Abstract
Background
External ventricular drain (EVD) management is a critical aspect of neurosurgical nursing practice. Nurses play a central role in monitoring patients, identifying early signs of complications, and preventing EVD-related infections. Understanding their knowledge, attitude, and practice (KAP) regarding EVD management is therefore critical to improving care quality and patient safety.
Methods
A multicenter cross-sectional study was conducted in accordance with the STROBE guidelines. This study recruited neurosurgical nurses from 10 hospitals in Hubei Province, China, between May and June 2024. Data were collected online using a self-administered questionnaire assessing KAP toward EVD management. Descriptive statistics and the rank-sum test were used to describe the knowledge, attitude, and practice. Bootstrapping mediation analysis was performed to examine the associations among the knowledge, attitude and practice.
Results
A total of 398 nurses participated. The median (interquartile range) scores for knowledge, attitudes and practices were 8 (1.25), 50 (9) and 55 (5), respectively. Nurses with prior EVD-related training demonstrated significantly higher knowledge and practice scores (p < 0.001; p < 0.001). Furthermore, holding a senior professional title, having EVD-related training experience, possessing longer years of general or neurosurgical nursing experience, and older age were associated with more positive attitudes. Mediation analysis revealed that attitude significantly mediated the relationship between knowledge and practice, accounting for 38.27% of the total effect.
Conclusion
Neurosurgical nurses demonstrated positive attitudes and good practice towards EVD management. However, their knowledge required further improvement. Attitudes played a key mediating role in bridging theoretical knowledge and clinical practice in EVD management. The findings suggested that training programs should focus not only on knowledge dissemination but also on fostering positive professional attitudes to effectively improve clinical practice.
Trial registration
Not applicable.
Keywords: Nurses, Knowledge, Attitude, Practice, External ventricular drain management
Introduction
External ventricular drain (EVD) insertion is a common neurosurgical procedure used to monitor intracranial pressure (ICP) and decompress the cerebrospinal fluid (CSF) in patients with life-threatening neurological conditions, such as traumatic brain injury or hydrocephalus [1, 2]. Despite its clinical importance, EVD placement and ongoing management pose significant health risks to critically ill neurological patients, most notably EVD-associated infections (EVDAIs) [3, 4]. The reported prevalence of EVDAIs varied globally (Thailand: ≤5%, USA: 9.9%, Ethiopia: 25.8%, and Brazil: 36%) [1, 5–7]. For instance, a multicenter investigation of 58 hospitals with neurocritical units in Thailand reported the EVDAI rate was ≤ 5% [6]. While a prospective study in Brazil investigated 94 patients with spontaneous intracranial hemorrhage and reported the EVDAI rate of 36% [7]. EVDAIs were associated with adverse health consequences, including prolonged hospital stays, increased healthcare costs, and elevated mortality risks [1, 4]. Therefore, optimizing EVD management protocols is crucial to mitigate infection risks and improve overall patient outcomes [8].
Effective EVD management requires adherence to evidence-based guidelines, which included practices such as labeling EVD tubing, maintaining a closed drainage system, monitoring infection rates, and implementing multi-component interventions [4, 9–12]. However, the effective implementation of EVD management is often hindered by barriers such as knowledge deficits and poor adherence to EVD care protocols [2, 13, 14]. For example, a previous study reported that only 21% anesthesiologists received formal training in EVD management [2]. Besides, Alrashidi [14] found that 37% of nurses felt uncomfortable caring for patients with EVD due to inadequate knowledge, and only 6.5% were confident in troubleshooting EVD malfunctions. These barriers mainly stem from three factors: (1) insufficient knowledge of EVD-related guidelines; (2) poor attitudes or awareness toward the importance of EVDAIs prevention; and (3) inadequate hands-on experience in EVD care, which collectively undermine the quality of care [2, 4, 13]. As the frontline caregivers responsible for continuous EVD monitoring, early detection of EVD-related complications and troubleshooting, nurses play a pivotal role in EVD management. Understanding their KAP related to EVD management is therefore critical for developing targeted interventions that empower nurses to translate evidence-based knowledge into consistent high-quality clinical practices, thereby reducing preventable EVD-related complications and improving health-related outcomes for patients requiring EVDs.
