Content area
Aim
To explore learning methods for nurses caring for patients with diabetes, focusing on foot care.
Background
Effective foot care is essential to prevent complications in patients with diabetes. While nurses play a key role in this care, many lack adequate knowledge and skills. Continuous professional development and targeted learning interventions are crucial for improving nurses’ knowledge.
Design
A rapid review was conducted to synthesize existing evidence on learning interventions for nurses in foot care for patients with diabetes.
Method
The literature search was performed in PubMed, CINAHL, MEDLINE and Academic Search Premier, which were selected for their broad coverage of nursing and medical research. The review followed Dobbins’ five-step model, which involves defining a practice question, systematically searching for evidence, critically appraising sources, synthesizing evidence and assessing applicability and transferability. Additionally, the PRISMA 2020 checklist was followed.
Results
Eight studies were included, highlighting learning to improve and contain knowledge through various learning interventions such as e-learning, workshops, problem-based learning and multidisciplinary consultations. The findings indicate that interactive and practical learning methods improve nurses’ knowledge and skills in foot care for patients with diabetes.
Conclusions
Practical and interactive learning methods are crucial for enhancing nurses’ knowledge in foot care for patients with diabetes. Continuous education and reflection are essential for long-term improvements in clinical practice. Future research should focus on the learning process itself to better understand how nurses internalize and apply new knowledge. Emphasizing theoretical and practical aspects of education can lead to more effective and sustainable learning outcomes.
1 Introduction
Diabetic foot ulcers (DFU) are a serious and common complication of long-standing and long-term elevated blood sugar levels. Globally, an estimated 589 million people live with diabetes (
International Diabetes Federation, 2025) and it is estimated that between 19 percent and 34 percent of those will develop DFU during their lifetime. DFUs are associated with significant morbidity, with approximately 20 percent of affected individuals requiring lower-extremity amputation (
Armstrong et al., 2017). The mortality rate within one year after the DFU diagnosis is 10 percent (
Hoffstad et al., 2015; Meloni et al., 2020). Given the severity and prevalence of DFUs, the role of nurses in prevention and management is critical. To promote patients to manage the self-care of their feet, nurses require not only clinical skills, but also continuous professional development tailored to the complexities of diabetes care. Persons with diabetes require comprehensive prevention and care for their feet in accordance with established guidelines, particularly for those at high risk of developing foot ulcers, as outlined by the
International Working Group on the Diabetic Foot IWGDF (2023) (for definition of foot care, see
The prevention and early detection of foot-related risk factors are central to prevent DFU and nurses play a crucial role not only in providing prevention and care, but also in educating patients through supporting the person’s capability of self-caring the feet (SCSF) ( IWGDF, 2023). However, many nurses still face gaps in their knowledge, especially regarding diabetes care and, more specifically, foot care for patients with diabetes ( Alotaibi et al., 2016; McPherson et al., 2022; Nikitara et al., 2019). To address the gaps of managing foot care and SCSF, it is relevant to consider how different learning methods can support both the acquisition and application of knowledge in clinical practice. Learning methods can be defined as structured approaches that guide how teaching and learning are carried out, where methods represent broader strategies (such as lectures, discussions and workshops). Learning methods can be classified based on focus (whether teacher-centered, interactive, or student-centered), the type of activity, or the degree of learner participation, encompassing expository methods (such as lectures), collaborative problem-solving (for example, group case work) and metacognitive practices (such as reflection) ( Landøy et al., 2020). By applying appropriate learning methods, nurses could gain theoretical knowledge through formal education programs and practical knowledge through hands-on experience and clinical practice. Even when nurses possessed theoretical knowledge, they often found it challenging to apply this knowledge in practice. This was especially true when it came to conducting foot examinations and teaching patients about their own foot care and SCSF ( Kaya and Karaca, 2018). Nurses are responsible for ensuring ethical and high-quality care, including foot care and part of this responsibility involves engaging in continuing professional development (CPD) to keep their knowledge and skills up to date. By participating in lifelong learning and reflecting on clinical experiences, nurses can prevent complications and improve patient outcomes ( International Council of Nurses ICN, 2021). Reflective practice, as a deliberate and dynamic process, enables nurses to critically examine their actions, values and assumptions, fostering experiential learning and contributing to improved clinical reasoning and patient care outcomes ( Patel and Metersky, 2022). Building on this, CPD encompasses both formal and informal learning, each of which plays a vital role in nurses’ ongoing professional development. CPD includes both formal learning, such as courses and workshops ( Govranos and Newton, 2014) and informal learning, such as supervision, team meetings and reflection in daily practice ( Tews et al., 2017). Informal learning is often initiated by the nurse and occurs through everyday interactions with colleagues and patients ( Lammintakanen and Kivinen, 2012; Tews et al., 2017). Because it is unplanned and unstructured, informal learning is difficult to capture in research ( Govranos and Newton, 2014).
