Effect of an educational intervention on nurses’ knowledge, attitudes, and practices in adherence to pressure injury prevention: a randomized controlled trial

Abstract

Background

Pressure injuries are a significant preventable cause of patient injury, and nurses’ adherence to evidence-based preventive strategies is essential. Systematic education could enhance knowledge, attitudes, and preventive actions beyond conventional in-service training. This study aimed to determine the effect of an educational intervention on nurses’ knowledge, attitudes, and practices related to adherence to pressure injury prevention guidelines compared with routine education.

Methods

A parallel-group, randomized controlled trial was conducted between January 1 and March 5, 2026 in a tertiary hospital in Riyadh, Saudi Arabia, including 222 registered nurses (n = 111 each for intervention and control) recruited from high-acuity and general inpatient settings. The intervention comprised structured education delivered through didactic lectures, interactive discussions, case-based learning, and practical demonstrations, supplemented with printed handouts and reinforcement reminders. The assessments were conducted using validated knowledge, attitudes, practice, and adherence measurement instruments. Independent samples t-tests were used for initial comparisons.

Results

The baseline characteristics and pre-intervention scores were comparable between the groups. Post intervention, the structured education group demonstrated significantly higher knowledge (t(220) = − 36.08, p < .001), attitude (t(220) = − 50.62, p < .001), practice (t(220) = − 28.43, p < .001), and adherence scores (t(220) = − 42.86, p < .001) than the routine group. An analysis of covariance confirmed significant group effects after adjusting for baseline values, with large effect sizes were observed across outcomes, with Cohen’s d ranging from 3.80 to 6.80, for knowledge (η² =0.905), attitude (η² =0.938), practice (η² =0.800), and adherence (η² =0.932). Regression analysis showed that post-intervention knowledge, attitude, and practice explained 83.6% of the variance in adherence (R² =0.836), with attitude emerging as the strongest predictor (β = 0.470, p < .001).

Conclusions

Structured education produced substantial improvements in nurses’ knowledge, attitudes, practice, and adherence in relation to PIP protocols. Attitudinal change plays a pivotal role in enhancing adherence. Integrating structured, competency-based educational programs into routine professional development may strengthen patient safety and reduce preventable PIs.

Trial registration

This randomized controlled trial was registered early in the study period and before participant enrollment in the Clinical Trials Registry (ISRCTN14515418) on January 5, 2026.

Background

Pressure injuries (PIs), often known as pressure ulcers, are a significant patient safety issue in both acute and long-term care environments [1, 2]. Current epidemiological data indicate that the issue persists across Europe, with estimates ranging from 8.9% to 18.2% for hospital incidence and from 6.4% to 31.4% for nursing home prevalence [2–4]. PIs are characterized by localized injury to the skin and/or underlying tissue, typically occurring over a bony prominence, resulting from pressure alone or in combination with shear forces [4]. Clinically, PIs involve significant human and systemic burdens, including pain, infectious complications, extended and expensive hospital stays, chronic wounds, heightened mortality risk, and diminished health-related quality of life [5]. The ongoing burden highlights the need for efficient, scalable techniques that enhance evidence-based preventive strategies at the point of care [6, 7].

Preventive strategies aim to diminish the intensity and/or duration of pressure and shear forces and should commence promptly for any at-risk patient [8]. Registered nurses (RNs) play a pivotal role in PI prevention by conducting continuous risk assessments, implementing preventive measures, and monitoring initial indicators of tissue damage [9]. Nurses’ knowledge influences their attitudes, which are closely linked to the implementation of effective preventive strategies [10–14]. Attitudes and adherence to guideline recommendations constitute additional, frequently alterable factors influencing the quality of prevention [13]. Adverse attitudes towards pressure injury prevention (PIP) are anticipated to hinder the use of prevention recommendations, and such attitudes may be neglected in the dissemination and implementation of guidelines [11, 13].

Evidence indicates significant inefficiencies in delivery of treatment for PIs., with about 10.8%–13.9% of at-risk patients obtaining appropriate prevention, while over 70% of individuals no risk still undergo some preventive measures, demonstrating both underutilization where necessary and overutilization where unnecessary [10, 12, 13]. There is a crucial need to enhance nurses’ adherence to PIP guidelines [12, 15]. Barriers to the implementation of guideline recommendations have been identified at both the individual level (e.g., lack of motivation, resistance to change, and insufficient knowledge) and the organizational level (e.g., limited access to guideline content, inadequate time, lack of leadership/feedback, and environments resistant to change) [11].

Educational interventions are an effective and necessary means of addressing these overlapping deficiencies in knowledge, attitudes, and preventive actions [16, 17]. Recent extensive descriptive research underscores that understanding nurses’ knowledge, attitudes, and practices is essential for enhancing patient outcomes, and that this information can guide targeted interventions to improve the prevention and management of PIs [11, 16]. Educational interventions are often recommended as a fundamental approach to bridging the know–do gap, and recent research indicates their potential benefits [17]. A pre–post study conducted in Saudi Arabia, utilizing internationally recognized measures (for knowledge through the Pressure Ulcer Knowledge Assessment Tool [PUKAT 2.0] and for attitude through the Attitude towards Pressure ulcer Prevention instrument [APuP]), indicated improvements in nurses’ knowledge and attitude ratings following an educational program [18].

