Effects of a Problem-Based and Simulation-Based Training Program on Operating Room Nurses’ Knowledge and Attitudes Toward Medical Device–Related Pressure Injuries

Effects of a Problem-Based and Simulation-Based Training Program on Operating Room Nurses’ Knowledge and Attitudes Toward Medical Device–Related Pressure Injuries | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects of a Problem-Based and Simulation-Based Training Program on Operating Room Nurses’ Knowledge and Attitudes Toward Medical Device–Related Pressure Injuries Feng Zhang, Zhi Lan Chen, Li En Qi, Xiao Yan Wang, Li Zhang, Jing Zhang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8382431/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Apr, 2026 Read the published version in BMC Medical Education → Version 1 posted 11 You are reading this latest preprint version Abstract Objective : To evaluate the effectiveness of a medical device–related pressure injury (MDRPI) care and prevention training program on the knowledge and attitudes of operating room (OR) nurses. Methods : A prospective, single-group, pretest–posttest quasi-experimental study was conducted in the OR of a tertiary hospital from March to June 2025. A total of 80 OR nurses who met the inclusion criteria were enrolled. The intervention consisted of eight small-group training sessions integrating problem-based learning (PBL), case discussions, and scenario-based simulation. Each theoretical PBL/case session lasted 2 hours and each simulation session 1 hour. MDRPI-related knowledge and attitudes were assessed before and after the intervention using the validated Chinese versions of the Pieper–Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT) and the Attitude towards Pressure Ulcer Prevention instrument (APuP). Results : The mean total PZ-PUKT score significantly increased from 40.58 ± 9.00 to 53.23 ± 6.78 ( P < 0.001), and the overall knowledge accuracy improved from 56.35% to 73.92%. Significant gains were observed in all subdomains, with accuracy increasing from 64.55% to 78.88% for risk factors/prevention, from 50.75% to 68.88% for staging, and from 51.46% to 72.33% for wound description. The total APuP score also significantly increased from 40.06 ± 3.33 to 44.60 ± 2.49 ( P < 0.001), corresponding to an accuracy improvement from 76.97% to 85.77%. Significant improvements were found in personal prevention capability, prioritization of prevention, perceived impact of pressure injuries, and confidence in the effectiveness of prevention (all P < 0.05). No statistically significant change was observed in the responsibility dimension ( P = 0.157). Conclusion : The hybrid training program integrating PBL-based theoretical teaching with scenario-based simulation significantly improved OR nurses’ MDRPI-related knowledge and attitudes. These findings support the implementation of structured, small-group, interactive education to strengthen MDRPI prevention in the operating room. medical device–related pressure injury operating room nurses problem-based learning simulation training knowledge attitude Introduction Medical device–related pressure injuries (MDRPIs) are defined as localized damage to the skin or mucous membranes resulting from the use of medical devices during diagnostic or therapeutic procedures, and their shape typically mirrors that of the causative device [ 1 ] . In the operating room (OR), a highly technology-dense environment with multiple devices, tubes, electrodes, and cables, patients are often required to maintain fixed positions for prolonged periods. These conditions substantially increase the risk of MDRPIs. Recent studies in China have reported that the incidence of MDRPIs in OR settings ranges from 0.56% to 12.00%, accounting for approximately 45% of all intraoperative hospital-acquired pressure injuries [ 2 ] . Patients using medical devices are 2.4 times more likely to develop pressure injuries than those not exposed to such devices [ 3 ] . Common devices associated with MDRPIs include oxygen delivery systems, non-invasive ventilation masks, urinary catheters, fixation devices, and other monitoring and therapeutic equipment [ 4 ] . MDRPIs may result in infection, pain, scarring, and impaired body image, which negatively affect patients’ quality of life and may prolong hospital stay and increase healthcare costs [ 5 ] . Prevention is recognized as the most cost-effective strategy for managing pressure injuries [ 6 ] . However, prevention of MDRPIs is more complex than that of traditional pressure injuries, as it requires consideration of multiple factors, such as patients’ nutritional status, device selection and positioning, duration of device use, and follow-up care. Inadequate nutrition impairs skin integrity and wound healing, while improper device placement or prolonged application can increase localized pressure, shear, and moisture, thereby elevating MDRPI risk. Nurses play a pivotal role in MDRPI prevention. Their responsibilities include regularly assessing device positioning and fixation, adjusting device use based on patients’ conditions, inspecting skin areas in contact with devices to promptly detect early signs of damage, and implementing protective measures such as pressure-relieving pads and prophylactic dressings [ 6 , 7 ] . Evidence suggests that nurses’ knowledge and attitudes toward pressure injury prevention are positively correlated [ 8 ] . Sufficient education can positively influence attitudes, promote preventive behaviors, and reduce the incidence of pressure injuries [ 9 ] . Nonetheless, prior research has shown that 74.6% of OR nurses exhibit relatively passive attitudes toward pressure injury prevention [ 10 ] , and knowledge related to MDRPI remains inadequate [ 2 ] . In recent years, studies have begun to develop tailored MDRPI training programs for specific clinical areas. Ergün et al. applied an evidence-based educational program combined with small-group problem-based learning (PBL) for neonatal intensive care unit (NICU) nurses, which significantly improved their knowledge of MDRPI in preterm infants [ 11 ] . Sayed et al. reported that an MDRPI-focused program for ICU nurses enhanced nurses’ knowledge and practice in the short term and reduced the incidence and severity of device-related injuries [ 12 ] . Similarly, Dallı and colleagues implemented the “Medical Device–Related Pressure Injury Care and Prevention Training Program (DevICeU)” in the ICU and found significant improvements in nurses’ knowledge and a reduction in MDRPI incidence from 24% to approximately 4% [ 13 ] . Despite these advances, there is a paucity of structured MDRPI training programs specifically targeting OR nurses, who face unique intraoperative risks and workflow constraints. Therefore, this study aimed to design and implement an MDRPI education program tailored to OR nurses by integrating PBL, case-based teaching, and scenario-based simulation, and to evaluate its effects on nurses’ MDRPI-related knowledge and attitudes. Method Study Design This study adopted a prospective, single-group, pretest–posttest quasi-experimental design to evaluate the effectiveness of an MDRPI prevention training program for OR nurses. Setting and Sample The study was conducted in the operating room of a tertiary hospital in China from March to June 2025. A total of 80 OR nurses who met the inclusion criteria were recruited using a census sampling approach. Inclusion criteria: At least 1 year of clinical nursing experience Full-time employment in the operating room Voluntary participation and provision of informed consent Exclusion criteria: Currently working in non-operating room clinical nursing positions Pregnancy, lactation, or serious illness that might interfere with training participation Data Collection Instruments 1. Demographic and Professional Characteristics Form This self-designed form collected data on gender, age, educational level, years of work experience, professional title, prior participation in MDRPI-related training, and prior experience in reporting or documenting MDRPIs. The English version of this questionnaire is provided as Supplementary File 1. 