CPD programs have been seen as a key mechanism for ensuring that nurses could continuously update their knowledge and skills; for example, in specialized areas such as diabetes ( Al-Omary et al., 2024). These programs varied in their requirements across different countries, with some being voluntary and others mandatory ( Pool et al., 2016; Ross et al., 2013). In a meta-analysis, Mlambo et al. (2021) highlighted the importance of organizational support to engage in CPD, noting that leadership support, flexible work cultures and access to necessary resources were critical to the success of these programs. Barriers such as lack of time and heavy workloads were frequently cited as reasons why nurses did not fully engage in CPD activities ( Al-Omary et al., 2024; Mlambo et al., 2021). Al-Omary et al. (2024) suggested that facilitators for implementing CPD included the structure of the training, the relevance of the course content and the opportunity for communal learning. These elements were most effective when clearly connected to nurses’ daily practice. In line with these facilitators, e-learning has been increasingly recognized as a valuable modality for delivering CPD. According to Alfaleh et al. (2023), e-learning has emerged as an effective and flexible tool for nurses’ ongoing education. It has provided opportunities for nurses to access up-to-date knowledge and skills at their own pace and convenience, which was particularly beneficial given the demands of their profession. Despite its benefits, the full potential of e-learning has not always been realized due to challenges such as inadequate institutional support, limited access to the necessary technology and limited digital literacy. It was necessary to address these barriers to ensure that nurses could fully use e-learning platforms as part of their professional development, helping them continuously enhance their knowledge and improve the care they provided to patients ( Alfaleh et al., 2023).
Lifelong learning is central in the continuous development and enhancement of nurses’ clinical and conceptual skills, including in specialized areas such as diabetes and foot care including SCSF. Work-integrated learning, which involved applying theoretical knowledge in practical, real-world settings, was essential for strengthening nurses’ abilities to manage complex care situations. This type of learning bridged the gap between theoretical knowledge and practical application, enabling nurses to develop both procedural and conceptual skills critical for high-quality care ( Billett and Choy, 2011; Billett et al., 2018). By participating in a combination of structured educational programs and learning opportunities that arose in everyday clinical practice, nurses were able to adapt to changing healthcare environments and meet the complex needs of their patients. This process of lifelong learning was supported not only by the individual nurse’s motivation and engagement, but also by organizational support, which was essential for fostering an environment conducive to ongoing professional development ( Billett, 2022; Mlambo et al., 2021). However, there remains a need to explore how specific learning methods, particularly for specialized areas such as SCSF for patients with diabetes, to strengthen both clinical practice and professional development. Given the importance of continuous learning for nurses in diabetes care and the challenges posed by various barriers, it is necessary to systematically examine the current learning methods available for nurses focusing on foot care. To achieve this, the authors conducted a rapid review to explore and summarize the existing evidence on learning methods for nurses caring for patients with diabetes, with a specific focus on foot care.
2 Aim
The aim was to explore learning methods for nurses caring for patients with diabetes, focusing on foot care.
3 Method
A rapid review is a form of systematic review that has been adapted to deliver insights within a shorter time frame than traditional systematic reviews, enabling quicker decision-making ( Dobbins, 2017). Dobbins’ model consists of five distinct steps, which allow for a structured and rigorous methodology for searching, selecting and extracting data from literature based on predefined criteria. Selected elements of the PRISMA 2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist ( Page et al., 2021) were used to ensure rigor and consistency throughout the rapid review, given the absence of a specific checklist for rapid reviews ( Stevens et al., 2024). Joanna Briggs Institute (JBI) critical appraisal tools were used to assess the quality of the studies ( JBI, n.d.).
