Pre–post changes in operating room nurses’ knowledge and attitudes toward medical device–related pressure injuries after a problem-based and simulation-based training program: a single-group pretest–posttest study

Abstract

Objective

To examine within-participant pre–post changes in operating room (OR) nurses’ knowledge and attitudes toward medical device–related pressure injuries (MDRPIs) following a problem-based learning (PBL) and simulation-based training program.

Methods

A prospective, single-group, pretest–posttest quasi-experimental study was conducted in the OR of a tertiary hospital from March to June 2025. A total of 80 OR nurses who met the inclusion criteria were enrolled. The intervention consisted of eight small-group training sessions integrating problem-based learning (PBL), case discussions, and scenario-based simulation. Each theoretical PBL/case session lasted 2 h and each simulation session 1 h. MDRPI-related knowledge and attitudes were assessed before and after the intervention using the validated Chinese versions of the Pieper–Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT) and the Attitude towards Pressure Ulcer Prevention instrument (APuP).

Results

The mean total PZ-PUKT score significantly increased from 40.58 ± 9.00 to 53.23 ± 6.78 (P < 0.001), and the overall knowledge accuracy improved from 56.36% to 73.93%. Significant gains were observed in all subdomains, with accuracy increasing from 64.57% to 78.88% for risk factors/prevention, from 50.75% to 68.90% for staging, and from 51.46% to 72.33% for wound description. The total APuP score also significantly increased from 40.06 ± 3.33 to 44.60 ± 2.49 (P < 0.001), corresponding to an accuracy improvement from 77.04% to 85.77%. Significant improvements were found in personal prevention capability, prioritization of prevention, perceived impact of pressure injuries, and confidence in the effectiveness of prevention (all P < 0.05). No statistically significant change was observed in the responsibility dimension (P = 0.157).

Conclusion

Participants’ knowledge and attitude scores were higher at post-test than at pretest. Statistical analysis indicated an association between the training intervention and improved MDRPI-related cognition and attitudes. These findings suggest potential benefits of this PBL-simulation hybrid training for operating room MDRPI prevention, though causal inference is limited by the single-group pretest-posttest design.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-026-09147-1.

Introduction

Medical device–related pressure injuries (MDRPIs) are localized damage to the skin or mucous membranes resulting from the use of medical devices during diagnostic or therapeutic procedures, and their shape typically mirrors that of the causative device [1]. In the operating room (OR), a highly technology-dense environment with multiple devices, tubes, electrodes, and cables, patients are frequently maintained in fixed positions for prolonged periods under anesthesia. These conditions substantially increase the risk of MDRPIs.

Recent studies in China have reported that the incidence of MDRPIs in OR settings ranges from 0.56% to 12.00%, accounting for approximately 45% of intraoperative hospital-acquired pressure injuries [2]. Patients exposed to medical devices are reported to be 2.4 times more likely to develop pressure injuries than those not exposed [3]. Common devices associated with MDRPIs include oxygen delivery systems, non-invasive ventilation masks, urinary catheters, fixation devices, and other monitoring and therapeutic equipment [4]. MDRPIs may lead to infection, pain, scarring, impaired body image, prolonged hospital stay, and increased healthcare costs [5].

Prevention is widely recognized as the most cost-effective strategy for managing pressure injuries [6]. However, MDRPI prevention is often more complex than prevention of traditional pressure injuries because it requires consideration of device-related factors (e.g., selection, positioning, fixation, duration of use, and the device–skin interface microclimate) in addition to patient-related factors such as nutrition and tissue tolerance. Inadequate nutrition impairs skin integrity and wound healing, while improper device placement or prolonged application can increase localized pressure, shear, and moisture, thereby elevating MDRPI risk.

Nurses play a pivotal role in MDRPI prevention. Their responsibilities include assessing device positioning and fixation, adjusting device use based on patients’ conditions, inspecting skin areas in contact with devices to detect early signs of damage, and implementing protective measures such as pressure-relieving pads and prophylactic dressings [6, 7]. Evidence suggests that nurses’ knowledge and attitudes toward pressure injury prevention are positively correlated [8], and education can positively influence attitudes and promote preventive behaviors [9]. Nevertheless, prior research has shown that 74.6% of OR nurses exhibit relatively passive attitudes toward pressure injury prevention [10], and MDRPI-related knowledge remains inadequate [2], indicating a clear need for targeted education.

Although many institutions provide pressure injury education, training is often general and ward-oriented, with limited emphasis on MDRPI mechanisms and device-specific prevention embedded within intraoperative workflows. Such training frequently relies on didactic, compliance-focused sessions that emphasize guideline awareness but provide insufficient opportunities to (i) analyze OR-specific device-risk scenarios, (ii) rehearse time-sensitive intraoperative tasks (e.g., device positioning/fixation checks and device-area skin inspection), (iii) practice appropriate application of protective materials under real workflow constraints, and (iv) strengthen perioperative team communication and escalation. As a result, OR nurses may find it difficult to translate general recommendations into consistent, situationally appropriate actions during surgery.