The KAP model provides a valuable framework for assessing and improving clinical practice [15, 16]. It hypothesizes that knowledge enhances attitude, which in turn, shapes behaviors [17, 18]. Research has shown that enhancing nurses’ knowledge can lead to improved attitudes and, ultimately, more effective clinical practice [19]. While previous studies have explored KAP among healthcare providers in various clinical settings [2, 13], none has specifically examined the KAP regarding EVD management among neurosurgical nurses. Given that nurses are the frontline professionals responsible for the continuous monitoring, maintenance, and early detection of EVD-related complications. Their understanding and adherence to evidence-based EVD protocols are therefore pivotal to patient safety and clinical outcomes. The absence of empirical evidence regarding nurses’ KAP toward EVD management represents a critical gap that limits the development of targeted educational interventions and standardized clinical guidelines in neurosurgical nursing practice. Addressing this gap is particularly relevant in China, where structured EVD training programs and unified care standards remain underdeveloped across institutions. Therefore, this study aimed to bridge this gap by conducting a multicenter investigation to evaluate the KAP related to EVD management among Chinese neurosurgical nurses. By identifying specific disparities in KAP regarding EVD management, the findings would provide empirical evidence to inform the development of standardized EVD training modules and optimize clinical routines, thereby improving patient outcomes and advancing nursing quality in neurosurgical settings.
Method
Design
This was a multicenter cross-sectional study, conducted in Hubei Province from May to June in 2024. This reporting of this study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement.
Subjects and settings
The convenience sampling was employed to recruit nurses from neurosurgery departments across 10 hospitals (eight tertiary and two secondary hospitals) in Hubei Province, located in the central area of China. The research team first obtained institutional consent by contacting the nursing departments of participating hospitals. Then, leaders in the Nursing Department assisted in distributing the survey link, as a QR code, to neurosurgical nurses via WeChat workgroups. The recruitment targeted a broad range of nursing staff, including both frontline clinical nurses and those in managerial positions, such as charge nurses, head nurses, and nursing supervisors, to capture perspectives from different levels of neurosurgical nursing practice. Eligible participants completed the online questionnaire via mobile phones or personal computers. Upon scanning the QR code, participants were informed about the purpose of this study, and provided the electronic informed consent. To mitigate duplicate responses and ensure data integrity, submissions were restricted to one per IP address. The inclusion criteria were: (a) being a full-time registered nurse, (b) currently practicing in neurosurgery wards or neurosurgery intensive care units, (c) having at least six months of nursing experience in neurosurgical nursing, and (d) voluntarily agreeing to participate in the study. Nursing assistants, nursing interns, or trainees were excluded.
Sample size
The sample size for the mediation analysis was estimated using the power analysis for mediation models as proposed by Schoemann et al. [20].The calculation was conducted with a statistical power of 0.80 and a significance level of 0.05, using standardized coefficients and standard deviations derived from prior literature [21]. This analysis indicated that a minimum of 156 participants was required to detect a significant mediated effect. Accounting for a potential 20% non-response rate, the target sample size was set at 195.
Questionnaire design and data collection
The development of the questionnaire on knowledge, attitude, and practice of EVD management was guided by the KAP Model [22]. The first draft of the questionnaire was developed based on a comprehensive literature review [10–12], and discussions among the research team. To establish the content validity, the questionnaire was reviewed by an expert panel comprising 16 local experts in neurosurgery nursing, critical nursing, nursing research, and neurosurgery. All experts held senior academic titles (e.g., associate chief senior nurse/doctor, associate professor or above) and were affiliated with tertiary hospitals or medical colleges. The panel assessed the item clarity, relevance, and comprehensiveness. After two rounds of expert reviews and modifications, the questionnaire achieved good content validity indices. The item-level content validity index (I-CVI) ranged from 0.813 to 1.000, and the scale-level content validity index/universal agreement (S-CVI/UA) and scale-level content validity index/average (S-CVI/Ave) were 0.844 and 0.978, respectively. Prior to the formal data collection, a pilot study was conducted with 50 eligible neurosurgical nurses to assess the reliability of this questionnaire. Analysis of the pilot data yielded an overall Cronbach’s alpha coefficient of 0.937.