3.1 Define a practice question
The first step is to define a clear research question that will guide the entire review process. Following an extensive literature review, the following research question was formulated: What learning methods are used and how is knowledge learned, to increase nurses’ knowledge of foot care for patients with diabetes? The purpose of this question is to explore existing learning methods and their impact on nurses’ knowledge in managing diabetes care, specifically in the context of foot care. This formulation was developed through a review of previous studies and existing knowledge in the field of foot care for patients with diabetes. Examining current research and past learning methods ensured that the question was both researchable and practically relevant. Consultation with subject matter experts and a review of similar contributed to the formulation of a research question that would allow for a rapid review and synthesis of relevant literature ( Grant and Booth, 2009). The chosen question captures both the specific need to examine learning methods in diabetes care and how these methods can be applied in practice to enhance nurses’ ability to provide optimal foot care to patients with diabetes. The outcome was to describe changes in knowledge and skills in foot care for patients with diabetes. This study explores learning interventions for nurses caring for patients with diabetes.
3.2 Search for research evidence
The second step involves a systematic search for research evidence. In this study, the search was conducted by the first author in databases that were deemed most relevant for nursing and medical research; namely, PubMed, CINAHL MEDLINE and Academic Search Premier. These databases provide extensive coverage of scientific publications in healthcare and are commonly used to identify literature related to nurse education and diabetes care. Prior to the initiation of the search process, a consultation was held with a librarian to optimize the search strategy and ensure coverage of the relevant literature. In CINAHL, a combination of CINAHL Headings and free-text searches was used to ensure a broad range of hits. In MEDLINE and Academic Search Premier, free-text searches were used. The search terms used in CINAHL, MEDLINE and Academic Search Premier included “nurs*”, “diabetic foot*”, as well as “lear*” or “educational intervention”. In PubMed, both MeSH terms and free-text searches were employed. To maximize retrieval, we tested both “diabetic foot” and “diabetic feet” and found that “diabetic feet” yielded more relevant hits in PubMed. The selected terms used in separate PubMed searches were “diabetic feet”, “nurse*” as well as “learning” or “educational intervention”. To avoid missing any critical studies, the Boolean operators “AND” and “OR” were used to combine the search terms optimally. The search was conducted without time restrictions to obtain a overview of the topic and was adjusted based on pilot studies and consultation with co-authors. In the initial literature searches, it was observed that learning was primarily described in terms of the interventions, with a clear step-by-step description of how the educational activities were implemented, rather than focusing on the specifics of the learning itself. Adjustments were made as the search term for learning often focused on artificial intelligence, such as deep learning and machine learning. Therefore, the term “educational intervention” was used because the search term “education” primarily focused on nursing students’ learning/education rather than the learning of professionals. During this process, reference management software was used to facilitate both screening and data extraction, which enabled efficient handling of potentially relevant studies ( Dobbins, 2017).
3.3 Critically appraise the information sources
The third step is to conduct a quality assessment of the articles that were identified as relevant to the research question. The purpose of this assessment was to ensure that only methodologically robust and scientifically reliable studies were included in the review, which is crucial for strengthening the credibility and validity of the findings ( Wilson et al., 2022). Two reviewers independently conducted the assessment to reduce the risk of bias and ensure that a high scientific standard was maintained throughout the process ( Dobbins, 2017).
3.4 Synthesize the evidence – “putting it all together”
Once the studies had undergone the quality assessment described in the previous step, the process continued with the fourth step: data extraction. The goal of this step was to collect relevant information from the approved studies and synthesize it for further analysis. This process involved systematically gathering data on each study, such as author, publication year, study design, participants’ demographic characteristics and the main findings (
Dobbins, 2017). It was necessary to include all relevant data to ensure that no critical information was omitted, especially regarding learning methods for nurses in diabetes care with a focus on foot care. To facilitate data analysis, a data extraction table (
3.5 Identifying applicability and transferability issues
The final step involved applying the principles of applicability and transferability, assessing the potential to implement the identified learning methods in other clinical contexts beyond those where the studies were originally conducted. This assessment of the transferability of the research findings is crucial because methods that work effectively in one context may need to be adapted or adjusted to be useful in other healthcare environments ( Burchett et al., 2013).
