care in the study setting.

The 60-s screening tool was developed by Sibbald et al. to identify high-risk diabetic foot status.²⁷ The tool is designed to quickly assess diabetic foot features, and a positive response to any item indicates the need for referral for specialist assessment.³¹ In the study setting, because of the unavailability of vascular surgeons, patients with high-risk diabetic foot features would be referred to general surgeons for management.

The study participants’ awareness of this screening tool is questioned, with indications that knowledge about its purpose and application may be insufficient. Only very few knew that the test was not to identify low-risk but high-risk diabetic feet. Poor knowledge was also shown in the response to some other items relating to this screening tool. For example, over half of the participants view a patient as high risk for diabetic foot only if both dorsalis pedis and posterior tibialis arteries pulses are absent. Periodic continuing healthcare provider education and training on this subject by healthcare professionals knowledgeable about diabetic foot care in collaboration with organisations such as SEMDSA may be needed. An educational intervention among primary care nurses in Brazil was shown to improve knowledge of diabetic foot care.³²

It was, however, applaudable that the majority of the participants were aware that diabetic foot is associated with neurological and vascular complications. The majority also knew that smoking cessation, weight reduction and good blood supply can decrease the risk of diabetic foot. The participants’ knowledge of diabetic foot care and relevant safety measures was also satisfactory. Regarding foot examination, most participants knew the need to inspect the 4th and 5th web spaces. There was, however, a poor knowledge of the 10 g monofilament used to check for neuropathy.

A study by Albagawi et al.³³ showed that nurses can play a crucial role in enhancing patients’ understanding, particularly in the context of diabetic care. Implementing educational programmes can significantly enhance the quality of life for individuals with diabetes by fostering self-care practices, particularly in relation to foot care.³⁴ Furthermore, nurses are strategically positioned to identify high-risk patients within the community, often overseeing community health workers, thus contributing to preventing or delaying diabetes-related foot issues.²⁰ The suboptimal knowledge regarding the screening and examination of diabetic foot among some PHC nurses in the study setting raises significant concerns. Given that most PHC centres serve as the initial point of contact for patients and are predominantly nurse-driven,^35,36 the lack of adequate knowledge is particularly problematic. The failure or delay in referring high-risk patients could have serious consequences for their health and wellbeing. Urgent attention and targeted interventions, such as online diabetic education and training classes at a regular frequency and leaflet distribution to healthcare workers and patients, are necessary to address these knowledge gaps and enhance the capabilities of PHC nurses in managing diabetic foot issues effectively.

Overall, it was reassuring that most (84.8%) of the study participants had moderate to good knowledge about diabetic foot care. There is, therefore, a foundation to build upon and potential for improvement through targeted interventions and education.

In this study, most participants strongly agree that educating diabetic patients is an important part of their jobs. A systemic review by Nikitara et al. supports the role of nurses as educators and the positive outcome of diabetic education on patients’ glycemic control when nurses play this role.³⁷ Chawla et al., in a case-control study in India, randomised patients to a case and control group; the case group received education on diabetes while the control group did not. They were followed up, and there was a significant decline in random blood glucose in the case group on follow-up.³⁸ This shows that effective health education can help maintain better glucose control and slow down disease progression and complications. Most nurses are trained to educate patients about various disease conditions, which would have influenced their positive responses. Most of the participants disagreed with the statement that it is not worth educating patients who already have foot ulcers. This was supported by Raju et al., who reported in their study about educational interventions and diabetic foot ulcers that educational interventions have reduced the severe foot complications and incidence of amputations associated with diabetic foot ulcers.³⁹ Most participants also disagree that diabetic education of patients is a waste of time; this was affirmed in a study by Manickum, Madiba and Ramklass, which showed that diabetic foot education effectively changed behaviours in patients with diabetes mellitus.⁴⁰ Lack of time on the part of the healthcare practitioners was not reported as a barrier to educating patients about foot care in the various studies reviewed.^41,42 This is in keeping with our study, where most of our participants disagreed with the statement that they do not educate patients with diabetes on diabetic foot problems because it is time-consuming. However, in some studies, authors and patients reported a lack of time on the side of healthcare practitioners as a barrier to diabetic foot care.^43,44

Most participants disagree with the statement, ‘I don’t think patients with diabetic foot problems are my concern’. Song and Chambers reported that intensive diabetic foot care and education by nurses reduce the amputation rate for high-risk diabetic feet and help control blood glucose.⁴⁵ In our study, some participants agree with this statement because, in certain instances, these patients are sent to specialists or podiatrists for management.¹⁸ In their study, Hill, Ellis and Gillison described different views of healthcare providers on the division of foot care responsibilities. Some practitioners prefer to pass on the responsibilities to the podiatrist as they are more focused on foot care.⁴²

Gallman, Corner and Johnson reported in a study about improving the detection of foot abnormalities in patients with diabetes that routine foot examinations should be completed and correctly documented using electronic medical records in the PHC setting.⁴⁴ This is in keeping with the response of our participants, who agree that patients with diabetes should have their foot examination recorded in their files at each visit to the PHC facility.