The final questionnaire included four sections: demographic data, knowledge, attitude, and practice dimensions. The demographic section included gender, age, educational level, professional title, years of nursing practice, time of nursing practice in neurosurgery departments, et al.
The knowledge dimension included 11 choice items primarily focused on key aspects of EVD management, such as the indications for EVD, the purpose of EVD, definition of increased ICP in adults, CSF drainage volume and rate in adults, complications associated with EVD, CSF sampling, and EVD removal. For example, Item K7 stated “CSF specimens are not routinely collected and are only obtained under the following circumstances” (Options: (A) Improvement in consciousness level; (B) Suspected intracranial infection; (C) Decreased muscle strength; (D) Occurrence of aspiration). Each correct answer was scored 1 point, yielding a total score range of 0–11 points, with higher scores indicating greater knowledge of EVD management.
The attitude dimension consisted of 10 items assessed using a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). This dimension assessed nurses’ perceptions of EVD management, including the perceptions of EVD’s impact, role perception in EVD management, and the importance of EVD management in clinical practice. For instance, Item A6 stated: “nurses should receive training on evidence-based care for EVD.” Total scores ranged from 10 to 50, with scores ≥ 4 per item indicating positive attitudes toward EVD management.
The practice dimension had 11 items rated on a 5-point Likert scale (1 = never to 5 = always). It assessed practices related to EVD maintenance as recommended in the guidelines, including EVD maintenance, dressing change, CSF sampling, documentation related to EVD, transporting patients with EVD, EVD management during changes in position, and caregiver’s education. For instance, Item P2 stated “nurse monitored the condition of patients with EVD, such as the color, volume, and characteristics of the CSF”. The total score ranged from 11 to 55, with higher scores indicating better adherence to appropriate EVD management practices.
Ethical considerations
Ethical approval was obtained from the ethics committee of the hospital (NO: TJ-IRB202409049). Prior to survey access, all potential participants were fully informed of the study’s purpose, the voluntary nature of their participation, and their right to withdraw at any stage without consequences. Written electronic informed consent was obtained from all participants. All data were collected anonymously, and confidentiality was strictly maintained throughout the research process.
Statistical analysis
Categorical variables were presented as frequencies and percentages. The total scores for knowledge, attitude, and practice were treated as continuous variables for all correlation and mediation analyses. The normality of continuous data was assessed using the Shapiro-Wilk test, which indicated a skewed distribution. For non-normally distributed continuous variables, medians and interquartile ranges (IQR) were used for statistical description. Differences in KAP scores across participants characteristics were analyzed using Wilcoxon rank-sum test or Kruskal Wallis rank-sum test.
To evaluate the potential mediating role of attitude in the association between knowledge and practice, bootstrapping mediation analysis with 5000 resamples was conducted. Bootstrapping is a robust, non-parametric resampling method used to test the significance of indirect effects in mediation analysis. It involves repeatedly sampling from the dataset with replacement to create an empirical approximation of the sampling distribution, which is particularly advantageous when data are not normally distributed. The model fit was assessed using several indices: Chi-square value (χ²/df), Comparative Fit Index (CFI), Tucker Lewis Fit Index (TLI), Root Mean Square Error of Approximation (RMSEA), and Standardized Root Mean Square Residual (SRMR). The data were analyzed using SPSS 27.0 and Mplus version 8.3. The p-value less than 0.05 was considered statistically significant.
Results
Characteristics of participants
A total of 407 participants were recruited, of whom 398 (97.8%) provided valid data for analysis. The analytical sample was predominantly female (n = 384, 96.5%). More than half of the participants (n = 233, 58.5%) possessed over 10 years of general nursing experience, with nearly half (n = 187, 47%) specializing in neurosurgery nursing for more than 10 years. The majority (90.7%) reported receiving training in EVD management. Participants reported utilizing multiple approaches to acquire EVD-related knowledge, including practice experience (95.2%), communication with colleagues (86.2%), specialist training (78.9%), self-directed learning (44%), college education (47.7%), and academic conferences/lectures (53.5%). Further details were provided in Table 1.
