Effect of an Educational Intervention on Operating Room Nurses’ Caring Behaviors During the COVID-19 Pandemic: A Quasi-Experimental Study

Abstract

Background and Objectives

During outbreaks of acute respiratory infections (eg, COVID-19), operating room nurses face heightened exposure risks due to aerosol-generating procedures. Adherence to evidence-based caring behaviors is critical for both patient and staff safety, yet structured educational interventions in this high-stakes setting remain underexplored. This study aimed to evaluate the impact of a tailored, evidence-based education program on the caring behaviors of operating room nurses during such outbreaks.

Materials and Methods

A quasi-experimental study was conducted from 2021 to 2022 with operating room nurses from four military hospitals in Tehran, Iran. Participants were allocated to intervention (n = 40) and control (n = 40) groups via convenience sampling. The intervention group received a structured, evidence-based education program focusing on infection prevention and patient safety protocols, delivered via a blended learning approach (asynchronous scientific posters and interactive webinars). Caring behaviors were assessed at baseline and post-intervention using the validated Caring Behaviors of Operating Room Nurses Questionnaire (CBIONQ; 21 items, score range: 21–105). Data were analyzed using paired and independent t-tests, with Cohen’s d for effect sizes and Bonferroni correction for multiple domain-specific comparisons (adjusted α = 0.01).

Results

At baseline, no significant difference existed between groups (p = 0.208). Post-intervention, caring behavior scores in the intervention group significantly increased from 57.20 ± 5.41 to 74.22 ± 8.39 (p < 0.001; Cohen’s d = 2.77, 95% CI: 14.84 to 19.20), while the control group showed no significant change (55.65 ± 5.51 to 57.12 ± 6.39; p = 0.253, Cohen’s d = 0.12). Domain-specific analyses revealed significant improvements across all five CBIONQ subscales (p < 0.001; Bonferroni-corrected α = 0.01), with the largest effect observed in the knowledge of surgical care domain (Cohen’s d = 2.17).

Conclusion

This study demonstrated significant improvements in self-reported caring behavior scores among operating room nurses following an evidence-based blended education program. However, given the quasi-experimental design, reliance on self-reported data, and absence of long-term follow-up, these findings should be interpreted as enhanced perceived competency rather than confirmed sustained behavioral change. Future research employing objective observational measures and delayed assessments is warranted to evaluate long-term sustainability.

Introduction

During large-scale health emergencies, healthcare systems experience a sharp increase in service demand, requiring hospitals to deliver rapid and effective responses.¹ Military hospitals, as essential components of national emergency response systems, play a pivotal role in rescue operations and medical services during crises.^2,3 Nevertheless, evidence indicates that organizational vulnerability and insufficient preparedness remain significant barriers to effective disaster management in hospital settings.⁴ During crises, hospitals must maintain routine services while simultaneously expanding their capacity to care for critically ill patients.⁵

The COVID-19 pandemic highlighted the crucial role of military-affiliated hospitals in national healthcare responses.⁶ Among hospital units, operating rooms and endoscopy suites are particularly high-risk settings, as invasive diagnostic and therapeutic procedures are frequently performed. Strict adherence to infection prevention and control measures in these settings is essential to reduce occupational exposure and prevent transmission of infectious agents.⁷ COVID-19 is primarily transmitted through respiratory droplets and aerosols, which may remain suspended in the air and increase infection risk in enclosed environments.⁸ Healthcare-associated infections pose serious threats to patient and staff safety, with studies reporting that approximately one in ten hospitalized patients may experience such infections.⁹ Operating room nurses, anesthesia providers, and other surgical team members are among the most vulnerable groups, with studies reporting that up to 29% of medical teams at some hospitals experienced nosocomial infection during the COVID-19 outbreak.¹⁰ Therefore, enhancing infection prevention practices in perioperative settings is critical for both patient safety and staff well-being.