Most participants disagreed with the statement, ‘I do not like to examine patients’ feet as it stink’, which contrasts with other studies on nurses’ feelings about malodorous wounds; Ousey and Roberts reported that when healthcare workers come close to exudating malodorous wounds, it becomes stressful to remain close to these patients. They strive to protect the patient’s vulnerability and the healthcare workers’ defenselessness’. In our study, the nurses may have found it embarrassing to admit that bad odour affects their examination of diabetic feet because healthcare workers are expected to learn how to cope with bad odour.⁴⁶

Almost all participants agree that foot care awareness is important for patient self-care; this was supported by most of the studies reviewed.^42,43,47

More than half of the participants admitted that they had read the diabetes management guidelines for primary care providers. In a study on diabetes care and management by Albagawi et al., they reported that nurses with access to diabetes management guidelines performed better than their peers.³³ About two-thirds of our participants had never attended a class on how to care for patients with diabetic foot problems, and most responded ‘Yes’ to the question ‘Do you need training in diabetic foot care?’ despite a majority indicating that they have wound care experience. These are similar to findings in a study by Kaya and Karaca on the evaluation of nurses on diabetic foot care; it was reported that only one-third (34%) of the nurses enrolled in the study were trained in diabetic foot care, 77.5% did not perform diabetic foot examination on patients and 42.8% stated they need training in diabetic foot care.²⁰ The reason for this in our study may be the lack of specific training programmes on the knowledge and practical applications of diabetic foot care.

A majority of our participants, even though they agree that patients should have their foot examination recorded in their files, more than half of them said that they do not record the foot examination in their patients’ files. Documenting the findings of patients’ foot examinations in the patient’s records is important.⁴⁴ If it is not being documented, it was probably not done.

The majority of our participants say that they do ask and also check patients’ feet for loss of sensations, deformities, calluses, ulcers and footwear. This practice is also stipulated in the SEMDSA diabetic foot care guidelines for primary health care professionals,¹⁸ which healthcare practitioners must follow. Hidalgo-Ruiz et al., in a study on the assessment of diabetic foot prevention by nurses in Spain, reported that 96.58% asked their patients to remove their footwear, 78.34% performed thorough examinations such as footwear, socks, temperature, pain, changes in skin colour on the feet, presence of oedema and foot deformities, and 80.25% assessed the risk of developing diabetic foot. Barefoot examination was performed at each visit by 36.31% of participants.⁴⁸ This contrasted with findings by Kaya and Karaca on the evaluation of nurses on diabetic foot care, where 77.5% of nurses do not perform foot examinations for patients in their units.²⁰

Most of the participants in the study did not practice using the 60-s screening tool for their diabetic patients; this is a well-known tool that has been piloted and validated.²⁷ It has been modified and is used by nurses and other healthcare professionals in many countries, such as Canada and Guyana.⁴⁹ The participants in our study probably did not know about the existence of the screening tool because of poor education on diabetic foot care.

Most of the study participants say that they continually educate patients on diets and smoking cessation. Song and Chambers discussed the positive role of intensive patient education by nurses; educating patients with diabetic feet about diet and other lifestyle modifications helps reduce the risk of foot ulceration and amputation.⁴⁵ This supports the findings of our study: nurses are usually trained to provide self-management healthcare advice to patients about various medical conditions. In contrast, Kaya and Karaca, in their study on the evaluation of nurses on diabetic foot care, reported that only 18.6% of nurses in the study teach patients about blood sugar control.²⁰

The study benefited from a high response rate from the required number of participants, which enhanced the accuracy and data quality. However, because of the COVID-19 pandemic, some participants could not be reached. Also, the study could only focus on nursing staff as doctors only do outreach in 3 of the 13 clinics. As the study was conducted in only one municipality in the Northern Cape, the external validity of applying these findings to the entire Northern Cape and South Africa is limited. Furthermore, using the self-reported methods and non-homogenous groups of participants may have introduced bias, as they might have over-reported their attitudes and practices in the provision of diabetic foot care. Additionally, the study’s ability to differentiate between the expected knowledge levels for each professional group was limited, as a professional nurse may be more likely to possess better diabetic foot care guideline knowledge than enrolled or auxiliary nurses.