Effectiveness of mobile application versus intranet-based posting for pressure ulcer education in nurses: a randomised controlled trial

Abstract

Background

Pressure ulcers are major patient safety concerns, and bedside nurses’ competencies are central to prevention. Given nurses’ workload in clinical settings, digital education delivery through mobile apps or intranet may be effective. However, direct comparisons between these modalities remain limited. This study aimed to compare mobile application and intranet-based pressure ulcer education for staff nurses and examine effects on knowledge, attitude, and self-efficacy.

Methods

This randomised controlled trial was conducted in an inpatient nursing department at a general hospital in Seoul, South Korea. Sixty-three ward nurses with at least one year of clinical experience were randomised to the mobile app group (n = 32) or the intranet group (n = 31). One participant assigned to the intranet group did not initiate the allocated education and did not complete the post-intervention assessment. Thus, the complete-case outcome analysis included 62 participants. A four-week pressure ulcer management programme was delivered via mobile app or weekly intranet postings. Knowledge, attitude, and self-efficacy were measured pre- and post-intervention. Difference-in-differences regression analysis assessed group-by-time effects.

Results

Baseline characteristics and baseline outcome scores were similar between groups. The group-by-time interaction terms were not statistically significant for knowledge (β = 0.31, p = .677), attitude (β = −0.64, p = .554), or self-efficacy (β = 0.57, p = .559), indicating no evidence that pre- to post-intervention changes differed between the mobile app and intranet groups. Descriptively, mean scores increased from baseline to post-intervention in both groups.

Conclusions

Mobile app-based pressure ulcer education did not demonstrate a statistically significant advantage over intranet-based delivery among experienced staff nurses. Mean scores increased from baseline to post-intervention in both groups, suggesting that structured digital access to the same educational content may support pressure ulcer continuing education in clinical nursing settings.

Trial registration

Retrospectively registered with the Clinical Research Information Service (CRIS) on January 5, 2026, registration number: KCT0011404 [https://cris.nih.go.kr/cris/search/detailSearch.do?seq=32007&search_page=L&sns_share=Y].

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12912-026-05069-x.

Background

Pressure ulcers (PUs), also referred to as pressure injuries, are localised damages to the skin and/or underlying soft tissue, usually over a bony prominence, due to prolonged pressure or pressure in combination with shear [1]. Globally, the number of people affected by PU has increased from approximately 300,000 in 1990 to 646,000 in 2021, more than doubling over three decades, and has become a major public health problem that seriously compromises patients’ health and imposes a substantial pressure on healthcare systems [2]. PUs are also closely associated with a reduced quality of life and negatively affects patients’ overall well-being [3].

A 2025 Global Burden of Disease analysis reported that global PU incident cases increased from approximately 1.14 million in 1990 to 2.47 million in 2021 [4]. In hospitalised adult patients, the pooled global prevalence of pressure injuries has been estimated at 12.8% [5]. Recent Korean hospital-based data also showed that 511 of 3,761 high-risk inpatients had PU reports, corresponding to 13.6% [6]. As key indicators of patient safety and quality of care, PUs can be addressed by systematic educational strategies to strengthen nurses’ knowledge and skills for prevention and management [7–9]. However, multiple studies using the Pressure Ulcer Knowledge Assessment Tool (PUKAT) have reported nurses’ knowledge levels at only 39.6%–51.5%, highlighting the need for ongoing education and effective learning strategy development [10–16]. Nevertheless, identifying the optimal mode of education delivery in busy clinical environments remains a critical challenge.

Continuing professional development is essential for clinical nurses to maintain and update their competence within rapidly evolving healthcare environments [17]. However, staff nurses often face barriers to traditional continuing education, including heavy workloads, shift-based schedules, and limited time availability [18]. Mobile app-based education may help address these barriers by providing flexible, self-paced access to educational content and opportunities for repeated review [19–22]. Previous app-based educational interventions in clinical nursing contexts have reported improvements in nurses’ knowledge, clinical skills, and self-efficacy [23, 24], and a systematic review found that mobile applications can support knowledge and skill acquisition in health education contexts [25]. However, most existing studies on mobile app-based PU education have focused on nursing students [26–28]. Although an interactive e-book app training programme improved nurses’ PU knowledge, attitudes, and confidence compared with conventional education [29], evidence remains limited on whether mobile app-based delivery provides added benefit over existing institutional web-based platforms for staff nurses engaged in continuing education.

