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

The study, published in BMC Nursing by Asako Futami, Maiko Noguchi-Watanabe, and Noriko Yamamoto-Mitani of the University of Tokyo, set out to answer a deceptively simple question: does the environment in which nurses work influence how faithfully they carry out guideline recommendations, and does that, in turn, leave a fingerprint on patient health? The researchers surveyed staff nurses in five acute care hospitals in Japan, collecting data on their awareness and implementation of guideline recommendations related to two of the most stubborn problems in hospital care — pressure ulcers and infection control — alongside their perceptions of the organizational context using a validated instrument called the Alberta Context Tool.

Clinical practice guidelines, or CPGs, are systematically developed statements that translate the best available research evidence into recommendations for care. They exist for nearly every major clinical scenario, from wound prevention to hand hygiene. Yet the gap between what guidelines recommend and what actually happens at the bedside is a persistent puzzle in health services research. Implementation science, the field devoted to closing that gap, has increasingly focused on organizational context — the shared norms, leadership behaviors, resources, and feedback loops that surround clinical work. The Promoting Action on Research Implementation in Health Services framework, from which the Alberta Context Tool derives, holds that successful implementation is a function of evidence, context, and facilitation working together.

The Alberta Context Tool, or ACT, breaks this context down into measurable concepts: leadership culture, workplace culture, evaluation practices — meaning how data on team performance are used — structural and electronic resources, social capital, informal interactions, formal interactions, staffing levels and skill mix, and organizational slack, which refers to the spare time, space, and staffing a unit has available to absorb new practices. Nurses rate their units on each of these dimensions, producing a profile of how receptive the environment is to evidence-based change. The tool has been used widely in Canada and Europe, but the Japanese researchers noted that the relationship between context and guideline implementation may be culture-bound, and that its specific contours within Japanese health care settings remained unclear.

What they found was sobering on one front and illuminating on another. Of the 508 staff nurses whose data were analyzed, approximately 40 percent reported that they were simply unaware of the clinical practice guidelines relevant to their work. This is a striking figure: four in ten nurses in acute care settings could not confirm they knew the very documents designed to standardize and improve their practice. Awareness, of course, is only the first rung of the implementation ladder. Even among nurses who knew the recommendations, consistent execution was far from universal. The percentage of respondents who said they always implemented a given recommendation ranged from 15.0 percent to 48.2 percent, depending on which recommendation was being measured. In other words, for some guideline elements, fewer than one in six nurses could claim consistent adherence.

The analysis then turned to the question of what distinguishes units where guidelines are followed from those where they are not. Using hierarchical linear modeling — a statistical approach appropriate for data in which individual nurses are nested within units, which are in turn nested within hospitals — the researchers identified several ACT concepts that were positively associated with the implementation of guideline recommendations. Workplace culture, structural and electronic resources, evaluation practices, and staffing emerged as significant factors. Units where the culture was supportive, where nurses had access to adequate material and digital resources, where performance data were actively used to assess and improve team practice, and where staffing was sufficient, saw higher rates of guideline implementation.

Perhaps the most consequential finding concerned patient outcomes. The researchers examined two hard, clinical endpoints: the incidence rate of pressure ulcers and the incidence of MRSA infection. Four concepts from the Alberta Context Tool — evaluation, leadership, staffing, and time — were significantly associated with these outcomes. This is a critical link in the causal chain that implementation scientists have long hypothesized but rarely documented so directly in the Japanese context. It suggests that the organizational environment does not merely shape nurse behavior in the abstract; it appears to ripple through to whether patients develop avoidable wounds or acquire dangerous antibiotic-resistant infections during their hospital stay.

The specificity of the associations carries practical implications. Each guideline recommendation was associated with a somewhat different configuration of organizational context, which the authors interpret as evidence that a one-size-fits-all implementation strategy is unlikely to succeed. A recommendation that depends heavily on electronic documentation may rise or fall with structural and electronic resources, while one that requires coordinated team behavior may hinge on culture and informal interactions. Hospital administrators seeking to improve adherence would therefore do well to diagnose which contextual dimensions matter most for each specific practice they hope to embed, rather than launching generic awareness campaigns.

The cultural dimension of the findings deserves particular attention. The researchers explicitly framed their study as an effort to understand whether the well-documented relationships between context and implementation hold within Japanese culture, where hierarchical communication patterns, group-oriented norms, and different staffing structures may shape how evidence-based practice takes root. Their results suggest that the fundamental associations do hold — supportive culture, data-driven evaluation, and adequate resources matter in Japan just as they do elsewhere — but the study also underscores that implementation strategies must be culturally calibrated. Importantly, the study found no funding source and was conducted with ethical approval from the research ethics committee of the Graduate School of Medicine at the University of Tokyo, with informed consent obtained from all respondents in accordance with the Declaration of Helsinki.

