Infection Control and Prevention Awareness Among Intensive and Cardiac Care Nurses: Implications for Managers and Policymakers

ABSTRACT

Aim

This study aimed to assess the awareness levels of infection control and prevention among intensive care nurses at two Ministry of Health hospitals in Saudi Arabia.

Design

A cross‐sectional survey conducted from September to December 2023.

Methods

A cross‐sectional survey was conducted online in the selected hospitals. Using convenience sampling, 82 nurses completed a self‐administered questionnaire that included data about their demographics and infection control training. Descriptive and inferential analysis were used to examine the study variables.

Results

The results indicated that 95.1% of intensive and cardiac care unit nurses had unsatisfactory awareness of hospital‐acquired infections, whereas 59.8% and 58.5% were aware of hand hygiene and standard precautions, respectively. Nearly one‐quarter of nurses had an unsatisfactory level of awareness regarding infection control, whereas 72.2% had satisfactory awareness.

Conclusion

While most nurses were aware of standard precautions, they had unsatisfactory awareness of infection control and hospital‐acquired infections. There was a significant difference between nurses' educational level and their workplace awareness of infection control and prevention measures.

Implications for Clinical Practice

Targeted educational interventions using evidence‐based quality improvement models should be implemented to ensure that nurses stay current with the latest recommendations and best practices. Regular training sessions, workshops, and seminars should also be conducted.

Patient or Public Contribution

No patient or public contribution.

1. Background

In intensive care units (ICUs) and cardiac care units (CCUs), infection control and prevention (ICP) represents a cornerstone of patient safety and quality care. These high‐acuity settings treat critically ill patients who are inherently vulnerable to infections due to compromised immune systems, invasive procedures, and prolonged hospitalisation. Hospital‐acquired infections (HAIs) in these environments can lead to devastating consequences, including increased morbidity, mortality, extended hospital stays, and substantial economic burden on healthcare systems (Alanazi et al. 2023).

Globally, HAIs affect approximately 2 million individuals annually, with nearly 100,000 fatalities. The burden is disproportionately higher in low‐ and middle‐income countries (LMICs), where approximately 25% of patients develop HAIs, accounting for 75% of the global prevalence (Harun et al. 2022). In Saudi Arabia, ICUs report central line‐associated bloodstream infection (CLABSI) rates of 3.48 per 1000 device‐days and ventilator‐associated pneumonia (VAP) rates of 3.21 per 1000 device‐days (Alanazi et al. 2023). These cardiac and critical care‐specific infections underscore the urgent need for enhanced infection prevention strategies tailored to these specialised environments.

The main factors predisposing patients to HAIs include substandard hygiene practices, inadequate hospital infrastructure, insufficient staffing, lack of equipment, and failure to implement evidence‐based infection control protocols (World Health Organization 2016). Routine infection control measures, including hand hygiene (HH), equipment sterilisation, appropriate use of personal protective equipment (PPE), and proper waste disposal, form the foundation of HAI prevention (Abalkhail et al. 2021). However, the effectiveness of these measures depends critically on healthcare workers' knowledge, attitudes, and adherence to established guidelines.

2. Introduction

In ICUs, where patients are critically ill and susceptible to infections, ICP is a crucial part of patient safety and quality of treatment (Alanazi et al. 2023). In addition to preventing the emergence and spread of antibiotic resistance, ICP can reduce the morbidity, mortality, and financial burden associated with nosocomial infections. Nurses play a crucial role in ICP because they have close contact with patients and perform various procedures that may put them or patients at risk of infection. Therefore, it is essential to assess and enhance ICP knowledge and practices (Alhumaid et al. 2021).

ICP measures are recommended and necessary for all individuals, regardless of whether they currently have infections. They are the principal methods for preventing infection development and transmission, and their implementation is crucial in high‐risk scenarios. Following these guidelines is a key step in mitigating the transmission of disease‐inducing organisms and diminishing the likelihood of items and the environment becoming contaminated with pathogens (National Health and Medical Research Council 2019).