Table 1.
Scores of knowledge, attitude, and practice regarding EVD among neurosurgical nurses (N = 398)
| Dimension | Items | Percentage(%) |
|---|---|---|
| Knowledge | Correct | |
| K1 | The indications for EVD placement | 17.8 |
| K2 | The purpose of EVD | 75.4 |
| K3 | Definition of increased ICP in adults | 51.3 |
| K4 | The highest point of EVD | 31.4 |
| K5 | CSF drainage volume and rate in adults | 84.9 |
| K6 | Regular replacement of external ventricular drainage devices | 67.6 |
| K7 | CSF specimen collector | 98.5 |
| K8 | EVD clamping permitted per order for ICP measurement when indicated | 82.4 |
| K9 | The indications for EVD removal | 88.2 |
| K10 | The indications for CSF specimen collection | 96.2 |
| K11 | The complications associated with EVD | 86.9 |
| Attitude | Agree or strongly agree | |
| A1 | Scientific EVD management can improve patient outcomes | 94 |
| A2 | Nurses play an important role in the assessment of EVD | 92.2 |
| A3 | Nurses play a significant role in preventing infections associated with EVD | 91.7 |
| A4 | Nurses should possess knowledge of EVD management | 93.7 |
| A5 | EVD management requires collaboration among neurosurgeons, neurosurgical nurses, and other relevant professionals | 94.7 |
| A6 | Nurses should receive training on evidence-based care for EVD | 94.2 |
| A7 | A comprehensive management protocol for EVD should be established in clinical practice | 93.7 |
| A8 | willing to receive training on knowledge related to EVD | 94.2 |
| A9 | Patients and their caregivers are participants in the EVD management | 93.2 |
| A10 | Willing to participate in continuous quality improvement practices for EVD | 93.7 |
| Practice | Often or always | |
| P1 | Mark the EVD tubes with easily identifiable labels | 95.7 |
| P2 | Monitor the condition of patients with EVD, such as the color, volume, and characteristics of the CSF | 97.9 |
| P3 | Record drainage-related information at least hourly, including ICP values, the volume, color, and characteristics of the CSF | 98.5 |
| P4 | Maintain the closed system of the drainage device and minimize unnecessary open manipulations of the drainage system | 98 |
| P5 | Evaluate the sterile dressing at the puncture site for cleanliness and dryness and notify the physician if moisture or leakage is observed | 98.7 |
| P6 | Clamp the drainage tube if the patient’s condition is stable, when changing the patient’s position | 89.1 |
| P7 | Assess the individual condition before deciding whether to open or clamp the drainage tube during intra-hospital transport | 95 |
| P8 | Observe and monitor the patient’s vital signs, level of consciousness, ICP, and other relevant parameters before and after patient transport | 97.4 |
| P9 | Implement measures to prevent unplanned EVD removal | 97.5 |
| P10 | Monitor factors that may induce increased intracranial pressure in patients, such as low body position, urinary retention, constipation, and others. | 98 |
| P11 | Provide health education on EVD care to patients and their caregivers | 97.5 |
knowledge, attitude, and practice score
The median score for EVD knowledge was 8.00 (IQR: 1.25). The performance varied across knowledge items, with correct response rates ranging from 17.8% (K1) to 98.5% (K7). Nurses with EVD-related training experience had significantly higher knowledge scores than their untrained counterparts(p < 0.001).
The median score for EVD attitude was 50.00 (IQR: 9.00). Over 91.7% of nurses held a positive attitude towards EVD management. Notably, nurses with a senior nurse professional title (p = 0.003), EVD-related training experience (p < 0.001), longer years of general nursing experience (p = 0.038), longer years of neurosurgery nursing experience (p = 0.002), as well as older age (p = 0.003), reported more positive attitudes.
The median score for EVD practice was 55.00 (IQR: 5.00). Over 89.1% of nurses consistently applied appropriate practices related to EVD management. Nurses with practice in clinical nursing (p = 0.021) and EVD-related training experience (p < 0.001) reported better performance in EVD management practices. Detailed statistics for the knowledge, attitude and practice detentions for EVD management were presented in Table 2.