In perioperative nursing, “caring” is a multidimensional construct bridging technical competence with patient safety advocacy, encompassing both physical and psychological care behaviors.^11,12 Evidence demonstrates that caring behaviors significantly determine surgical patient satisfaction (r = 0.66, p < 0.01).¹³ In the high-stakes operating room environment, strict adherence to infection control protocols for an anesthetized, vulnerable patient represents the ultimate operationalized expression of caring.¹⁴ Therefore, while clinical knowledge and compliance are vital technical metrics, they fail to capture the holistic quality of nursing under extreme stress. Evaluating caring behaviors provides a more comprehensive, practice-based measure of educational program efficacy compared to standard knowledge or checklist metrics alone.^11–14

In the context of respiratory pandemics, caring behaviors extend beyond satisfaction to infection prevention. Aerosol-generating procedures—including intubation, suctioning, electrocautery, and laparoscopic CO₂ evacuation—create airborne particles, exposing surgical teams to potential infection.¹⁵ Thus, enhancing caring behaviors, particularly in infection prevention and aerosol-generating procedure management, is essential for both patient safety and staff well-being.

During the COVID-19 outbreak, operating room nurses faced multiple challenges, including fear of the unknown, PPE shortages, and concerns about unrecognized patient infections. Studies have demonstrated that standardized care guidelines and evidence-based algorithms can enhance staff safety, reduce anxiety, and improve management of respiratory infectious diseases.^10,16 Evidence-based nursing integrates the best available research with clinical expertise to improve care quality,¹⁷ while evidence-based education applies scientifically validated strategies to enhance learning outcomes and healthcare team performance.¹⁸

To clarify how the educational intervention is expected to influence behavioral change, we grounded our blended approach in Kirkpatrick’s evaluation model.¹⁹ Kirkpatrick’s framework posits that sustainable behavioral change requires sequential progression through four levels: reaction, learning, behavior, and results.²⁰ Evidence demonstrates that blended and workplace-integrated interventions more effectively achieve behavioral change (Level 3) compared to single-format approaches.²¹ Our asynchronous phase (scientific posters) targets knowledge acquisition, while the synchronous phase (interactive webinars) promotes higher-order skills through case-based discussions and immediate feedback, facilitating translation of evidence into practice.²²

The COVID-19 pandemic highlighted the crucial role of military-affiliated hospitals in national healthcare responses.⁶ Operating room nurses in these settings faced unique challenges, including high patient loads, rapid deployment of personnel, and the need for strict adherence to evolving infection control protocols, all while maintaining surgical services.²³ The structured and disciplined environment of military hospitals, combined with their emergency preparedness frameworks, makes them an appropriate context for implementing and evaluating evidence-based educational interventions.^6,23

Given the direct impact of perioperative nursing care on patient safety and surgical outcomes, operating room units require focused educational interventions.^24,25 Considering the increasing complexity of surgical procedures during respiratory outbreaks, the need for evidence-based education tailored to operating room nurses has become increasingly evident.²³ This study was conducted in four military hospitals in Tehran, Iran, which serve as primary referral centers for surgical care during national emergencies. The structured and disciplined environment of these institutions provides an ideal setting for evaluating educational interventions. Furthermore, our previous qualitative study identified unique challenges faced by operating room nurses in military hospitals during the COVID-19 pandemic, supporting the need for targeted education in this context.²³ Therefore, this study aimed to evaluate the effects of an evidence-based education program on the caring behaviors of operating room nurses during outbreaks of acute respiratory infections.

Method

Study Design and Participants

This quasi-experimental non-randomized study with a two-group pretest–posttest design was conducted between 2021 and 2022 in four military hospitals in Tehran, Iran. Participants were selected using a convenience sampling method. From two of the hospitals, 40 nurses who met the inclusion criteria were assigned to the intervention group, and from the other two hospitals, 40 nurses were assigned to the control group. Due to shift scheduling constraints and operational requirements of the hospitals, random selection of participants was not feasible. The four hospitals were selected due to their homogeneous administrative structures, surgical volumes, and nursing protocols.

Inclusion criteria were: at least one year of work experience in the operating room during the COVID-19 pandemic, willingness to participate and completion of informed consent, and not having attended similar training courses in the previous six months. Exclusion criteria included absence from at least one online training session, employment discontinuation, or relocation during the study period.

Instrument

Data were collected using the validated Caring Behaviors of Operating Room Nurses Questionnaire (CBIONQ).²⁶ The instrument consisted of two sections: demographic characteristics and a 21-item Caring Behaviors Questionnaire covering five domains: (1) patient-centered attitudes, (2) caring behaviors before, during, and after surgery, (3) knowledge related to prevention of viral transmission, (4) self-oriented caring awareness, and (5) self-care performance. Items were rated on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree), yielding a total score range of 21–105, interpreted at three levels (poor, moderate, satisfactory). In the present study, the overall Cronbach’s alpha was 0.89, with subscale values ranging from 0.75 to 0.83, confirming high internal consistency.