Educational approaches that explicitly target clinical reasoning and skills transfer may be particularly suitable for closing this gap. Problem-based learning (PBL) promotes active, case-driven learning and can strengthen nurses’ ability to identify device-related risks, prioritize prevention strategies, and justify decisions in complex perioperative cases. Scenario-based simulation complements PBL by enabling deliberate practice of intraoperative processes in a safe environment (e.g., device placement and fixation checks, inspection of skin–device interfaces, moisture control under adhesives, application of prophylactic dressings, and team communication), supported by structured debriefing and feedback to improve performance and facilitate translation to clinical practice.

In recent years, tailored MDRPI training programs incorporating active learning components have been reported in specialized units. Ergün et al. applied an evidence-based educational program combined with small-group PBL for neonatal intensive care unit (NICU) nurses and reported significant improvements in MDRPI knowledge among nurses caring for preterm infants [11]. Sayed et al. reported that an MDRPI-focused program for ICU nurses enhanced nurses’ knowledge and practice in the short term and reduced the incidence and severity of device-related injuries [12]. Similarly, Dallı and colleagues implemented the “Medical Device–Related Pressure Injury Care and Prevention Training Program (DevICeU)” in the ICU and found significant knowledge improvements alongside a reduction in MDRPI incidence from 24% to approximately 4% [13]. However, evidence remains limited for OR-specific MDRPI education that is explicitly designed around intraoperative devices, workflow constraints, and perioperative team processes.

Therefore, we developed an MDRPI education program tailored to OR nurses by integrating PBL, case-based teaching, and scenario-based simulation. The program comprised eight sessions delivered over eight weeks. Sessions 1–3 used a standardized PBL format (brief targeted instruction followed by small-group case discussion). Sessions 4–8 used a standardized simulation format (peer role-play with real OR devices to rehearse device-related prevention tasks, followed by facilitator-led structured debriefing and feedback.The overall assessment framework and simulation-based training structure are summarized in Supplementary Appendix S0–S5.).This exploratory study used a single-group pretest–posttest design to describe and estimate within-participant pre–post changes in OR nurses’ MDRPI-related knowledge and attitudes following the training, reporting effect sizes with 95% confidence intervals to inform future controlled studies. The research questions were: (1) Do nurses’ MDRPI-related knowledge scores (PZ-PUKT total and subdomain scores) differ between post-test and pre-test, and what is the magnitude of the change (effect size with 95% CI)? (2) Do nurses’ attitudes toward pressure injury prevention (APuP total and dimension scores) differ between post-test and pre-test, and what is the magnitude of the change (effect size with 95% CI)?

Methods

Study design

This study adopted a prospective, single-group, pretest–posttest quasi-experimental design to examine pre–post changes associated with an MDRPI prevention training program for OR nurses.

Setting

The study was conducted in the operating room of a tertiary hospital in China from March to June 2025.

Participants and sample

A census (total population) sampling approach was used. All operating room nurses who met the eligibility criteria during the recruitment period were invited to participate through departmental meetings, and those who provided written informed consent were enrolled. A total of 80 OR nurses participated in the study.

Inclusion criteria:

1. At least 1 year of clinical nursing experience.

2. Full-time employment in the operating room.

3. Voluntary participation and provision of informed consent.

Exclusion criteria:

1. Currently working in non-operating room clinical nursing positions.

2. Pregnancy, lactation, or serious illness that might interfere with training participation.

Sample size

No a priori power calculation was performed. The study employed a census (total population) sampling strategy in the operating room of a single tertiary hospital; thus, the achievable sample size was constrained by the number of eligible nurses during the recruitment period. Given the single-group pretest–posttest design and limited prior data to inform an anticipated effect size for this specific hybrid MDRPI training in OR nurses, a formal a priori sample size estimation was not undertaken. Future multi-center studies with control or comparison groups will use pilot-derived effect sizes to conduct power-based sample size calculations.

Data collection instruments

Demographic and professional characteristics form

A self-designed form was used to characterize the sample and to describe baseline factors that may influence MDRPI-related knowledge and attitudes. It collected information on gender, age, educational level, years of work experience, professional title, prior participation in MDRPI-related training, and prior experience in reporting or documenting MDRPIs. These variables were selected because prior training exposure and clinical documentation experience may be associated with baseline preparedness for MDRPI prevention and could help interpret pre–post changes. The English version of this questionnaire is provided as Supplementary File 1.

Pieper–Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT), Chinese version

The Pieper–Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT), developed by Pieper and Zulkowski [14], was used to assess nurses’ knowledge regarding pressure injuries, including MDRPIs. We selected the PZ-PUKT for this study because it provides comprehensive coverage of prevention-relevant knowledge domains that are directly targeted by our hybrid curriculum—particularly risk factors/prevention, staging, and wound description—and it is widely used in nursing education research, supporting comparability across studies.