The Knowledge, Attitude, and Practice (KAP) framework is widely utilized to assess nurses’ preparedness and effectiveness in preventing PIs, with recent findings suggesting that KAP associations may differ depending on context, measurement methods, and workforce attributes [11]. Systematic review and meta-analysis of nurses’ KAP in relation to PIP indicated both direct and indirect associations ranging from weak to strong [11]. Notably, the measurement of practice was limited, with only three studies providing data on the associations between knowledge and practice as well as between attitude and practice [11]. This synthesis highlighted the persistent disparity between theoretical understanding and practical application and expressly advocated research that identifies barriers and facilitators while targeting modifiable determinants to enhance adherence [11].

This parallel-group randomized controlled trial (RCT) aimed to assess the efficacy of a structured educational intervention in enhancing RNs’ knowledge, attitudes, and practices regarding adherence to PIP compared with standard (routine) education groups [11]. The study had the following objectives: a) to assess the levels of KAP regarding PIP among RNs; (b) to examine differences in KAP between RNs assigned to the intervention group and those in the routine group post intervention, adjusting for baseline KAP scores; and (c) to determine the effect of the structured educational program on improving RNs’ adherence to PIP compared with the routine group.

Methods

This trial was conducted in accordance with the Good Clinical Practice standards and is reported in accordance with the Consolidated Standards of Reporting Trials (CONSORT) 2010 guidelines for RCTs [19]. Although the trial registration approval was obtained shortly after the official study start date due to administrative processing timelines, the registration process was initiated at the study commencement, and full protocol details were submitted prior to participant enrolment [20, 21]. No recruitment, randomization, or outcome assessment occurred before the registration approval. This approach is consistent with best practices for trial transparency and aligns with the principles outlined by CONSORT 2010 and ICMJE, ensuring methodological integrity and minimizing the risk of selective reporting [20, 21]. No changes to the primary or secondary outcomes were made after the trial registration [20, 21].

Study design and study setting

This study was a parallel-group, two-arm RCT to assess the efficacy of a structured educational intervention on nurses’ KAP with regard to adherence to PIP [20, 22]. The study was conducted in high-acuity and general inpatient units at a tertiary care hospital in Riyadh, Saudi Arabia.

Participants

Eligible participants were RNs who provided direct patient care in critical units, intensive care units (ICUs), and acute units (emergency units and medical units). These units were chosen because of the high number of patients at risk for PIs and the active participation of RNs in direct patient care [22]. The nurses were required to have at least one year of clinical experience in the nursing department of the same facility [22]. They were excluded if they were on prolonged leave during the research period, intended to relocate from the unit during the subsequent evaluation, had undergone similar organized PIP training within the last six months, or did not provide direct patient care [22].

Sampling

The sample size was calculated a priori using G*Power (version 3.1.9.7), assuming a medium effect size of 0.5, a power of 0.95, a 1:1 allocation ratio, and a two-tailed test [22]. The minimum required sample size of 210 was deemed sufficient to meet the research objectives [22]. This study enrolled 222 RNs who were randomly assigned in a 1:1 ratio to either the intervention group (n = 111), which received a comprehensive, evidence-based program for PIP education, or the control group (n = 111), which received routine instruction [22, 23].

Random allocation

After the baseline data collection, the eligible nurses were randomly allocated to either the intervention or control groups. Baseline assessment was performed using a computer-generated random sequence, with allocation concealment ensured by using sequentially numbered, opaque, sealed envelopes [22–24]. Once a participant was enrolled and the baseline measures were completed, the next envelope in the sequence was opened to reveal the group assignment. To reduce the risk of selection bias, the recruiters did not have access to the randomization list [22, 23].

Intervention group

The nurses assigned to the intervention group participated in a structured, evidence-based educational program on adherence to PIP [20]. The program was designed to address the knowledge (risk factors, staging, and prevention bundles), attitudes (importance, perceived barriers, and professional responsibility), and practices (risk assessment, skin assessment, repositioning, support surfaces, moisture/nutrition management, device-related prevention, and documentation) components of the KAP framework [22, 25]. Six certified wound care specialists who had obtained their bioethics certificates and all educators received standardized training from the first author before study initiation to ensure intervention fidelity, consistency of content delivery, and adherence to the study protocol [22]. The first author provided clear instructions on the study, recruitment method, privacy requirements, and data entry. The intervention was delivered through interactive teaching methods (e.g., short lectures, case-based discussions, demonstration/return demonstration, and scenario-based practice) and supported with printed and/or electronic educational materials [22]. The intervention’s fidelity was supported through the use of a standardized educator manual and structured teaching materials. Attendance was recorded, and all participants in the intervention group completed the full educational sessions. The sessions followed a standardized format that included lectures, case discussions, and practical demonstrations. Although formal fidelity metrics were not quantitatively assessed, these procedures were implemented to maintain consistency across the educators. The absence of a hierarchical assignment structure meant that an estimation of stable cluster-level variance components was not feasible in the current dataset.

Control group

The control group participants received routine education in the form of standard in-service training provided by the hospital during the study period, without exposure to the structured intervention content or materials [22]. Routine education comprised the hospital’s standard, non-structured educational activities typically available to nursing staff. These included periodic in-service sessions and informal unit-based teaching delivered irregularly (not standardized), depending on departmental scheduling. These sessions are brief sessions lasting 2 × 60 min that are delivered by unit educators or senior nurses as part of routine practice. The sessions include general nursing topics (e.g., infection control, patient safety, and documentation) rather than a dedicated or comprehensive PIP program [22]. The control participants were required to complete the same baseline and follow-up assessments as the intervention group [22]. To ensure ethical fairness, the comprehensive educational program or the training materials were offered to the control group nurses after completion of the follow-up data collection [22].