Digital learning has been increasingly adopted as a means to improve access to continuous professional development in clinical nursing [30–33]. Various digital learning interventions, including online platforms, e-learning systems, mobile applications (apps), and augmented reality have demonstrated educational benefits, predominantly in academic settings [30–32, 34]. Mobile learning offers flexibility in time and place and promotes self-directed learning, highlighting its importance in clinical nursing education [30, 35, 36]. However, from an educator’s perspective, mobile apps require ongoing maintenance and incur costs beyond the initial design and development [37]. Nonetheless, smartphone-based mobile learning has shown positive effects in nursing students, with its use expanding in nursing education [31, 38].

E-learning programmes improve knowledge, attitude, and clinical performance related to nurses’ PU management [29, 39]. Intranet-based education, as a form of e-learning, enhances nurses’ knowledge and clinical competence across various domains [40–42]. Nevertheless, few studies have directly compared the specific effects of mobile-app- and intranet-based education. Given the development and maintenance costs of custom-built mobile apps, an important pragmatic question for hospitals is whether app-based education offers meaningful value over simpler, more widely available options such as intranet-based posting. Therefore, in this study, we provided PU education with the same core content to clinical nurses via a mobile app or intranet and compared their effectiveness.

Educational effectiveness evaluation solely in terms of knowledge gain may overlook the complexity of clinical practice. Nurses’ theoretical knowledge does not automatically translate into preventive actions, as the knowledge-practice gap is shaped by educational structures and individual and organisational factors [43]. In examining the effects of an educational programme within an institution, organisational characteristics may be relatively homogeneous across groups, making individual factors, such as attitude, intrinsic motivation, and learning styles, particularly salient [43]. As research has consistently shown that nurses’ attitude towards PU prevention is significantly associated with their preventive behaviours [44], attitude was considered as a key outcome in this study. Self-efficacy is a well-established outcome in educational research, reflecting individuals’ confidence in their ability to perform specific tasks and known to be responsive to educational interventions [45]. Considering its sensitivity to learning experiences, self-efficacy was included as a key outcome alongside knowledge and attitudes to comprehensively capture PU education’s effects.

This study evaluated and compared mobile app-based and intranet-based delivery of the same weekly PU education content for experienced staff nurses. Specifically, we sought to examine the effects of these two delivery modes on nurses’ PU management knowledge, attitude, and self-efficacy as the primary outcomes. By assessing these three key outcomes, we aimed to analyse changes in learning outcomes and derive implications for future digital continuing educational strategies.

Following were the study hypotheses:

1. Nurses who receive mobile app-based education would have higher post-intervention PU management knowledge scores than those who receive intranet-based education.

2. Nurses who receive mobile app-based education will have higher post-intervention PU prevention attitude scores than those who receive intranet-based education.

3. Nurses who receive mobile app-based education will have higher post-intervention PU management self-efficacy scores than those who receive intranet-based education.

Methods

Study design

This was a single-centre, open-label, randomised controlled trial with a pretest–post-test design. The trial was conducted and reported in accordance with the Consolidated Standards of Reporting Trials (CONSORT) guidelines. The participant flow through the study stages is presented in Fig. 1 [46].

Fig. 1.

CONSORT flow diagram of participant enrolment, allocation, follow-up, and complete-case analysis (Hopewell et al., 2025)

Participants and setting

The participants were ward nurses employed at the inpatient nursing department of a general hospital in Seoul, South Korea, had at least one year of clinical experience at the study hospital, understood the purpose of the study, voluntarily agreed to participate, and could participate in the educational intervention (mobile app or intranet-based learning) during the study period. Those who had served as unit education leaders or PU leaders in the previous year or worked in the principal investigator’s ward were excluded. Of the 64 nurses who expressed interest to participate, one with less than one year of clinical experience was excluded based on the eligibility criteria, leaving 63 nurses eligible for randomisation.

The adequate sample size was determined using G*Power version 3.1.9.7 [47], based on an independent samples t-test (α = 0.05, power 1-β = 0.80). A prior e-learning study on PU management in nurses reported a large effect on knowledge, with a standardised mean difference of 1.4 [39]. Smartphone-based mobile learning also demonstrated large effect sizes for knowledge (Hedges’ g = 1.47), learning attitude (g = 1.69), and confidence in performance (g = 1.54), with an overall effect size of g = 1.12 (95% confidence interval 0.72–1.52) [31]. Therefore, we assumed an effect size of 0.8 in this study, resulting in a minimum sample size of 26 participants per group. Anticipating an attrition rate of 20%, we recruited 64 nurses.