The instrument comprises 72 items in three domains: risk factors/prevention (28 items), pressure injury staging (20 items), and wound description (24 items). Each item has three response options: “true”, “false”, and “don’t know”. Correct answers are scored as 1 point; incorrect and “don’t know” responses are scored as 0, yielding a total score range of 0–72. Knowledge levels are categorized as unsatisfactory (≤ 70%), satisfactory (70–80%), and excellent (> 80%).

The Chinese version of the PZ-PUKT demonstrates excellent reliability, with an overall Cronbach’s α of 0.932, and Cronbach’s α values of 0.831, 0.823, and 0.840 for the risk factors/prevention, staging, and wound description domains, respectively [15].

Attitude towards Pressure Ulcer Prevention (APuP), Chinese version

Nurses’ attitudes toward pressure injury prevention were assessed using the Chinese version of the Attitude towards Pressure Ulcer Prevention (APuP) instrument, originally developed by Beeckman et al. [16]. We selected the APuP because it measures multiple attitude dimensions that are conceptually aligned with the non-technical targets of our intervention, including perceived capability, importance/priority of prevention, perceived impact, responsibility, and confidence in prevention effectiveness. These constructs are particularly relevant for OR practice, where prevention behaviors must be prioritized under time, sterility, and workflow constraints, and where multidisciplinary collaboration influences accountability for MDRPI prevention.

The scale includes 13 items across five dimensions: personal prevention capability (3 items), importance of prevention (3 items), impact of pressure injuries (3 items), responsibility (2 items), and confidence in prevention effectiveness (2 items). Items are rated on a 4-point Likert scale (1 = strongly disagree to 4 = strongly agree). Negative items are reverse-coded. The total score ranges from 13 to 52, with an average score ≥ 75% of the maximum indicating a satisfactory attitude.

The Chinese version has demonstrated good internal consistency, with an overall Cronbach’s α of 0.899 and α values of 0.808 (personal capability), 0.753 (priority), 0.818 (impact), 0.870 (responsibility), and 0.700 (confidence) [15].

Training program

Training objectives

The training program aimed to enhance OR nurses’ capability to prevent MDRPIs by strengthening: (1) risk identification; (2) prevention planning; (3) skill execution under OR constraints; (4) team communication and safety behaviors; and (5) documentation of inspection sites, preventive actions, and reassessment plans.

Intervention design and theoretical basis

A multidisciplinary training team consisting of one department head nurse, three unit head nurses, and two senior nurses developed and delivered a hybrid problem-based learning (PBL) and scenario-based simulation curriculum. The program was informed by published MDRPI education models (Sayed et al.; Dallı et al. [12, 13]) and adapted to OR-specific workflows and device-related risk exposures. The intervention was operationalized using a standardized assessment framework (Supplementary Appendix S0) and five simulation scenarios (Supplementary Appendices S1–S5).The pedagogical design integrated: Problem-based learning, to promote clinical reasoning, guideline-based decision-making, and prevention planning for device-related risks; Scenario-based simulation, to support skills transfer, teamwork, and communication in realistic OR contexts.

Program structure and delivery

Training was delivered face-to-face in the OR teaching classroom in small groups of approximately 10 nurses over eight weekly sessions (total scheduled dose: 11 h), comprising: PBL module (theoretical component): 3 sessions × 2 h each (6 h total); Simulation module (practical component): 5 sessions, each consisting of 40 min of scenario execution followed by 20 min of structured debriefing (5 h total).An overview of session content, modalities, and core activities is presented in 1. The intervention is reported in accordance with the TIDieR checklist (Supplementary Table S9).

Table 1.

Overview of the 8-session hybrid problem-based learning (PBL) plus scenario-based simulation training program for MDRPI prevention

Session	Duration	Modality	Core content	Key activities
1	2 h	PBL	MDRPI concepts, risk assessment, common OR devices	Case trigger + group discussion; prevention plan
2	2 h	PBL	Skin assessment & staging; documentation; prevention bundle	Case trigger + worksheet; peer feedback
3	2 h	PBL	Management & escalation; interdisciplinary communication	Case trigger + role-play; action checklist
4	40 min + 20 min	Simulation	Scenario 1: high-risk device fixation/positioning	Team simulation; debrief with checklist
5	40 min + 20 min	Simulation	Scenario 2: airway-related device pressure risks	Simulation; debrief; corrective actions
6	40 min + 20 min	Simulation	Scenario 3: monitoring-related device pressure risks	Simulation; debrief; documentation
7	40 min + 20 min	Simulation	Scenario 4: perioperative immobilization-related risks	Simulation; debrief; prevention bundle
8	40 min + 20 min	Simulation	Scenario 5: comprehensive OR MDRPI prevention workflow	Simulation; debrief; OSCE-style checklist

PBL Problem-based learning, MDRPI Medical device–related pressure injury, OSCE Objective structured clinical examination

• Training content and teaching strategies

• Module 1: Problem-based learning (PBL)