4 Result
The systematic searches in PubMed, CINAHL, MEDLINE and Academic Search Premier yielded a volume of studies; however, to avoid the inclusion of irrelevant material, specific inclusion and exclusion criteria were developed. The first and last authors worked closely together during the literature search and selection process to ensure that the procedure followed the methodological description. The last literature search was conducted in September 2024. For instance, studies focusing on nursing students were excluded, as the review aimed to investigate learning methods for already qualified nurses; see
JBI critical appraisal tools were used to assess the quality of the studies. These tools were applied based on the type of study being reviewed, which allowed the reviewers to systematically evaluate each study’s reliability, relevance and findings ( JBI, n.d.). For qualitative studies, the JBI “Critical Appraisal Checklist for Qualitative Research” was used ( Lockwood et al., 2015). Quantitative studies, including quasi-experimental and quantitative studies, were assessed using the JBI “Checklist for Quasi-Experimental Studies” ( Tufanaru et al., 2020). Adaptations were made for studies lacking a comparison group by marking non-applicable items and focusing on relevant methodological aspects. Reviewers were able to use these tools to identify methodological weaknesses and ensure that the studies selected for further analysis were of scientific quality. The two reviewers involved in the process conducted the review independently and analyzed the strengths and weaknesses of each study. This process contributed to the relevance and trustworthiness of the review, which was essential for maintaining scientific standard in accordance with established quality assessment guidelines ( Dobbins, 2017; JBI, n.d.).
A total of eight publications were included in the final review: three from Iran ( Aalaa et al., 2022; Aalaa et al., 2021; Varaei et al., 2013), one from the United States ( Christensen et al., 1990), one from the United Kingdom ( Goulding and Bale, 2019), one from Canada ( Kuhnke et al., 2014), one from Switzerland ( Pataky et al., 2007) and one from Brazil ( Felix et al., 2021). Four of the included publications used a quasi-experimental design ( Aalaa et al., 2022; Aalaa et al., 2021; Varaei et al., 2013), two used a quantitative design interpreted as quasi-experimental based on pre- and post-test evaluations ( Christensen et al., 1990; Pataky et al., 2007), one used a qualitative design ( Kuhnke et al., 2014) and one used action research methodology ( Goulding and Bale, 2019). Aalaa et al. (2021) primarily compared e-learning with workshops, while Aalaa et al. (2022) focused only on workshops. Christensen et al. (1990) employed a more traditional learning approach, combining theory and practice. Felix et al. (2021) applied problem-based learning. Goulding and Bale (2019) used a mixed learning methods approach, incorporating both didactic instruction and practical tools. Kuhnke et al. (2014) explored participants’ views through open-ended surveys conducted during learning workshops. Pataky et al. (2007) employed multidisciplinary consultations, while Varaei et al. (2013) focused on workshops regarding evidence-based care. A common thread among all these studies is that they have not delved deeply into the learning process itself and instead focus more on outcomes like knowledge improvements. Some studies have evaluated the impact of training on nurses’ practices and routines, but the specifics of how nurses internalize and apply this learning remain underexplored ( Christensen et al., 1990; Pataky et al., 2007) ( Table 1).
5 Discussion
The aim of the present study was to explore learning methods for nurses caring for patients with diabetes, focusing on foot care. The review included a total of eight studies from various geographical contexts and with differing methodological approaches. Despite this variation, the studies primarily focused on the outcomes of education (such as increased knowledge or changes in routines) rather than on the learning process itself. While several studies showed that nurses’ knowledge improved following learning interventions, few described how this learning occurred. The studies predominantly emphasized formal learning, such as structured workshops and other organized training activities. Informal learning, which is typically self-directed, unstructured and often takes place through everyday interactions with colleagues and patients, was not addressed ( Lammintakanen and Kivinen, 2012). Consequently, there is a lack of deeper understanding regarding how nurses internalize, process and apply new knowledge in practice. This means that although the educational efforts appear to have had an effect, the mechanisms behind the learning remain largely unexplored. The findings of this review offer a comprehensive overview of the learning methods employed in nurses’ professional development for foot care for patients with diabetes and are discussed under two main thematic headings in the following sections. First, practice-based and interactive learning for direct clinical application emerges as a dominant theme. This emphasizes hands-on learning, where nurses participate in workshops, group discussions and interactions with patients to enhance their skills. Studies under this heading consistently show that practical engagement, whether through interactive workshops or problem-based learning, leads to significant improvements in nurses’ knowledge and clinical competence. The second heading – reflection and continuous education as tools for long-term learning – highlights the importance of integrating reflection and evidence-based education into nursing practice. Through repeated assessments, feedback and ongoing learning interventions, nurses not only acquire new knowledge, but also become better equipped to sustain changes in their clinical behavior over time. This heading underscores the lasting impact that structured reflection and continuous learning can have on improving clinical care. Both headings align with Billett’s (2022) view that lifelong learning is a dynamic process that requires not only the nurses’ own motivation and engagement, but also support from their organizations.