The participants were recruited between 9 and 25 January 2024, through open announcements on the hospital intranet system and notice boards within the facility. Participation was voluntary and self-initiated via a QR code or web link embedded in the recruitment notice to minimise perceived coercion in staff nurses.

Randomisation

Sixty-four nurses who expressed interest in participating were initially assigned sequential identification numbers from 1 to 64. Subsequently, their clinical experience was verified and stratified into two groups: ≥1 to < 5 years and ≥ 5 years. One nurse with less than one year of experience was excluded in this step. Stratified randomisation was performed within each stratum using a computer-generated random number table. An external researcher who was independent of the study hospital conducted the randomisation procedure to ensure allocation independence. Consequently, 32 nurses were allocated to the mobile app group and 31 to the intranet group. After allocation, one participant assigned to the intranet group completed the baseline assessment but did not join the group-specific intranet notice board and did not initiate the allocated education. This participant did not complete the post-intervention assessment.

Measurements

Participants’ general characteristics

We collected information on the major patient group in the participants’ ward and participants’ age group, highest educational level, total months of clinical experience, experience caring for patients with PUs, completion of PU education within the past year, perceived need for PU-related education for nurses.

PU knowledge

Pressure ulcer knowledge was measured using the Korean Pressure Ulcer Knowledge Assessment Tool 2.0 (K-PUKAT 2.0), developed by Ryu et al. [48] and used with permission from the original author. This instrument is an adapted version of the Pressure Ulcer Knowledge Assessment Tool 2.0 (PUKAT 2.0) developed by Manderlier et al. [49]. The PUKAT 2.0 comprises 25 items across six domains (aetiology, six items; classification and observation, four; risk assessment, two; nutrition, three; prevention of PUs, eight; and specific patient groups, two). It was translated and revised for the Korean clinical context and reorganised into 15 items across six domains (aetiology, three items; assessment and observation, three; classification and equipment, three; risk factors and location, two; immobilisation, two; and vulnerability, two). In the present study, the response option for item 4 (‘Which statement is correct regarding the frequency of in-hospital skin assessment at pressure-prone areas?’) was modified to align with the institutional guidelines at the study site. Each correct answer scored 1 point, yielding a total score range of 0–15, with higher scores indicating greater knowledge. Ryu et al. [48] reported an intraclass correlation coefficient of 0.69 for PUKAT 2.0 and 0.75 for K-PUKAT 2.0; reliability indices were not recalculated in this intervention study.

Attitude towards PU prevention

Attitude towards PU prevention was assessed using the Attitude towards Pressure Ulcer Prevention instrument (APuP), developed by Beeckman et al. [50], with permission from the original author. The APuP comprises 13 items related to PU prevention, rated on a 4-point Likert scale (1 = strongly disagree, 4 = strongly agree), with higher scores indicating a more positive attitude towards PU prevention. Cronbach’s α was 0.79 in the original study; 0.51, pretest; and 0.54, post-test in the present study.

Self-efficacy in PU management

Self-efficacy in PU management was measured using a 6-item scale developed by Park [51], with permission from the original author. Each item is rated on a 5-point Likert scale (1 = not at all confident, 5 = very confident), with higher scores indicating greater self-efficacy. Cronbach’s α was 0.91 in the original study; 0.82, pretest; and 0.80, post-test in the present study, indicating good reliability.

Frequency of accessing educational materials (exposure times)

The post-intervention survey asked the participants, ‘How many times did you access the educational materials during the 4-week programme?’ Responses mentioning ‘four or more times’ were coded as 4 and ‘8–10 times’, 8.

Development of the mobile app

The mobile app for PU education for clinical nurses, which served as the intervention tool in this study, was developed based on the analysis-design-development-implementation-evaluation (ADDIE) instructional design model [52].

The analysis phase involved a literature review and survey to identify nurses’ educational needs. A systematic review of PU education programmes for nurses reported that most interventions addressed PU prevention and management and that approximately one-third additionally included risk assessment, visual differentiation of ulcer stages, and skin problems according to classification systems [53].

