Nursing Students Know Pressure Injury Prevention in Theory but Face Barriers in Practice

Pressure injuries, also known as pressure ulcers or bedsores, remain one of the most stubborn and largely preventable problems in modern hospitals. They develop when sustained pressure cuts off blood supply to the skin and underlying tissue, most often over bony prominences such as the heels, sacrum, and hips in patients who are immobile, critically ill, or elderly. Despite decades of evidence-based prevention guidelines, the burden of these wounds across acute care settings in the United Arab Emirates and the wider Gulf region remains substantial. A new study published in BMC Medical Education has now examined a critical link in the prevention chain: whether nursing students, the future frontline workforce, actually possess the knowledge needed to stop pressure injuries before they start, and what stands in their way when they try to apply that knowledge at the bedside.

The research, led by Doreen Mukona of the University of Massachusetts Dartmouth together with colleagues at Ajman University, the University of Zimbabwe, and the University of Global Health Equity in Kigali, took place at a tertiary health sciences college in the United Arab Emirates. The team designed a concurrent, equal-status mixed-methods study, meaning that quantitative survey data and qualitative free-text responses were collected at the same time and given equal analytical weight. A total of 133 nursing students in academic years two through four participated. The quantitative arm used an adapted 31-item Pressure Injury Prevention Knowledge questionnaire, derived from the internationally recognized Pressure Ulcer Knowledge Assessment Tool, while two open-ended questions invited students to describe the barriers they perceived and the improvements they would suggest.

The headline finding is sobering. On average, students scored 19.9 out of 31 points, equivalent to 64.1 percent, with a standard deviation of 16.6 percent. Only 20.3 percent of participants reached the pre-specified threshold for good knowledge of 80 percent or higher. A further 42.1 percent fell into the moderate band of 60 to 79 percent, while 37.6 percent scored below 60 percent, classed as poor. In other words, nearly four in ten future nurses at this institution had knowledge levels that fell short of what most educators would consider safe for independent clinical practice. The participants, who had a mean age of 21.9 years and were almost entirely Emirati nationals at 99.2 percent, represent the demographic that will staff the country’s expanding hospital network in the coming years.

One of the most technically revealing results concerns how students performed on different types of test items. The questionnaire included both true-keyed items, where the correct answer affirms a correct practice, and false-keyed items, where the correct answer requires students to reject a plausible but wrong statement. Students scored a striking 79.7 percent correct on true-keyed items but only 40.5 percent on false-keyed ones, a difference that was highly statistically significant with a paired t-value of 18.96 and p less than 0.001, corresponding to a very large effect size with Cohen’s d of 1.65. This pattern suggests that students can recognize correct prevention practices when they see them but struggle to identify incorrect ones, a cognitive profile consistent with surface learning rather than the deep conceptual understanding needed to make sound clinical judgments in ambiguous real-world situations.

The researchers also explored whether knowledge grew with experience. Knowledge was weakly but significantly associated with year of study, with Spearman correlation coefficients between 0.23 and 0.25 and p values below 0.01, and with the number of clinical placements completed, at rho equal to 0.22 and p equal to 0.01. However, when the team built an adjusted multivariable linear regression model, no individual predictor remained statistically significant, and the model explained only seven percent of the variance in knowledge scores, with p equal to 0.09. This weak explanatory power is itself informative: it implies that academic seniority alone does not reliably produce pressure injury expertise, and that other factors, such as teaching quality, curriculum emphasis, and individual study habits, likely play larger roles than the researchers could capture with the variables available.

The qualitative arm of the study painted a vivid picture of why knowledge fails to translate into action. Using qualitative content analysis, the researchers identified six categories of barriers. The most frequently cited was a poor training-practice linkage, reported by 54 percent of students, meaning that what they learned in lectures did not match what they encountered or were allowed to do during clinical placements. Lack of time followed closely at 51 percent, reflecting the relentless pace of hospital wards where prevention tasks such as repositioning patients every two hours compete with medications, documentation, and emergencies. Workforce-capacity constraints were cited by 43 percent of respondents, pointing to understaffing that leaves too few hands to turn and reposition immobile patients as often as guidelines demand.