• Each PBL session followed a standardized sequence to ensure consistency across groups:

  1. Case trigger presentation (5–10 min): An OR-specific MDRPI vignette describing patient characteristics, surgical position, expected duration, applied devices, and operational constraints.
  2. Clarification of terms and data (5–10 min): Participants clarified unfamiliar terminology and identified missing clinical information.
  3. Problem listing and learning issues (15–20 min): Identification of potential MDRPI risks, particularly high-risk device–skin interfaces, and formulation of learning questions.
  4. Self-study/evidence search (20–30 min): Conducted in-session or between sessions using international guidelines and local standard operating procedures.
  5. Group discussion and solution planning (40–60 min): Development of a guideline-aligned prevention plan covering risk assessment, device positioning and fixation, protective materials, inspection frequency, escalation, and documentation.
  6. Facilitator summary linked to guidelines (10–15 min): Synthesis of key points, correction of misconceptions, and provision of take-home checklist items.

• Module 2: Scenario-based simulation

Simulation training comprised five OR scenarios (S1–S5) delivered weekly. Each session included 40 min of scenario execution followed by 20 min of structured debriefing.

Roles within each scenario included a primary nurse, circulating nurse, anesthetist/assistant (played by a trainer or participant), and an observer using standardized checklists.

Across all scenarios, participants performed core MDRPI prevention tasks, including device positioning and fixation checks, skin–device interface inspection, selection and application of protective materials, escalation and team communication, and documentation of inspected sites, devices involved, actions taken, and reassessment plans or results.

Scenarios were designed to reflect common high-risk OR contexts, such as prolonged prone orthopedic surgery, prolonged neurosurgery with head fixation, frequent use of common device interfaces, prolonged gastrointestinal surgery, and cardiac surgery with high device density.

• Session flow and debriefing

• Each simulation session followed a standardized flow:

  1. Briefing: introduction of objectives, roles, and safety rules;
  2. Scenario execution (40 min): performance of MDRPI prevention behaviors under time pressure and sterility constraints;
  3. Structured debriefing (20 min): facilitated reflection and consolidation of transferable actions.

• Debriefing followed a Description–Analysis–Application (DAA) framework:

• Description (5 min): review of key events and decision points;

• Analysis (10–12 min): examination of why actions succeeded or failed, with reference to checklists and guideline principles;

• Application (3–5 min): translation of learning into specific actions for future OR practice.

Facilitators, setting, and materials

All sessions were facilitated by unit head nurses and senior nurses under the oversight of the department head nurse. Training was conducted in an OR teaching classroom equipped for skills training and simulation. Standardized OR-relevant devices, positioning aids, protective materials, and training documents (including PBL case triggers, worksheets, observer checklists, simulation scripts, skills rating forms, and a debriefing guide) were used to enhance reproducibility.

Intervention fidelity

Performance during simulation sessions was evaluated using a structured observer checklist and OSCE-style skills rating forms (Supplementary Appendices S6–S7), with predefined critical items and scenario-specific NA rules to ensure scoring consistency across scenarios (Supplementary Appendix S8). These observational measures were used to support training fidelity and formative feedback and were not prespecified as primary study outcomes.

Intervention fidelity was supported through a standardized intervention package, including session plans, PBL case triggers and worksheets, simulation scenario scripts, observer checklists, skills rating forms, and a structured debriefing guide. All trainers participated in a calibration process prior to program delivery to align facilitation approaches and scoring criteria.

Training adherence (dose delivered vs. dose received) was monitored using attendance and session completion records. Overall participation and completion across the 8-week program was approximately 90%. Any deviations from the planned content or delivery were prospectively documented; no modifications were made during implementation.

Ethical considerations

This study was approved by the Ethics Review Committee of Biomedical Research, Xuzhou Central Hospital (Approval No. XZXY-LK-20241210-0105). Eligible nurses received written and verbal information about study aims, procedures, time commitment, potential risks/benefits, confidentiality, and voluntariness via staff meeting. Trained research staff then answered questions and obtained written informed consent prior to baseline assessment. Participation was voluntary, and nurses could withdraw at any time without consequences. Data were anonymized and used solely for research purposes. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki and relevant national and institutional guidelines for research involving human participants.

Statistical methods

Given the absence of a control group, analyses focus on within-participant pre–post changes, and results are interpreted descriptively/associationally rather than causally. Data were analyzed using SPSS version 27.0. Categorical variables were summarized as frequencies and percentages. Continuous variables were summarized as mean ± standard deviation (SD) or median (interquartile range, IQR), as appropriate. For pre–post comparisons, normality of change scores (post–pre) was assessed using the Shapiro–Wilk test. Paired-samples t-tests were used when change scores were approximately normally distributed; otherwise, the Wilcoxon signed-rank test was applied. To limit inflation of type I error due to multiple secondary comparisons across subdomains, we applied the Holm–Bonferroni procedure. In addition to P-values, we reported mean differences with 95% confidence intervals and effect sizes for paired designs. All tests were two-tailed, and P < 0.05 was considered statistically significant.