2. Pieper–Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT), Chinese Version The PZ-PUKT, developed by Pieper and Zulkowski [ 14 ] , was used to assess nurses’ knowledge regarding pressure injuries, including MDRPIs. The instrument comprises 72 items in three domains: risk factors/prevention (28 items), pressure injury staging (20 items), and wound description (24 items). Each item has three response options: “true”, “false”, and “don’t know”. Correct answers are scored as 1 point; incorrect and “don’t know” responses are scored as 0, yielding a total score range of 0–72. Knowledge levels are categorized as unsatisfactory (≤ 70%), satisfactory (70–80%), and excellent (> 80%). The Chinese version of the PZ-PUKT demonstrates excellent reliability, with an overall Cronbach’s α of 0.932, and Cronbach’s α values of 0.831, 0.823, and 0.840 for the risk factors/prevention, staging, and wound description domains, respectively [ 15 ] . 3. Attitude towards Pressure Ulcer Prevention (APuP), Chinese Version Nurses’ attitudes toward pressure injury prevention were assessed using the Chinese version of the APuP instrument, originally developed by Beeckman et al. [ 16 ] . The scale includes 13 items across five dimensions: personal prevention capability (3 items), importance of prevention (3 items), impact of pressure injuries (3 items), responsibility (2 items), and confidence in prevention effectiveness (2 items). Items are rated on a 4-point Likert scale (1 = strongly disagree to 4 = strongly agree). Negative items are reverse-coded. The total score ranges from 13 to 52, with an average score ≥ 75% of the maximum indicating a satisfactory attitude. The Chinese version has demonstrated good internal consistency, with an overall Cronbach’s α of 0.899 and α values of 0.808 (personal capability), 0.753 (priority), 0.818 (impact), 0.870 (responsibility), and 0.700 (confidence) [ 15 ] . Training Program A multidisciplinary MDRPI training team was established, consisting of one department head nurse, three unit head nurses, and two senior nurses. The head nurse was responsible for designing the training plan and evaluation framework. Unit head nurses and senior nurses delivered the training sessions and facilitated case discussions and simulations. All trainers completed preparatory sessions to standardize MDRPI-related knowledge and skills. Drawing on the programs developed by Sayed et al. and Dallı et al. [ 12 , 13 ] , the research team designed a hybrid curriculum tailored to OR nurses, integrating theoretical and practical components. Training was delivered to small groups of 10 nurses, with each group participating in 8 sessions, the detailed training content is presented in Table 1 . Table 1 Overview of the MDRPI Training Program for Operating Room Nurses Component Theoretical component Practical component Format Problem-based learning (PBL) + case discussions Scenario-based, hands-on simulation training Main-Content 1. Definitions, characteristics, and pathophysiology of pressure injuries and MDRPIs 2. OR-specific devices contributing to MDRPI (positioning pads, electrode pads, pulse oximetry probes, operative instruments, and various tubes) 3. Risk factors, staging, and wound assessment 4. Prevention strategies and management in high-risk patient 5. MDRPI treatment principles, clinical practice guidelines, and international consensus statements 1. Skin assessment in device contact areas 2. Application and replacement of prophylactic dressings 3. Use of positioning aids and pressure-relief pads 4. Correct operation and adjustment of nasal oxygen tubes and other common OR devices 5. Device repositioning strategies to minimize pressure and shear Duration 2 hours per session Approximately 1 hour per session Ethical Considerations This study was approved by the Ethics Review Committee of Biomedical Research, Xuzhou Central Hospital (Approval No. XZXY-LK-20241210-0105). Written informed consent was obtained from all participating nurses. Data were anonymized and used solely for research purposes.The study was conducted in accordance with the ethical principles of the Declaration of Helsinki and relevant national and institutional guidelines for research involving human participants. Statistical Methods Data were analyzed using SPSS version 27.0. Categorical variables were summarized as frequencies and percentages, and compared using the chi-square test. Continuous variables were assessed for normality using the Shapiro-Wilk test. Normally distributed variables were presented as mean ± standard deviation (SD) and analyzed using paired-samples t-tests for pre–post comparisons. Non-normally distributed variables were transformed; if normality remained unmet, they were expressed as median (interquartile range) and compared using the Wilcoxon signed-rank test. All tests were two-tailed, and a P -value < 0.05 was considered statistically significant. Results 1. Characteristics of Operating Room Nurses A total of 80 OR nurses completed the study. The mean age was (31.45 ± 7.20) years, and the mean length of nursing experience was (8.95 ± 7.43) years. The male-to-female ratio was approximately 1:9. Most participants (88.75%) were younger than 40 years, and 76.25% had less than 10 years of work experience. In terms of educational background, 80.0% held a bachelor’s degree. Notably, 60 nurses (75.0%) had never received formal training related to MDRPIs prior to this study. Detailed baseline characteristics are presented in Table 2 : Sociodemographic and professional characteristics of the operating room nurses. Table 2 Sociodemographic and professional characteristics of the operating room nurses (n = 80) Characteristic n (%) Gender Male 8 Female 72 Age, Mean ± SD (Range) 31.45 ± 7.20 (22 to 54) Age(in years) 21–30 39 31–40 32 ≧ 41 9 Educational level Technical Institute of nursing 16 Bachelor degree in nursing 64 Experience inside operating room (in years), Mean ± SD (Range) 8.95 ± 7.43 (1 to 38) Experience inside operating room (in years) ≤ 5 31 6–10 30 11–15 10 16–20 3 ≥ 21 6 Title Nurse 30 Nurse practitioner-in-charge 36 Associate Chief Nurse 4 Chief Nurse 2 Training duration, h (n = 20 ), Mean ± SD (Range) 2.8 ± 1.24 (1 to 6) Is there a report and record of MDRPIs status? Yes 3 No 77 2. Changes in MDRPI-Related Knowledge Following the training program, the total PZ-PUKT score increased significantly from 40.58 ± 9.00 to 53.23 ± 6.78 ( P < 0.001). All three subdomain scores improved significantly: Risk factors/prevention: from 18.08 ± 3.91 to 22.08 ± 2.92 ( P < 0.001); Staging: from 10.15 ± 2.76 to 13.78 ± 2.61 ( P < 0.001); Wound description: from 12.35 ± 3.75 to 17.36 ± 3.24 ( P < 0.001).(see Table 3 :ieper-Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT) scores of operating room nurses before and after the training program). Table 3 Pieper-Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT) scores of operating room nurses before and after the training program (n = 80) Domain a Pre-training score Mean ± SD Post-training score Mean ± SD P -value Total PZ-PUKT score 40.58 ± 9.00 53.23 ± 6.78 < 0.001 Risk factors/prevention 18.08 ± 3.91 22.08 ± 2.92 < 0.001 Pressure ulcer staging 10.15 ± 2.76 13.78 ± 2.61 < 0.001 Wound Description 12.35 ± 3.75 17.36 ± 3.24 < 0.001 The overall knowledge accuracy rate increased from 56.35% to 73.92% ( P < 0.001). Accuracy in the risk factors/prevention domain improved from 64.55% to 78.88%, in the staging domain from 50.75% to 68.88%, and in the wound description domain from 51.46% to 72.33% ( P < 0.001 for all; see Table 4 : Percentage correctness of Pieper-Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT) among operating room nurses before and after the training program). Table 4 Percentage correctness of Pieper-Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT) among operating room nurses before and after the training program (n = 80) Domain a Pre-training correctness (%) Post-training correctness (%) P -value Total PZ-PUKT score 56.35 ± 12.50 73.92 ± 9.40 < 0.001 Risk factors/prevention 64.55 ± 13.97 78.88 ± 10.42 < 0.001 Pressure ulcer staging 50.75 ± 13.78 68.88 ± 13.05 < 0.001 Wound Description 51.46 ± 15.62 72.34 ± 13.51 < 0.001 Note: Percentage correct (%) = score / full score x 100%. 