The design and development phases aimed to create a mobile educational app that nurses could easily consult in clinical practice. We reviewed the interface layout, structure, and functions of the main and submenus and how well the app environment and features met nurses’ needs [54]. Knowledge, attitude, and self-efficacy related to PU care were selected as dependent variables and appropriate instruments for each construct were reviewed. The educational content was developed based on PU-related safety alerts and information materials from the Korea Patient Safety Reporting and Learning System (KOPS), including PU prevention and management, guide to choosing dressing for different PU stages, and severe harm to patients due to PUs (notification dates: 27 August 2021; 3 September 2021; and 15 April 2022) [55]. The development and validation team comprised one professor of adult nursing, one nurse who was a doctoral student in nursing informatics, and two nurses who had completed Wound, Ostomy and Continence Nursing (WOCN) courses. All three nurses had more than 10 years of clinical experience and completed education on the use of information technology to develop clinical education programmes. The app was developed from April to November 2023 using the no-code platform ‘Adalo’.The 4-week PU management education programme is summarised in Table 1. The app comprised 75 screens (Supplementary Figures) covering topics such as PU staging, dressing selection, assessment and documentation, and management principles. All PU images were carefully reviewed to ensure that no personal identifiers or information that could reveal patient identity were included.

Table 1.

Composition of the 4-week pressure ulcer management education programme

Week	Topic		Objectives	Contents	Self-test
Week 1	Principles of PU management	1) Explain the importance of repositioning for the prevention of PUs. 2) Perform PU prevention activities (e.g. pressure redistribution, repositioning, nutritional management). 3) Develop a positive attitude towards PU prevention activities.		Pressure redistribution management, repositioning, nutritional management, skin and incontinence care (urinary and fecal), and patient education.	None
Week 2	PU staging	1) List the terminology and key characteristics of each PU stage. 2) Correctly classify the PU stages. 3) Develop confidence in classifying PU stages.		PU terminology, staging of PUs.	Quiz
Week 3	PU assessment and documentation	1) Accurately assess the location, size, and exudate of PUs. 2) Develop confidence in assessing PU location, size, and exudate.		Assessments of PU location, size, and exudate.	Quiz
Week 4	PU dressing methods	1) Select appropriate dressings according to the PU stage. 2) Plan dressings based on the condition of PUs at each stage. 3) Perform dressing procedures using the provided educational materials.		Dressing for stage 1, 2, 3, and 4 PUs and unstageable and deep tissue PUs.	None

Note. The same educational content was delivered to the mobile app group and the intranet group through different digital platforms

In the implementation phase, the research team deployed the mobile app on Android and iOS devices, with access restricted to individual credentials. In the evaluation phase, the app underwent heuristic evaluation by three external professors of nursing informatics using a 13-item usability checklist adapted from Kumar and Goundar [56]. After using the app for more than one hour, each professor rated the problems and their severity on a 5-point scale. The mean severity score was 1.4, and no item had a major problem. Based on the qualitative feedback, minor adjustments were made to the selected functions and screens.

Study procedures

Nurses in the mobile app group were instructed to use the app for 4 weeks from 12 February to 10 March 2024 using individual IDs and passwords and to access the weekly modules at their convenience. For the intranet group, a group-specific online notice board was created on the hospital’s staff intranet; the same educational content was uploaded weekly according to the same schedule. Participants in the intranet group were instructed to review the posted materials. To reduce potential contamination and procedural differences between groups, both groups received the same educational content over the same 4-week period, and access to each educational platform was restricted to participants assigned to that group. Participant blinding was not feasible owing to the nature of the digital education platforms. The pre-intervention survey was administered online via Google Forms from 5 to 11 February 2024. The post-intervention survey was administered from 11 to 16 March 2024, immediately after completion of the 4-week intervention. In the post-intervention survey, participants also self-reported the number of times they accessed the assigned educational materials during the intervention period. No cross-use between groups was reported during the intervention period. Following study completion, access to the mobile app was offered to participants in the intranet group.

Data analysis

Data were analysed using R version 4.5.1. Descriptive statistics were used to summarise the characteristics of the complete-case analytic sample. Baseline characteristics and baseline outcome scores were compared between groups using chi-square or Fisher’s exact tests for categorical variables and independent-samples t-tests for continuous variables. Of the 63 randomised participants, one nurse assigned to the intranet group completed the baseline assessment but did not initiate the allocated education and did not complete the post-intervention assessment. Consequently, for this participant, no post-intervention outcome data were available, and no imputation was performed. The final analytic sample for the outcome analyses comprised 62 participants: 32 and 30 in the mobile app and intranet groups, respectively. The outcome analyses were therefore conducted using a complete-case approach rather than a strict intention-to-treat analysis.

Self-reported educational material access frequency was measured after the intervention and treated as a post-randomisation engagement indicator. After confirming no evidence of unequal variances, this variable was compared between groups using an independent-samples t-test. It was not included as a covariate in the DID models because it was measured after randomisation and could have been influenced by the assigned delivery mode.

