Prioritizing the Prevention of Diabetic Foot Disease: We Each Have a Role to Play

For nursing students

Study summary

People living with diabetes mellitus (DM) face a serious risk: diabetic foot disease (DFD). DFD can lead to ulcers, infections, hospital stays, limb amputation, and a lower quality of life. Preventing DFD is supposed to be a routine part of diabetes self-management, yet many people struggle to keep up with the daily foot-care tasks their care team recommends. This Canadian study, published in the Canadian Journal of Nursing Research by Audrey Walsh and Janet L. Kuhnke, asked a simple but important question: how do people actually manage the day-to-day work of protecting their feet from diabetes-related complications?

The researchers used a qualitative descriptive design, which is well suited to capturing real-world experiences in participants' own words rather than testing a specific hypothesis. They recruited 23 adults from small communities in an Eastern Canadian province (population 475 to 6,000) through posters placed in libraries, pharmacies, and senior centres. Participants ranged in age from 24 to 85 (mean age 56.5), included 13 women and 10 men, and had lived with diabetes anywhere from 13 months to 49 years. Six had type 1 diabetes, 12 had type 2, and 5 did not specify their type. Each person took part in a semi-structured, in-person interview lasting 40 to 60 minutes, which was recorded, transcribed, and analyzed using reflexive thematic analysis in NVivo software until the researchers reached data saturation, meaning new interviews stopped producing new insights.

Two major themes emerged from these conversations. The first, called Ineffective Coping: Distancing Self from Disease, describes how participants often mentally separated themselves from their diabetes to cope with its demands. This showed up in three ways: disconnecting, where people avoided foot checks or care when they felt fine, reasoning that they should not go looking for a problem; predestined thinking, where participants blamed genetics for their diabetes, telling themselves it runs in my family, which reduced their sense of personal responsibility for prevention; and personification, where people described their blood sugar as behaving on its own, saying things like my sugars creep up, as though the disease had a will separate from their own choices.

The second theme, Vacillating Responsibility: Multiple Mixed Messages, captures how participants received confusing and inconsistent signals from the people and systems around them about whose job it was to prevent DFD. Some described physicians who only addressed foot problems reactively, once something had already gone wrong, rather than emphasizing prevention up front. Others said their workplaces did not accommodate the practical needs of diabetes management, such as time for meals, medication, or properly fitted footwear, which the study describes as treating diabetes like an invisible disease. Many participants also expressed genuine uncertainty about exactly which foot-care steps they were supposed to follow, suggesting that the education they had received was incomplete or unclear.

Together, these themes suggest that DFD prevention is not simply a matter of individual willpower. It is shaped by how healthcare providers communicate, whether workplaces support self-management, and whether people are given consistent, clear guidance. The authors conclude that nurses are uniquely positioned to fill this gap: nurses can provide the ongoing education and support people need to carry out complex self-care routines, and they can also work to align the messages patients receive across different providers and settings.

For nursing students, this study is a reminder that patient education is not a one-time event delivered at diagnosis. Foot care for diabetes requires repeated, consistent reinforcement, and nurses should watch for signs that a patient is distancing themselves from their disease or receiving mixed signals from other sources. It also highlights that structural and workplace factors matter as much as individual motivation when it comes to whether people can realistically follow through on recommended self-care. Because this was a qualitative study with a relatively small, geographically limited, and largely homogeneous (22 of 23 participants were White) sample from small Eastern Canadian communities, the findings describe patterns worth exploring further rather than results that can be generalized to all people living with diabetes.

For educators

Teaching and appraisal notes

Walsh and Kuhnke's qualitative descriptive study, published in the Canadian Journal of Nursing Research, addresses a persistent clinical problem: despite clear guidelines, adherence to diabetic foot disease (DFD) prevention behaviours remains inconsistent, and DFD continues to drive morbidity, hospitalization, amputation, and reduced quality of life. Rather than measuring adherence quantitatively, the authors chose a qualitative descriptive approach with reflexive thematic analysis to surface how people experience and make sense of the daily work of foot self-protection, an approach well matched to a question about lived experience and meaning rather than prevalence or effect size.

The sample comprised 23 adults recruited via community posters (libraries, pharmacies, senior centres) in small communities (population 475-6,000) in an Eastern Canadian province. Ages ranged from 24 to 85 (mean 56.5); the sample included 13 women and 10 men; 6 participants had type 1 diabetes, 12 had type 2, and 5 did not specify type; disease duration ranged from 13 months to 49 years. Semi-structured interviews of 40-60 minutes were audio-recorded, transcribed, and coded in NVivo 11 using a constructivist reflexive thematic analysis approach, with recruitment continuing until data saturation was reached. This is a methodologically sound approach for the stated aim, though instructors should note the sample was 22 of 23 White participants from small, rural-adjacent communities, which substantially limits transferability to urban, ethnically diverse, or Indigenous-majority populations, and the authors acknowledge this limitation directly.

Two themes structure the findings. Ineffective Coping: Distancing Self from Disease describes three related mechanisms by which participants psychologically separated themselves from ongoing disease management: disconnecting (avoiding checks when asymptomatic), predestined thinking (attributing diabetes to heredity in ways that diminished perceived personal agency), and personification (describing glucose fluctuations as autonomous, e.g., 'my sugars creep up'). Vacillating Responsibility: Multiple Mixed Messages captures external, systemic contributors to inconsistent self-management: reactive rather than proactive care from physicians, workplace environments that functionally treated diabetes as an invisible disease by failing to accommodate meal timing, medication schedules, or appropriate footwear, and participant-reported uncertainty about correct foot-care techniques, suggesting gaps or inconsistencies in patient education.

For discussion, this study is useful for illustrating how thematic analysis moves from raw interview data to organizing themes and how a qualitative descriptive design differs from grounded theory or phenomenology in its lower level of interpretive abstraction. It also offers a strong prompt for examining the intersection of individual health behaviour and systemic/organizational determinants of health, a useful corrective to purely individual-blame framings of non-adherence. Faculty might pair this article with epidemiological Canadian data on DFD-related amputation (amputation rates in people with diabetes are substantially elevated relative to the general population, and the large majority of amputations are preceded by a foot ulcer) to contextualize why the stakes of inconsistent messaging are high.

Limitations meriting classroom discussion include the small, homogeneous, geographically concentrated sample; the qualitative design's inherent lack of generalizability; potential recruitment bias toward individuals motivated enough to respond to community posters; and the absence of provider or workplace perspectives, meaning the 'mixed messages' theme is described only from the patient's vantage point. The authors' clinical implication, that nurses are well positioned to provide consistent education and to coordinate messaging across providers and workplace settings, is a defensible extension of the findings and offers a concrete discussion point for students on interprofessional communication and care coordination in chronic disease management.