Table 2.
Differences in knowledge, attitude, and practice regarding EVD among nurses with multiple characteristics
| Items | N(%) | Knowledge Median (IQR) |
Attitude Median (IQR) | Practice Median (IQR) |
|---|---|---|---|---|
| Sex | ||||
| female | 384(96.5) | 8(3) | 50(9) | 55(5) |
| male | 14(3.5) | 8(2) | 50(5) | 55(6) |
| Z | − 0.112 | − 0.478 | − 0.323 | |
| P | 0.911 | 0.633 | 0.747 | |
| Age | ||||
| 30 years below | 84(21.1) | 8(3) | 47.5(10) | 55(11) |
| 30–40 | 231(58.0) | 8(2) | 50(8) | 55(5) |
| 40 years or above | 83(20.9) | 8(2) | 50(5) | 55(3) |
| H | 0.660 | 11.330 | 0.873 | |
| P | 0.719 | 0.003 | 0.646 | |
| Educational attainment | ||||
| Junior college or below | 34(8.5) | 7(2) | 48(8) | 54.5(8) |
| Bachelor’s degree | 358(89.9) | 8(2) | 50(9) | 55(5) |
| Master’s degree and above | 6(1.5) | 7.5(1) | 47.5(6) | 55(4) |
| H | 1.099 | 2.198 | 0.741 | |
| P | 0.577 | 0.333 | 0.691 | |
| Academic title | ||||
| Junior nurse | 26(6.5) | 7.5(2) | 42(9) | 48(11) |
| senior nurse | 142(36.4) | 8(3) | 50(10) | 55(6) |
| Supervisor nurse | 208(51.5) | 8(2) | 50(6) | 55(4) |
| Assistant chief senior nurse and above | 22(5.5) | 8(3) | 48.5(5) | 53.5(4) |
| H | 1.362 | 13.643 | 7.547 | |
| P | 0.715 | 0.003 | 0.056 | |
| Position | ||||
| Clinical nursing | 358(89.9) | 8(3) | 50(10) | 55(5) |
| Nursing management | 40(10.1) | 8(2) | 49(5) | 53(5) |
| Z | -1.529 | − 0.663 | -2.312 | |
| P | 0.126 | 0.507 | 0.021 | |
| Hospital level | ||||
| Tertiary hospital | 373(94.7) | 8(3) | 50(9) | 55(5) |
| Secondary hospital | 25(6.3) | 8(3) | 48(10) | 53(5) |
| Z | − 0.870 | − 0.575 | − 0.037 | |
| P | 0.384 | 0.566 | 0.971 | |
| Training experience | ||||
| none | 37(9.3) | 7(2) | 48(10) | 51(11) |
| 1-2times | 143(35.9) | 7(2) | 49(10) | 53(8) |
| ≥ 3 times | 218(54.8) | 8(2) | 50(4) | 55(2) |
| H | 15.857 | 20.839 | 38.888 | |
| P | < 0.001 | < 0.001 | < 0.001 | |
| Years of nursing practice | ||||
| 0–5 | 51(6.0) | 8(3) | 48(10) | 55(1) |
| 5–10 | 114(28.6) | 7(2) | 50(10) | 55(7) |
| 10 years above | 233(58.5) | 8(2) | 50(6) | 55(4) |
| H | 5.839 | 6.558 | 1.242 | |
| P | 0.054 | 0.038 | 0.537 | |
| Years of neurosurgery nursing practice | ||||
| 3 years or below | 63(15.8) | 8(3) | 46(10) | 53(11) |
| 3–5 | 53(13.3) | 8(1) | 49(10) | 54(8) |
| 5–10 | 95(23.9) | 8(3) | 50(4) | 55(5) |
| 10 years above | 187(47) | 8(2) | 50(5) | 55(4) |
| H | 1.688 | 15.333 | 5.774 | |
| P | 0.640 | 0.002 | 0.123 |
Mediation analysis of knowledge, attitude, and practice regarding EVD management
The Spearman’s correlation analysis indicated that knowledge was positively associated with both attitude (r = 0.25, p < 0.001) and practice (r = 0.24, p < 0.001). Additionally, attitude was positively associated with practice (r = 0.57, p < 0.001). The findings confirmed the hypothesis that knowledge would be associated with practice both directly and indirectly through attitude. Bootstrapping mediation analysis demonstrated the acceptable model fit (χ2/df = 4.889, p = 0 0.086, CFI = 0.97; TLI = 0.90; RMSEA = 0.06; SRMR = 0.04). There was a significant direct effect of knowledge on practice (β = 0.099, p = 0.04) and a partial indirect effect mediated by attitude (β = 0.062, p = 0.017), yielding a total effect of 0.162 (p < 0.01). The mediating role of attitude accounted for 38.27% of the total effect. Notably, the mediating effect remained robust even after adjusting for covariates such as practice in clinical nursing and EVD-related training experience (Fig. 1).