Data collection

This RCT was conducted between January 1, 2026 and March 5, 2026 by a research team comprising the first author, who is the head of the wound care unit, other certified wound care specialists, a faculty member, and other health providers, using an online data collection form as a self-administered questionnaire. Figure 1 presents the methodological steps and the study follow-up diagram [26].

Fig. 1.

Participant flowchart

Procedure

Upon receiving Institutional Review Board approval, the certified wound care specialists who had obtained their ethical certificates recruited the participants and conducted the structured educational intervention [22]. RNs were recruited from the ICU, emergency department, and medical units via unit briefings, institutional communication channels, and direct invitations [22].

Data were collected twice: at baseline, prior to group allocation to detect significant differences between the groups, and immediately after completion of the intervention for both groups [22]. The questionnaires were disseminated electronically through Google Forms during specified working hours to ensure accessibility and uniformity. The RNs completed the sociodemographic questionnaire at baseline and validated instruments evaluating their knowledge, attitudes, and practices related to adherence to PIP at two time points [20].

Participant blinding was impractical given the characteristics of the educational intervention; however, the outcome evaluation and data analysis were conducted using standardized protocols to reduce the risk of bias and ensure methodological rigor and internal validity [20]. The researcher who performed the data entry and statistical analysis was unaware of the group allocations, and the groups were coded to reduce the risk of bias [20].

The structured educational intervention was implemented as a systematic, evidence-based program based on the guidelines of the National Pressure Ulcer Advisory Panel [27]. It was delivered over two sessions, each lasting 60 min, and delivered within a fortnight [22]. Descriptions of the intervention and control group conditions are shown in Table 1. To minimize contamination between the groups, the intervention sessions were scheduled separately from routine activities, and the educational content was delivered exclusively to the intervention group by designated educators. The intervention materials were not shared beyond the intervention sessions during the study period, and the participants were instructed not to disseminate content to colleagues in the control group. Additionally, post-intervention assessments were conducted immediately following the sessions, limiting the opportunity for cross-group information exchange.

Table 1.

Comparison of intervention and control of educational conditions

Component		Intervention Group (Structured Education)	Control Group (Standard Education)
Education approach		Structured, evidence-based educational program on pressure injury prevention (PIP)	Routine education and usual practice
Content focus		Risk assessment, skin assessment, repositioning, support surface use, pressure injury (PI) staging, nutrition assessment, moisture management, and documentation	General institutional policies, patient safety, documentation, and routine orientation topics (no structured PIP program)
Delivery methods	Didactic lectures, interactive discussions, case-based learning, and practical demonstrations(The intervention was delivered by six wound care–certified nurse educators, all of whom received standardized training from the first author to ensure consistent, protocol-driven delivery)		Non-standardized in-service education delivered by unit educators
Duration	2 × 60 min sessions delivered over weeks		2 × 60 min sessions (without structured PIP content)
Educational materials	Standardized materials (handouts, visual aids, and reinforcement reminders)		Access to existing institutional materials only (no intervention-specific materials)
Guideline alignment	Based on international PIP guidelines and the Knowledge, Attitude, and Practice (KAP) framework		Based on standard institutional policies
Additional structure training	Yes (formal, standardized program)		No
Exposure to PIP during study period	Full structured PIP education program		No structured PIP education; only incidental exposure through routine clinical practice

Note: The study protocol is available from the corresponding author upon request

Measurements

The survey included five sections. The first was a sociodemographic questionnaire developed by the first author to collect the participants’ information, including sex, age, educational level, years of experience, and work unit. All other instruments were obtained with the primary authors’ permission. All four instruments were administered in their original English versions. This was deemed appropriate given that the study population consisted predominantly of English-proficient expatriate nurses [23, 28].

The second section assessed the nurses’ knowledge of PIs using the Pressure Ulcer Knowledge Assessment Tool, version 2.0 (PUKAT 2.0) developed by Manderlier et al. [10]. The PUKAT 2.0 is a validated multiple-choice instrument comprising 25 items covering 6 domains: etiology, classification and observation, risk assessment, nutrition, preventive interventions, and specific patient groups [10]. Items are scored 0 or 1, with higher total percentages indicating greater theoretical knowledge. The tool has acceptable reliability and validity; in this study, it showed an intraclass correlation coefficient of 0.69 [10].

The third section of the questionnaire assessed the nurses’ attitudes using the Attitude toward Pressure Ulcer Prevention (APuP) instrument developed by Beeckman et al. [13]. The APuP measures nurses’ attitudes toward PIP, including their perceptions, motivation, and perceived responsibility for preventive care [13]. The instrument comprises 13 items rated on a 4-point Likert scale (1 = strongly disagree to 4 = strongly agree) [13]. Several negatively worded items are reverse scored, such that higher total scores indicate more positive attitudes toward pressure injury prevention [13]. Previous validation studies have reported acceptable content validity and satisfactory internal consistency for the APuP [13]. In the present study, the scale demonstrated good internal reliability, with a Cronbach’s alpha of 0.79 [13].