Results

Characteristics of operating room nurses

A total of 80 OR nurses completed the study. The mean age was (31.45 ± 7.20) years, and the mean length of nursing experience was (8.95 ± 7.43) years. The male-to-female ratio was approximately 1:9. Most participants (88.75%) were younger than 40 years, and 76.25% had less than 10 years of work experience. In terms of educational background, 80.0% held a bachelor’s degree. Notably, 60 nurses (75.0%) had never received formal training related to MDRPIs prior to this study. Detailed baseline characteristics are presented in Table 2.

Table 2.

Sociodemographic and professional characteristics of operating room nurses at baseline (n = 80)

Characteristic	n (%)
Gender
Male	8 (10.0%)
Female	72 (90.0%)
Age, Mean ± SD (Range)	31.45 ± 7.20 (22 to 54)
Age(in years)
21–30	39 (48.8%)
31–40	32 (40.0%)
≧ 41	9 (11.2%)
Educational level
Technical Institute of nursing	16 (20.0%)
Bachelor degree in nursing	64 (80.0%)
Experience inside operating room (in years), Mean ± SD (Range)	8.95 ± 7.43 (1 to 38)
Experience inside operating room (in years)
≤ 5	31 (38.8%)
6–10	30 (37.5%)
11–15	10 (12.5%)
16–20	3 (3.8%)
≥ 21	6 (7.5%)
Title
Nurse	30 (37.5%)
Nurse practitioner-in-charge	36 (45.0%)
Associate Chief Nurse	4 (5.0%)
Chief Nurse	2 (2.5%)
Training duration, h (n = 20 ), Mean ± SD (Range)	2.8 ± 1.24 (1 to 6)
Is there a report and record of MDRPIs status?
Yes	3 (3.8%)
No	77 (96.2%)

Values are presented as n (%) unless otherwise indicated. Mean ± SD and ranges are shown for continuous variables

MDRPI Medical device–related pressure injury

Changes in MDRPI-related knowledge

Knowledge scores increased from pre-test to post-test. the total PZ-PUKT score increased from 40.58 ± 9.00 to 53.23 ± 6.78. All three subdomain scores also increased: Risk factors/prevention: from 18.08 ± 3.91 to 22.08 ± 2.92; Staging: from 10.15 ± 2.76 to 13.78 ± 2.61; Wound description: from 12.35 ± 3.75 to 17.36 ± 3.24 (all Holm-adjusted P < 0.001; Table 3).

Table 3.

Pre–post changes in PZ-PUKT domain scores and total score after the training program (paired t-test with Holm–Bonferroni adjustment; effect size reported as Cohen’s dz; n = 80)

Domain	Pre-training (Mean ± SD)	Post-training (Mean ± SD)	Post–Pre MD	95% CI (MD)	t (df = 79)	P (Holm-adjusted)	Cohen’s dz​	95% CI (dz​)
Risk factors/prevention	18.08 ± 3.91	22.08 ± 2.92	4.00	3.44–4.59	13.922	< 0.001	1.557	1.23–1.88
Pressure ulcer staging	10.15 ± 2.76	13.78 ± 2.61	3.63	3.00–4.25	11.567	< 0.001	1.293	0.99–1.59
Wound description	12.35 ± 3.75	17.36 ± 3.24	5.01	4.34–5.68	14.945	< 0.001	1.671	1.33–2.01
Total PZ-PUKT score	40.58 ± 9.00	53.23 ± 6.78	12.65	11.39–13.91	19.953	< 0.001	2.231	2.01–2.45

Values are percentage-correct scores (Mean ± SD). Pre–post differences were analyzed using paired t-tests (two-sided). Holm (Holm–Bonferroni) adjustment was applied within this Table (4 comparisons) to control the family-wise Type I error rate. Effect size was reported as Cohen’s dz​ for paired designs (mean change divided by the SD of the paired differences)

MD Mean difference (Post–Pre), MD95% CI 95% confidence interval

When converted to percentage correctness, the overall accuracy rate increased from 56.36% to 73.93% (P < 0.001). Accuracy in the risk factors/prevention domain improved from 64.57% to 78.88%, in the staging domain from 50.75% to 68.90%, and in the wound description domain from 51.46% to 72.33% (all P < 0.001; Table 4).

Table 4.

Percentage-correct performance on the PZ-PUKT before and after training (percentage = score/full score × 100%; n = 80)

Domain	Pre-training correctness (%)	Post-training correctness (%)	P-value
Total PZ-PUKT score	56.36 ± 12.50	73.93 ± 9.40	< 0.001
Risk factors/prevention	64.57 ± 13.97	78.88 ± 10.42	< 0.001
Pressure ulcer staging	50.75 ± 13.78	68.90 ± 13.05	< 0.001
Wound Description	51.46 ± 15.62	72.33 ± 13.51	< 0.001

Percentage correct (%) = score / full score x 100%

Changes in attitudes toward pressure injury prevention

APuP scores were higher at post-test than at pre-test. The total APuP score increased from 40.06 ± 3.33 to 44.60 ± 2.49 (Holm-adjusted P < 0.001; Table 5), with the corresponding attitude accuracy rate increasing from 76.97% to 85.77%. Across the five dimensions, post-test scores were higher were observed in:

Table 5.