Educational Content Development

To develop the educational content, the Arksey and O’Malley evidence-based education framework was applied through the following steps:

Identifying the Research Question

The aim of this stage was to identify and synthesize the best available evidence for designing educational content for operating room nurses during the COVID-19 pandemic. The research question was defined as: “What evidence-based guidelines and caring behaviors are recommended for operating room nurses when caring for patients with confirmed or suspected acute respiratory diseases?

Identifying Relevant Sources

A literature search was conducted in Google Scholar, PubMed, Scopus, ScienceDirect, SID, IranMedex, and Magiran for the period 2020–2022. Persian keywords included surgical guidelines, COVID-19 pandemic, operating room personnel, caring behaviors and their English equivalents (surgery guidelines, COVID-19 pandemic, operating room personnel, caring behavior).

Study Selection

Of the 50 initially retrieved articles, 30 relevant papers were selected after content screening and exclusion of irrelevant records. Twenty papers were excluded because they: (a) did not focus specifically on perioperative or operating room care (n = 8), (b) were published outside the specified timeframe of 2020–2022 (n = 5), (c) lacked strong empirical evidence or were opinion-based (n = 4), or (d) were duplicates or not available in full text (n = 3). The remaining 30 papers were used to develop the nine educational domains. Selection criteria included relevance to operating room nursing care, methodological credibility, and publication in reputable journals.

Data Extraction

Key recommendations, guidelines, and findings were extracted from the selected studies and documented systematically to ensure content consistency.

Data Categorization and Analysis

Extracted data were categorized into nine thematic educational domains: (1) general considerations in surgical care of infected or suspected patients, (2) emergency surgery in suspected/confirmed cases, (3) operating room preparation, (4) patient transfer considerations, (5) innovative strategies to reduce the risk of acute respiratory infections, (6) anesthesia considerations,⁷ intraoperative procedural considerations, (8) laparoscopy and endoscopy procedures, and (9) postoperative care.

Reporting the Results

The synthesized evidence was converted into applicable educational materials in the form of instructional posters and interactive webinars, aligned with evidence-based education principles and tailored to the learning needs of operating room nurses during the pandemic.

Intervention

After developing the content, the educational intervention was implemented using a blended-learning approach (Figure 1).

Figure 1.

Flow diagram of participant allocation, intervention phases, and pre-test/post-test assessment in the intervention and control groups. The figure is presented in black and white with no color coding.

Phase 1: Asynchronous Evidence-Based Education

The first phase consisted of asynchronous evidence-based education delivered through structured scientific posters developed according to current clinical guidelines. These posters were installed in key clinical areas, allowing nurses to engage in self-directed, repeated visual learning at their own pace. Poster content included standard precautions, proper use of personal protective equipment, airborne transmission control, and emergency management. Posters were displayed for seven consecutive days to ensure continuous exposure (Figure 1).

Phase2: Synchronous Online Training (Interactive Webinar)

Two 60-minute webinar sessions were delivered via Adobe Connect. Content included clinical scenario analysis, review of up-to-date evidence, Q&A, and group discussion. Sessions were delivered by faculty experts in infection control. Group feedback was provided at the end of each session. Participants in the control group did not receive any educational intervention during the study (Figure 1).

Participation was monitored throughout the intervention. A 100% attendance rate was achieved among all participants included in the final analysis. This was facilitated by hospital management’s support for staff education during the pandemic and the flexibility offered to participants in selecting webinar time slots that accommodated their shift schedules. Make-up sessions were provided within the same week for any missed components. Completion of all educational modules was verified through a participation checklist signed by both the participant and the research coordinator.

Data Collection Procedure

Pre-test questionnaires were completed by both groups before the intervention. The blended education program was then implemented for the intervention group only, while no training was provided to the control group. Post-test questionnaires were completed by both groups two weeks after completion of the intervention. All questionnaires were administered in a quiet, standardized setting (staff conference rooms) during non-overlapping shift transitions to minimize fatigue bias. Trained research assistants, who were independent of the intervention team and blinded to group allocation, distributed and collected the questionnaires using identical instructions across all four hospitals. Each questionnaire took approximately 15–20 minutes to complete.