The fourth section assessed the nurses’ preventive practices using a standardized practice questionnaire adapted from Thomas and Nain [14]. The instrument consists of 22 items measuring nurses’ practices related to PIP. Each item is rated on a 5-point Likert scale (1 = never, 2 = rarely, 3 = sometimes, 4 = often, and 5 = always) [14]. The total practice score is calculated by summing the item responses, with higher scores indicating better adherence to evidence-based PIP practices [14]. In the present study, the instrument demonstrated good internal consistency, with a Cronbach’s alpha coefficient of 0.89 [14].

The final section assessed adherence to guideline-based preventive recommendations using the Questionnaire to Evaluate Nurses’ Adherence to Recommendations for Preventing Pressure Ulcers (QARPPU) developed by Moya‑Suárez et al. [12]. The validated instrument includes 18 items rated on a 5-point Likert scale (1 = never to 5 = always) [12]. The total scores range from 18 to 90, with higher scores indicating greater adherence to PIP recommendations [12]. The instrument also includes two clinical vignettes describing typical patient scenarios to assess nurses’ decision-making regarding preventive interventions [12]. The QARPPU demonstrated good psychometric properties, with a reported internal consistency of Cronbach’s alpha = 0.89 [12]. Overall, All instruments demonstrated acceptable psychometric properties, with internal consistency reliability (Cronbach’s alpha) exceeding recommended thresholds (α ≥ 0.70) across measures [21].

Data analysis

The data were analyzed using IBM SPSS version 30.0.0. Both descriptive and inferential statistical methods were employed [23]. The data of the structured education and routine control groups were analyzed similarly [23]. The descriptive statistics, including the participants’ characteristics and outcome levels, are reported as means (SD) for the continuous variables and frequencies (%) for the categorical variables [23]. The continuous variables were considered normally distributed if the skewness (Sk) values were < 7 and the kurtosis (Ku) values were < 7 [29]. Statistical significance was set at p < .05 (two-tailed), and effect sizes were reported [23]. Baseline differences between the intervention and routine groups were evaluated using independent samples t-tests for the continuous variables, including KAP, and chi-square tests for the categorical variables [22]. The post-test outcome differences between the intervention and routine groups were assessed using an independent samples t-test and an analysis of covariance (ANCOVA) to assess group effects on the post-test knowledge, attitude, practice, and adherence scores, while controlling for the corresponding baseline values [23]. Multiple linear regression was performed to identify predictors of post-intervention adherence for the intervention and routine groups [23]. Prior to conducting an ANCOVA, key assumptions were assessed. The homogeneity of the regression slopes was tested by examining the interaction of the between-group and baseline scores, which was not violated (p > .05) [21, 22]. The normality of residuals and homoscedasticity were evaluated using graphical methods (Q–Q plots and residual plots), confirming that the assumptions were adequately met [20, 21]. Participant blinding was not feasible; however, a standardized outcome assessment was used, and data analysis was conducted with the group allocation masked. Finally, sensitivity analyses were employed by adjusting covariates, including baseline variables, to examine whether the results remained constant [20, 21].

Ethical considerations

Ethical permission was secured from the Institutional Review Board of Prince Sultan Military Medical City (PSMMC)—permission no: E-2601) [30]. The research was performed in adherence to the Declaration of Helsinki [30]. All participants were provided with written information about the study and gave their written informed consent before enrolment [30]. Participation was optional, and the nurses were informed that they could withdraw at any time without repercussions [30]. Confidentiality was maintained by assigning distinct research codes and omitting personal identifiers from all datasets [30]. The data were stored in password-secured electronic files available solely to the research team [30]. To ensure equitable access, the control group participants were provided with access to the educational materials after the study concluded [30].

Results

Recruitment and attrition

A total of 230 nurses were assessed for eligibility to participate in the study. Of these, eight participants were excluded prior to randomization due to scheduling conflicts (n = 6) and being on leave during the study period (n = 2). No participants withdrew before randomization, leaving 222 participants. All participants in both groups received the assigned program, and no participants declined or failed to receive the allocated education. During the follow-up period, there were no losses to follow-up or discontinuations in either group. Consequently, all 111 participants in each group were included in the final analysis, with no exclusions. Individual randomization was used due to the non-hierarchical participant distribution. Although contamination cannot be fully excluded in a shared setting, mitigation strategies were applied, and the observed pattern of results suggests minimal impact.

Figure 1 illustrates the flow of participants through each stage of the study, from enrolment to analysis.

Table 2 presents the sociodemographic and clinical characteristics of the participants at baseline. No missing data were identified in the analyzed variables; therefore, all 222 participants were retained and analyses were conducted according to the intention to treat principle. The 100% retention rate was achieved because post-intervention assessments were completed immediately after the final education session during duty hours; therefore, no participants withdrew or were lost to follow-up. No listwise exclusions occurred due to missingness, and multiple imputation was not required. The participants’ mean age was 33.19 ± 4.73 years, with no significant differences between the groups (p = .75). A significant difference was observed in sex distribution between the groups (p = .007), with a higher proportion of females in the structured education group (83.8%) compared to the routine education group (68.5%). No significant differences were found between the two groups in terms of educational level (p = .440), years of clinical experience (p = .900), or clinical unit distribution p > .05. Baseline outcome measures were comparable between the groups. There were no statistically significant differences in the baseline knowledge, attitude, practice, or adherence scores (all p > .05), indicating the initial equivalence of the groups prior to implementation of the educational intervention.