Fig. 1.
The final empirical model of knowledge, attitude, and practice regarding EVD management
Discussion
This is the first study to evaluate neurosurgical nurses’ KAP regarding EVD management. The findings indicated that neurosurgical nurses demonstrated acceptable levels of knowledge, positive attitudes, and appropriate practices in EVD management. Notably, both knowledge and attitude were associated with practice, suggesting that improvements in nurses’ understanding and professional attitudes may translate into better clinical behaviors in EVD management. The findings provided valuable insights into the current KAP status of EVD management among Chinese neurosurgical nurses, and may help inform the development of targeted interventions to better support nurses in the EVD management.
In terms of EVD-related knowledge, participants demonstrated a solid grasp of CSF specimen collection, EVD removal indicators, indications for CSF specimen collection, and the complications associated with CSF. It suggested that fundamental knowledge of EVD management was generally well established among nurses. However, notable deficiencies persisted in more specialized or technical domains, including the indications for EVD placement, the definition of elevated ICP, and the adjustment of EVD height. Such gaps among healthcare professionals have been documented in earlier studies [23, 24], indicating that these deficiencies may be a common, rather than isolated, challenge. Therefore, it is essential to develop targeted and evidence-based education or training programs to enhance nurses’ capabilities in EVD care. Approaches such as the Plan–Do–Check–Act (PDCA) cycle, high-fidelity simulation training, and case-based learning have been shown to improve clinical reasoning, procedural competence, and adherence to best practices in specialized nursing contexts [25, 26]. Consistent with previous evidence, this study found that nurses with EVD-related training experience achieved significantly higher knowledge scores than their untrained counterparts. This finding reinforced the importance of continuous professional education and aligned with prior evidence that advanced training enhances nurses’ theoretical understanding and technical proficiency in complex clinical procedures such as EVD care [23, 27, 28]. Therefore, integration of EVD-related knowledge into nursing education curricula could strengthen understanding and procedural readiness, ultimately contributing to safer and more effective EVD management.
The present study revealed that most nurses exhibited a positive attitude toward EVD management. Nurses with EVD-related training experience, longer overall and neurosurgical nursing experience, and older age were more likely to report favorable attitudes. These findings align with previous research linking clinical experience and training to constructive professional attitudes [29, 30]. Notably, current findings demonstrated that attitude mediated the relationship between knowledge and practice. It suggested that enhanced knowledge influences clinical behavior primarily through shaping nurses’ attitudes. This observation supports the established premise that attitudes serve as a critical psychological mechanism linking knowledge to behavioral change [30, 31]. Therefore, nursing leaders and educators should recognize the important role of attitudes in translating theoretical knowledge into effective clinical practice, and incorporate attitude-building strategies into both preservice education and in-service training programs [26, 32, 33]. Moreover, healthcare organizations should cultivate a supportive clinical environment that reinforces positive attitudes through mentorship, recognition, and a culture of safety. Such multidimensional efforts could help bridge the persistent gap between knowing and practicing, thereby promoting more consistent and evidence-based EVD care.