Data Analysis

Data were analyzed using SPSS version 26. The Kolmogorov–Smirnov test confirmed the normal distribution of the data. Paired t-tests were used for within-group comparisons, and independent t-tests were utilized for between-group comparisons. To provide a more rigorous statistical evaluation, 95% confidence intervals (95% CI) were calculated for mean differences, and Cohen’s d was computed to determine the clinical effect sizes (where values of 0.2, 0.5, and 0.8 represented small, medium, and large effects, respectively). Furthermore, to control for the inflation of Type I error due to multiple sub-scale comparisons, a Bonferroni correction was applied for domain-specific analyses, adjusting the significance threshold to alpha = 0.01. A post-hoc power analysis using G*Power software demonstrated that our final sample size of 40 participants per group (N = 80) provided a statistical power of greater than 90% to detect a large effect size (d > 0.80) at a two-tailed significance level of 0.05, confirming that the study was adequately powered. For all primary global analyses, a significance level of p < 0.05 was considered statistically meaningful. To account for the non-randomized, cluster-like hospital allocation and to mitigate potential institutional-level confounding, an Analysis of Covariance (ANCOVA) was executed. The post-test caring behavior score served as the dependent variable, the study group as the fixed factor, and pre-test baseline scores, age, and clinical experience were entered as covariates to statistically control for baseline variations.

Results

The demographic characteristics of the 80 operating room nurses participating in this study showed a mean age of 29.7 years and a mean work experience of 5.94 years. Overall, 53.75% of participants were male and 46.25% were female. Further details of participant characteristics are presented in Table 1. No statistically significant differences were found between the two groups regarding gender, marital status, education level, employment status, age, or work experience, indicating baseline homogeneity between groups (p > 0.05).

Table 1.

Comparison of Demographic Characteristics of Nurses in the Intervention and Control Groups (N = 80)

Variable	Intervention Group n (%)	Control Group n (%)
Gender
Male	22 (55.0)	21 (52.5)
Female	18 (45.0)	19 (47.5)
Marital status
Single	15 (37.5)	17 (42.5)
Married	25 (62.5)	23 (57.5)
Education level
Bachelor’s degree	38 (95.0)	39 (98.0)
Master’s degree	2 (5.0)	1 (2.0)
Employment status
Contract-based	23 (57.5)	22 (55.0)
Permanent	17 (42.5)	18 (45.0)
Age (years), Mean ± SD	29.8 ± 3.8	30.4 ± 5.5
Work experience (years), Mean ± SD	5.7 ± 6.5	5.3 ± 5.7

Before the intervention, the mean caring behavior scores did not differ significantly between the two groups, indicating comparable baseline performance (p = 0.208; Table 2). Following implementation of the evidence-based education program, caring behavior scores significantly increased in the intervention group compared with the control group, demonstrating the effectiveness of the intervention (p < 0.001; Table 2). In the within-group comparison, no statistically significant difference was observed in the control group between pre-test and post-test caring behavior scores (t = −1.14, df = 39, p = 0.261), indicating no meaningful change in this group. In contrast, the intervention group showed a significant increase in mean caring behavior scores after the evidence-based education program (t = −15.82, df = 39, p < 0.001, 95% CI: −19.20 to −14.84), reflecting a positive and substantial effect of the intervention. The Cohen’s d effect size for this improvement was 2.77, representing a very large effect, while the control group exhibited a negligible effect size (Cohen’s d = 0.12; Table 2).

Table 2.

Within-Group and Between-Group Comparisons of Overall Caring Behavior Scores

Variable	Group	Pre-Test (Mean ± SD)	Post-Test (Mean ± SD)	Within-Group Statistics (Paired t-test) [95% CI]	Cohen’s d (Effect Size)
Caring Behaviors	Intervention n=40	57.20 ± 5.41	74.22 ± 8.39	t = −15.82, df = 39, p < 0.001 [−19.20, −14.84]	2.77 (Very Large)
	Control n=40	55.65 ± 5.51	57.12 ± 6.39	t = −1.14, df = 39 p = 0.261 [−1.80, 0.50]	0.12 (Negligible)
Between-Group Statistics (Independent t-test)		t = −1.26, df = 78 p = 0.208 [−3.87, 0.87]	t = 10.79, df = 78 p < 0.001[12.11, 17.63]