To estimate the intervention effect of mobile app-based education compared with intranet-based education, difference-in-differences (DID) regression analyses were conducted. Each DID model included group, time, and a group-by-time interaction term, with the interaction term representing the between-group difference in pre- to post-intervention change. A two-sided significance level of 0.05 was applied for all statistical analyses.

Ethical considerations

This study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of the SMG-SNU Boramae Medical Center, Seoul National University College of Medicine (IRB No.: 20-2023-51; Date of Approval: Nov.21st 2023). As the participants were staff nurses working at an institution where the first author was the nurse manager, they were considered potentially vulnerable to undue influence. To minimise coercion, an external researcher was responsible for the recruitment, randomisation, and data collection. The first author did not have access to identifiable participant information. All nurses received a full explanation of the study purpose, procedures, data protection, voluntariness of participation, and the right to withdraw at any time before providing written informed consent. All collected data were anonymised and managed under strict confidentiality to protect the participants’ privacy. The study protocol was retrospectively registered at the Clinical Research Information Service (CRIS) on January 5, 2026 (registration number: KCT0011404) and is available online.

[https://cris.nih.go.kr/cris/search/detailSearch.do?seq=32007&search_page=L&sns_share=Y].

Results

Participants’ general characteristics

Overall, 69.4% of the participants were younger than 30 years and had 66.02 months of mean clinical experience. No statistically significant differences were observed between the groups in age (p = .920), clinical experience category (p = .472), total clinical experience in months (p = .685), ward type (p = .432), highest educational level (p > .999), experience in caring for patients with PUs (p = .152), completion of PU education within the past year (p = .429), perceived need for PU education (p = .622), or baseline scores for PU management knowledge (p = .330), attitude (p = .173), or self-efficacy (p = .585) at baseline. The self-reported frequency of accessing educational materials, assessed after the intervention, was higher in the mobile app group than in the intranet group (p < .001) (Table 2).

Table 2.

Baseline characteristics and post-intervention educational material access by group

Characteristics	Categories	Total (n = 62)	Mobile app (n = 32)	Intranet (n = 30)	χ2 or t	p
		n (%)
Age (years)	< 30	43 (69.4)	23 (71.9)	20 (66.7)		0.920†
	30–39	14 (22.6)	7 (21.9)	7 (23.3)
	≥ 40	5 (8.0)	2 (6.2)	3 (10.0)
Clinical experience	< 5 years	42 (67.7)	23 (71.9)	19 (63.3)	0.52	0.472‡
	≥ 5 years	20 (32.3)	9 (28.1)	11 (36.7)
	M ± SD (months)	66.02 ± 65.46	62.69 ± 57.35	69.57 ± 73.98	0.41	0.685§
Ward type	Medical	24 (38.7)	10 (31.2)	14 (46.7)	1.68	0.432‡
	Surgical	25 (40.3)	15 (46.9)	10 (33.3)
	Medical-surgical	13 (21.0)	7 (21.9)	6 (20.0)
Highest education level	Bachelor’s or less	61 (98.4)	31 (96.9)	30 (100.0)		> 0.999†
	Master’s or higher	1 (1.6)	1 (3.1)	0 (0.0)
Experience caring for patients with PUs	Almost none	1 (1.6)	1 (3.1)	0 (0.0)		0.152†
	Sometimes	11 (17.8)	8 (25.0)	3 (10.0)
	Often	24 (38.7)	9 (28.1)	15 (50.0)
	Every shift	26 (41.9)	14 (43.8)	12 (40.0)
Completion of PU education within the past year	No	28 (45.2)	16 (50.0)	12 (40.0)	0.63	0.429‡
	Yes	34 (54.8)	16 (50.0)	18 (60.0)
Perceived need for PU education	Strongly agree	33 (53.2)	18 (56.2)	15 (50.0)	0.24	0.622‡
	Agree	29 (46.8)	14 (43.8)	15 (50.0)
	Disagree	0 (0.0)	0 (0.0)	0 (0.0)
	Strongly disagree	0 (0.0)	0 (0.0)	0 (0.0)
Knowledge	M ± SD (score)	8.90 ± 2.35	9.19 ± 2.72	8.60 ± 1.89	0.98	0.330§
Attitude	M ± SD (score)	38.61 ± 2.86	39.09 ± 2.88	38.10 ± 2.80	1.38	0.173§
Self-efficacy	M ± SD (score)	17.87 ± 2.82	18.06 ± 2.71	17.67 ± 2.96	0.55	0.585§
*Self-reported educational material access frequency	M ± SD (times)	5.19 ± 2.35	6.44 ± 1.92	3.87 ± 2.05	5.10	< 0.001§