3. Changes in Attitudes Toward Pressure Injury Prevention The total APuP score significantly increased from 40.06 ± 3.33 to 44.60 ± 2.49 ( P < 0.001), with the corresponding attitude accuracy rate increasing from 76.97% to 85.77%. Across the five dimensions, significant improvements were observed in: Personal prevention capability: from 8.61.36 to 10.12 ± 1.18 ( P < 0.001); Prevention priority: from 9.41 ± 1.18 to 10.35 ± 1.01( P < 0.001); Impact of pressure injuries: from 9.34 ± 1.17 to 10.26 ± 0.89 ( P = 0.002); Confidence in the effectiveness of prevention: from 6.21 ± 1.09 to 6.83 ± 0.94 ( P = 0.007). In contrast, the increase in the responsibility in pressure ulcer prevention dimension (from 6.38 ± 0.86 to 6.49 ± 0.90) did not reach statistical significance ( P = 0.157)(see Tables 5 : Attitude towards Pressure Ulcer Prevention (APuP) scores of operating room nurses before and after the training program ). Table 5 Attitude towards Pressure Ulcer Prevention (APuP) scores of operating room nurses before and after the training program (n = 80) Domain a Pre-training score (Mean ± SD) Post-training score (Mean ± SD) P -value Total APuP score 40.06 ± 3.33 44.60 ± 2.49 < 0.001 Personal competency to prevent PUs 8.69 ± 1.36 10.12 ± 1.18 < 0.001 Priority of PU prevention 9.41 ± 1.18 10.35 ± 1.01 < 0.001 Impact of PUs 9.34 ± 1.17 10.26 ± 0.89 0.002 Responsibility in PU prevention 6.38 ± 0.86 6.49 ± 0.90 0.157 Confidence in the effectiveness of PU prevention 6.21 ± 1.09 6.83 ± 0.94 0.007 When APuP scores were converted into percentages of the maximum possible score, similar trends were observed (Table 6 :Percentage correctness of Attitude towards Pressure Ulcer Prevention (APuP) among operating room nurses before and after the training program). The overall attitude correctness rate increased from 76.97% ± 6.40% before training to 85.77% ± 4.80% after training ( P < 0.001). Subdomain correctness rates improved as follows: Personal prevention capability: from 72.40%±11.38% to 84.38%±9.88%( P < 0.001); Prevention priority: from 77.81%±9.70% to 85.21%±7.40% ( P = 0.002); Impact of pressure injuries: from 77.81%±9.74% to 85.21%± 7.38% ( P = 0.002); Responsibility in pressure ulcer prevention: from 79.69%±10.78% to 88.44%±11.21% ( P = 0.157); Confidence in the effectiveness of pressure ulcer prevention: from 77.66%±13.59% to 85.31%±11.73% ( P = 0.007). Consistent with the absolute APuP scores, all attitude dimensions showed significant improvement in correctness except for responsibility, which exhibited a non-significant increase. Table 6 Percentage correctness of Attitude towards Pressure Ulcer Prevention (APuP) among operating room nurses before and after the training program (n = 80) Domain a Pre-training correctness (%) Post-training correctness (%) P -value Total APuP score 76.97 ± 6.40 85.77 ± 4.80 < 0.001 Personal competency to prevent PUs 72.40 ± 11.38 84.38 ± 9.88 < 0.001 Priority of PU prevention 77.81 ± 9.7 85.21 ± 7.40 0.002 Impact of PUs 77.81 ± 9.74 85.21 ± 7.38 0.002 Responsibility in PU prevention 79.69 ± 10.78 88.44 ± 11.21 0.157 Confidence in the effectiveness of PU prevention 77.66 ± 13.59 85.31 ± 11.73 0.007 Note: Percentage correct (%) = score / full score x 100%. Discussion This study demonstrated that a hybrid MDRPI training program integrating PBL, case-based learning, and scenario-based simulation significantly improved OR nurses’ knowledge and attitudes related to MDRPI prevention. Improvement in Knowledge The mechanism of pressure injury development begins with transient reactive hyperemia secondary to pressure-induced hypoxia, and may progress to persistent ischemia, tissue damage, and necrosis if pressure is not relieved [17] . MDRPIs, caused by medical devices such as casts, ventilator masks, braces, and endotracheal tubes, frequently occur at the nose, ears, and fingertips [18,19] . Recognizing risk factors and early signs is therefore essential for timely prevention. Consistent with the findings of Dallı et al. in ICU nurses [13] , this study showed a significant increase in the overall PZ-PUKT score and in all three knowledge domains following the intervention. The gains in our study were also greater than the short-term improvements reported by Sayed et al. [12] , which may be attributable to our more interactive and problem-oriented educational approach. The theoretical component of our program applied PBL principles, starting from real clinical problems and guiding learners through literature searching, group discussion, and case analysis [20] . By focusing on high-risk OR devices (e.g., positioning pads, electrode patches, pulse oximetry probes), nurses were encouraged to explore how device characteristics-including frequency and duration of use, material, and design-affect skin microclimate and mechanical loading. This approach helped them understand how changes in local temperature and humidity can alter skin stiffness, strength, and friction, thereby increasing susceptibility to pressure injuries. Prior research has shown, for example, that thermal pre-cooling can reduce the coefficient of friction on skin surfaces [21] , highlighting the impact of temperature on frictional behavior. The scenario-based simulation further translated theoretical knowledge into practical skills. Nurses practiced systematic skin inspection, timely replacement of pulse oximeter probes, appropriate use and maintenance of positioning pads, cleaning and drying skin under electrode patches, and adjusting blood pressure cuffs and other devices to reduce pressure duration and intensity. This hands-on component addressed limitations of traditional lecture-based education, which often overemphasizes theory at the expense of clinical decision-making and psychomotor skills [22] . Despite these improvements, the post-training knowledge accuracy rate remained lower than that reported by Luo et al. among nurses in Shaanxi Province [23] , particularly in the “staging” and “wound description” domains. This may reflect the OR nurses’ predominant focus on acute intraoperative risks (e.g., bleeding, infection), with less emphasis on postoperative skin assessment and wound documentation. Future programs should strengthen visual training on staging and wound description, for example by using images, videos, and standardized clinical scenarios. Enhancement of Attitudes and Remaining Gaps Nurses’ attitudes toward pressure injury prevention are critical determinants of preventive behavior [24-26] . In line with previous research [11,27,28] , our findings showed significant improvement in overall attitudes and in key dimensions such as personal capability, prioritization of prevention, perceived impact, and confidence in prevention effectiveness. This suggests that integrating PBL and simulation can not only convey knowledge but also enhance self-efficacy and the perceived importance of prevention, particularly among younger nurses with higher educational levels [29] . The group-based training model used in this study, in which more experienced or higher-educated nurses acted as peer trainers, may have contributed to these improvements. As reported by Sun et al. [28] , nurses with a bachelor’s degree or above tend to have better knowledge, attitudes, and practices regarding MDRPI. Our design leveraged this by assigning such nurses to mentor colleagues with less experience or lower educational attainment. However, the responsibility dimension of the APuP did not significantly change after training. This may be related to the complex, multidisciplinary nature of perioperative care, where roles and responsibilities for skin assessment and MDRPI prevention may not be clearly delineated. OR nurses often prioritize intraoperative hemodynamic monitoring and surgical support, while postoperative skin assessment and long-term follow-up are typically handled by ward nurses. The absence of a feedback loop regarding postoperative MDRPIs may further weaken OR nurses’ sense of responsibility. Furthermore, although the “prevention priority” dimension improved, the post-training level remained lower than that reported by Parisod et al. among nursing staff in other settings [30] . This suggests that pressure injury prevention is still perceived as secondary to other intraoperative tasks. Future interventions should therefore include: Clarification of roles and responsibilities in MDRPI prevention within multidisciplinary teams Establishment of cross-departmental feedback mechanisms to inform OR nurses about postoperative pressure injury outcomes Integration of MDRPI prevention as a visible quality indicator in OR performance evaluation Comparison With Previous Studies Our results support and extend previous findings on the effectiveness of structured pressure injury education. Kim et al. [29] concluded that programs combining theoretical and practical components, delivered in small groups and lasting more than 2 hours, are more effective in improving nurses’ knowledge and clinical judgment. The design of the present study aligns well with these recommendations and confirms their applicability in the OR context. At the same time, the relatively high proportion of nurses without prior MDRPI training (75%) and their initially passive attitudes are consistent with international reports that knowledge