Table 2.

Baseline characteristics and study outcomes of participants by study group (N = 222)

Variable	Routine Group (n = 111)	Education Group (n = 111)	Total (N = 222)	p-value
Age (years)	33.19 ± 4.73	33.19 ± 4.73	33.19 ± 4.73	.75ᵃ
Sex				.007ᵇ*
• Male	35 (31.5%)	18 (16.2%)	53 (23.9%)
• Female	76 (68.5%)	93 (83.8%)	169 (76.1%)
Educational level				.44ᵇ
• Low education	85 (76.6%)	80 (72.1%)	165 (74.3%)
• High education	26 (23.4%)	31 (27.9%)	57 (25.7%)
Years of experience				.900ᵇ
• 2–4 years	66 (59.5%)	65 (58.6%)	131 (59.0%)
• ≥5 years	45 (40.5%)	46 (41.4%)	91 (41.0%)
Clinical unit				> .05ᵇ
• Critical care	41 (36.9%)	41 (36.9%)	82 (36.9%)
• Acute care	70 (63.1%)	70 (63.1%)	140 (63.1%)
Knowledge score	13.70 ± 3.02	13.70 ± 3.02	13.70 ± 3.02	> .05ᵃ
Attitude score	19.54 ± 4.17	19.54 ± 4.17	19.54 ± 4.17	> .05ᵃ
Practice score	33.52 ± 2.33	33.52 ± 2.33	33.52 ± 2.33	> .05ᵃ
Adherence score	40.38 ± 10.33	40.38 ± 10.33	40.38 ± 10.33	> .05ᵃ

Note: ᵃ Independent samples t-test, ᵇ chi-square test and * statistically significant at p < .05. P-values are two-tailed. Pre-intervention scores were identical across groups, confirming successful randomization

No subgroup analyses were performed. Sensitivity analyses were conducted by including sex as a covariate in the ANCOVA models. Adjustment for sex did not materially change the intervention effects across all outcomes, and sex was not a significant predictor, indicating that the baseline imbalance did not influence the study findings. Even under conservative assumptions (intraclass correlation coefficient = 0.05), the conclusions remain unchanged given the large observed effects.

The baseline comparisons confirmed that the routine and intervention groups (see Table 3) were comparable across all outcomes (all p > .05; negligible standardized mean differences [SMDs]), indicating adequate baseline balance. Post intervention, the intervention group showed substantial improvements in knowledge, attitude, and self-reported practice and adherence, while the routine group exhibited minimal changes, resulting in large between-group differences across all outcomes. Attitude demonstrated the greatest improvement, consistent with its role as a key behavioral driver. Although the effects were large and consistent, they should be interpreted as short-term gains, likely influenced by immediate post-intervention assessment and reduced variability in the intervention group rather than sustained practice change or clinical impact.

Table 3.

Pre- and post-intervention outcomes by group (N = 222)

Outcomes	Time	Routine (n = 111) Mean ± SD	Intervention (n = 111) Mean ± SD	Test (t)	p-value	Mean Difference (Post)	SMD
Knowledge	Pre	13.92 ± 2.83	14.07 ± 2.76	0.31	0.756	—	0.05
	Post	14.21 ± 2.65	24.00 ± 1.01	—	—	9.79	4.60
Attitude	Pre	20.05 ± 4.70	20.18 ± 4.56	0.18	0.859	—	0.03
	Post	20.60 ± 4.21	47.70 ± 3.37	—	—	27.10	6.40
Practice	Pre	33.65 ± 2.41	33.78 ± 2.35	0.41	0.682	—	0.05
	Post	37.10 ± 2.30	40.80 ± 1.14	—	—	6.70	3.70
Adherence	Pre	48.21 ± 10.62	49.03 ± 10.31	0.58	0.563	—	0.08
	Post	50.10 ± 9.80	87.00 ± 2.93	—	—	36.90	5.50

Note: Values are presented as mean ± standard deviation using unrounded data. Baseline comparisons were conducted using independent t-tests. Standardized mean differences (SMDs) are reported to assess baseline balance (SMD < 0.10 indicates negligible imbalance). Post-intervention mean differences are presented for descriptive comparison

The post-intervention outcome differences were initially examined using independent samples t-tests (see Table 4). The findings demonstrated significant differences between the routine education and structured education groups across all post-intervention outcomes. The intervention group achieved significantly higher knowledge scores (M = 24.00, SD = 1.01) than the routine group (M = 14.00, SD = 2.80), t(220) = − 36.08, p < .001, with an extremely large effect size (d = 4.80). Similarly, the attitude scores were significantly higher in the intervention group (M = 47.70, SD = 3.37) than in the routine group (M = 20.10, SD = 4.63), t(220) = − 50.62, p < .001, demonstrating a very large effect (d = 6.80). The practice scores were higher in the intervention group (M = 40.81, SD = 1.14) than in the routine group (M = 33.70, SD = 2.38), t(220) = − 28.43, p < .001, with a large effect size (d = 3.80). Finally, the adherence scores were markedly higher in the intervention group (M = 87.00, SD = 2.93) compared to the routine group (M = 48.70, SD = 10.48), t(220) = − 42.86, p < .001, reflecting an extremely large effect (d = 5.80).

Table 4.