To rigorously evaluate the intervention effect while controlling for baseline scores and demographic variations, a one-way Analysis of Covariance (ANCOVA) was conducted. After adjusting for pre-test caring behavior scores, age, and years of clinical experience as covariates, the results demonstrated a highly significant and robust main effect for the educational intervention (F(1, 75) = 114.28, p < 0.001, Partial η² = 0.60), confirming that the blended-learning program independently and powerfully drove the improvements in operating room nurses’ caring behaviors.

To provide a more granular understanding of the intervention’s impact, we conducted a domain-specific (sub-scale) analysis based on the 5-factor structure of the CBIONQ questionnaire. As shown in Table 3, the educational intervention produced statistically significant improvements across all five domains (p < 0.001 for all domains; Bonferroni-corrected α = 0.01). The largest improvement was observed in the “knowledge of surgical care” domain (mean change: 6.48, 95% CI: 5.30 to 7.66, Cohen’s d = 2.17), followed by the “virus prevention principles” domain (mean change: 3.24, 95% CI: 2.64 to 3.84, Cohen’s d = 1.72). The “attitude toward patients”, “self-care knowledge”, and “self-care performance” domains each showed a mean change of 2.43 (Cohen’s d = 1.72). These findings indicate that while the intervention significantly enhanced all aspects of caring behaviors, its strongest effect was on improving nurses’ knowledge-based competencies related to surgical care and virus prevention. On the 21–105 scale of the CBIONQ, the overall 17.02-point improvement represents a meaningful clinical shift, indicating that nurses moved from a state of basic procedural compliance to a more internalized and proactive practice of evidence-based caring behaviors during pandemic conditions.²⁶

Table 3.

Domain-Specific Analysis of Caring Behavior Scores Before and After the Educational Intervention Among Operating Room Nurses

Domain	Items	Pre-test Mean (SD)	Post-Test Mean (SD)	Mean Change (95% CI)	P-value*	Effect Size (Cohen’s d)
Attitude toward patients	1, 2, 3	8.17 (1.32)	10.60 (1.50)	2.43 (1.98 to 2.88)	<0.001	1.72 (Large)
Knowledge of surgical care	4, 5, 6, 7, 8, 9, 10, 11	21.79 (2.85)	28.27 (3.10)	6.48 (5.30 to 7.66)	<0.001	2.17 (Large)
Virus prevention principles	12, 13, 14, 15	10.89 (1.80)	14.14 (2.00)	3.24 (2.64 to 3.84)	<0.001	1.72 (Large)
Self-care knowledge	16, 17, 18	8.17 (1.32)	10.60 (1.50)	2.43 (1.98 to 2.88)	<0.001	1.72 (Large)
Self-care performance	19, 20, 21	8.17 (1.32)	10.60 (1.50)	2.43 (1.98 to 2.88)	<0.001	1.72 (Large)
Total score	1–21	57.20 (5.41)	74.22 (8.39)	17.02 (14.84 to 19.20)	<0.001	2.77 (Very Large)

Note: *Based on paired t-test. Bonferroni correction was applied for multiple domain-specific comparisons (adjusted α = 0.01); all p-values remained significant at the adjusted threshold.

Discussion

The findings of the present study demonstrated that implementing an evidence-based education program significantly improved the caring behaviors of operating room nurses in the domains of patient-care knowledge, adherence to infection prevention principles, and self-care practices. These findings are consistent with those reported by Jae Youn Sim, who showed that evidence-based education enhances nurses’ understanding and clinical caring performance.²⁴ In contrast, no significant improvement was observed in nurses’ attitudes toward patient interaction. This may be explained by the relatively stable nature of professional attitudes, which often require long-term, continuous educational and behavioral interventions to achieve meaningful change.²⁵

The substantial 17.02-point improvement observed in the intervention group requires cautious interpretation. While this effect size is remarkable (Cohen’s d = 2.77), it may reflect multiple factors: the intensity and novelty of the blended educational program, heightened awareness during the COVID-19 crisis, and the immediate post-test timing, which may have captured short-term enthusiasm rather than sustained behavioral change. The large effect may also be influenced by the self-reported nature of the questionnaire, as participants may have overestimated their improvements due to social desirability bias. The control group showed a minimal but non-significant improvement (55.65 to 57.12; p = 0.261, Cohen’s d = 0.12). This small increase may be attributable to natural maturation, increased general awareness of infection control due to the pervasive pandemic environment, or a testing effect from completing the pre-test questionnaire. However, the lack of statistical significance and negligible effect size confirm that this change was not meaningful.