and attitudes regarding pressure injury prevention are often suboptimal among nurses [8–10,25,26,30] . This highlights the need to institutionalize continuous MDRPI education as part of routine OR training and competency assessment. Limitations This study has several limitations. First, it used a single-group pretest–posttest design in one tertiary hospital with a relatively small sample size, which may limit the generalizability of the findings. Multi-center randomized controlled trials with larger samples are needed to confirm the effectiveness of this educational model. Second, data were collected primarily via self-administered questionnaires, which are susceptible to recall bias and social desirability bias. Future studies could incorporate objective assessments, such as knowledge tests under exam conditions, direct observation of clinical practice, or OSCE-style evaluations. Third, the study only evaluated short-term outcomes. Long-term follow-up is needed to determine the durability of improvements in knowledge and attitudes and to assess whether refresher training is necessary. Finally, and most importantly, we did not examine the impact of the training program on patient-level outcomes, such as MDRPI incidence, severity, or healing time. Future research should link nurse-related outcomes with clinical indicators to more comprehensively evaluate the effectiveness and clinical significance of MDRPI education. Conclusion This study demonstrated that a structured MDRPI care and prevention training program, integrating problem-based learning, case discussions, and scenario-based simulation, significantly improved OR nurses’ knowledge and attitudes toward MDRPI prevention. The program was particularly effective in enhancing knowledge of risk factors, staging, and wound description, as well as in strengthening nurses’ perceived capability, prioritization of prevention, perceived impact, and confidence in preventive measures. However, no significant change was observed in the responsibility dimension of attitudes, and post-training knowledge in staging and wound description remained suboptimal compared with some previous reports. These findings suggest that, in addition to improving knowledge and general attitudes, future interventions should focus on clarifying responsibility within multidisciplinary teams, strengthening feedback mechanisms, and reinforcing training on injury staging and wound assessment. Despite its limitations, this study provides empirical support for implementing hybrid, small-group, interactive MDRPI training programs tailored to OR nurses. Such programs may serve as a practical framework for hospital-wide MDRPI prevention strategies and as a basis for future multi-center studies linking nurse education with patient outcomes. Declarations Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author Contribution FZ reviewed and edited the manuscript. ZLC, QLE, XYW, LZ collected and analyzed the data. FZ, JZ and PW conceived the study, participated in the study design, interpreted the data, and coordinated the study. All authors have read and approved the final version of the manuscript. Acknowledgements The authors would like to thank the operating room nurses at Xuzhou Central Hospital for their participation and support in this study. Data Availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. References Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. J Wound Ostomy Cont Nurs. 2016;43:585–97. Liu J, Nan M, Yu C, Yao D. Prevention of Medical Device-Related Pressure Injury in The Operating Room: Nurses’ Knowledge and Training Imperatives. Int J Nurs Health Care Res. 2024;7:1579. Brophy S, Moore Z, Patton D, O’Connor T, Avsar P. 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Pressure injury prevention practice and associated factors among nurses at Wolaita Sodo University Teaching and Referral Hospital, South Ethiopia: a cross-sectional study. BMJ Open. 2022;12(3):e047687. Sun XX, Chen RB, Fang PP, Yu R, Wang XX, Liu JQ, Chen Y, Ling H. Model construction of factors influencing intensive care unit nurses' medical device-related pressure injury knowledge, attitude, and practice. Int Wound J. 2023;20(7):2582–93. Kim G, Park M, Kim K. The effect of pressure injury training for nurses: A systematic review and meta-analysis. Adv Skin Wound Care. 2020;33(3):1–11. Parisod H, Holopainen A, Kielo-Viljamaa E, Puukka P, Beeckman D, Haavisto E. Attitudes of nursing staff towards pressure ulcer prevention in primary and specialised health care: A correlational cross-sectional study. Int Wound J. 2022;19(2):399–410. Additional Declarations No competing interests reported. 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09:57:11","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":117054,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8382431/v1/e517fab8f3054e24eb715c59.html"},{"id":107350846,"identity":"1bec0468-9526-4c54-a1e5-02708c80fceb","added_by":"auto","created_at":"2026-04-20 16:05:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":548792,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8382431/v1/14ecd6e9-fa70-423d-ba6e-32f2cb7a6345.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of a Problem-Based and Simulation-Based Training Program on Operating Room Nurses’ Knowledge and Attitudes Toward Medical Device–Related Pressure Injuries","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMedical device\u0026ndash;related pressure injuries (MDRPIs) are defined as localized damage to the skin or mucous membranes resulting from the use of medical devices during diagnostic or therapeutic procedures, and their shape typically mirrors that of the causative device\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. In the operating room (OR), a highly technology-dense environment with multiple devices, tubes, electrodes, and cables, patients are often required to maintain fixed positions for prolonged periods. These conditions substantially increase the risk of MDRPIs.\u003c/p\u003e \u003cp\u003eRecent studies in China have reported that the incidence of MDRPIs in OR settings ranges from 0.56% to 12.00%, accounting for approximately 45% of all intraoperative hospital-acquired pressure injuries\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Patients using medical devices are 2.4 times more likely to develop pressure injuries than those not exposed to such devices\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Common devices associated with MDRPIs include oxygen delivery systems, non-invasive ventilation masks, urinary catheters, fixation devices, and other monitoring and therapeutic equipment\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. MDRPIs may result in infection, pain, scarring, and impaired body image, which negatively affect patients\u0026rsquo; quality of life and may prolong hospital stay and increase healthcare costs\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePrevention is recognized as the most cost-effective strategy for managing pressure injuries\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. However, prevention of MDRPIs is more complex than that of traditional pressure injuries, as it requires consideration of multiple factors, such as patients\u0026rsquo; nutritional status, device selection and positioning, duration of device use, and follow-up care. Inadequate nutrition impairs skin integrity and wound healing, while improper device placement or prolonged application can increase localized pressure, shear, and moisture, thereby elevating MDRPI risk.