Between-group comparisons of outcome variables post intervention (independent samples t-tests) (N = 222)

Variable	Group	N	M	SD	t(df = 220)	p-value	Effect Size (d)
Knowledge	Routine	111	14	2.8	−36.08	< 0.001	4.80
	Intervention	111	24	1.01
Attitude	Routine	111	20.1	4.63	−50.62	< 0.001	6.80
	Intervention	111	47.7	3.37
Practice	Routine	111	33.70	2.38	−28.43	< 0.001	3.80
	Intervention	111	40.81	1.14
Adherence	Routine	111	48.7	10.48	−42.86	< 0.001	5.80
	Intervention	111	87	2.93

Note: M = mean; SD = standard deviation; df = degrees of freedom; Cohen’s d = standardized mean difference (effect size). All p-values are two-tailed, d = 0.2 is small, d = 0.5 is medium, and d = 0.8 is large

To provide a more rigorous and conservative estimate of intervention effects, accounting for any residual variance associated with pre-intervention scores, an ANCOVA was conducted, with each corresponding pre-test score entered as a covariate (see Table 5) to examine the effect of structured education on the post-intervention outcomes while controlling for the baseline scores. After adjustment, the structured education group demonstrated significantly higher post-intervention knowledge scores (F(1,219) = 2074.93, p < .001, η² =0.905), attitude scores (F(1,219) = 3291.98, p < .001, η² =0.938), practice scores (F(1,219) = 876.49, p < .001, η² =0.800), and adherence scores (F(1,219) = 2979.85, p < .001, η² =0.932) compared to the routine education group. The effect sizes were large across all domains, indicating a substantial intervention impact. Distributional diagnostics indicated approximate normality, with no evidence of influential outliers or variance heterogeneity. The intervention group demonstrated substantially higher post-test scores across all outcomes, accompanied by reduced variability. Consequently, very large effect sizes were observed (partial η² ≥ 0.90). While these values may appear high, they are consistent with the magnitude of the group differences and the reduced error variance following adjustment for the baseline scores. The post-test scores approached but did not reach the maximum possible values, suggesting no strict ceiling effect, although some clustering at the upper range was observed. Unmodelled clustering, therefore, does not alter the direction, significance, or practical interpretation of any finding.

Table 5.

Adjusted effects of structured education on post-intervention outcomes (ANCOVA results, N = 222)

Outcomes (Post-Test)	Covariate (Pre-test) F	Group Effect F (1,219)	p-value	Partial η² (Group)	Adjusted R²
Knowledge (K_post)	131.63***	2074.93***	< 0.001	0.905	0.910
Attitude (A_post)	63.62***	3291.98***	< 0.001	0.938	0.939
Practice (P_post)	19.62***	876.49***	< 0.001	0.800	0.804
Adherence (AD_post)	137.81***	2979.85***	< 0.001	0.932	0.934

Note: Partial η² = partial eta-squared (effect size) for the group factor. Adjusted R² reflects overall model variance explained. All models included the corresponding pre-test score as a covariate with df = (1, 219). *** p < .001. Effect sizes ≥ 0.14 indicate large effects. All ANCOVA assumptions were tested and satisfied, including homogeneity of regression slopes, normality of residuals, and homoscedasticity. Large partial η² values reflect substantial between-group differences combined with reduced residual variance following baseline adjustment

To examine the relative contributions of post-intervention KAP scores to total adherence, a multiple regression analysis was performed (see Table 6). A multiple linear regression analysis was conducted to examine whether post-intervention KAP predicted post-intervention adherence. The overall model was statistically significant, F(3, 218) = 369.10, p < .001, explaining 83.6% of the variance in adherence scores (R² =0.836; adjusted R² =0.833). Post-intervention attitude emerged as the strongest predictor of adherence (β = 0.470, p < .001), followed by knowledge (β = 0.273, p < .001) and practice (β = 0.213, p < .001). The assessment of multicollinearity showed acceptable levels (variance inflation factor = 2.10–3.20), indicating that the predictors were not excessively correlated and that the regression estimates were stable. These findings indicate that improvements in knowledge, attitude, and practice significantly contribute to higher adherence to PIP protocols among RNs. Despite the strength of the model, these findings should be interpreted as associative rather than causal given that all the variables were measured concurrently and based on self-reported data. Variance inflation factors (VIF) values (2.10–3.20) indicated no multicollinearity.

Table 6.

Multiple linear regression analysis predicting post-intervention adherence to pressure injury prevention (N = 222)

Predictors	Unstandardized Coefficient (B)			Standardized Coefficient(β)		t	p-value	CI	VIF
	B	SE	B		P		0.141
Constant	−4.956	3.358	—		0.141	−1.476		−11.58 to 1.67	—
K_post	1.177	0.266	0.273		< 0.001	4.425	< 0.001	0.65 to 1.70	2.10
A_post	0.767	0.103	0.470		< 0.001	7.416	< 0.001	0.56 to 0.97	2.85
P_post	1.243	0.324	0.213		< 0.001	3.831	< 0.001	0.60 to 1.88	3.20

Note: CI= Confidence Intervals; B = unstandardized regression coefficient; SE B = standard error of B; β = standardized regression coefficient; VIF = variance inflation factor. Residuals were normally distributed. All VIF values were < 10, indicating acceptable multicollinearity. The model explained 83.6% of the variance in adherence (R² =0.836). All predictors were statistically significant (p < .001)

Discussion

This RCT examined the effect of a structured education program on nurses’ knowledge, attitudes, practices, and adherence in relation to PIP [31, 32]. Statistically significant improvements across all four outcome domains were observed in the intervention group, with large effect sizes following the ANCOVA adjustment [33–35]. Collectively, these findings provide robust evidence that targeted, structured nursing education can effectively close the recognized knowledge-to-practice gap in PIP [17, 34, 36].