5.1 Practice-based and interactive learning for direct clinical application
This topic centers on practice-based and interactive learning methods designed to enhance nurses’ clinical skills in foot care and SCSF for patients with diabetes. Practical exercises and direct application have been shown to be particularly effective at improving nurses’ knowledge and ability to manage diabetes-related foot issues. This is particularly relevant as nurses often struggle to translate theoretical knowledge into practice, especially when it comes to foot examinations, SCSF and patient education ( Kaya and Karaca, 2018). Building on this, simulation-based teaching has been suggested as a promising approach to strengthen learning outcomes. For example, Anning and Tehan (2024) demonstrated that simulation in podiatry significantly improved knowledge, confidence and educational outcomes. Simulation offered a controlled environment where healthcare professionals could practice skills safely, with opportunities for repeated training and feedback, thereby enhancing both technical abilities and professional confidence. Learning assessments also showed positive results in knowledge retention and application, indicating that simulation may serve as an important complement to other practice-based learning strategies. These findings suggest that simulation may also support nurses in foot care
Aalaa et al. (2021) highlighted this point by comparing the effects of an e-learning course with an interactive workshop on foot care for patients with diabetes. While both methods led to improved knowledge, the interactive workshop was superior, with a significantly higher learning value (66 percent compared with 42 percent). This underscores the importance of integrating practical elements and group discussions into the training, as nurses could apply their knowledge directly in concrete situations. Although e-learning can support CPD cost-effectively, its impact may be limited by nurses’ digital literacy and the lack of adequate digital technology and support in healthcare organizations ( Alfaleh et al., 2023). Building on the value of practical engagement, Felix et al. (2021) demonstrated that a problem-based learning approach with a focus on practical exercises led to a broader understanding of the prevention and assessment of diabetes-related foot complications. This methodology allowed nurses to apply theory to real clinical scenarios, which significantly improved their skills and clinical decision-making. The ICN (2021) stressed that nurses have a personal responsibility to maintain ethical practice through continuous professional development. Part of this responsibility is participation in practical and interactive education, which allows nurses to implement their knowledge directly in clinical settings. According to Mlambo et al. (2021), a supportive work environment with access to resources plays a crucial role in effective learning, but high workloads and a lack of time can be barriers to participation in continuing education. Aalaa et al. (2022) broadened the practical approach by describing a multidisciplinary workshop with hands-on sessions where nurses and physicians jointly improved their practical skills. By working with patients and engaging in practical activities such as debridement and wound dressing, the nurses not only gained theoretical knowledge, but also had the opportunity to practice in real-world clinical situations. This led to improvements in the diagnosis and treatment of diabetic foot ulcers. Pataky et al. (2007) emphasized the importance of continuous practical training through a multidisciplinary consultation program focused on patients with diabetes with foot ulcers and neuropathy. Through regular meetings and practical discussions on therapeutic strategies, nurses improved both their theoretical and practical skills, resulting in long-term improvements in their care practices. Finally, Goulding and Bale (2019) illustrated how a combination of practical demonstrations, e-learning and mentorship at the ward level led to improved compliance with performing a structured foot assessments. By offering a multifaceted education that integrated direct practical guidance, nurses were able to perform more guideline-adherent foot assessments and apply their newly acquired knowledge in clinical work. Billett and Choy (2011) described how work-integrated learning enables the connection between theoretical knowledge and practical experience, enhancing nurses’ capacity to handle complex care situations. This finding emphasizes the importance of applying abstract knowledge in concrete care contexts, making the learning more sustainable over time.
Together, the above-mentioned studies demonstrate that practical and interactive learning is crucial to improve nurses’ clinical skills. By actively participating in educational elements, whether in workshops, group discussions, or direct patient encounters, the nurses’ learning becomes more applicable and sustainable over time.