\u003c/p\u003e \u003cp\u003eNurses play a pivotal role in MDRPI prevention. Their responsibilities include regularly assessing device positioning and fixation, adjusting device use based on patients\u0026rsquo; conditions, inspecting skin areas in contact with devices to promptly detect early signs of damage, and implementing protective measures such as pressure-relieving pads and prophylactic dressings\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Evidence suggests that nurses\u0026rsquo; knowledge and attitudes toward pressure injury prevention are positively correlated\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Sufficient education can positively influence attitudes, promote preventive behaviors, and reduce the incidence of pressure injuries\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Nonetheless, prior research has shown that 74.6% of OR nurses exhibit relatively passive attitudes toward pressure injury prevention \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e, and knowledge related to MDRPI remains inadequate\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn recent years, studies have begun to develop tailored MDRPI training programs for specific clinical areas. Erg\u0026uuml;n et al. applied an evidence-based educational program combined with small-group problem-based learning (PBL) for neonatal intensive care unit (NICU) nurses, which significantly improved their knowledge of MDRPI in preterm infants \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Sayed et al. reported that an MDRPI-focused program for ICU nurses enhanced nurses\u0026rsquo; knowledge and practice in the short term and reduced the incidence and severity of device-related injuries\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Similarly, Dallı and colleagues implemented the \u0026ldquo;Medical Device\u0026ndash;Related Pressure Injury Care and Prevention Training Program (DevICeU)\u0026rdquo; in the ICU and found significant improvements in nurses\u0026rsquo; knowledge and a reduction in MDRPI incidence from 24% to approximately 4% \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDespite these advances, there is a paucity of structured MDRPI training programs specifically targeting OR nurses, who face unique intraoperative risks and workflow constraints. Therefore, this study aimed to design and implement an MDRPI education program tailored to OR nurses by integrating PBL, case-based teaching, and scenario-based simulation, and to evaluate its effects on nurses\u0026rsquo; MDRPI-related knowledge and attitudes.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis study adopted a prospective, single-group, pretest\u0026ndash;posttest quasi-experimental design to evaluate the effectiveness of an MDRPI prevention training program for OR nurses.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting and Sample\u003c/h3\u003e\n\u003cp\u003eThe study was conducted in the operating room of a tertiary hospital in China from March to June 2025. A total of 80 OR nurses who met the inclusion criteria were recruited using a census sampling approach.\u003c/p\u003e \u003cp\u003eInclusion criteria:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAt least 1 year of clinical nursing experience\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eFull-time employment in the operating room\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eVoluntary participation and provision of informed consent\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eExclusion criteria:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCurrently working in non-operating room clinical nursing positions\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePregnancy, lactation, or serious illness that might interfere with training participation\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eData Collection Instruments\u003c/b\u003e \u003c/p\u003e \u003cp\u003e1. Demographic and Professional Characteristics Form\u003c/p\u003e \u003cp\u003eThis self-designed form collected data on gender, age, educational level, years of work experience, professional title, prior participation in MDRPI-related training, and prior experience in reporting or documenting MDRPIs. The English version of this questionnaire is provided as Supplementary File 1.\u003c/p\u003e \u003cp\u003e2. Pieper\u0026ndash;Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT), Chinese Version\u003c/p\u003e \u003cp\u003eThe PZ-PUKT, developed by Pieper and Zulkowski\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e, was used to assess nurses\u0026rsquo; knowledge regarding pressure injuries, including MDRPIs. The instrument comprises 72 items in three domains: risk factors/prevention (28 items), pressure injury staging (20 items), and wound description (24 items). Each item has three response options: \u0026ldquo;true\u0026rdquo;, \u0026ldquo;false\u0026rdquo;, and \u0026ldquo;don\u0026rsquo;t know\u0026rdquo;. Correct answers are scored as 1 point; incorrect and \u0026ldquo;don\u0026rsquo;t know\u0026rdquo; responses are scored as 0, yielding a total score range of 0\u0026ndash;72. Knowledge levels are categorized as unsatisfactory (\u0026le;\u0026thinsp;70%), satisfactory (70\u0026ndash;80%), and excellent (\u0026gt;\u0026thinsp;80%).\u003c/p\u003e \u003cp\u003eThe Chinese version of the PZ-PUKT demonstrates excellent reliability, with an overall Cronbach\u0026rsquo;s α of 0.932, and Cronbach\u0026rsquo;s α values of 0.831, 0.823, and 0.840 for the risk factors/prevention, staging, and wound description domains, respectively\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e3. Attitude towards Pressure Ulcer Prevention (APuP), Chinese Version\u003c/p\u003e \u003cp\u003eNurses\u0026rsquo; attitudes toward pressure injury prevention were assessed using the Chinese version of the APuP instrument, originally developed by Beeckman et al.\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. The scale includes 13 items across five dimensions: personal prevention capability (3 items), importance of prevention (3 items), impact of pressure injuries (3 items), responsibility (2 items), and confidence in prevention effectiveness (2 items). Items are rated on a 4-point Likert scale (1\u0026thinsp;=\u0026thinsp;strongly disagree to 4\u0026thinsp;=\u0026thinsp;strongly agree). Negative items are reverse-coded. The total score ranges from 13 to 52, with an average score\u0026thinsp;\u0026ge;\u0026thinsp;75% of the maximum indicating a satisfactory attitude.\u003c/p\u003e \u003cp\u003eThe Chinese version has demonstrated good internal consistency, with an overall Cronbach\u0026rsquo;s α of 0.899 and α values of 0.808 (personal capability), 0.753 (priority), 0.818 (impact), 0.870 (responsibility), and 0.700 (confidence)\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003ch3\u003eTraining Program\u003c/h3\u003e\n\u003cp\u003eA multidisciplinary MDRPI training team was established, consisting of one department head nurse, three unit head nurses, and two senior nurses. The head nurse was responsible for designing the training plan and evaluation framework. Unit head nurses and senior nurses delivered the training sessions and facilitated case discussions and simulations. All trainers completed preparatory sessions to standardize MDRPI-related knowledge and skills.\u003c/p\u003e \u003cp\u003eDrawing on the programs developed by Sayed et al. and Dallı et al.\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e, the research team designed a hybrid curriculum tailored to OR nurses, integrating theoretical and practical components. Training was delivered to small groups of 10 nurses, with each group participating in 8 sessions, the detailed training content is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverview of the MDRPI Training Program for Operating Room Nurses\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComponent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTheoretical component\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePractical component\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormat\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProblem-based learning (PBL)\u0026thinsp;+\u0026thinsp;case discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eScenario-based, hands-on simulation training\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain-Content\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1. Definitions, characteristics, and pathophysiology of pressure injuries and MDRPIs\u003c/p\u003e \u003cp\u003e2. OR-specific devices contributing to MDRPI (positioning pads, electrode pads, pulse oximetry probes, operative instruments, and various tubes)\u003c/p\u003e \u003cp\u003e3. Risk factors, staging, and wound assessment\u003c/p\u003e \u003cp\u003e4. Prevention strategies and management in high-risk patient\u003c/p\u003e \u003cp\u003e5. MDRPI treatment principles, clinical practice guidelines, and international consensus statements\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1. Skin assessment in device contact areas\u003c/p\u003e \u003cp\u003e2. Application and replacement of prophylactic dressings\u003c/p\u003e \u003cp\u003e3. Use of positioning aids and pressure-relief pads\u003c/p\u003e \u003cp\u003e4. Correct operation and adjustment of nasal oxygen tubes and other common OR devices\u003c/p\u003e \u003cp\u003e5. Device repositioning strategies to minimize pressure and shear\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 hours per session\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eApproximately 1 hour per session\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e This study was approved by the Ethics Review Committee of Biomedical Research, Xuzhou Central Hospital (Approval No. XZXY-LK-20241210-0105). Written informed consent was obtained from all participating nurses. Data were anonymized and used solely for research purposes.The study was conducted in accordance with the ethical principles of the Declaration of Helsinki and relevant national and institutional guidelines for research involving human participants.