In cardiac care settings, infection risks extend beyond general healthcare‐associated infections to include procedure‐specific complications. Ventilator‐associated pneumonia (VAP) remains a significant concern in intensive and coronary care units, and strong evidence demonstrates that adherence to ventilator care bundles significantly reduces VAP incidence (Leong et al. 2024; Mastrogianni et al. 2023; Maertens et al. 2025). Central line‐associated bloodstream infections (CLABSIs) represent another critical risk due to frequent hemodynamic monitoring and vasoactive medication administration in cardiac intensive care, with studies showing increased morbidity and prolonged hospitalisation when prevention practices are suboptimal (Mazzeffi et al. 2025). Furthermore, patients supported with ventricular assist devices (VADs) experience unique infection challenges; VAD‐related infections, particularly driveline and device‐specific infections, are consistently associated with increased morbidity, rehospitalisation, and mortality (Brandão et al. 2024; DeMarco and Kumar 2025). These cardiac‐specific infection risks necessitate specialised knowledge and rigorous adherence to evidence‐based infection‐prevention protocols among coronary care unit nursing staff (Brandão et al. 2025).

The knowledge of healthcare workers (HCWs) is not only a matter of professional development but also dictates the efficacy of IPCs. The potential risks of not following IPC guidelines, such as the transmission of pathogens to patients, underscore the importance of their familiarity with and understanding of these guidelines (Hammoud et al. 2021).

IPC precautions extend beyond basic hygiene practices. These include immunisation strategies for preventing communicable diseases and understanding the modes of transmission of infectious organisms (Alhumaid et al. 2021). They should know how to evaluate patients for potential infections and sterilise clinical instruments. Effective waste management policies and proper disposal of sharps are essential. Additionally, they must be skilled in managing needle‐stick injuries. These principles should be followed to reduce the incidence of HAIs in clinical practice (Rodríguez‐González et al. 2023).

Successful compliance with infection control protocols and the practical application of HAIs preventive measures are not just a matter of policy but depend on nurses' knowledge (Salu et al. 2023). A thorough understanding of the subject can enable nurses to recognise possible hazards, perform preventive actions successfully, and respond to infection control challenges (Salu et al. 2023).

This study is guided by the Theory of Planned Behaviour (TPB). The TPB suggests that an individual's intention to engage in a behaviour is determined by their attitudes towards the behaviour, subjective norms, and perceived behavioural control (Conner 2020). In the context of infection prevention and control (IPC) among ICU and CCU nurses, TPB provides a comprehensive framework for understanding the factors that influence IPC practices (Conner 2020).

2.1. Aim

To assess the level of infection control and prevention (ICP) awareness among nursing staff working in Intensive Care Units (ICUs) and Cardiac Care Units (CCUs) in major hospitals in Saudi Arabia.

2.2. Objectives

1. To evaluate nurses' awareness of key ICP components in ICU and CCU settings, including hospital‐acquired infections (HAIs), hand hygiene (HH) practices, and standard precautions (SP).

2. To identify specific gaps in ICP knowledge/awareness that are particularly relevant to these high‐risk clinical environments

3. To examine the association between nurses' demographic and professional characteristics and their level of ICP awareness.

Guided by the Theory of Planned Behaviour, the study will also explore how nurses' beliefs related to ICP (e.g., perceived importance and effectiveness of ICP measures) may inform areas for targeted improvement and support hospital and nursing administrators in developing focused interventions to strengthen ICP practice and patient safety.

3. Methods

3.1. Design

A cross‐sectional survey design was used to assess infection control and prevention (ICP) awareness among nurses working in Intensive Care Units (ICUs) and Cardiac Care Units (CCUs) at two major Ministry of Health (MoH)‐affiliated hospitals in Saudi Arabia. Data were collected between September and December 2023.

3.2. Participants

Convenience sampling was used for participant recruitment. This method was chosen because of practical constraints, including time limitations, access to target hospitals, and the need for voluntary participation during a busy clinical period. Although convenience sampling has limitations in generalisability, it is an acceptable approach when studying specific populations in defined settings and when the primary aim is to identify knowledge gaps rather than population‐level prevalence estimates (Shorten and Moorley 2014).