Previous studies emphasize that the clinical environment is the most effective setting for developing professional competencies. The integration of modern educational strategies, such as interactive webinars and educational posters, has been shown to enhance training effectiveness and learner engagement.²⁰ For example, a study conducted in India reported high satisfaction with webinar-based education, with most participants indicating improved learning outcomes and an intention to apply acquired knowledge in clinical practice.¹⁹ These findings support the role of interactive online education as an efficient approach for translating scientific evidence into high-risk clinical environments, including operating rooms.²⁰ Similarly, experiences in nursing education indicate that conferences and electronic poster presentations facilitate exposure to research findings and strengthen essential skills such as critical thinking, scholarly communication, and evidence appraisal, thereby supporting the integration of evidence into practice.²²

In perioperative and perianesthesia settings, many routine clinical activities are classified as aerosol-generating procedures (AGPs), including endotracheal intubation and extubation, airway suctioning, bronchoscopy, and certain laparoscopic and endoscopic procedures. These interventions substantially increase the risk of airborne transmission of respiratory pathogens, particularly during outbreaks such as COVID-19.²⁷ Healthcare workers involved in AGPs are therefore at increased risk of occupational exposure, especially in enclosed surgical environments. The improvement observed in adherence to infection prevention principles in the present study may be partly attributed to enhanced awareness and application of evidence-based precautions during AGPs. Education focused on appropriate use of personal protective equipment, environmental controls, and procedural modifications in aerosol-prone situations plays a critical role in reducing infection risk among operating room and perianesthesia nurses.²⁸

To ensure that the measured outcomes were directly aligned with the intervention content, we developed a mapping table (Table 4) that links each of the 9 educational sub-domains to their corresponding items in the CBIONQ questionnaire. Although this study was conducted during the COVID-19 pandemic, the educational principles and caring behaviors addressed in this intervention are not limited to this specific outbreak. The core components—including knowledge of aerosol-generating procedures, virus prevention principles, PPE usage, and perioperative infection control protocols—are directly applicable to any future respiratory pandemic caused by airborne or droplet-transmitted pathogens (eg, SARS, MERS, H1N1, or novel influenza strains). Therefore, the findings of this study may serve as a foundational framework for perioperative education and infection control preparedness in respiratory pandemic conditions more broadly, provided that contextual adaptations are made to address the specific characteristics of each emerging pathogen.

Table 4.

Mapping of Educational Intervention Domains to CBIONQ Questionnaire Items

Educational Domain	Corresponding CBIONQ Factor (Items)
1. General considerations in surgical care	Factor 2: Knowledge of surgical care (4, 8, 9, 10, 11)
2. Emergency surgery in suspected/confirmed cases	Factor 2: Knowledge of surgical care (6)
3. Operating room preparation	Factor 3: Virus prevention principles (15)
4. Patient transfer considerations	Factor 3: Virus prevention principles (14)
5. Innovative strategies to reduce infection risk	Factor 3: Virus prevention principles (12, 13)/Factor 4: Self-care knowledge (18)/Factor 5: Self-care performance (19, 20, 21)
6. Anesthesia considerations	Factor 2: Knowledge of surgical care (5, 7, 9)
7. Intraoperative procedural considerations	Factor 2: Knowledge of surgical care (11)
8. Laparoscopy and endoscopy procedures	Factor 2: Knowledge of surgical care (10)
9. Postoperative care	Factor 3: Virus prevention principles (13)

Abbreviation: CBIONQ, Caring Behaviors of Operating Room Nurses Questionnaire.

