The research team, led by Rateba Said Mohammed of the Occupational and Environmental Medicine department at Cairo University’s Faculty of Medicine, together with colleagues at Al-Baha University, Shaqra University and Princess Nourah Bint AbdulRahman University in Saudi Arabia, recruited second-year through internship-year students using a convenience sampling approach. Participants completed a structured online questionnaire covering three domains: knowledge of needlestick injury prevention and management, self-reported practice behaviours, and attitudes toward sharps safety. The psychometric properties of the scales were respectable, with Cronbach’s alpha values of 0.70 for knowledge, 0.84 for practice and 0.77 for attitude, indicating acceptable to good internal consistency. Reporting followed the STROBE guidelines for observational studies, and the work received ethical approval from two Cairo University research ethics committees in accordance with the Declaration of Helsinki.

The descriptive results reveal a paradox that will be familiar to anyone who studies occupational safety. Satisfactory knowledge of needlestick injury prevention was present in only 44.2 percent of the cohort, yet satisfactory practice was reported by 82.4 percent and positive attitudes by 71.9 percent. In other words, most students were behaving safely and thinking safely about sharps without necessarily being able to pass a knowledge test on the subject. This dissociation between knowing and doing is precisely what the regression analysis then interrogated. Rather than treating knowledge, practice and attitude as interchangeable proxies for safety competence, the study modelled them as separate predictors of a binary outcome: whether a student had experienced any needlestick injury in the previous year.

The adjusted odds ratios tell a coherent story about where risk concentrates. Internship-year students faced 3.41 times the adjusted odds of a needlestick injury compared with their junior counterparts, with a 95 percent confidence interval of 1.87 to 6.22. Students placed in intensive care units or emergency departments had 2.78 times the adjusted odds, with a confidence interval of 1.65 to 4.68. Those who had never received prior education specifically about needlestick injuries carried 2.14 times the odds, at 1.18 to 3.88. Unsatisfactory practice nearly doubled the odds at 1.95, with a confidence interval of 1.07 to 3.57, and a negative attitude raised them 1.83-fold, at 1.02 to 3.29. All of these associations reached statistical significance at the conventional p less than 0.05 threshold.

The null result is arguably the most important number in the paper. Knowledge score, entered into the same multivariable model, produced an adjusted odds ratio of 1.12 with a 95 percent confidence interval spanning 0.89 to 1.41 and a p value of 0.340. Once practice, attitude, training stage, placement setting and prior education were accounted for, knowing the correct facts about sharps safety conferred no measurable protection against being stuck. The authors are careful to frame this correctly: the null association should not be read as evidence that knowledge is unimportant, because the three KAP domains were operationalised differently and the data are cross-sectional. Still, the pattern is consistent with a broader theme in safety science, where the gap between declarative knowledge and procedural behaviour is often the critical vulnerability.

Why would internship year carry the highest risk? The answer likely lies in exposure volume and autonomy. Interns work longer shifts, handle sharps more frequently, and perform procedures with less direct supervision than second- or third-year students who are closely watched during basic clinical placements. Intensive care and emergency department placements compound this exposure: these environments combine high patient acuity, time pressure, frequent intravenous procedures, and a prevalence of blood-borne pathogens that makes every needlestick a potential exposure event for hepatitis B, hepatitis C or HIV. A student recapping a needle in a calm ward during daylight faces different pressures than one doing so at three in the morning during a resuscitation, and the odds ratios suggest the study captured that reality.

The protective signal from prior needlestick education is equally instructive. Students who had received dedicated training on needlestick injury prevention and post-exposure management had significantly lower adjusted odds of injury, independent of their knowledge scores, practice ratings and attitudes. This suggests that targeted, scenario-based safety education, as opposed to general infection-control content folded into broader curricula, may change behaviour in ways that generic knowledge does not. It also points toward a practical intervention: if a single exposure to focused NSI education measurably reduces injury odds, then embedding such modules before and during high-risk placements, particularly before ICU and emergency rotations, could be a low-cost, high-yield policy for nursing schools.

Methodologically, the study has limitations that the authors acknowledge implicitly through their cautious conclusions. The convenience sample of 455 students from a single faculty in Cairo limits generalisability, and self-reported injury history is vulnerable to recall bias and underreporting, particularly for minor superficial sticks that students may dismiss as insignificant. The cross-sectional design means the temporal direction of associations cannot be established with certainty; students who develop negative attitudes after a frightening needlestick experience would look the same in the data as students whose attitudes preceded their injuries. The authors also note that the KAP domains were operationalised differently, so the null knowledge finding reflects how knowledge was measured in this instrument rather than a universal truth about safety education.

What the study does establish is a clear hierarchy of modifiable targets. Clinical training stage and placement setting are structural factors that institutions can manage through staffing ratios, supervision levels and workload design. Prior NSI education is a curriculum decision. Practice quality and attitude are trainable competencies that respond to simulation, supervised competency assessment and mentorship. Knowledge, by contrast, appears to be a necessary but insufficient ingredient, one that must be translated into habitual behaviour and genuine safety culture before it protects anyone. The authors call for prospective studies to evaluate integrated safety education combined with supervised competency assessment, a design that would track students forward through their training and capture injuries as they occur rather than retrospectively.

For the global nursing workforce, the stakes are considerable. Nursing students represent a continuous pipeline of new healthcare workers, and their formative years establish the safety habits they will carry into decades of practice. A 42.4 percent annual injury prevalence means that in this cohort, roughly two in every five students experienced a potential occupational blood-borne pathogen exposure within a single year of training. Each of those events carries medical consequences, from post-exposure prophylaxis to chronic anxiety, and institutional consequences, from reporting burdens to lost training time. The Cairo study’s central message, that behaviour and attitude independently predict injury while knowledge alone does not, offers nursing educators everywhere a sharper hypothesis to test: stop asking only whether students know the rules, and start measuring whether they follow them and believe the rules matter.

Subject of Research: Needlestick injury risk factors among nursing students during clinical training

Article Title: Beyond knowledge: practice behaviours and attitudes independently associated with needlestick injuries among nursing students – a cross-sectional study with logistic regression modelling

Article References: Mohammed, R. S., Badr, M. N., Abdelwahab, S. R., & Seif-Eldin, A. S. (2026). Beyond knowledge: practice behaviours and attitudes independently associated with needlestick injuries among nursing students – a cross-sectional study with logistic regression modelling. BMC Nursing. https://doi.org/10.1186/s12912-026-05407-z

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05407-z

Keywords: needlestick injuries, nursing students, logistic regression, occupational safety, nursing education, knowledge-practice-attitude, cross-sectional study, infection control, clinical training, Egypt, blood-borne pathogens, sharps safety