The required sample size was calculated using Thompson's formula (Thompson 2012), where p, d, and N represent the probability (50%), error fraction (0.05), and population size (104), respectively. Based on this calculation, a minimum sample of 82 participants was required. Participants were recruited from two hospitals after the ethical approval letter, issued by the Local Committee of Bioethics at the University, was sent to the nursing administration offices at both hospitals. Eighty‐two nurses participated in this study.

3.3. Inclusion and Exclusion Criteria

Inclusion criteria were: (1) registered nurses working as staff, charge, or head nurses; (2) at least 3 years of clinical experience in ICU or CCU settings; (3) willingness to provide informed consent; and (4) ability to read and comprehend English or Arabic. Exclusion criteria were: (1) nursing students or interns; (2) nurses with less than 3 years of ICU/CCU experience; (3) nurses on leave or on temporary assignment during the study period; and (4) those who declined to participate.

The study specifically targeted nurses for participation because they play a critical, direct role in implementing infection control practices in ICUs and CCUs. Nurses are frontline healthcare providers who spend the most time with patients and are primarily responsible for administering care, monitoring patient conditions, ensuring adherence to hand hygiene protocols, managing invasive devices, and implementing standard precautions, all of which are fundamental to infection prevention.

3.4. Data Source and Measure

An online survey was used to administer a self‐directed questionnaire comprising demographic data and the Infection Control Standardised Questionnaire, adopted from Tavolacci et al.'s (2008) study; permission to use this survey was obtained from Cambridge University Press prior to the start of data collection. The questionnaire's reliability, as measured by Cronbach's alpha, was reported as 0.61 (Tavolacci et al. 2008).

The participant demographic data included sex, age, hospital type, nursing unit, education level, work experience, nationality, and work position. The second section of the questionnaire covers infection control precautions and contains 25 multiple‐choice questions across three domains: hand hygiene, standard precautions, and nosocomial infections. For this study, the survey has been modified to include only 23 questions.

A binary coding system was applied to each question's possible responses: 1 = aware and 0 = unaware. Therefore, the maximum score was 23, and 70% was the cutoff percentage, indicating a satisfactory overall awareness level for each category (HAIs, HH and SP). The positive awareness score thresholds were as follows: HAIs, ≥ 2.1; HH, ≥ 5.6; SP, ≥ 8.4; and overall, ≥ 16.1. Any score below the defined threshold was considered substandard, reflecting a poor level of awareness.

3.5. Consent Procedures

Electronic informed consent was obtained from all participants before survey completion. The online survey platform presented a detailed information sheet outlining: (1) the study purpose and objectives; (2) the voluntary nature of participation; (3) the right to withdraw at any time without consequences; (4) confidentiality and anonymity measures; (5) data storage and security procedures; (6) the estimated completion time (approximately 15–20 min); and (7) contact information for the research team. Participants were required to check a box indicating ‘I have read and understood the information provided and agree to participate’ before accessing the survey questions. Only those who provided electronic consent could proceed with the questionnaire.

3.6. Validity and Reliability

To ensure the credibility and trustworthiness of study findings, several measures were implemented (Moorley and Cathala 2019). The questionnaire utilised was previously validated by Tavolacci et al. (2008) with demonstrated internal consistency (Cronbach's α = 0.61). Content validity was ensured through expert review by infection control specialists and nurse educators. The online survey platform was pilot‐tested with five ICU nurses (not included in the final sample) to identify any technical issues or ambiguous questions. Data accuracy was maintained through automated data capture, eliminating transcription errors. To minimise response bias, the survey was anonymous, and participants were assured that their responses would not affect their employment status.

3.7. Statistical Analysis

Data management and analysis were performed using SPSS software, version 26 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used for data presentation; qualitative and quantitative variables were expressed as frequencies, percentages, and means ± standard deviations. Normal data distribution was confirmed using the Shapiro–Wilk and Kolmogorov–Smirnov tests. When this assumption could not be made, non‐parametric Kruskal–Wallis and Mann–Whitney U tests were applied to compare awareness mean rank discrepancies among the demographic variables. Statistical significance was set at p < 0.05.