The remaining barriers, though less frequently mentioned, are no less important. Lack of equipment was reported by 26 percent of students, a reminder that even well-trained nurses cannot deliver prevention without pressure-redistributing mattresses, cushions, and adequate dressing supplies. Communication or documentation breakdowns accounted for 13 percent of responses, highlighting how prevention depends on seamless handovers and accurate skin assessments recorded across shifts. Finally, patient-related complexity, cited by 12 percent, acknowledged that some patients present challenges, such as restlessness, obesity, or medical instability, that make standard prevention protocols difficult to follow. Together, these six categories describe a system problem rather than an individual failing: students may know exactly what to do, yet find themselves embedded in clinical environments that do not support doing it.

When asked how nursing education could be improved, the students were remarkably consistent. Regular training was the most popular suggestion at 58.9 percent, followed by simulation-based learning at 35.7 percent and updated guidelines at 22.3 percent. Simulation deserves particular attention from educators and policymakers alike. High-fidelity manikins and scenario-based exercises allow students to practice skin assessments, risk scoring with tools such as the Braden Scale, and repositioning techniques in a safe environment where mistakes carry no human cost. The strong student demand for simulation echoes a broader international movement in nursing education toward experiential learning, and the findings suggest that in the UAE context this shift has not yet gone far enough to close the theory-practice gap that students themselves identified as the leading barrier.

The study’s methodology merits confidence as well as scrutiny. The authors followed the STROBE reporting guidelines for observational studies and the SRQR standards for qualitative research, and they used Kuder-Richardson Formula 20 to assess the internal consistency of the adapted questionnaire. Ethical approval was granted by the Fatima College of Health Sciences Research Ethics Committee, and the study was conducted in accordance with the Declaration of Helsinki, with electronic informed consent and voluntary participation. The authors transparently disclose that the first author held a teaching role at the participating institution, a potential influence on both student disclosures and data interpretation, and they describe coding safeguards used to mitigate this. The study was not prospectively registered and received no external funding, details that readers should weigh when interpreting the results.

What, then, should change? The findings point to a coordinated agenda. Nursing curricula in the UAE and similar settings should place greater emphasis on false-keyed reasoning, teaching students not just what correct prevention looks like but how to spot and correct unsafe practice. Clinical placements need structured, supervised opportunities to perform actual prevention tasks rather than merely observe them. Hospitals and colleges should jointly invest in simulation laboratories, ensure equipment availability, and address the workforce and time constraints that students identified so clearly. Pressure injuries cost health systems enormously in prolonged stays, infections, and litigation, and they inflict real suffering on vulnerable patients. If nearly 80 percent of graduating nurses fall short of good knowledge, and if even knowledgeable students are blocked by systemic barriers, then the solution must span the classroom, the simulation suite, and the ward floor simultaneously. This study provides the regional evidence base to start that conversation.

Subject of Research: Nursing students' knowledge of pressure injury prevention and barriers to applying it in the United Arab Emirates

Article Title: Knowledge of pressure injury prevention and perceived barriers to applying it among nursing students at a tertiary institution in the United Arab Emirates: a mixed-methods study

Article References: Mukona, D., Mukona, R. F., Zvinavashe, M., & Ndaimani, A. (2026). Knowledge of pressure injury prevention and perceived barriers to applying it among nursing students at a tertiary institution in the United Arab Emirates: a mixed-methods study. BMC Medical Education. https://doi.org/10.1186/s12909-026-10537-8

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10537-8

Keywords: pressure injuries, pressure ulcers, nursing education, nursing students, knowledge assessment, mixed methods, theory-practice gap, simulation training, clinical placements, United Arab Emirates, wound care, patient safety