In this study, neurosurgical nurses demonstrated generally good practice of EVD management across different demographic and professional groups. This encouraging finding may reflect the expanding clinical responsibilities of nurses and their well-established professional identity within neurosurgical teams [34, 35]. As hypothesized, nurses who were engaged in direct patient care and had received EVD-related training reported significantly higher practice scores, suggesting that targeted training programs equipped nurses with essential skills to effectively translate theoretical knowledge into effective clinical behaviors. This result was consistent with previous evidence indicating that structured, skill-based education improves nurses’ procedural competence [30, 36]. This finding also aligned with the KAP theory, which posits that comprehensive knowledge forms the foundation for shaping positive attitudes and fostering desired behavioral change [17, 18, 37]. Accordingly, continuous professional development initiatives emphasizing both theoretical and hands-on components are essential to sustain and advance practical competencies in EVD care.
Implications for practice
This study provided valuable evidence to guide nurse managers and educators in optimizing the EVD management. Identified knowledge gaps, contributing factors, and existing training coverage highlighted the need for multilevel, evidence-based in-service education that integrated innovative and practical approaches to EVD management. Such initiatives could empower neurosurgical nurses to deliver the safe, high-quality and standardized care to patients with EVD.
As attitude mediated the relationships between knowledge and practice in EVD management, educational interventions should be designed not only to strengthen theoretical understanding but also to cultivate confidence, motivation, and professional accountability among nurses. Tailored training modules that combine technical instruction with attitude-enhancing components—such as reflective learning, simulation-based exercises, and mentorship—may further improve clinical decision-making and adherence to best practices.
Moreover, the development and enforcement of clear institutional policies and standardized clinical protocols are essential to sustain adherence to EVD management procedures. These efforts, combined with a supportive organizational culture fostered by healthcare managers, can collectively enhance the quality and safety of EVD-related nursing practices.
Limitations
The findings of this study should be interpreted in consideration of limitations. First, this study employed a convenience sampling method. While practical, it may introduce selection bias and limit the generalizability of the findings. The included participants may not fully represent Chinese neurosurgical nurses with diverse demographic or professional characteristics. Future investigations could consider employing probability-based sampling strategies to improve representativeness and enhance the external validity of findings. Second, although approximately one-tenth of the participants held managerial positions, such as head nurse or nursing supervisor, subgroup analyses were not performed due to the limited sample size of this subgroup. Given that nursing leaders are instrumental in shaping unit protocols and culture, future studies could specifically target this subgroup to better understand the organizational and leadership influences on EVD management.
Conclusion
Given the critical role of nurses in EVD management, understanding and addressing their knowledge, attitude, and practice are essential for ensuring high-quality and safe patient care. This study found that nurses generally exhibited a positive attitude and appropriate practices towards EVD management; however, their knowledge required further improvement. Future initiatives should prioritize targeted continuous education and structured hands-on training in EVD management to strengthen both theoretical understanding and practical competence in EVD care. Integrating EVD management into standardized nursing protocols and care bundles, alongside institutional support for ongoing professional development, may further enhance consistency, safety, and adherence to evidence-based practices in neurosurgical settings.
Acknowledgements
We appreciate all the neurosurgical nurses who participated in this study.
Author contributions
XYY, CLL, YRZ, YZZ and ZC designed the present study. XYY, YRZ, and ZC analyzed the data. ZC and XYY wrote the first draft of the manuscript. XYY, YRZ, CLL and ZC revised the manuscript. All authors have read and approved the final version for submission.
Funding
This work is supported by 2024 Nursing Research Fund (General Project) of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (Grant/Award Number: 2024D22), and 2025 Nursing Research Fund of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (Grant/Award Number: 2025C06).
Data availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
This study was granted by the ethics committee of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (NO: TJ-IRB202409049) and strictly adhered to the tenets of the Declaration of Helsinki. The participants were informed about this study, and they provided written informed consent after it was emphasized that participation was completely voluntary and participants could withdraw from the research at any time.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Yanrong Zhou and Zi Chen contributed equally to this work and share corresponding authorship.
Contributor Information
Yanrong Zhou, Email: 1002406585@qq.com.
Zi Chen, Email: u1chenzi@connect.hku.hk.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.