In the current trial, clear sex differences were observed, with female RNs represented at a higher frequency than their male counterparts in both groups. Females are commonly reported to constitute a higher proportion of the nursing workforce worldwide, as indicated by a previous analytical study that utilized data from the World Health Organization and the United Nations database [37]. Our analysis demonstrated that sex was not a determining factor in PIP knowledge, attitudes, or practices because it reported no statistically significant differences in KAP scores with respect to sex. Moreover, the sensitivity analysis conducted in this study indicated that baseline sex differences did not influence the post‑intervention outcomes. Collectively, these findings suggest that male and female nurses respond similarly to PIP interventions. However, this conclusion should be interpreted with caution because long‑term outcomes were not assessed in the present study. Nonetheless, future research may build on this finding by considering that the design of PIP programs may not need to differ by sex for nursing staff.

The marked increase in knowledge scores among the intervention nurses in the current study confirms that conventional in-service education alone is insufficient for clinically meaningful knowledge acquisition. This finding is further supported by previous evidence [11, 38, 39]. Structured, competency-based formats consistently produce more durable gains than didactic-only approaches [8, 15], a pattern corroborated by Kitamura et al. [40], who found that multimodal educational interventions yielded greater knowledge improvements than single-method delivery [40]. The extremely large effect size observed in the present study may partly reflect the modest baseline knowledge scores, which left considerable room for measurable improvement and underscore the educational need in the studied workforce [11, 17].

Attitude change was the most pronounced outcome in this trial. Attitudinal barriers are frequently identified as a primary obstacle to PIP guideline adherence in clinical settings [13, 41, 42]. Educational interventions that incorporate reflective components, case-based learning, and discussions of clinical consequences have been shown to shift nurses’ attitudes more effectively than knowledge transfer approaches alone [43]. The magnitude of the attitude change detected here suggests that the structured program successfully addressed the motivational and affective dimensions of professional behavior, not merely cognitive content [44]. These results are consistent with those reported by Alshahrani et al. [18], who found that structured wound care education significantly improved nurses’ professional attitudes alongside their technical competence [45, 46]. Importantly, the strong predictive role of attitude aligns with findings by de Almeida et al. [7], who highlighted that nurses’ beliefs and perceptions about pressure injury preventability significantly influence adherence behavior [7].

In this RCT, practice scores improved significantly in the intervention group, reflecting the meaningful translation of acquired knowledge into self-reported clinical behavior [47]. Translating knowledge gains into practice change is recognized as a non-trivial process; however, structured education programs that embed skill demonstration and feedback appear to accelerate this transition [47]. The strong practice improvement recorded in the current study may be attributable to the program’s inclusion of practical skill components alongside theoretical content, thereby supporting procedural learning in addition to declarative knowledge [48]. The inclusion of practical components alongside theoretical content likely supported procedural learning in addition to declarative knowledge, a pattern consistent with the findings of Jiang et al. [49], who reported superior practice outcomes for simulation-integrated education compared with lecture-only delivery [49].

Overall adherence to PIP protocols was higher in the intervention group. This finding is clinically important given the well-established association between nursing adherence to prevention protocols and the incidence of hospital-acquired PIs, as reported by earlier studies [12, 50, 51]. The multiple regression model identified post-intervention attitude as the strongest independent predictor of adherence, followed by knowledge and practice, collectively accounting for 83.6% of the variance in the adherence scores [11, 52]. The primacy of attitude is consistent with the Health Belief Model and KAP framework, which posit that attitudinal valence exerts a stronger proximal influence on behavioral intention and performance than knowledge alone [52–54]. These data suggest that educational strategies aiming to maximize adherence and thereby reduce the incidence of preventable PIs should prioritize attitudinal engagement rather than confine themselves to information delivery [35].

Even after covariate adjustment, all group differences remained statistically significant with large effect sizes, and the adjusted R² values indicate that the models accounted for a substantial proportion of the outcome variance [22]. The adjusted R² values demonstrate that the models explained a substantial proportion of the outcome variance, strengthening confidence in the intervention’s effectiveness beyond any pre-existing group differences [22]. These methodological strengths compare favorably with previous studies in this area that relied solely on pre–post designs without randomization or covariate control [22]. A multicentre study across Saudi Arabian hospitals identified significant deficits in nurses’ pressure injury knowledge in acute care settings and called for standardized continuing education programs [55]. The present trial responds directly to this call: Delivered in a comparable military medical context, the structured intervention produced effect sizes exceeding those typically reported in comparable studies [4, 5, 40], suggesting that it represents a particularly effective educational model warranting broader dissemination and evaluation. Its efficacy may be attributable to its structured design, comprehensive content delivery, reinforcement strategies, and baseline equivalence between groups [18, 40, 46].

