What Really Drives Nurses to Prevent Bedsores? New Study Weighs Knowledge Against Support

Pressure injuries—commonly known as bedsores—are among the most stubborn and costly problems in long-term care, and a new study from South Korea suggests that fixing them may depend less on hiring more staff and more on what nurses know, how confident they feel, and whether their institutions invest in regular training. The research, published in BMC Nursing, applied a well-established psychological framework to a practical bedside question: why do some nurses consistently deliver evidence-based pressure injury care while others fall short, even when working in the same facilities with the same patients?

The study was led by Hyung-Ju Na, a wound, ostomy, and continence nurse at Seoul Metropolitan Dongbu Hospital, together with Sung-Hee Yoo of the College of Nursing at Chonnam National University. Rather than simply cataloging gaps in practice, the researchers anchored their investigation in the Information–Motivation–Behavioral Skills model, or IMB model, a framework originally developed to explain health behavior change and later adapted to clinical performance. The model proposes that behavior is driven by three interacting ingredients: accurate information, motivation to act, and the behavioral skills needed to translate intention into action. In this study, those ingredients were mapped onto pressure injury care knowledge, attitudes and institutional support, and self-efficacy, respectively.

Pressure injuries develop when sustained pressure, often combined with shear and moisture, compromises blood flow to the skin and underlying tissue, particularly over bony prominences such as the sacrum, heels, and hips. In frail, elderly residents who may be immobile, incontinent, or malnourished, the risk escalates dramatically. Once a deep injury forms, it can take months to heal, exposes the patient to infection and pain, and signals a breakdown in preventive care. That is why pressure injury management is widely treated as a critical indicator of nursing quality in long-term care facilities, and why understanding its determinants carries weight well beyond the ward.

To probe those determinants, the team conducted a descriptive, cross-sectional survey of 200 nurses working at five long-term care facilities in Seoul. Data were collected between June 1 and December 1, 2020, using a self-administered questionnaire that measured four domains: knowledge of pressure injury care, attitudes and perceived institutional support, self-efficacy, and actual performance of evidence-based pressure injury care. The researchers then used hierarchical stepwise regression, a statistical technique that adds predictor variables in stages to see how much additional explanatory power each contributes, while first accounting for the nurses’ general characteristics such as age, experience, and education level.

The headline finding was sobering but instructive. The mean item score for evidence-based pressure injury care performance was 3.89 out of 5, with a standard deviation of 0.61. In other words, nurses in these facilities were performing reasonably well but not at the near-perfect level that evidence-based prevention ideally demands. The regression analysis then identified four significant factors, ranked by the strength of their influence. Knowledge of pressure injury care came first, with a standardized beta coefficient of 0.38 and a p-value below 0.001. Self-efficacy followed at 0.23 (p = 0.001), then the provision of annual pressure injury care education at 0.22 (p = 0.003), and finally education level at 0.17 (p = 0.003). Together, these variables explained 38.3 percent of the total variance in performance, a substantial share for a complex clinical behavior measured in a real-world setting.

The prominence of knowledge is perhaps the most striking result. In the IMB framework, information is the foundation upon which motivation and skills build, and the data here bear that out: nurses who scored higher on pressure injury knowledge were markedly more likely to perform evidence-based care. This matters because clinical knowledge is not static. Pressure injury prevention guidelines evolve, covering topics such as risk assessment tools, repositioning schedules, support surfaces, skin moisture management, and nutrition. Nurses whose training predates current recommendations may be applying outdated techniques without realizing it, which makes periodic knowledge updating a genuine safety issue rather than an administrative box-tick.

Yet knowledge alone did not carry the story. Self-efficacy, the confidence a nurse has in her own ability to execute the required behaviors, emerged as the second strongest predictor. This aligns with a large body of behavioral science showing that people who believe they can perform an action are more likely to persist at it, especially when the action is effortful or the environment is challenging. Preventing pressure injuries in a busy long-term care ward is exactly that kind of effortful behavior: it requires vigilance, coordination with aides, advocacy for equipment, and repeated reassessment. A nurse who knows what to do but doubts her capacity to do it amid competing demands may quietly let best practice slip.

The third significant factor, the provision of annual pressure injury care education, shifts the lens from the individual to the organization. This is a notable finding because it demonstrates that institutional support contributes to performance independently of nurses’ personal educational backgrounds. A facility that commits to yearly training is, in effect, doing two things at once: refreshing the knowledge base of its staff and signaling that pressure injury prevention is a priority worth the organization’s time and resources. The authors conclude that enhancing care quality requires systematic, multi-level interventions that focus on updating clinical knowledge and bolstering nurses’ self-efficacy through sustained organizational commitment, not one-off lectures or posters in the break room.

Even the weakest predictor in the model, education level, carries practical implications. Its significance suggests that nurses with higher formal qualifications tend to perform better evidence-based care, but the fact that it ranked last—behind knowledge, self-efficacy, and annual training—implies that targeted continuing education can compensate for differences in academic credentials. For long-term care facilities, which often struggle to recruit highly credentialed nurses, this is an encouraging message: investment in structured, recurring in-service education may narrow the gap that degrees alone cannot.

The study does have boundaries worth noting. It was cross-sectional, capturing a single moment in time, so it can identify associations but cannot prove that boosting knowledge or self-efficacy causes better performance. The sample comprised 200 nurses from five facilities in a single city, and data were self-reported, which introduces the possibility of response bias. The researchers also note that the work received no specific grant from any funding agency, and the study was approved by the Institutional Review Board of Chonnam National University with written informed consent from all participants, conducted in accordance with the Declaration of Helsinki. Still, by grounding the analysis in a tested behavioral model and quantifying the relative weight of each factor, the study offers long-term care administrators a concrete roadmap: audit and refresh staff knowledge, build confidence through skills-based training and supportive supervision, and institutionalize annual pressure injury education. In a field where a single deep wound can mean months of suffering for a vulnerable resident, those levers may prove among the most cost-effective tools available.

Subject of Research: Determinants of evidence-based pressure injury care performance among nurses in long-term care facilities using the Information–Motivation–Behavioral Skills model

Article Title: Factors associated with evidence-based pressure injury care among nurses in long-term care facilities: an information–motivation–behavioral skills model-based study

Article References: Na, H.-J., & Yoo, S.-H. (2026). Factors associated with evidence-based pressure injury care among nurses in long-term care facilities: an information–motivation–behavioral skills model-based study. BMC Nursing. https://doi.org/10.1186/s12912-026-05472-4

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05472-4

Keywords: pressure injury, bedsores, long-term care facilities, nursing, evidence-based practice, IMB model, self-efficacy, nurse education, cross-sectional study, South Korea, wound care, nursing quality