Pakistani Nurses Know Infection Control Rules but Fail to Follow Them, Review Finds

In the fight against healthcare-associated infections, the people standing closest to the patient are often the decisive variable. A new systematic review and meta-analysis published in BMC Nursing has now quantified just how wide the gap can be between what nurses in Pakistan know about infection prevention and control, what they believe about it, and what they actually do at the bedside. The findings paint a picture that is at once encouraging and sobering: knowledge is moderately strong, attitudes are largely favorable, but day-to-day practice lags well behind both.

The research team, led by Hamideh Ebrahimi and Rashida Bibi of the Lahore School of Nursing at the University of Lahore, together with colleagues at Gandhara University, Zhengzhou University, and the Marie Adelaide Leprosy Centre, pooled data from 29 studies comprising 30 datasets and a total of 3,383 nurses. The work followed the PRISMA 2020 reporting guidelines, was prospectively registered in PROSPERO, and applied the Joanna Briggs Institute critical appraisal tools to judge the quality of each included study. Cross-sectional surveys and baseline measurements from quasi-experimental studies were eligible, and random-effects meta-analyses were used to combine the reported proportions.

The headline numbers tell a layered story. Based on the classifications used in the original studies, the pooled proportion of Pakistani nurses with adequate knowledge of infection prevention and control was 67 percent, with a 95 percent confidence interval of 60 to 74 percent. Favorable attitudes were even more common, reaching a pooled 76 percent, though with a wide interval of 65 to 88 percent that reflects substantial variation between studies. Good practices, by contrast, were reported for only 56 percent of nurses, with a confidence interval spanning 47 to 65 percent. In other words, roughly one in five nurses who understand infection control principles and view them positively does not translate that understanding into consistent action.

This knowledge-practice gap is a well-recognized phenomenon in behavioral science, and the authors frame their findings through that lens. Knowing that hand hygiene prevents transmission is not the same as performing hand hygiene between every patient contact during a twelve-hour shift in an understaffed ward. The review suggests that closing the gap will require far more than classroom education. The authors point to ongoing training, organizational support, adequate resources, effective supervision, and a strong patient-safety culture as the multifaceted ingredients needed to move practice levels upward.

Technically, the meta-analysis confronted a formidable statistical challenge: heterogeneity. The I-squared statistic, which measures the proportion of variability in pooled estimates attributable to true differences between studies rather than chance, exceeded 90 percent across the analyses. That is an extreme level, signaling that the included studies differed profoundly in their settings, instruments, scoring thresholds, and populations. Subgroup analyses and meta-regression probing the effects of publication year and province found no significant moderators, meaning the researchers could not identify what was driving the variability. Publication bias, the tendency for positive findings to be published more readily than null results, appeared to exert minimal influence on the pooled estimates, which lends some credibility to the overall picture.

A critical caveat concerns measurement itself. The categories of adequate knowledge, favorable attitudes, and good practices were defined according to the scoring systems of each individual study, and specific cut-off points were not consistently reported. Without standardized, validated assessment tools applied uniformly, the pooled percentages should be read as approximate syntheses of heterogeneous local estimates rather than precise national statistics. The authors explicitly caution that the findings should be interpreted with this limitation in mind, and they call for future research using standardized and validated knowledge, attitude, and practice instruments.

The geographic coverage of the evidence base is also uneven. No eligible studies were identified from Baluchistan, one of Pakistan’s largest provinces, leaving a significant blind spot in the national picture. The pooled estimates therefore largely reflect conditions in provinces such as Punjab, Sindh, and Khyber Pakhtunkhwa, where most of the included research was conducted. Whether nurses in Baluchistan, a region with distinct infrastructure and resource constraints, would show similar patterns remains an open question that future studies must address.

The stakes of this research are considerable. Healthcare-associated infections remain a major burden in low- and middle-income countries, contributing to substantial morbidity and mortality, and structural constraints in health systems often amplify the problem. Nurses, as the frontline providers who spend the most time in direct patient contact, are central to implementing the measures that interrupt transmission: hand hygiene, personal protective equipment use, safe injection practices, and the prevention of catheter-associated urinary tract infections, surgical site infections, and ventilator-associated pneumonia. When practice levels among this workforce fall short, the consequences ripple directly into patient outcomes.

What makes the Pakistani case particularly instructive is the pattern itself. The hierarchy of scores, with attitudes highest, knowledge in the middle, and practices lowest, suggests that motivation is not the bottleneck. Nurses largely believe in the value of infection prevention and control. The deficit lies in the translation of belief into behavior, which points squarely at environmental and organizational factors: workload, staffing ratios, availability of supplies such as gloves, gels, and masks, the physical layout of wards, and whether institutional leadership holds safety as a genuine priority rather than a slogan.

For policymakers and hospital administrators in Pakistan and comparable settings, the review offers a data-driven mandate. Investment in infection control should not stop at training curricula, because the evidence indicates that education alone has not closed the practice gap. Supervision structures that reinforce correct behavior, reliable supply chains that make compliance feasible, and a culture in which patient safety is measured and rewarded are the levers most likely to shift the practice figure from 56 percent toward the levels already achieved in knowledge and attitude. The study, published open access with a permanent DOI, provides both a baseline against which future progress can be measured and a methodological warning: until standardized instruments and broader geographic coverage arrive, the true state of infection control practice in Pakistan’s nursing workforce will remain only partially visible.

Subject of Research: Nurses' knowledge, attitudes, and practices toward infection prevention and control in Pakistan

Article Title: Nurses’ knowledge, attitudes, and practices toward infection prevention and control in Pakistan: a systematic review and meta-analysis

Article References: Ebrahimi, H., Bibi, R., Asboeck, A., & Khan, H. (2026). Nurses’ knowledge, attitudes, and practices toward infection prevention and control in Pakistan: a systematic review and meta-analysis. BMC Nursing. https://doi.org/10.1186/s12912-026-05266-8

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05266-8

Keywords: infection prevention and control, nurses, Pakistan, healthcare-associated infections, systematic review, meta-analysis, knowledge-practice gap, nursing research, hand hygiene, patient safety, low- and middle-income countries, KAP assessment