3.8. Ethical Considerations

The Local Committee of Bioethics at Northern Border University (HAP‐09‐A‐043) provided ethical approval. To uphold ethical principles, voluntary and anonymous participation and data confidentiality were safeguarded. The permission form contained all the information required to understand the study, including its importance and goal and the freedom to withdraw participation at any moment without experiencing any harm. The data were collected after obtaining permission from the two hospitals, which was conditional on the university's ethical approval letter. A link to the online self‐report questionnaire was then distributed.

4. Results

4.1. Descriptive Results

4.1.1. Demographics

Table 1 presents the participants' demographic characteristics. Less than half of the nurses (43.9%) were aged < 30 years (mean age: 32.34 years). Nearly three‐quarters were females (75.6%) with a bachelor's degree (85.4%). Most nurses were Saudi (92.7%), and nearly two‐thirds had < 5 years of experience (65.9%). Most nurses worked as nursing staff (80.5%), nurse supervisors (11.0%), or head nurses (8.5%).

TABLE 1.

Distribution of participating nurses based on their demographic characteristics (N = 82).

Demographic characteristics	N	%
Age (years)
< 30	36	43.9
30–35	24	29.3
36–40	13	15.9
> 40	9	11.0
Mean and SD	32.34 ± 5.940
Gender
Men	19	23.2
Women	63	76.8
Educational level
Bachelor	70	85.4
Diploma	9	11.0
High institute	3	3.7
Nationality
Saudi	76	92.7
Non‐Saudi	6	7.3
Years of experience
< 5 years	54	65.9
5–10 years	18	22.0
≥ 10 years	10	12.2
Mean and SD	4.94 ± 3.574
Work position
Head nurse	7	8.5
Nurse supervisor	9	11.0
Nursing staff	66	80.5

Abbreviation: SD, standard deviation.

4.1.2. Infection Control Awareness

Table 2 presents significant insights into the level of infection control awareness regarding HAIs among the included nurses. For questions related to the environment, the data indicated that < 10% of the participants responded correctly, unaware that bacteria that cause HAIs may be present in the air or water and on inert surfaces. Approximately 60% of participants knew that the likelihood of infection was heightened in older adults, and practically all the participants (98.8%) knew that invasive procedures increased the risk.

TABLE 2.

Distribution of participating nurses based on correct responses to questions on infection control awareness (N = 82).

Items	N	%
Healthcare‐associated infections
The environment (air, water, and inert surfaces) is the major source of bacteria responsible for nosocomial infection	8	9.8
Advanced age or very young age increases the risk of nosocomial infection	49	59.8
Invasive procedures increase the risk of nosocomial infection	81	98.8
Standard precautions
Include recommendations to protect only the patients	53	64.6
Include recommendations to protect the patients and healthcare workers	74	90.2
Apply to all patients	77	93.9
Apply to only healthcare workers who have contact with bodily fluids	47	57.3
When is hand hygiene recommended?
Before or after contact with (care of) a patient	75	91.5
Before and after contact with (care of) a patient	75	91.5
Between patient contacts	72	87.8
After the removal of the gloves	72	87.8
The standard precautions recommend the use of gloves
For each procedure	4	4.9
When there is a risk of contact with blood or bodily fluids	79	96.3
When there is a risk of a cut	73	89.0
When healthcare workers have a cutaneous lesion	73	89.0
When there is a risk of splashing or spraying blood and bodily fluids, the healthcare workers must wear
Only a mask	60	73.2
Only eye protection	58	70.7
Only a gown	68	82.9
Mask, goggles, and gowns	59	72.0
What are the indications for the use of alcohol‐based hand rubs (on unsoiled hands)?
Instead of a traditional handwashing	39	47.6
Instead of antiseptic handwashing	39	47.6
Instead of surgical handwashing	41	50.0
Traditional handwashing must be performed before handwashing with alcohol‐based hand rub	46	56.1
Mean and SD of Total awareness of infection control	16.09 ± 2.13

Abbreviation: SD, standard deviation.