\u003c/p\u003e\n\u003ch3\u003eStatistical Methods\u003c/h3\u003e\n\u003cp\u003eData were analyzed using SPSS version 27.0. Categorical variables were summarized as frequencies and percentages, and compared using the chi-square test. Continuous variables were assessed for normality using the Shapiro-Wilk test. Normally distributed variables were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) and analyzed using paired-samples t-tests for pre\u0026ndash;post comparisons. Non-normally distributed variables were transformed; if normality remained unmet, they were expressed as median (interquartile range) and compared using the Wilcoxon signed-rank test. All tests were two-tailed, and a \u003cem\u003eP\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e1. Characteristics of Operating Room Nurses\u003c/p\u003e\u003cp\u003eA total of 80 OR nurses completed the study. The mean age was (31.45\u0026thinsp;\u0026plusmn;\u0026thinsp;7.20) years, and the mean length of nursing experience was (8.95\u0026thinsp;\u0026plusmn;\u0026thinsp;7.43) years. The male-to-female ratio was approximately 1:9. Most participants (88.75%) were younger than 40 years, and 76.25% had less than 10 years of work experience. In terms of educational background, 80.0% held a bachelor\u0026rsquo;s degree. Notably, 60 nurses (75.0%) had never received formal training related to MDRPIs prior to this study. Detailed baseline characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e: Sociodemographic and professional characteristics of the operating room nurses.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic and professional characteristics of the operating room nurses (n\u0026thinsp;=\u0026thinsp;80)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (Range)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.45\u0026thinsp;\u0026plusmn;\u0026thinsp;7.20\u003c/p\u003e \u003cp\u003e(22 to 54)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge(in years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e≧\u0026thinsp;41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducational level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTechnical Institute of nursing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBachelor degree in nursing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExperience inside operating room (in years), Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (Range)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.95\u0026thinsp;\u0026plusmn;\u0026thinsp;7.43\u003c/p\u003e \u003cp\u003e(1 to 38)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExperience inside operating room (in years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTitle\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse practitioner-in-charge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssociate Chief Nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChief Nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTraining duration, h (n\u0026thinsp;=\u0026thinsp;20 ), Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (Range)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.24\u003c/p\u003e \u003cp\u003e(1 to 6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIs there a report and record of MDRPIs status?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e2. Changes in MDRPI-Related Knowledge\u003c/p\u003e \u003cp\u003eFollowing the training program, the total PZ-PUKT score increased significantly from 40.58\u0026thinsp;\u0026plusmn;\u0026thinsp;9.00 to 53.23\u0026thinsp;\u0026plusmn;\u0026thinsp;6.78 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). All three subdomain scores improved significantly: Risk factors/prevention: from 18.08\u0026thinsp;\u0026plusmn;\u0026thinsp;3.91 to 22.08\u0026thinsp;\u0026plusmn;\u0026thinsp;2.92 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001); Staging: from 10.15\u0026thinsp;\u0026plusmn;\u0026thinsp;2.76 to 13.78\u0026thinsp;\u0026plusmn;\u0026thinsp;2.61 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001); Wound description: from 12.35\u0026thinsp;\u0026plusmn;\u0026thinsp;3.75 to 17.36\u0026thinsp;\u0026plusmn;\u0026thinsp;3.24 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).(see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e:ieper-Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT) scores of operating room nurses before and after the training program).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePieper-Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT) scores of operating room nurses before and after the training program (n\u0026thinsp;=\u0026thinsp;80)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-training score\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-training score\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal PZ-PUKT score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e40.58\u0026thinsp;\u0026plusmn;\u0026thinsp;9.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e53.23\u0026thinsp;\u0026plusmn;\u0026thinsp;6.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRisk factors/prevention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e18.08\u0026thinsp;\u0026plusmn;\u0026thinsp;3.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e22.08\u0026thinsp;\u0026plusmn;\u0026thinsp;2.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePressure ulcer staging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e10.15\u0026thinsp;\u0026plusmn;\u0026thinsp;2.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e13.78\u0026thinsp;\u0026plusmn;\u0026thinsp;2.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound Description\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e12.35\u0026thinsp;\u0026plusmn;\u0026thinsp;3.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e17.36\u0026thinsp;\u0026plusmn;\u0026thinsp;3.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe overall knowledge accuracy rate increased from 56.35% to 73.92% (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Accuracy in the risk factors/prevention domain improved from 64.55% to 78.88%, in the staging domain from 50.75% to 68.88%, and in the wound description domain from 51.46% to 72.33% (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for all; see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e: Percentage correctness of Pieper-Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT) among operating room nurses before and after the training program).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePercentage correctness of Pieper-Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT) among operating room nurses before and after the training program (n\u0026thinsp;=\u0026thinsp;80)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-training\u003c/p\u003e \u003cp\u003ecorrectness (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-training\u003c/p\u003e \u003cp\u003ecorrectness (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal PZ-PUKT score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e56.35\u0026thinsp;\u0026plusmn;\u0026thinsp;12.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e73.92\u0026thinsp;\u0026plusmn;\u0026thinsp;9.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRisk factors/prevention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e64.55\u0026thinsp;\u0026plusmn;\u0026thinsp;13.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e78.88\u0026thinsp;\u0026plusmn;\u0026thinsp;10.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePressure ulcer staging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e50.75\u0026thinsp;\u0026plusmn;\u0026thinsp;13.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e68.88\u0026thinsp;\u0026plusmn;\u0026thinsp;13.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound Description\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e51.46\u0026thinsp;\u0026plusmn;\u0026thinsp;15.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e72.34\u0026thinsp;\u0026plusmn;\u0026thinsp;13.