Note: M = mean; SD = standard deviation; PU = pressure ulcer; *Measured post-intervention^† Fisher’s exact test^‡ Chi-squared test^§ Independent samples t-test

Effects of the mobile-app-based PU education on knowledge, attitude, and self-efficacy

Table 3 presents the results of the DID regression analyses for PU management knowledge, attitude, and self-efficacy. The group-by-time interaction terms were not statistically significant in any of the three models, indicating no evidence that pre- to post-intervention changes differed between the mobile app and intranet groups.

Table 3.

Results of difference-in-differences analysis of the effects of the intervention

Outcome	Group	Pre-intervention	Post-intervention	Time effect		Group effect		DID
		M ± SD	M ± SD	β2 (95% CI)	p	β3 (95% CI)	p	β4 (95% CI)	p
Knowledge (score)	Mobile app (n = 32)	9.19 ± 2.72	11.00 ± 1.72	1.50 (0.44 ~ 2.56)	0.006	0.59 (-0.46 ~ 1.63)	0.268	0.31 (-1.17 ~ 1.79)	0.677
	Intranet (n = 30)	8.60 ± 1.89	10.10 ± 1.81
Attitude (score)	Mobile app (n = 32)	39.09 ± 2.88	41.16 ± 2.80	2.70 (1.17 ~ 4.23)	< 0.001	0.99 (-0.51 ~ 2.50)	0.193	-0.64 (-2.76 ~ 1.49)	0.554
	Intranet (n = 30)	38.10 ± 2.80	40.80 ± 3.46
Self-efficacy (score)	Mobile app (n = 32)	18.06 ± 2.71	23.03 ± 2.19	4.40 (3.02 ~ 5.78)	< 0.001	0.40 (-0.96 ~ 1.75)	0.565	0.57 (-1.35 ~ 2.49)	0.559
	Intranet (n = 30)	17.67 ± 2.96	22.07 ± 2.90

Note: M = mean; SD = standard deviation; CI = confidence interval; DID = difference-in-differences. The intranet group at pre-intervention served as the reference category. The time effect indicates the pre- to post-intervention change in the intranet group. The group effect indicates the baseline difference between the mobile app and intranet groups, calculated as mobile app minus intranet. The DID effect indicates the between-group difference in pre- to post-intervention change, calculated as the change in the mobile app group minus the change in the intranet group. Model statistics for the DID regression analyses were as follows: knowledge, F_{(3, 120)} = 7.98, p < .001, adjusted R² = 0.145; attitude, F_{(3, 120)} = 7.14, p < .001, adjusted R² = 0.130; and self-efficacy, F_{(3, 120)} = 31.97, p < .001, adjusted R² = 0.430

The estimated between-group differences in change were 0.31 points for knowledge (p = .677), − 0.64 points for attitude (p = .554), and 0.57 points for self-efficacy (p = .559). The time coefficients indicated significant pre- to post-intervention increases in the intranet group, which served as the reference group: 1.50 points for knowledge (p = .006), 2.70 points for attitude (p < .001), and 4.40 points for self-efficacy (p < .001). Descriptively, mean scores increased from baseline to post-intervention in both groups. Pre- and post-intervention changes in knowledge, attitude, and self-efficacy are shown in Fig. 2.

Fig. 2.

Pre- and post-intervention scores for pressure ulcer management knowledge, attitude, and self-efficacy by group. Note. Data are presented as mean ± standard error. DID effects were determined from the group-by-time interaction terms in the regression models

Discussion

This study examined the effects of mobile app- versus intranet-based PU education on nurses’ knowledge, attitude, and self-efficacy.

At baseline, the mobile app and intranet groups did not differ in knowledge. However, the overall knowledge in this sample was higher than that in previous studies; the baseline knowledge level was 59.3%, whereas previous studies have reported 51.5% or lower [10–16]. Post-intervention knowledge scores increased to 73.3% in the mobile app group and 67.3% in the intranet group. Although the pre-post improvement was greater in the mobile app group, the between-group difference in the post-intervention mean scores was not significant (Table 3). This finding suggests that, among experienced staff nurses, structured educational participation may be a crucial contributor to knowledge gain, though the present study cannot isolate the effect of participation from other time-related or contextual factors.