Regarding SPs, nearly two‐thirds of the nurses (64.6%) responded correctly to questions on SPs for protecting patients. Most participants (90.2%) responded correctly regarding SPs for protecting patients and HCWs; 93.9% responded that SPs should be followed with all patients, while nearly half (57.3%) only recommended SPs for HCWs in contact with bodily fluids. Most nurses (91.5%) recommended HH before or after patient care (87.8%), between patient contacts, and after removing gloves. Additionally, most nurses (96.3%) correctly responded to questions on the SPs for using gloves, including gloves for procedures and contact with blood, bodily fluids, cuts, or cutaneous lesions. However, a minority (4.9%) correctly answered questions about using gloves for every procedure. PPEs, including gowns, gloves, masks, and goggles, should be worn by HCWs in situations where there is a risk of contamination from blood or bodily fluid splattering; only 73.2% of the nurses responded correctly to questions in these situations, whereas 82.9% answered correctly about using masks, goggles, and gowns. Furthermore, 47.6% of nurses responded correctly to questions on using alcohol‐based hand rubs on unsoiled hands. In comparison, 51.0% recommended traditional handwashing, antiseptic handwashing, and surgical handwashing and suggested the need for traditional handwashing before using alcohol‐based hand rubs. Nurses demonstrated a mean level of infection control awareness of 16.09 (standard deviation: 2.13).

Figure 1 shows that most nurses (95.1%) had unsatisfactory awareness of HAIs. More than half were aware of HH and SPs (59.8% and 58.5%, respectively).

FIGURE 1.

Distribution of participating nurses based on awareness of hospital‐acquired infections, hand hygiene, and standard precautions (N = 82). The figure demonstrates that 95.1% of nurses had unsatisfactory awareness of HAIs, while 59.8% and 58.5% had satisfactory awareness of hand hygiene and standard precautions, respectively. Blue bars represent satisfactory awareness; red bars represent unsatisfactory awareness.

Regarding total awareness of infection control among nurses, 26.8% had an unsatisfactory level of awareness (Figure 2). Nearly three‐quarters (73.2%) of the participants had satisfactory awareness.

FIGURE 2.

Distribution of participating nurses based on total awareness of infection control (N = 82). This pie chart illustrates that 73.2% of participating nurses demonstrated satisfactory overall infection control awareness (blue/green), while 26.8% had unsatisfactory awareness (red/orange).

4.1.3. The Relationship Between Demographic Characteristics and Nurses' Infection Control Awareness

Table 3 shows the relationships between demographic characteristics and nurses' infection control awareness. These include age, sex, educational level, nationality, years of experience, and work position. The mean awareness score for nurses aged > 40 years was 16.33, the highest compared to the other age groups. Male nurses had a mean awareness score of 15.85, while female nurses had a slightly higher mean score of 16.16. Nurses with bachelor's degrees had the highest mean awareness score of 16.20, those with diplomas had a mean score of 16.33, and those with high institute educational levels had the lowest mean score of 12.66. The mean score varied based on nationality between Saudi and non‐Saudi nurses, with Saudi nurses having the highest mean awareness score of 16.05. Years of experience varied among nurses, and those with < 5 years of experience had the lowest mean awareness score of 16.1852, followed by those with 5–10 years of experience, while those with ≥ 10 years of experience had the highest mean awareness score of 16.20. The scores also varied based on work position, with head nurses having the lowest mean awareness score of 14.8571, while nursing staff had the highest mean awareness score of 16.23, followed by nurse supervisors.

TABLE 3.

Relation of demographic characteristics and total awareness of infection control (N = 82).

Parameter	Perception of simulation‐based learning		Z/H‐test	p
	$\overline{X}$	SD
Age (years)
< 30	16.0833	2.23447	0.193	0.979
30–35	16.0000	2.12644
36–40	16.0769	2.36155
> 40	16.3333	1.65831
Gender
Men	15.8500	2.32322	−0.702	0.483
Women	16.1613	2.08188
Educational level
Bachelor	16.2000	2.08236	6.387	0.041*
Diploma	16.3333	2.00000
High institute	12.6667	0.57735
Nationality
Saudi	16.0526	2.15341	−0.180	0.857
Non‐Saudi	16.5000	1.97484
Years of experience
< 5 years	16.1852	2.08385	0.945	0.623
5–10 years	15.7222	2.24409
≥ 10 years	16.2000	2.34758
Work position
Head nurse	14.8571	2.54484	3.085	0.214
Nurse supervisor	16.0000	2.12132
Nursing staff	16.2273	2.08139

Note: * denotes statistical significance at p < 0.05.