5.2 Reflection and continuous education as tools for long-term learning
This topic focuses on the importance of reflection and continuous education in achieving long-term changes in nursing practice. Here, the need to integrate evidence-based education and ongoing learning activities as a central part of professional development emerges. Christensen et al. (1990) explored the effects of a learning model that focuses on theoretical knowledge, while also emphasizing reflection and practical application over time. Asking nurses to assess five patients over a six-week period and reflect on their experiences in follow-up sessions achieved a broader understanding of foot care. This continuous process led to lasting changes in their clinical practice and ability to integrate new knowledge into daily routines. Varaei et al. (2013) emphasized the importance of evidence-based nursing education as a tool to improve nurses’ knowledge and skills. Introducing workshops that taught participants how to develop clinical questions and search for high-quality evidence increased the nurses’ ability to apply research-based knowledge in clinical practice, which led to significant improvements in their daily care routines and a better understanding of how evidence can be used to enhance care. Ross et al. (2013) reinforced this point, emphasizing how CPD programs play an important role in ensuring that nurses’ knowledge and skills remain current, which is critical in meeting complex patient needs. Kuhnke et al. (2014) highlighted the importance of regular and relevant education, identifying how nurses and other healthcare providers benefited from ongoing learning efforts that included both theoretical and practical aspects. By providing timely educational modules and relevant case studies, the knowledge was quickly implemented into daily clinical practice, contributing to long-term improvements in care quality. By reflecting on their experiences and continuously updating their skills, nurses can sustainably incorporate new methods. This was emphasized by Alfaleh et al. (2023), who noted the potential of e-learning when appropriate support and equipment are provided. Aalaa et al. (2022) extended this theme by showing how their multidisciplinary workshop not only improved knowledge and skills, but also how this learning effort had a long-term impact on how nurses and doctors handled foot ulcers in patients with diabetes in clinical settings. By constantly reflecting on their experiences and updating their skills, healthcare providers were able to integrate new practices in a sustainable way.
These studies demonstrate that reflection and continuous education are essential for creating lasting changes in nurses’ practice. By constantly evaluating and improving their knowledge, nurses can maintain a high standard of care and ensure that they apply the latest evidence-based research in their daily work. In this context, reflective practice has been identified as a key component of lifelong learning, where nurses critically examine their actions and experiences to develop clinical reasoning and improve the quality of care ( Patel and Metersky, 2022; ICN, 2021).
5.3 Sustainable change through reflection and continuous learning
Dobbins’ (2017) final step involved applying the principles of applicability and transferability, assessing whether effective learning methods, such as workshops, e-learning, problem-based learning and multidisciplinary consultations, can be adapted to healthcare settings beyond those where they were first tested. While practice-oriented and interactive approaches show the greatest potential, their impact depends on organizational support, available resources and a culture that promotes continuous learning. Sustainable change further requires reflection, feedback and experiential learning, rather than focusing solely on knowledge transfer. This also means that learning occurs not only through formal education, but continuously in daily practice and in interaction with colleagues and patients. To ensure transferability, the core elements of an intervention must be preserved while adapting the design to local needs and conditions. As Burchett et al. (2013) noted, transferability is determined not only by the content itself, but also by how it is perceived and applied in a new context.
5.4 Limitations
This research has certain limitations. First, the inclusion of studies from multiple countries presents both advantages and disadvantages. On one hand, using diverse international studies offers a broader perspective and makes it possible to compare learning methods across different healthcare systems and cultural contexts. This diversity can enhance the generalizability of the findings ( Dobbins, 2017). However, variations in healthcare practices, learning approaches and the interpretation of key concepts between countries may limit the direct applicability of the results in specific settings. Additionally, the exclusion of studies not published in English might have restricted the scope, which could mean that valuable insights from non-English-speaking contexts are missed ( Tricco et al., 2022). Nevertheless, we acknowledge that including nursing students can provide valuable insights into what is taught in education and students’ baseline knowledge for entry to practice, which may have long-term implications for nursing practice and teaching methods. While this was beyond the scope of the present review, it represents an important perspective for future research.
In the initial literature searches, it was observed that learning was primarily described in terms of the interventions, with a clear step-by-step description of how the educational activities were implemented. What was lacking, however, was an exploration of the learning process itself for the specific participants involved, particularly those caring for patients with diabetes and focusing on foot care. This gap highlights the need for further research into the underlying mechanisms of learning and how nurses internalize and apply new knowledge in their practice.
Another limitation is the relatively small number of studies identified in the literature search. Despite a comprehensive strategy, the limited pool of studies restricts the robustness of the conclusions about the learning processes in foot care for patients with diabetes in the context of education. This scarcity may indicate gaps in the literature regarding how nurses and healthcare professionals learn in this area. Expanding the scope of future research to include additional sources, such as grey literature, could ensure a more thorough understanding of the learning processes involved in foot care education for nurses responsible for diabetes care. This rapid review included both qualitative and quantitative studies to capture a broad understanding of the phenomenon. While this approach provided a richer perspective, it may also influence the validity and generalizability of the findings, as methodological differences between studies can affect comparability. Furthermore, no explicit time frame was applied in the selection of studies, since learning was considered as a phenomenon that is not limited to a specific period. Instead, inclusion was guided by relevance to the review aim. This choice increases the breadth of perspectives but may also introduce variation in how learning has been conceptualized across different contexts and time periods.