In a previous study, an e-learning programme had a stronger short-term effect on nurses’ accuracy in PU classification than traditional lecture-based education; however, this advantage disappeared at the 3-month follow-up [57]. This pattern indicates that the superiority of one delivery mode over another may be limited and that sustained engagement and reinforcement may be critical for consolidating PU knowledge in clinical practice.

Although K-PUKAT 2.0 was used to assess knowledge, its reliability indices were not recalculated in this intervention study. Future research should refine and validate PU knowledge instruments for local clinical contexts and explore reliability assessment methods compatible with intervention designs.

At baseline, participants’ PU prevention attitude score was 74.3% of the maximum. This is comparable to 62.3%–76.9% of the maximum score reported in previous studies [14, 15, 58, 59]—clinical nurses in this study generally held positive PU prevention attitude. Post-test mean scores increased in both groups, reaching 79.2% in the mobile app and 78.5% in the intranet group. Although attitude improved in both groups, the DID estimate for between-group differences was not significant, whereas the time effect was significant.

These findings may reflect a ceiling effect, given that baseline attitudes were relatively high. Additionally, Cronbach’s α for APuP in this sample was low, which may have increased measurement error and attenuated the estimated effects. Together, these results suggest that participation in an educational programme itself may contribute more to enhancing attitudes than the specific mode of delivery for experienced nurses. As PU prevention attitudes are significantly associated with preventive behaviours [44], future studies should link attitude changes with behavioural indicators to clarify the clinical implications of attitudinal improvement.

Notably, the time effect for self-efficacy (β₂ = 4.40, p < .001) was larger than that for knowledge (β₂ = 1.50) or attitude (β₂ = 2.70). Although the DID estimate for between-group differences was not significant, self-efficacy increased significantly from pre to post-test in both groups. Self-efficacy refers to an individual’s belief in their capability to successfully perform a specific task or achieve a desired outcome [60] and is a sensitive predictor of changes resulting from educational interventions [45]. In this study, participation in the educational programme appeared to have strengthened nurses’ beliefs that they could successfully provide PU care in clinical practice, which has important implications beyond knowledge gain.

The self-reported frequency of accessing educational materials was higher in the mobile app group than in the intranet group. As this measure was collected after randomisation and after the intervention, it was treated as a post-randomisation engagement indicator rather than a baseline covariate. For this reason, access frequency was not adjusted for in the DID models, because it was a post-randomisation variable that could have been influenced by the assigned delivery mode. Moreover, because access frequency was measured retrospectively by self-report and the mobile app and intranet platforms differed structurally, the effects of platform type, exposure frequency, and learner engagement could not be disentangled. Therefore, the difference in access frequency should be interpreted cautiously. Future studies should use objective platform logs, completion rates, time spent on modules, and time-stamped usage data to examine associations between platform engagement and educational outcomes. Collectively, the non-significant group-by-time interaction terms suggest that mobile app-based education did not demonstrate superiority over intranet-based delivery for improving PU management knowledge, attitude, or self-efficacy in this sample. This finding should be interpreted as a lack of evidence for the superiority of the mobile app, rather than evidence that the two delivery modes are equivalent or non-inferior. Descriptively, mean scores increased from baseline to post-intervention in both groups, which may indicate that structured access to the same PU educational content through flexible digital platforms may support learning among experienced staff nurses. One possible explanation for the limited between-group contrast is that intranet-based delivery in this study shared several core attributes of mobile learning, including self-directed use, flexible access, and weekly exposure to the same educational content [61]. This interpretation differs from previous studies conducted primarily with nursing students, in which mobile app-based interventions demonstrated superiority over conventional educational approaches [26–28]. The difference may reflect the learner population, the relatively high baseline competence of experienced nurses, and the use of an active digital comparator rather than a conventional or no-education control condition.

The clinical profiles of our participants as experienced staff nurses are also relevant. Their relatively high baseline knowledge and attitude may have contributed to a ceiling effect, limiting their improvement potential. A recent meta-analysis has reported that diverse educational programme types were effective in enhancing hospital nurses’ PU prevention competencies without clear evidence that one specific medium was superior [62]. This suggests that rather than a technological platform, the structural support that enables learners to engage in and complete educational activities is crucial. Prioritizing regular, scheduled participation and designing programmes that align with principles of adult learning and experiential learning cycles may be more effective for experienced nurses, transforming their clinical experience into a learning resource [63]. Additionally, to sustainably enhance nurses’ competencies, offering a range of educational programmes and addressing barriers to participation, such as shift patterns, workload, and lack of follow-up support, is essential to improve enrolment and completion rates [64].