Pre–post changes in APuP dimension scores and total score after the training program

Domain	Pre-training (Mean ± SD)	Post-training (Mean ± SD)	Post–Pre MD	95% CI (MD)	t (df = 79)	P (Holm-adjusted)	Cohen’s dz​	95% CI (dz​)
Personal competency to prevent PUs	8.69 ± 1.36	10.12 ± 1.18	1.43	1.15–1.72	10.11	< 0.001	1.131	0.85–1.41
Priority of PU prevention	9.41 ± 1.18	10.35 ± 1.01	0.94	0.69–1.18	7.58	< 0.001	0.847	0.59–1.10
Impact of PUs	9.34 ± 1.17	10.26 ± 0.89	0.92	0.62–1.15	6.61	0.006	0.739	0.49–0.98
Responsibility in PU prevention	6.38 ± 0.86	6.49 ± 0.90	0.11	−0.17–0.39	0.80	0.157	0.09	−0.13–0.31
Confidence in the effectiveness of PU prevention	6.21 ± 1.09	6.83 ± 0.94	0.62	0.35–0.90	4.60	0.014	0.514	0.28–0.75
Total APuP score	40.06 ± 3.33	44.60 ± 2.49	4.54	3.99–5.16	15.46	< 0.001	1.728	1.51–1.95

Values are Mean ± SD. Pre–post differences were analyzed using paired t-tests (two-sided). Holm (Holm–Bonferroni) adjustment was applied within this Table (6 comparisons) to control the family-wise Type I error rate; adjusted p-values are reported. Effect size was reported as Cohen’s dzfor paired designs

MD Mean difference (Post–Pre), MD95% CI 95% confidence interval

Personal prevention capability: from 8.69 ± 1.36 to 10.12 ± 1.18; Prevention priority: from 9.41 ± 1.18 to 10.35 ± 1.01; Impact of pressure injuries: from 9.34 ± 1.17 to 10.26 ± 0.89; Confidence in the effectiveness of prevention: from 6.21 ± 1.09 to 6.83 ± 0.94 (Holm-adjusted P < 0.05 for these domains; Table 5).

In contrast, the increase in the responsibility in pressure ulcer prevention dimension (from 6.38 ± 0.86 to 6.49 ± 0.90) did not reach statistical significance (Holm-adjusted P = 0.157; Table 5).

When APuP scores were converted into percentages of the maximum possible score, similar trends were observed (Table 6). The overall attitude correctness rate increased from 76.97% ± 6.40% before training to 85.77% ± 4.80% after training (P < 0.001). Subdomain correctness rates improved as follows:

Table 6.

Percentage of the maximum possible APuP score before and after training (percentage = score/full score × 100%; n = 80)

Domain	Pre-training correctness (%)	Post-training correctness (%)	P-value
Total APuP score	77.04 ± 6.40	85.77 ± 4.80	< 0.001
Personal competency to prevent PUs	72.42 ± 11.38	84.33 ± 9.88	< 0.001
Priority of PU prevention	78.42 ± 9.7	86.25 ± 7.40	0.002
Impact of PUs	77.83 ± 9.74	85.50 ± 7.38	0.002
Responsibility in PU prevention	79.75 ± 10.78	88.46 ± 11.21	0.157
Confidence in the effectiveness of PU prevention	77.63 ± 13.59	85.38 ± 11.73	0.007

Percentage correct (%) = score / full score x 100%

Personal prevention capability: from 72.42%±11.38% to 84.33%±9.88% (P < 0.001); Prevention priority: from 78.42.%±9.70% to 86.25%±7.40% (P = 0.002); Impact of pressure injuries: from 77.83%±9.74% to 85.50%± 7.38% (P = 0.002); Responsibility in pressure ulcer prevention: from 79.75%±10.78% to 88.46%±11.21% (P = 0.157); Confidence in the effectiveness of pressure ulcer prevention: from 77.63%±13.59% to 85.38%±11.73% (P = 0.007). Overall, improvements were observed in most attitude dimensions, with the exception of responsibility, which did not show a statistically significant difference between pre- and post-test.

Normality and sensitivity analyses

Several change-score variables deviated from normality (Shapiro-Wilk P < 0.05 for most domains). Therefore, Wilcoxon signed-rank tests were performed as sensitivity analyses; conclusions were unchanged (improvements remained significant for all domains except responsibility in APuP).