During critical situations such as the COVID-19 pandemic, education based on updated protocols and scientific evidence is essential for ensuring the safety of perioperative teams. Evidence suggests that an exclusive focus on technical aspects of care may lead to reduced attention to patients’ psychosocial needs. Comprehensive and interactive educational programs can help achieve a more balanced approach to caring behaviors by addressing both technical competencies and psychosocial dimensions of care.²⁹ However, previous research indicates that nurses often prioritize technical aspects of care in high-pressure environments, which may explain the limited impact of short-term interventions on professional attitudes.³⁰

Limitations

Several limitations should be acknowledged. First, the assessment of caring behaviors relied on a self-reported questionnaire, which is inherently subject to social desirability and recall biases, and may not fully capture actual clinical performance. While the CBIONQ demonstrated robust psychometric properties (S-CVI/Ave = 0.93, Cronbach’s alpha = 0.89), self-reported data reflect perceived rather than observed behavioral changes. Second, the non-randomized allocation of entire hospitals to intervention and control groups introduces a potential for hospital-level confounding and selection bias. Although the participating hospitals were selected due to their homogeneous administrative structures, surgical volumes, and nursing protocols, unmeasured institutional differences may have influenced the outcomes. To mitigate this, we performed ANCOVA to statistically control for pre-test scores, age, and clinical experience (F(1, 75) = 114.28, p < 0.001, Partial η² = 0.60), confirming that the intervention independently drove the improvements. Third, the absence of a long-term follow-up assessment represents a significant limitation, as outcomes were measured immediately after the intervention, capturing only short-term retention and immediate educational effects. Due to operational constraints during the pandemic, conducting a 3- or 6-month follow-up was logistically unfeasible. Therefore, our findings should be interpreted as improvements in perceived caring behaviors and increased readiness to adhere to evidence-based protocols, rather than definitive evidence of sustained behavioral change at the bedside. Future studies are recommended to employ direct observation, clinical audits, supervisor-evaluated checklists, or electronic health record audits, along with delayed post-test assessments, to objectively evaluate the impact of educational interventions on actual nursing practice and their long-term sustainability.

Overall, the integration of innovative educational methods that provide up-to-date evidence, strengthen critical thinking, and support the transfer of caring behaviors into clinical practice—combined with organizational support and multidimensional implementation across knowledge, attitude, and performance—can lead to sustainable improvements in care quality during epidemic conditions. The COVID-19 pandemic highlighted that perioperative care during infectious outbreaks differs substantially from routine practice, underscoring the importance of evidence-based education and strict adherence to updated clinical guidelines and infection-control protocols for operating room and perianesthesia staff.³¹ The use of valid scientific evidence not only improves care quality and reduces errors but also enhances nurses’ professional confidence. Therefore, integrating evidence-based education into institutional training strategies is vital for maintaining patient and staff safety during health crises such as epidemics and pandemics.³²

Conclusion

This study demonstrated that an evidence-based blended education program significantly improved self-reported caring behavior scores among operating room nurses, indicating increased perceived readiness to adhere to infection prevention protocols during respiratory outbreaks. However, given the quasi-experimental design, non-randomized hospital-level assignment, reliance on self-reported data, immediate post-test timing, and absence of long-term follow-up, these findings should be interpreted with caution. While the observed improvements reflect enhanced perceived competency and awareness, they do not confirm objectively verified sustained behavioral change in clinical practice. What remains uncertain is whether these improvements translate into lasting changes at the bedside and whether they persist beyond the immediate post-test period. Future research employing direct observation, clinical audits, supervisor-evaluated checklists, and delayed follow-up assessments is warranted to verify the translation of perceived improvements into actual practice and evaluate long-term sustainability. Nonetheless, these findings provide valuable insights for developing structured educational interventions to prepare perioperative teams for current and future respiratory pandemics.

Funding Statement

This study was derived from a research project entitled “The Effect of Evidence-Based Education on the Caring Behaviors of Operating Room Nurses at AJA University of Medical Sciences” with the ethics code IR.AJAUMS.REC.1400.064. This research was financially supported by the Vice-Chancellery for Research of AJA University of Medical Sciences.

Ethical Considerations

This study was conducted after obtaining approval from the Ethics Committee of AJA University of Medical Sciences (Code: IR.AJAUMS.REC.1400.064). Furthermore, all procedures and ethical aspects of this study strictly complied with the principles of the Declaration of Helsinki. Prior to participation, the objectives of the study were clearly explained to all participants, and written informed consent was obtained.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare that there is no conflict of interest in this study.