Limitations

This study had several limitations. The small sample size from a single institution limits the generalisability of the findings, and the sample size calculation was based on a large effect size that may have been overly optimistic; therefore, the study may have been underpowered to detect small between-group differences. Moreover, this study was designed to compare the effects of mobile app-based education and intranet-based delivery, not to establish equivalence or non-inferiority; therefore, the absence of significant group-by-time interaction terms should be interpreted as a lack of evidence for superiority of the mobile app rather than evidence that the two delivery modes are equivalent or non-inferior. Additionally, one participant assigned to the intranet group did not initiate the allocated education and did not provide post-intervention outcome data; consequently, the outcome analyses were conducted using a complete-case approach rather than a strict intention-to-treat analysis. Although the amount of missing data was small, the missingness occurred after randomisation and may have been related to engagement with the assigned educational platform; thus, residual attrition bias cannot be ruled out. The trial was open label because participant blinding was not feasible, and expectancy or performance bias cannot be ruled out, despite the use of the same educational content, the same intervention period, restricted group-specific access, and external researcher involvement in recruitment, randomisation, and data collection. While no cross-use between groups was reported, informal sharing of educational materials could not be completely excluded in a single-institution setting. Furthermore, nurses’ compliance and behavioural engagement with each platform were not comprehensively assessed using objective indicators; the frequency of accessing educational materials was measured retrospectively by self-report and may have been affected by recall bias and differences in the structure of the two platforms. Finally, outcomes were assessed only once immediately after the intervention and were limited to knowledge, attitude, and self-efficacy, preventing evaluation of long-term sustainability, behavioural change, or patient-level outcomes such as PU incidence. Future multicentre studies with larger samples, pre-specified analytic approaches for missing data, objective platform usage logs, multiple follow-up points, and behavioural and patient outcome measures are needed to strengthen the evidence on digital continuing education for PU prevention.

Conclusions

This study compared mobile app-based and intranet-based delivery of the same 4-week PU education programme for experienced staff nurses. Mobile app-based education did not demonstrate a statistically significant advantage over intranet-based delivery for PU management knowledge, attitude, or self-efficacy. Mean scores increased from baseline to post-intervention in both groups.

These findings have practical implications for nursing education and institutional resource planning. When the same educational content is provided, intranet-based posting may serve as a feasible and lower-resource delivery option for PU education, particularly in institutions wherein mobile app development and maintenance are challenging. Mobile app-based education may still be useful when flexible access, repeated review, and learner convenience are priorities; however, its added value over existing digital platforms should be evaluated with objective engagement data. Future studies should employ adequately powered multicentre designs, objective platform-use metrics, longer follow-up periods, and behavioural or patient-level outcomes to clarify how digital education delivery influences sustained learning, PU prevention practices, and PU incidence.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

ADDIE

Analysis-Design-Development-Implementation-Evaluation

APuP

Attitude towards Pressure Ulcer Prevention instrument

CONSORT

Consolidated Standards of Reporting Trials

CRIS

Clinical Research Information Service

DID

Difference-In-Differences

KOPS

Korea Patient Safety Reporting and Learning System

K-PUKAT

Korean Pressure Ulcer Knowledge Assessment Tool

PU

Pressure Ulcer

PUKAT

Pressure Ulcer Knowledge Assessment Tool

WOCN

Wound, Ostomy and Continence Nursing

Author contributions

S. S.: conceptualization, methodology, validation, investigation, data curation, writing – original draft preparation, writing – review and editing, visualization, project administration, funding acquisition. E. L.: conceptualization, methodology, software, investigation, visualization, project administration. J. K.: conceptualization, methodology, investigation, resources, project administration. M. J.: software, formal analysis, validation, visualization, writing – original draft preparation. M. K.: conceptualization, methodology, funding acquisition. H. L.: conceptualization, methodology, validation, data curation, writing – original draft preparation, writing – review and editing, supervision, project administration. All authors have read and agreed to the final version of the manuscript.

Funding

This study was supported partially by the clinical nursing research fund of Seoul National University Hospital in 2024.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of the SMG-SNU Boramae Medical Center, Seoul National University College of Medicine (IRB No.: 20-2023-51; Date of Approval: Nov.21st 2023). Informed consent was obtained from all individual participants included in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.