Discussion

This exploratory study used a single-group pretest–posttest design to describe and estimate within-participant pre–post changes in operating room (OR) nurses’ knowledge and attitudes related to medical device–related pressure injury (MDRPI) prevention following a hybrid training program integrating problem-based learning (PBL), case-based learning, and scenario-based simulation. To align the Discussion with the study’s prespecified framing, we interpret the findings in relation to the following research questions: (1) What were the pre–post changes in MDRPI-related knowledge (PZ-PUKT total and subdomains), and what was the magnitude of change (effect sizes with 95% CIs)? and (2) What were the pre–post changes in attitudes toward pressure injury (PU) prevention (APuP total and dimensions), and what was the magnitude of change (effect sizes with 95% CIs)? Overall, post-test scores were higher than pre-test scores across all knowledge domains and most attitude dimensions, with effect sizes suggesting changes of potential practical relevance. At the same time, the responsibility dimension showed minimal change, indicating a likely need for complementary system-level strategies beyond education alone.

Interpretation of knowledge improvement and links to learning theory

Understanding the pathophysiology of pressure injury—from transient reactive hyperemia caused by pressure-induced hypoxia to persistent ischemia and tissue necrosis when pressure is not relieved—is foundational to prevention [17]. MDRPIs commonly occur at device–skin interfaces (e.g., masks, casts, braces, endotracheal tubes), often involving vulnerable sites such as the nose, ears, and distal extremities [18, 19]. In the OR, device exposure can be prolonged and combined with immobility and microclimate changes, making risk recognition and early prevention behaviors especially critical.

The increase in knowledge observed in this study was consistent with previous educational interventions among nurses in ICU settings reporting improved pressure injury prevention knowledge after structured training [13]. Compared with short-term or predominantly didactic programs that produced more modest gains [12], our approach may have been associated with larger gains because it was designed around active learning and application rather than passive content delivery.

Importantly, the pedagogical rationale of our intervention aligned with well-established adult learning and constructivist principles: learners build durable knowledge when training starts from authentic clinical problems, requires active reasoning, and connects new concepts to prior experience. In the Methods, the theoretical component was delivered through PBL-oriented, small-group case work, which guided participants through problem identification, targeted literature searching, discussion, and synthesis [20]. By anchoring cases in high-risk OR devices (e.g., positioning pads, electrode patches, pulse oximetry probes), nurses were prompted to analyze how device characteristics (duration, fit, material, design) influence mechanical loading and local skin microclimate. This framing supports mechanistic understanding (e.g., how temperature and humidity affect skin friction and susceptibility) and is consistent with evidence that temperature-related changes can influence frictional behavior at the skin surface [21].

The scenario-based simulation component further operationalized this knowledge into observable prevention actions. Simulation is theoretically supported by experiential learning and deliberate practice: skills are strengthened by rehearsal in realistic contexts, immediate feedback, and repeated performance. Through guided scenarios, nurses practiced systematic device-area skin inspection, timely device adjustment/replacement, moisture control under adhesives, and device repositioning to reduce pressure magnitude and duration—addressing a known limitation of lecture-only education that often underemphasizes clinical decision points and psychomotor competence [22]. In practice, this “theory-to-action” bridge is particularly relevant in the OR, where workflow constraints and competing priorities demand rapid, context-sensitive decisions.

Despite improvement, some knowledge domains (notably staging and wound description) remained below levels reported in other nurse populations [23]. A plausible explanation is that OR nurses’ daily focus is predominantly intraoperative risk management (e.g., bleeding, infection control, hemodynamics), while postoperative skin assessment and wound documentation are more commonly performed on wards. Future training should therefore strengthen visual discrimination and documentation competencies for staging and wound description (e.g., image-based quizzes, video exemplars, standardized photo libraries, and scenario-based charting exercises), which may improve transfer to interdisciplinary postoperative pathways.

Attitude changes, the “responsibility” gap, and system implications

Attitudes toward pressure injury prevention influence preventive behavior and sustained adherence to protocols [24–26]. Consistent with prior studies [11, 27, 28], we observed improvements in several attitude dimensions such as perceived personal capability, prioritization of prevention, perceived impact, and confidence in prevention effectiveness. This pattern is consistent with the notion that active, experiential formats can increase self-efficacy and salience of preventable harm, particularly when training is framed around realistic OR scenarios and device-related risks.

However, the responsibility dimension did not show a statistically meaningful change. This finding likely reflects the multidisciplinary nature of perioperative care and the diffusion of responsibility for MDRPI prevention across teams. In many hospitals, postoperative skin assessment, longitudinal monitoring, and documentation of pressure injuries are primarily completed by ward nurses, while OR nurses may have limited visibility into downstream outcomes. The absence of a feedback loop can weaken perceived accountability and reduce motivation to prioritize prevention during high-demand intraoperative periods. This interpretation is compatible with broader literature noting that suboptimal responsibility attribution and competing priorities can hinder pressure injury prevention behaviors [8–10, 25, 26, 29].