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: Percentage correct (%)\u0026thinsp;=\u0026thinsp;score / full score x 100%.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e3. Changes in Attitudes Toward Pressure Injury Prevention\u003c/p\u003e \u003cp\u003eThe total APuP score significantly increased from 40.06\u0026thinsp;\u0026plusmn;\u0026thinsp;3.33 to 44.60\u0026thinsp;\u0026plusmn;\u0026thinsp;2.49 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with the corresponding attitude accuracy rate increasing from 76.97% to 85.77%. Across the five dimensions, significant improvements were observed in:\u003c/p\u003e \u003cp\u003ePersonal prevention capability: from 8.61.36 to 10.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001); Prevention priority: from 9.41\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18 to 10.35\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01(\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001); Impact of pressure injuries: from 9.34\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17 to 10.26\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002); Confidence in the effectiveness of prevention: from 6.21\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09 to 6.83\u0026thinsp;\u0026plusmn;\u0026thinsp;0.94 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.007).\u003c/p\u003e \u003cp\u003eIn contrast, the increase in the responsibility in pressure ulcer prevention dimension (from 6.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86 to 6.49\u0026thinsp;\u0026plusmn;\u0026thinsp;0.90) did not reach statistical significance (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.157)(see Tables\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e: Attitude towards Pressure Ulcer Prevention (APuP) scores of operating room nurses before and after the training program ).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAttitude towards Pressure Ulcer Prevention (APuP) scores of operating room nurses before and after the training program (n\u0026thinsp;=\u0026thinsp;80)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-training score\u003c/p\u003e \u003cp\u003e(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-training score\u003c/p\u003e \u003cp\u003e(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal APuP score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e40.06\u0026thinsp;\u0026plusmn;\u0026thinsp;3.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e44.60\u0026thinsp;\u0026plusmn;\u0026thinsp;2.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersonal competency to prevent PUs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e8.69\u0026thinsp;\u0026plusmn;\u0026thinsp;1.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e10.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePriority of PU prevention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e9.41\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e10.35\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImpact of PUs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e9.34\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e10.26\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResponsibility in PU prevention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e6.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e6.49\u0026thinsp;\u0026plusmn;\u0026thinsp;0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.157\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConfidence in the effectiveness of PU prevention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e6.21\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e6.83\u0026thinsp;\u0026plusmn;\u0026thinsp;0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhen APuP scores were converted into percentages of the maximum possible score, similar trends were observed (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e:Percentage correctness of Attitude towards Pressure Ulcer Prevention (APuP) among operating room nurses before and after the training program). The overall attitude correctness rate increased from 76.97% \u0026plusmn; 6.40% before training to 85.77% \u0026plusmn; 4.80% after training (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Subdomain correctness rates improved as follows:\u003c/p\u003e \u003cp\u003ePersonal prevention capability: from 72.40%\u0026plusmn;11.38% to 84.38%\u0026plusmn;9.88%(\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001); Prevention priority: from 77.81%\u0026plusmn;9.70% to 85.21%\u0026plusmn;7.40% (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002); Impact of pressure injuries: from 77.81%\u0026plusmn;9.74% to 85.21%\u0026plusmn; 7.38% (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002); Responsibility in pressure ulcer prevention: from 79.69%\u0026plusmn;10.78% to 88.44%\u0026plusmn;11.21% (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.157); Confidence in the effectiveness of pressure ulcer prevention: from 77.66%\u0026plusmn;13.59% to 85.31%\u0026plusmn;11.73% (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.007). Consistent with the absolute APuP scores, all attitude dimensions showed significant improvement in correctness except for responsibility, which exhibited a non-significant increase.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePercentage correctness of Attitude towards Pressure Ulcer Prevention (APuP) among operating room nurses before and after the training program (n\u0026thinsp;=\u0026thinsp;80)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-training correctness (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-training\u003c/p\u003e \u003cp\u003ecorrectness (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal APuP score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e76.97\u0026thinsp;\u0026plusmn;\u0026thinsp;6.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e85.77\u0026thinsp;\u0026plusmn;\u0026thinsp;4.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersonal competency to prevent PUs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e72.40\u0026thinsp;\u0026plusmn;\u0026thinsp;11.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e84.38\u0026thinsp;\u0026plusmn;\u0026thinsp;9.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePriority of PU prevention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e77.81\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e85.21\u0026thinsp;\u0026plusmn;\u0026thinsp;7.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImpact of PUs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e77.81\u0026thinsp;\u0026plusmn;\u0026thinsp;9.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e85.21\u0026thinsp;\u0026plusmn;\u0026thinsp;7.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResponsibility in PU prevention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e79.69\u0026thinsp;\u0026plusmn;\u0026thinsp;10.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e88.44\u0026thinsp;\u0026plusmn;\u0026thinsp;11.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.157\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConfidence in the effectiveness of PU prevention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e77.66\u0026thinsp;\u0026plusmn;\u0026thinsp;13.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e85.31\u0026thinsp;\u0026plusmn;\u0026thinsp;11.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: Percentage correct (%)\u0026thinsp;=\u0026thinsp;score / full score x 100%.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrated that a hybrid MDRPI training program integrating PBL, case-based learning, and scenario-based simulation significantly improved OR nurses\u0026rsquo; knowledge and attitudes related to MDRPI prevention.\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eImprovement in Knowledge\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe mechanism of pressure injury development begins with transient reactive hyperemia secondary to pressure-induced hypoxia, and may progress to persistent ischemia, tissue damage, and necrosis if pressure is not relieved\u003csup\u003e[17]\u003c/sup\u003e. MDRPIs, caused by medical devices such as casts, ventilator masks, braces, and endotracheal tubes, frequently occur at the nose, ears, and fingertips\u003csup\u003e[18,19]\u003c/sup\u003e. Recognizing risk factors and early signs is therefore essential for timely prevention.