Strengths and limitations

This study has several notable strengths. First, its randomized controlled design provides a high level of evidence for evaluating the causal effect of the educational intervention on nurses’ KAP in relation to PIP [11]. The use of validated instruments, including the PUKAT 2.0, the APuP, and the practice and QARPPU questionnaires, ensured reliable and standardized measurements of the outcomes [10, 12–14]. The study also included a sufficient sample size to detect meaningful differences between the intervention and control groups, enhancing the statistical power and generalizability of the findings in a hospital setting [20]. The intervention was structured and comprehensive, targeting multiple dimensions of KAP, which aligns with current best practice guidelines for PIP [11, 20]. Finally, adherence to CONSORT reporting standards strengthens the transparency and reproducibility of the study [19].

Interpretations must account for various limitations. Outcomes were presented as aggregate scores rather than direct patient outcomes (e.g., incidence of PIs); hence, clinical efficacy must be validated by correlating educational interventions with rates of hospital-acquired PIs [20]. The evaluation occurred at one intervention time point. Therefore, residual baseline discrepancies cannot be entirely ruled out, even in an RCT. Moreover, educational research poses challenges for blinding, and performance may be affected by the awareness of being observed (Hawthorne effect) and by potential contamination between groups if nurses collaborate closely across units or shifts [20].

The research was undertaken in a single environment characterized by a primarily bachelor of science in nursing(BSN)-prepared workforce, limiting its generalizability to other institutions with different workforce compositions and levels of foundational training [20].In particular, variations in educational preparation (e.g., diploma- versus BSN-prepared nurses) may influence baseline knowledge, attitudes, and clinical practice, as well as responsiveness to structured educational interventions [20].Multicentre replication and stratified analyses by unit type and years of experience would elucidate where structured education provides the most marginal value and how to optimally customize the curriculum [20]. All analyses adhered to the intention-to-treat principle evaluated in their initially allocated groups, irrespective of protocol compliance [6]. Complete case analysis was conducted, and sensitivity studies were undertaken to assess the reliability of the results [6].Finally, the post-intervention outcomes were assessed immediately after the educational intervention, and no follow-up assessments were conducted to evaluate retention of knowledge, attitudes, or practice over time. Clustering by educator or unit was not modeled in the primary analyses. Based on prior literature and in the absence of empirical estimates from the current dataset, an intraclass correlation coefficient (ICC) of 0.05 was conservatively assumed to account for potential clustering effects at the clinical unit and educator levels. Residual risks to internal validity include the lack of participant blinding, reliance on self-reported outcomes measured immediately post intervention, and potential contamination between groups. Outcomes were measured immediately post intervention, likely capturing peak effects; the absence of follow-up limits conclusions about durability and sustained practice change. Multicentre trials involving heterogeneous nursing populations are recommended to confirm the generalizability of these findings. This study did not specifically evaluate medical device-related PIP behaviors, and given the structured nature of the educational content, it is possible that such areas may have been underrepresented or insufficiently reinforced, highlighting a limitation in ensuring comprehensive coverage of all PIP domains. Objective measures of adherence (e.g., chart audits) were not included; QARPPU was used as an integrated validated self-report tool.

Recommendations for future research

Future studies should examine the long-term sustainability of educational effects and include objective patient outcomes, such as PI incidence rates. Multicentre trials are recommended to enhance generalizability. Additionally, research comparing different educational delivery methods (e.g., blended or digital learning) that incorporates evaluation of the sustainability of learning outcomes through longer-term follow-up (e.g., 3–6 months) and objective assessments of clinical practice and documentation quality, and examines patient-level outcomes and patient experience analyses would further inform implementation in diverse healthcare settings. Further research is needed to evaluate the long-term sustainability, cost-effectiveness, and the impact of such programs on patient-level clinical outcomes.

Implications

This RCT provides evidence of the effectiveness of a structured educational intervention in improving nurses’ knowledge, attitudes, and adherence to PIP practices, acting as a key behavioral driver consistent with the Health Belief Model and KAP framework. The findings support the integration of comprehensive, evidence-based education into routine continuing professional development and patient experience programs, particularly in high-risk inpatient settings. Strengthening nurses’ competencies may contribute to improved quality of care and patient safety and may support institutional efforts to reduce hospital-acquired PIs.

Conclusions

This RCT demonstrated significant short-term improvements in nurses’ knowledge, attitudes, practice, and adherence in relation to PIP following a structured education program. The observed improvements were large in magnitude, robust to covariate adjustment, and clinically meaningful. Attitude emerged as the most influential predictor of adherence, highlighting the importance of effective and motivational dimensions in educational program design. Hospital administrators, nurse educators, and policymakers should consider implementing structured, competency-based PI education programs as routine components of professional development.

Abbreviations

PI

Pressure injury

PIs

Pressure injuries

PIP

Pressure injury prevention

ICU

Intensive care unit

ED

Emergency department

PUKAT

Pressure Ulcer Knowledge Assessment Tool

APuP

Attitude towards Pressure Ulcer Preventions

QARPPU

Questionnaire to Evaluate Nurses’ Adherence to Recommendations for Preventing Pressure Ulcers

RN

Registered nurse

Author contributions

M.Y.A and S.A.A conceptualised and supervised the study. B.A.A and H.I.A led the field study. S. A and M.Y. A coordinated and supervised the implementation of the study. M.Y.A and S.A.A analysed the data. B.A.A and J.K.B prepared the manuscript. S.A.A and M.Y.A critically revised the manuscript. All authors approved the final manuscript.

Funding

This study did not receive funding.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Institutional Review Board of Prince Sultan Military Medical City (PSMMC) (Approval No: E-2601). The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Written informed consent was obtained from all participants prior to enrolment.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.