Although we identified studies that address formal learning methods such as workshops and structured courses, we did not find any studies that specifically explore informal learning among nurses in the context of diabetic foot care and SCSF. This gap could be due to limitations in the search strategy, suggesting that alternative keywords might be necessary. Alternatively, it may indicate that informal learning in this specific area remains underexplored and warrants further research.
In reflecting on the limitations of the research, one study stood out as not fully achieving the expected learning outcomes. Goulding and Bale (2019) reported that the ward-based learning intervention did not lead to significant improvements on Ward 1 and only partial success was seen on Ward 2. They highlighted barriers such as time constraints, engagement issues and resistance to change. While this may seem like a limitation, the study was not excluded because it still provided relevant insights into the complexities of applying learning interventions in clinical settings. Despite its limited success, Goulding and Bale’s study aligns with the research objective of exploring real-world challenges in diabetic foot care education, offering a broader understanding of the obstacles that healthcare professionals face when integrating new learning into practice.
6 Conclusions
This study has shown that continuous practice-based and interactive learning methods for clinical application and reflection are crucial for enhancing nurses’ knowledge in foot care and SCSF for patients with diabetes. Practice-based and interactive learning methods for direct clinical applications address hands-on learning, where nurses participate in workshops, group discussions and interactions with patients to enhance their skills. This practical engagement reflects the need for organizational support to create learning opportunities that are directly applicable to clinical settings. The use of reflection and continuous education as tools for long-term learning underscores the lasting impact that these tools can have on improving clinical care. Both aspects align with the view that lifelong learning is a dynamic process that requires not only the nurses’ own motivation and engagement, but also the support from their organizations. Together, these aspects highlight that effective professional development involves a balance between individual initiative and a structured learning environment, allowing nurses to acquire new knowledge and sustain clinical improvements over time. However, given the emphasis on the value of hands-on and reflective learning, the way where the learning process itself unfolds tends to be overlooked. This lack of focus on the learning process raises certain considerations within the broader context of education. Learning is not just about the acquisition of knowledge, but also how individuals process, reflect on and apply new knowledge in practice. Although learning methods and improvements in test scores and clinical routines are highly emphasized, they also tend to fall short in terms of exploring how learners engage with learning material, use critical thinking skills, or integrate theoretical knowledge into their daily care routines. For future research, it is essential to analyze not only the immediate impact of learning interventions, but also how the learning process itself is facilitated and sustained over time.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statement
Björk Kristofer: Writing – original draft, Methodology, Formal analysis, Conceptualization. Hellstrand Tang Ulla: Writing – review & editing, Conceptualization. Andersson Susanne: Writing – review & editing, Conceptualization. Eriksson Henrik: Writing – review & editing, Methodology, Formal analysis, Conceptualization.
Declaration of Competing Interest
Nothing to declare.
Acknowledgements
This work was conducted in collaboration with and supported by the infrastructure of the Swedish Research School in Integrated Care for Future Teachers (
Table 1
| Author year | Type of study | Population | Summary of findings | Learning strategies |
|
Aalaa et al. (2021)
Iran |
Quasi-experimental study | Nurses (n = 77).
