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

The research, led by Ping Gao and Xiaomei Chen of Chengdu Wenjiang District People’s Hospital along with colleagues at several Chinese institutions, addressed a well-known gap in clinical training. Nursing interns, who have just transitioned from classroom to bedside, are among the most vulnerable members of the hospital workforce. They perform injections, venipunctures, and sharps disposal under time pressure and supervision that is often inconsistent. Traditional safety training, typically delivered as lectures or static pamphlets, tends to fade quickly once the demands of real clinical work take over. Although animation-based education has proven effective in other areas of clinical teaching, its potential for preventing needlestick injuries had been largely unexplored until now.

The intervention at the heart of the study was what the researchers call caricature storyline-based audiovisual education. Rather than presenting isolated facts about sharps safety, the educational materials wove preventive principles into a narrative told through exaggerated, cartoon-like animated images, which the authors note were generated with the assistance of the AI tool Doubao. The storyline format is more than an aesthetic choice. Educational psychology suggests that narrative structure helps learners encode and retrieve procedural information, because characters, conflicts, and resolutions give abstract rules a concrete emotional and situational anchor. For a novice nurse, watching a caricatured character fumble a recapping maneuver and face the consequences may be more memorable than memorizing a checklist.

To test whether the approach actually worked, the team used a sequential mixed-methods design, combining rigorous quantitative measurement with in-depth qualitative exploration. They recruited 260 nursing interns enrolled in junior college or undergraduate nursing programs, all of whom had completed one to two months of clinical practice before entering the study. This timing was deliberate: the participants had enough ward experience to understand the risks firsthand, but were still early enough in their training for education to shape lasting habits. Every participant received the caricature-based audiovisual education, and the researchers measured outcomes at three points: before the intervention, immediately afterward, and again three months later.

The quantitative results were striking. Using validated scales, the team assessed four dimensions: knowledge about needlestick injuries, attitudes toward prevention, actual safety behaviors, and preventive motivation. Repeated-measures analysis of variance revealed significant main effects of time across all four outcomes, with p values below 0.001 and partial eta-squared values ranging from 0.968 to 0.992, effect sizes so large they are rarely seen in behavioral research. Corrected post-hoc comparisons confirmed that every score rose significantly from baseline to both the post-test and the three-month follow-up. In practical terms, the interns did not merely perform better on a quiz immediately after watching the videos; they internalized the material in a way that persisted.

The follow-up data revealed an especially interesting pattern. Knowledge and attitude scores plateaued between the post-test and the three-month mark, remaining statistically stable with p values of 0.473 and 0.541 respectively. Behavior and preventive motivation, however, continued to climb significantly during the same period, both with p values below 0.001. This suggests that the intervention did more than transmit information. It appears to have triggered a self-reinforcing cycle in which motivated interns kept practicing safer behaviors, and those behaviors in turn deepened their commitment to prevention. The most concrete outcome measure was perhaps the simplest: only six needlestick injuries were reported across the entire group during the follow-up period.

Numbers alone cannot explain why the intervention worked, which is where the qualitative arm of the study proved valuable. A subsample of 49 participants took part in ethnographic observations and semi-structured interviews, allowing the researchers to see how the education translated, or failed to translate, into daily ward practice. Thematic analysis of this material yielded four themes and six subthemes, capturing how the interns perceived the intervention and how it reshaped their thinking about sharps safety. The researchers report that most nursing interns rated the intervention positively, describing it as engaging and relevant to their real clinical situations, and suggesting that the format could be extended to other healthcare disciplines beyond nursing.

The study’s methodological choices strengthen its credibility. By requiring participants to have completed at least a month of clinical practice, the researchers ensured that baseline knowledge and attitudes reflected genuine ward experience rather than classroom theory. The three-time-point measurement design allowed them to distinguish immediate learning effects from durable behavioral change, a distinction that many training evaluations miss. The combination of repeated-measures ANOVA with corrected post-hoc testing guards against the inflated error rates that can plague before-and-after studies, and the very large effect sizes, while partly a reflection of a single-group design without a control arm, indicate that the intervention moved every measured dial.

That single-group design is also the study’s main limitation, and the authors and readers alike should interpret the findings with appropriate caution. Without a randomized control group receiving standard lecture-based training, it is difficult to isolate the specific contribution of the caricature storyline format from the general benefit of receiving any structured, engaging education on needlestick prevention. Self-reported behavior scales can also diverge from observed practice, although the ethnographic observations in the qualitative arm partially offset this concern. Still, the consistency of improvement across four distinct outcome dimensions, and the continued rise in behavior and motivation over three months, make a compelling case that the intervention produced real change rather than a fleeting testing effect.

The implications reach well beyond one hospital in Chengdu. Needlestick injuries impose enormous costs on health systems, from post-exposure prophylaxis and testing to the psychological toll of waiting weeks for serology results. If a low-cost, scalable package of animated videos can meaningfully reduce these injuries among the newest and most vulnerable members of the clinical workforce, hospital educators have a practical tool they can deploy widely. The authors suggest the model may support the standardization of clinical practice and help reduce the occurrence of needlestick injuries more broadly. As hospitals worldwide grapple with how to instill safety culture in a constantly rotating stream of trainees, this study offers a reminder that sometimes the most effective teacher is a well-told story, even one drawn in exaggerated cartoon lines.

Subject of Research: Caricature storyline-based audiovisual education for preventing needlestick injuries among nursing interns

Article Title: Effects of caricature storyline audiovisual education on knowledge, attitudes, behavior, and preventive motivation regarding needlestick injuries among nursing interns: a mixed methods study

Article References: Gao, P., Cheng, L., Wang, Z., Zeng, X., Xu, X., Huang, J., Li, L., Li, W., Tang, M., Wang, Q., & Chen, X. (2026). Effects of caricature storyline audiovisual education on knowledge, attitudes, behavior, and preventive motivation regarding needlestick injuries among nursing interns: a mixed methods study. BMC Nursing. https://doi.org/10.1186/s12912-026-05373-6

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05373-6

Keywords: needlestick injuries, nursing interns, audiovisual education, caricature animation, nursing education, occupational safety, mixed methods study, preventive motivation, clinical training, BMC Nursing, healthcare workers, sharps safety