Abbreviation: SD, standard deviation.

Age, sex, nationality, years of experience, and work position did not significantly affect total awareness scores. However, significant differences were observed between nurses with different levels of education (H = 6.387, p = 0.041).

5. Discussion

Healthcare‐associated infections (HAIs) remain a persistent problem across health systems, and infection prevention and control (IPC) depend heavily on what nurses know and what they actually do at the bedside. In high‐acuity areas such as intensive care units (ICUs) and coronary care units (CCUs), the margin for error is small because patients frequently have invasive devices, complex procedures, and reduced physiological reserve. For that reason, nurses' understanding of IPC principles and the extent to which those principles are translated into day‐to‐day practice are central to preventing avoidable harm.

Evidence from different contexts illustrates that IPC knowledge is not always comprehensive, particularly regarding transmission routes and environmental contamination. Mustafa and Lahu (2019), for instance, reported that nurses did not consistently recognise air, water, and inert surfaces as important media for the transmission of HAI‐causing pathogens. This is concerning because it signals an incomplete appreciation of the hospital environment as part of the transmission chain. Other studies have reported stronger knowledge and attitudes towards standard precautions (SPs). Da'seh et al. (2023) found high recognition of SPs and noted that 71.6% of participants agreed that full PPE should be used when blood or bodily fluids may splatter. Taken together, this literature suggests variability across settings and supports the value of examining local patterns of knowledge and gaps.

In the present study, most nurses (64.6%) answered SP items correctly, suggesting a generally acceptable baseline of knowledge. This aligns with Ghabayen et al. (2023), who reported a high level of knowledge and compliance with SPs, with a mean awareness score of 15.59/20 and nearly 60% of participants scoring between 14 and 17. When these findings are examined by domain, HH and glove‐related precautions were areas of relative strength. A large proportion of participants correctly identified HH indications around patient care (91.5%), and nearly all responded correctly to glove‐use items across different clinical circumstances (96.3%). Knowledge related to masks, goggles, and gowns was lower (72.0%), which may reflect the reality that glove use is more routine and more continuously reinforced in daily workflow, whereas decisions about other PPE can be more context‐dependent and therefore more prone to inconsistent interpretation. Comparable results have been described in other regional work. Al‐Faouri et al. (2021) reported high awareness of SPs and the need to apply IPC measures to every patient. Da'seh et al. (2023) likewise emphasised the perceived need for masks, goggles, and gowns when splashes are anticipated.

At the same time, the present study identified a specific weakness with practical consequences: nurses' understanding of alcohol‐based hand rubs (ABHRs) in relation to soap‐and‐water handwashing. Fewer than half of participants (47.6%) identified ABHRs as an appropriate alternative to traditional handwashing in relevant situations, and only 56.1% recognised circumstances in which handwashing should be performed before ABHR use. This matters because ABHRs are central to modern HH practice when hands are not visibly soiled, while soap‐and‐water washing remains necessary when hands are visibly dirty and after restroom use. The observed gap may be driven by uneven training messages, differences in how guidelines are communicated locally, or the practical shortcuts that emerge in busy units. It also reinforces an important interpretive point: knowledge assessed by questionnaire does not automatically translate into consistent compliance under real clinical conditions. Prior studies similarly emphasise that continuing education, clear unit‐level guidance, and repeated reinforcement are needed to strengthen HH knowledge and adherence (Assefa et al. 2021; Boyce and Schaffner 2021).

Although HH is widely recognised as fundamental to patient safety, translating knowledge into consistent practice remains challenging in many clinical environments. Healthcare workers (HCWs), including nurses, have frequent patient contact, which increases the risk of cross‐transmission via hands when HH is missed or performed inconsistently (Bakarman et al. 2019). This risk may be amplified in ICUs compared with other wards due to a higher infection burden, the presence of high‐risk patients with complex conditions, and variability in awareness and preventive measures (Madden et al. 2021). Effective HH is associated with lower complication rates, shorter hospital stays, and reduced mortality risk, thereby improving patient outcomes. However, despite its importance, low acceptance and suboptimal adherence to HH measures have been reported among HCWs (Ahmadipour et al. 2022).