For a field often dominated by discussions of new drugs and devices, this study is a reminder that some of the most powerful levers for improving patient care are organizational rather than pharmacological. A hospital that cultivates a supportive work culture, applies performance data to assess its teams, invests in resources, and protects staff time may see fewer pressure ulcers and fewer MRSA infections — not because it purchased new technology, but because it built an environment in which nurses can actually practice the evidence they already possess. With roughly 40 percent of nurses unaware of relevant guidelines and consistent implementation rates sometimes dipping below one in five, the headroom for improvement in Japanese acute care appears substantial. The message for hospital leaders worldwide is equally clear: the fastest route to better guideline adherence may run not through the guidelines themselves, but through the daily conditions of the nurses expected to follow them.

Subject of Research: The relationship between organizational context, nurses' implementation of clinical practice guidelines, and patient outcomes in Japanese acute care hospitals

Article Title: The relationship between organizational context and nurses’ implementation of clinical practice guidelines and patient outcomes in Japanese acute care settings: a cross-sectional survey

Article References: Futami, A., Noguchi-Watanabe, M., & Yamamoto-Mitani, N. (2026). The relationship between organizational context and nurses’ implementation of clinical practice guidelines and patient outcomes in Japanese acute care settings: a cross-sectional survey. BMC Nursing. https://doi.org/10.1186/s12912-026-05457-3

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05457-3

Keywords: clinical practice guidelines, organizational context, nursing, Alberta Context Tool, evidence-based practice, Japan, pressure ulcers, MRSA, infection control, acute care hospitals, implementation science, cross-sectional survey

The study, conducted by Karin Falk-Brynhildsen, Carina Bååth, Dimitri Beeckman, Christine Leo Swenne, Charlotte Raepsaet and Camilla Wistrand, set out to describe Swedish operating room nurses’ self-estimated knowledge and attitudes regarding the prevention of intraoperative pressure ulcers. Using a cross-sectional design reported according to the STROBE guidelines for observational studies, the team distributed an online questionnaire by email to operating room nurses across all 21 of Sweden’s healthcare regions. Of the 2247 addresses contacted, 343 proved non-functional, leaving 1904 eligible recipients. After two reminders, 284 nurses completed the survey, a response rate of 15 percent. Data collection took place in August and September 2020 as part of a larger project developing two validated instruments tailored to the operating room: the Pressure Ulcer Knowledge Assessment Tool for the operating room, known as PUKAT 2.0 OR, and the Attitudes toward Pressure Ulcer Prevention instrument adapted for the same setting, the APuP-OR.

The scale of the clinical problem provides the context for why this matters. According to the European Pressure Ulcer Advisory Panel guidelines, surgery-related pressure ulcers occur in approximately 4 to 45 percent of surgical procedures. Recent studies have documented intraoperative incidence rates ranging from 6.2 to 16.2 percent, and one study of patients aged 65 and older reported an incidence of 18.8 percent, with operative times of 180 minutes or longer strongly associated with increased risk. Medical devices compound the danger: blood pressure cuffs, adhesive tapes, endotracheal tubes and spectral index monitors can all damage skin and mucosal surfaces, and device-related pressure ulcers have been estimated at a prevalence of around 11.8 percent, while positioning-related ulcers may reach 23.5 percent. The operating room is therefore recognised as a high-risk environment where every member of the surgical team shares responsibility for tissue protection.

The 284 respondents were an experienced and highly educated group. Their mean age was 42.8 years, 93 percent were women, and 37 percent held a master’s degree while another 33.8 percent held a professional operating room nursing degree. More than 63 percent had over 11 years of experience in healthcare, and 37.7 percent had more than 20 years. When asked to rate their own expertise using Benner’s classic proficiency levels, half identified as proficient and 38 percent as competent, with 11.3 percent claiming expert status and only two nurses describing themselves as novices. Crucially, 87 percent said that further education in pressure ulcer prevention would be beneficial, an appetite for learning that the study’s findings suggest is well founded.

The knowledge assessment told a story of two halves. In the domain of aetiology, the nurses performed impressively. More than 95 percent correctly identified the causes of pressure ulcers and understood the biomechanical consequences of a patient sliding in a semi-upright position, and 90.1 percent recognised that body weight contributes to risk. These results align with previous research emphasising the role of knowledge in delivering evidence-based care. But when the questions turned to prevention, classification and observation, performance dropped sharply. Only 38 percent correctly identified where deep tissue injuries develop during surgery, and just 41.2 percent correctly classified blisters observed on both heels after a three-hour procedure. Nearly 60 percent answered incorrectly when asked about heel protection measures for a patient already lying on a pressure-redistributing mattress, and questions about patient positioning yielded correct response rates of only around 51 to 52 percent.