Intervention group 33 (10 male/23 female, age <25–>45) and control group 40 (14 male/26 female, age <25–>45). |
The study demonstrated that both the e-learning course and the workshop format led to significant improvements in participants’ knowledge of preventing and treating diabetic foot ulcers, with increases in test scores from pre-test to post-test in both groups. However, the workshop format proved to be more effective, accounting for 66 percent of the improvement in knowledge, compared to 42 percent for the e-learning course, highlighting the greater impact of interactive learning on knowledge acquisition in this area. | E-learning course (intervention group) and a face-to-face interactive workshop (control group) on preventing and treating diabetic foot ulcer using a pre-test and post-test evaluation. |
|
Aalaa et al. (2022)
Iran |
Quasi-experimental study | Nurses and physicians (n = 396). 61 male/335 female, age 30–34. | The study showed a significant improvement in the participants’ knowledge, with pre-test scores ranging from 1 to 17 and post-test scores from 6 to 20, reflecting a substantial increase after the educational intervention. The practical significance of the change was measured at 1.42, indicating that the learning outcomes were positively impacted by the intervention. | Workshop, conducted over two days, facilitated learning through interactive lectures and small group discussions. Pre-test and post-test evaluation. |
|
Christensen et al. (1990)
United States |
Quantitative | Nurses (n = 23). 23 female, age 22–51. | The study demonstrated that the educational program significantly improved nurses’ comfort and confidence in handling difficult aspects of foot care, such as dealing with unsightly or smelly feet. Additionally, the program fostered a more empathetic approach to patient care, improved patient communication, and led to lasting changes in foot assessment and care practices, with 91 percent of nurses reporting improvements in their clinical routines. | Educational program with theoretical instruction and practical demonstrations, pre-test and post-test evaluation. |
|
Felix et al. (2021)
Brazil |
Quasi-experimental study | Nurses (n = 53). 53 female, age 23–63. | The study revealed a significant increase in nurses’ knowledge about diabetic foot care after the educational intervention, particularly in areas related to neurological assessments, where the post-test results showed statistically significant improvements. Despite the overall knowledge gains, some gaps remained, with the lowest post-test performance relating to the frequency of foot assessments based on risk classification. | The educational intervention methods included the problem-based learning approach, pre-test and post-test evaluation. |
| Goulding and Bale (2019) United Kingdom | Action research methodology | Nurses (n = 33). Gender not specified, age 21–> 51. | The study found that both wards had similar initial levels of diabetic foot assessments (DFA) performed, with no significant improvement after the educational intervention and the introduction of the foot protection tool (FPT), especially in Ward 1, which faced challenges due to staff shortages. Despite a slight increase in DFA completion by Week 12, most assessments lacked key components like pulse palpation and sensory testing, limiting the ability to assess patients’ risk of developing diabetic foot ulcers (DFU). However, there was improvement in skin inspections, and increased support from the medical staff in Ward 2 facilitated discussions about expanding DFA practices throughout the organization. | Mixed educational methods provided to nurses on two wards, which included completion of a DFA tool (Foot Protection Tool). |
|
Kuhnke et al. (2014)
Canada |
Qualitative, descriptive study | Participants were health-care managers, clinical leaders, nurses and
allied health members who are part of wound care services. (n = 261 participants took part and n = 194 surveys were returned). Age and gender not specified. |
The study highlighted the need for comprehensive, evidence-based education for healthcare staff on wound care, emphasizing topics such as diabetic foot assessments, pressure ulcer prevention, surgical wound care, and the proper use of compression in treating leg ulcers. Participants recommended a mix of e-learning modules, hands-on training, and patient education materials, with an emphasis on consistent, context-specific education delivered by trained wound care specialists. The study also identified the need for better access to diagnostic tools like ABI and Doppler equipment, alongside sufficient time, policies, and managerial support to ensure safe and effective wound care practices. | Open-ended surveys were distributed to participants in a series of learning workshops. |
|
Pataky et al. (2007)
Switzerland |
Quantitative | Different professions of health care providers (HCP) (doctors, nurses, nursing aides, physiotherapists, occupational therapists, speech-language therapists, and psychologists). 236 questionnaires before the education and 172 questionnaires 12 months later.
Age and gender not specified. |
The study demonstrated significant improvements in knowledge for nurses, nursing aides, and other healthcare professionals after 12 months of an educational program, with statistically significant increases in correct answer rates and overall knowledge scores. However, medical doctors did not show a statistically significant improvement in their knowledge scores over the same period, indicating that the program's impact varied across different professional groups. | Educational program consisted of a multidisciplinary biweekly consultation, managed by a
specialist and attended by different HCPs in charge of the patient, pre-test and post-test evaluation. |
|
Varaei et al. (2013)
Iran |
Quasi-experimental study | Nurses (n = 19). 2 male/17 female. Age 20–29. | The study demonstrated that, following the intervention, nurses’ attitudes towards evidence-based nursing (EBN) improved significantly, with a shift from predominantly neutral to a majority holding a positive attitude. Additionally, there was a notable enhancement in EBN practice and performance in assessing diabetes foot care, with mean scores increasing significantly over time, reflecting effective learning and application of the EBP approach in practice. Nurses’ performance also significantly improved in analyzing and investigating diabetic foot ulcers, with a notable difference in mean scores between the second and third months after the intervention. | Before and after educational intervention (workshops of evidence based practice), the data about nurses’ knowledge, attitude, and practice were gathered by questionnaire and then compared. |
© 2025 The Authors