In the present study, nurses demonstrated a mean infection control awareness score of 16.09 (SD = 2.13). Overall, 72.2% of participants had satisfactory awareness, whereas 26.8% had unsatisfactory awareness. Sebro et al. (2023) similarly reported variability in knowledge related to HAI prevention, with 45.5% of nurses demonstrating sufficient knowledge and 54.5% lacking sufficient knowledge. In the current sample, awareness also differed across domains; notably, 95.1% of nurses had unsatisfactory awareness of HAIs, whereas 59.8% and 58.5% were aware of HH and SPs, respectively.

Regarding factors associated with awareness, age, sex, nationality, years of experience, and job position did not significantly influence the total infection control awareness score. However, significant differences were observed by educational level, suggesting that educational preparation may shape nurses' IPC awareness and their capacity to apply evidence‐based measures. Elgazzar and Ahmed (2020) reported a significant association between nurses' educational level and understanding of infection control fundamentals and sterilisation‐related principles. Similarly, Soleimani and Yarahmadi (2023) concluded that education significantly influenced knowledge, attitudes, and practices (KAP). In contrast, Kim and Choi (2023) found that respondents' demographic characteristics did not significantly affect infection control‐related variables, indicating that local context and organisational factors may also influence IPC awareness and practice.

5.1. Implications for Managers and Policymakers in Hospitals

The implications of the present findings extend beyond knowledge reinforcement and highlight the need for structured, unit‐based implementation strategies that support sustained improvement in HH and IPC performance. The implication is not simply ‘more education’, but more deliberate implementation. Improving HH and IPC performance typically requires structured quality improvement (QI) work that reshapes routines and expectations over time. One useful way to frame this is Kotter's 8‐step change model, which has been applied in healthcare to support sustained behaviour change. Hu et al. (2024) reported that using Kotter's framework in an ICU QI initiative was associated with sustained improvements in HH adherence. In practical terms, Kotter's approach aligns with what is needed in busy clinical units: establishing a clear urgency around preventable infections, building a multidisciplinary coalition (including nurse leaders and frontline champions), communicating a simple shared vision, removing barriers (such as poorly placed dispensers or unclear local rules), and then reinforcing improvements through short‐term wins, feedback, and standardisation.

Within that structure, several interventions are realistic and evidence‐informed: (1) regular observation or electronic monitoring with rapid feedback to staff; (2) visible prompts at the point of care and simplified unit‐level HH rules (including ABHR indications); (3) ensuring ABHR availability at every bedside and at room entry/exit; (4) peer‐led coaching and ‘just‐in‐time’ reminders delivered by trained unit champions; and (5) leadership walkrounds that keep HH performance visible and normalise accountability. These options are particularly relevant to the ABHR gap identified in this study because they combine knowledge clarification with changes to the practice environment.

Optimising HH should also be framed for staff and decision‐makers as a measure that reduces not only overall HAI burden but also the horizontal spread of multidrug‐resistant organisms (MDROs). The hands of healthcare workers are a recognised vehicle for MDRO transmission, and improvements in HH adherence are associated with reductions in MDRO spread and colonisation (Boyce 2024). This is especially important in ICU and CCU contexts, where MDRO colonisation is common and prolonged critical care exposure is associated with higher risk of nosocomial colonisation, which can then translate into difficult‐to‐treat infections, extended hospitalisation, and worse outcomes (Garcia‐Parejo et al. 2025). In other words, HH is not merely a policy requirement; it is a frontline containment strategy for antimicrobial resistance.

A further implication is that a solid IPC knowledge base is necessary for nurses to organise, implement, and sustain QI initiatives, including those focused on preventing procedure‐ and device‐related infections. This is evident in surgical site infection (SSI) prevention, where nursing responsibilities span preoperative preparation, perioperative asepsis support, and postoperative wound surveillance. Evidence highlights that these nursing‐led actions are integral to SSI prevention and early complication detection (Bae et al. 2024). In cardiac care settings, where procedures are common and patients are vulnerable, strengthening IPC literacy supports nurses' pivotal role in implementing evidence‐based practice and sustaining improvement.