Accordingly, the results suggest that education alone may be insufficient to shift the responsibility construct unless it is paired with workflow and organizational changes. Future interventions in the OR context should emphasize: Role clarification for MDRPI prevention within multidisciplinary teams (OR, anesthesia, surgery, PACU/ward). Cross-department feedback mechanisms that report postoperative MDRPI outcomes back to OR teams. Embedding MDRPI prevention into OR quality metrics and routine safety checks (e.g., device-area skin checkpoints, standardized positioning/device checklists).

Comparison with existing studies and contribution to the field

Recent evidence further supports the need for targeted MDRPI prevention education. Recent syntheses and surveys have identified persistent gaps in nurses’ MDRPI/pressure injury knowledge and practice, with prior training exposure considered a contributing factor to their preparedness [30, 31]. To address this gap, researchers have explored various educational formats. For instance, studies have shown that video-based programs can help improve MDRPI prevention knowledge [32]. In ICU settings, structured MDRPI care and prevention training programs have been associated with reductions in MDRPI point prevalence [13]. These findings suggest that nurse education is a noteworthy component of MDRPI prevention protocols [33]. Within this context, the present study attempted to apply this approach to the operating room (OR) setting. Our findings are generally consistent with the evidence above: a blended curriculum integrating theoretical instruction, Problem-Based Learning (PBL), and scenario-based simulation was associated with positive changes in participating OR nurses’ knowledge levels and preventive attitudes. This aligns with the view of Kim et al. [34] that small-group programs incorporating hands-on elements may be more effective than purely didactic sessions. Given that a majority of nurses in our study had not received prior MDRPI-specific training, and that baseline attitude scores, similar to international reports [8–10, 25, 26, 29], indicated room for improvement, our findings suggest that the potential for integrating such education into routine OR competency development warrants further exploration, with the aim of gradually moving away from ad hoc training initiatives. Future research could consider employing more rigorous designs, such as waitlist-controlled or stepped-wedge trials, to more accurately assess training effects.

Limitations

This study has several limitations. First, the single-group pretest–posttest quasi-experimental design without a concurrent control group substantially limits causal inference. The observed pre–post improvements may be partly attributable to alternative explanations, including maturation effects, testing effects (e.g., increased familiarity with the instruments or learning from the pretest), and history effects (e.g., concurrent institutional initiatives, policy changes, workload or rotation arrangements, or informal peer learning). Accordingly, the findings should be interpreted as associations rather than definitive evidence that the intervention alone caused the observed changes.

Second, the study was conducted in a single tertiary hospital with a relatively small and potentially homogeneous sample, which constrains generalizability to other hospitals, regions, or professional groups. Differences in clinical context, organizational support, baseline training levels, and MDRPI-related policies may influence the magnitude and applicability of the intervention effects. Future research should adopt multi-center designs with more diverse samples and incorporate control or comparison conditions (e.g., usual training, waitlist control, cluster randomization, or stepped-wedge designs) to strengthen both internal and external validity.

Third, outcomes were primarily assessed using self-administered questionnaires, which may be subject to recall bias and social desirability bias. Future studies should include objective outcome measures, such as proctored knowledge tests, direct observation of preventive practices using standardized checklists, or OSCE-style skill assessments.

Fourth, this study focused on short-term outcomes immediately after the training program; longer follow-up is needed to determine the durability of knowledge and attitude changes and whether booster sessions are required to sustain improvements.

Finally, patient-level outcomes (e.g., MDRPI incidence, severity, or healing time) were not evaluated. Linking nurse-related educational outcomes with clinical indicators will be essential in future studies to establish the clinical significance and real-world impact of MDRPI prevention training.

Conclusion

In this study, a structured hybrid MDRPI prevention training program integrating problem-based learning, case discussions, and scenario-based simulation was associated with improved OR nurses’ MDRPI-related knowledge and more favorable attitudes toward prevention. Improvements were observed across key knowledge domains and most attitude dimensions, suggesting that small-group, interactive training tailored to OR workflows may be a feasible approach for strengthening MDRPI prevention readiness.

Nevertheless, attitudes related to responsibility did not change significantly, and post-training performance in staging and wound description remained comparatively weaker. These findings indicate that future interventions should not only reinforce staging/wound assessment through enhanced visual and documentation-focused training, but also address system-level determinants of responsibility through clearer role delineation, multidisciplinary coordination, and feedback mechanisms that connect intraoperative practices with postoperative outcomes. Despite design limitations, the present study provides practical support for implementing hybrid MDRPI training in OR settings and offers a foundation for future multi-center evaluations that integrate both educational outcomes and patient-level indicators.

Authors’ contributions

FZ reviewed and edited the manuscript. ZLC, QLE, XYW, LZ collected and analyzed the data. FZ, JZ and PW conceived the study, participated in the study design, interpreted the data, and coordinated the study. All authors have read and approved the final version of the manuscript.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. The intervention reporting checklist (Supplementary Table S10), baseline questionnaire (Supplementary File 1) are provided as supplementary materials.

Declarations

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.