The researchers applied a demanding benchmark to these results, using a 90 percent threshold for correct answers, and only 3 of the 14 knowledge items met it. Even when the cut-off was lowered to 70 percent, the number of adequate responses remained limited. The authors deliberately retained the stricter threshold, reflecting on whether adjusting the standard of what counts as sufficient knowledge in pressure ulcer prevention is appropriate at all. The finding that positioning competencies are limited is consistent with earlier work by Sørensen and colleagues, who reported similar gaps among surgical teams, and it points to a specific, teachable weakness at the heart of intraoperative care: knowing how to position a patient safely is not the same as knowing why pressure damages tissue.

Attitudes, by contrast, were overwhelmingly positive. A remarkable 94.7 percent of respondents reported feeling confident in their ability to prevent pressure ulcers, and 98.6 percent agreed that prevention should be a priority and a personally important responsibility. Fully 94 percent acknowledged the financial burden that pressure ulcers place on society. The nurses firmly rejected dismissive statements: 93.7 percent disagreed that the impact of pressure ulcers on patients is exaggerated, 96.5 percent rejected the notion that too much attention is paid to prevention, and 96.1 percent refused the idea that they bear no responsibility if an ulcer develops in their patient. Attitude scores were higher than those reported in a previous study by Khong and colleagues, suggesting Swedish operating room nurses occupy an unusually favourable motivational position.

Experience shaped confidence in measurable ways. Pairwise comparisons revealed statistically significant differences across years of operating room experience in perceived training: nurses with more than 20 years of experience felt significantly better trained than those with 5 to 10 years, with a p-value of 0.049. A similar pattern emerged for perceived confidence, with significant differences between the most experienced nurses and those with 5 to 10 years of experience, and between the 11-to-20-year group and their less experienced colleagues. Yet the study’s central paradox remains: despite this confidence and experience, overall knowledge was insufficient, and positive attitudes did not translate into consistently correct answers about prevention strategies such as surgical linen use, positioning angles and heel offloading.

The authors are candid about the limitations of their work. Self-reported data are vulnerable to recall bias and social desirability bias, and some question wording may have confused participants. The 15 percent response rate restricts generalisability, and it is possible that respondents were more interested in pressure ulcer prevention than non-respondents, which could have inflated the apparent knowledge and attitude scores. The measurement instruments themselves, while validated, showed modest internal consistency on some subscales, and the authors note that PUKAT 2.0 OR requires further refinement to capture the complexity of pre-positioning across different surgical procedures while preserving operative exposure for the surgeon.

The implications reach beyond Sweden. Because most pressure ulcers are preventable, the authors argue, raising awareness and promoting evidence-based prevention strategies across the entire operating room team is imperative, including surgeons, anaesthesiologists and nurse anaesthetists, not nurses alone. They call for systematic, evidence-based educational interventions, structured training programmes, simulation-based learning and regular competency assessments integrated into continuing professional development, alongside mixed-methods research to clarify why positive attitudes fail to produce adequate knowledge or consistent preventive action. Structured risk assessment tools, which guidelines consider the gold standard, should complement rather than replace clinical judgement. For a complication that can begin forming the moment a patient is positioned on the table, the message of this survey is clear: the will to prevent pressure ulcers is present in the operating room, but the knowledge to do so reliably still needs to be built, one training programme at a time.

Subject of Research: Operating room nurses' knowledge and attitudes regarding intraoperative pressure ulcer prevention

Article Title: Preventing Pressure Ulcers in the Operating Room: A National Survey of Operating Room Nurses' Knowledge and Attitudes

Article References: Falk‐Brynhildsen, K., Bååth, C., Beeckman, D., Leo Swenne, C., Raepsaet, C., & Wistrand, C. (2026). Preventing Pressure Ulcers in the Operating Room: A National Survey of Operating Room Nurses' Knowledge and Attitudes. Nursing Open, 13(9), Article e70808. https://doi.org/10.1002/nop2.70808

Image Credits: AI Generated

DOI: 10.1002/nop2.70808

Keywords: pressure ulcers, operating room nurses, patient safety, intraoperative care, nursing knowledge, survey research, Sweden, patient positioning, surgical complications, nursing education, pressure injury prevention, cross-sectional study