From a policy and management perspective, infection control link nurse (ICLN) models offer a feasible way to strengthen IPC practice at the unit level. Link nurses can serve as unit‐based facilitators who translate guidance into daily routines, provide informal coaching, and bridge infection control teams and frontline staff. Evidence from critical care settings supports their role in reinforcing adherence and sustaining IPC initiatives (Dekker et al. 2024). This approach may be particularly suitable for ICU/CCU environments because it provides dependable, on‐shift access to a staff member with additional IPC training who can address real‐time questions and promote consistent application of standard precautions and hand hygiene protocols.

To support and scale this work, institutions can pair ICLN programmes with multidisciplinary infection control committees that strengthen collaboration among nurses, infection control specialists, and hospital leadership. Such committees can facilitate communication, routine monitoring of compliance, and continuous improvement of IPC practices. Institutions should also incorporate sustainability considerations into IPC policy by balancing patient safety requirements with environmental stewardship, guided by evidence‐based risk assessment to support long‐term feasibility (Lee et al. 2024; Rickard et al. 2023). Collectively, these aligned strategies may strengthen IPC implementation, reduce infection risk, and improve patient outcomes.

6. Limitations

This study has several limitations that should be considered when interpreting the findings. The use of convenience sampling may limit generalisability, as the sample may not reflect nurses working in other regions, healthcare settings, or clinical specialties. In addition, only six participants (7.3%) were non‐Saudi nationals. Given that Saudi Arabia employs a substantial international nursing workforce, this limited representation may reduce the comprehensiveness of the findings and limit conclusions regarding potential differences in IPC awareness across cultural and educational backgrounds. Future research should aim for more proportionate representation of the nursing workforce to allow more meaningful subgroup comparisons.

The study also relied on self‐reported responses, which may introduce bias because participants can overestimate awareness due to social desirability or inaccurate self‐assessment. Moreover, the cross‐sectional design captures awareness at a single point in time, which precludes causal inference and does not allow assessment of changes over time. Finally, while the study identified knowledge gaps, it did not directly measure observed clinical practice or behavioural compliance with IPC protocols, which may differ from self‐reported awareness. These limitations suggest that the findings should be interpreted with caution, particularly with respect to generalisability and the potential overestimation of IPC awareness.

7. Conclusion

This cross‐sectional study of 82 ICU and CCU nurses in Saudi Arabia identified important gaps in infection prevention and control (IPC) awareness. While 72.2% demonstrated satisfactory overall awareness, 95.1% had unsatisfactory knowledge of hospital‐acquired infections (HAIs), and only 9.8% correctly identified environmental sources of HAI‐causing pathogens. In contrast, awareness of hand hygiene (59.8%) and standard precautions (58.5%) was relatively higher. Educational level was the only demographic factor significantly associated with IPC awareness (p = 0.041).

These gaps are particularly relevant in ICU and CCU settings, where patients are at increased risk of device‐ and procedure‐related infections. The observed pattern—more favourable awareness of routine precautions alongside limited understanding of HAIs and environmental transmission—suggests that some practices may be performed without a consistently strong conceptual basis for transmission prevention in high‐risk cardiac critical care environments.

Healthcare administrators should strengthen targeted IPC education with emphasis on HAI epidemiology, environmental contamination, and cardiac care–specific infection risks. Institutional strategies may include infection control link nurse programmes, structured quality improvement initiatives guided by Kotter's 8‐step change model, and support for continuing professional development. Future research should evaluate the effectiveness of such interventions and explore associations between nurses' IPC awareness and unit‐level HAI outcomes in cardiac critical care settings.

Author Contributions

The authorship contributions for this study are the study conception and design by Ibrahim Naif Alenezi. Fathia A. Mersal conducted the data collection and analysis. Taghreed H. Aboelola led the interpretation of the results and drafting of the conclusion section. All authors actively participated in drafting and revising the manuscript, ensuring the integrity and quality of the final work.

Funding

The authors extend their appreciation to the Deanship of Scientific Research at Northern Border University, Arar, KSA, for funding this research work through the project number ‘NBU‐FFR‐2026‐1626‐02’.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data supporting this study's findings are available from the corresponding author upon reasonable request.