\u003c/p\u003e\n\u003cp\u003eConsistent with the findings of Dallı et al. in ICU nurses\u003csup\u003e[13]\u003c/sup\u003e, this study showed a significant increase in the overall PZ-PUKT score and in all three knowledge domains following the intervention. The gains in our study were also greater than the short-term improvements reported by Sayed et al.\u003csup\u003e[12]\u003c/sup\u003e, which may be attributable to our more interactive and problem-oriented educational approach.\u003c/p\u003e\n\u003cp\u003eThe theoretical component of our program applied PBL principles, starting from real clinical problems and guiding learners through literature searching, group discussion, and case analysis\u003csup\u003e[20]\u003c/sup\u003e. By focusing on high-risk OR devices (e.g., positioning pads, electrode patches, pulse oximetry probes), nurses were encouraged to explore how device characteristics-including frequency and duration of use, material, and design-affect skin microclimate and mechanical loading. This approach helped them understand how changes in local temperature and humidity can alter skin stiffness, strength, and friction, thereby increasing susceptibility to pressure injuries. Prior research has shown, for example, that thermal pre-cooling can reduce the coefficient of friction on skin surfaces\u003csup\u003e[21]\u003c/sup\u003e, highlighting the impact of temperature on frictional behavior.\u003c/p\u003e\n\u003cp\u003eThe scenario-based simulation further translated theoretical knowledge into practical skills. Nurses practiced systematic skin inspection, timely replacement of pulse oximeter probes, appropriate use and maintenance of positioning pads, cleaning and drying skin under electrode patches, and adjusting blood pressure cuffs and other devices to reduce pressure duration and intensity. This hands-on component addressed limitations of traditional lecture-based education, which often overemphasizes theory at the expense of clinical decision-making and psychomotor skills\u003csup\u003e[22]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eDespite these improvements, the post-training knowledge accuracy rate remained lower than that reported by Luo et al. among nurses in Shaanxi Province\u003csup\u003e[23]\u003c/sup\u003e, particularly in the \u0026ldquo;staging\u0026rdquo; and \u0026ldquo;wound description\u0026rdquo; domains. This may reflect the OR nurses\u0026rsquo; predominant focus on acute intraoperative risks (e.g., bleeding, infection), with less emphasis on postoperative skin assessment and wound documentation. Future programs should strengthen visual training on staging and wound description, for example by using images, videos, and standardized clinical scenarios.\u003c/p\u003e\n\u003col start=\"2\"\u003e\n \u003cli\u003eEnhancement of Attitudes and Remaining Gaps\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eNurses\u0026rsquo; attitudes toward pressure injury prevention are critical determinants of preventive behavior\u003csup\u003e[24-26]\u003c/sup\u003e. In line with previous research\u003csup\u003e[11,27,28]\u003c/sup\u003e, our findings showed significant improvement in overall attitudes and in key dimensions such as personal capability, prioritization of prevention, perceived impact, and confidence in prevention effectiveness. This suggests that integrating PBL and simulation can not only convey knowledge but also enhance self-efficacy and the perceived importance of prevention, particularly among younger nurses with higher educational levels\u003csup\u003e[29]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe group-based training model used in this study, in which more experienced or higher-educated nurses acted as peer trainers, may have contributed to these improvements. As reported by Sun et al.\u003csup\u003e[28]\u003c/sup\u003e, nurses with a bachelor\u0026rsquo;s degree or above tend to have better knowledge, attitudes, and practices regarding MDRPI. Our design leveraged this by assigning such nurses to mentor colleagues with less experience or lower educational attainment.\u003c/p\u003e\n\u003cp\u003eHowever, the responsibility dimension of the APuP did not significantly change after training. This may be related to the complex, multidisciplinary nature of perioperative care, where roles and responsibilities for skin assessment and MDRPI prevention may not be clearly delineated. OR nurses often prioritize intraoperative hemodynamic monitoring and surgical support, while postoperative skin assessment and long-term follow-up are typically handled by ward nurses. The absence of a feedback loop regarding postoperative MDRPIs may further weaken OR nurses\u0026rsquo; sense of responsibility.\u003c/p\u003e\n\u003cp\u003eFurthermore, although the \u0026ldquo;prevention priority\u0026rdquo; dimension improved, the post-training level remained lower than that reported by Parisod et al. among nursing staff in other settings\u003csup\u003e[30]\u003c/sup\u003e. This suggests that pressure injury prevention is still perceived as secondary to other intraoperative tasks. Future interventions should therefore include:\u003c/p\u003e\n\u003cp\u003eClarification of roles and responsibilities in MDRPI prevention within multidisciplinary teams\u003c/p\u003e\n\u003cp\u003eEstablishment of cross-departmental feedback mechanisms to inform OR nurses about postoperative pressure injury outcomes\u003c/p\u003e\n\u003cp\u003eIntegration of MDRPI prevention as a visible quality indicator in OR performance evaluation\u003c/p\u003e\n\u003col start=\"3\"\u003e\n \u003cli\u003eComparison With Previous Studies\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eOur results support and extend previous findings on the effectiveness of structured pressure injury education. Kim et al.\u003csup\u003e[29]\u003c/sup\u003e concluded that programs combining theoretical and practical components, delivered in small groups and lasting more than 2 hours, are more effective in improving nurses\u0026rsquo; knowledge and clinical judgment. The design of the present study aligns well with these recommendations and confirms their applicability in the OR context.\u003c/p\u003e\n\u003cp\u003eAt the same time, the relatively high proportion of nurses without prior MDRPI training (75%) and their initially passive attitudes are consistent with international reports that knowledge and attitudes regarding pressure injury prevention are often suboptimal among nurses\u003csup\u003e\u0026nbsp;[8\u0026ndash;10,25,26,30]\u003c/sup\u003e.\u003csup\u003e\u0026nbsp;\u003c/sup\u003eThis highlights the need to institutionalize continuous MDRPI education as part of routine OR training and competency assessment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has several limitations. First, it used a single-group pretest\u0026ndash;posttest design in one tertiary hospital with a relatively small sample size, which may limit the generalizability of the findings. Multi-center randomized controlled trials with larger samples are needed to confirm the effectiveness of this educational model.\u003c/p\u003e\n\u003cp\u003eSecond, data were collected primarily via self-administered questionnaires, which are susceptible to recall bias and social desirability bias. Future studies could incorporate objective assessments, such as knowledge tests under exam conditions, direct observation of clinical practice, or OSCE-style evaluations.\u003c/p\u003e\n\u003cp\u003eThird, the study only evaluated short-term outcomes. Long-term follow-up is needed to determine the durability of improvements in knowledge and attitudes and to assess whether refresher training is necessary.\u003c/p\u003e\n\u003cp\u003eFinally, and most importantly, we did not examine the impact of the training program on patient-level outcomes, such as MDRPI incidence, severity, or healing time. Future research should link nurse-related outcomes with clinical indicators to more comprehensively evaluate the effectiveness and clinical significance of MDRPI education.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrated that a structured MDRPI care and prevention training program, integrating problem-based learning, case discussions, and scenario-based simulation, significantly improved OR nurses\u0026rsquo; knowledge and attitudes toward MDRPI prevention. The program was particularly effective in enhancing knowledge of risk factors, staging, and wound description, as well as in strengthening nurses\u0026rsquo; perceived capability, prioritization of prevention, perceived impact, and confidence in preventive measures.\u003c/p\u003e \u003cp\u003eHowever, no significant change was observed in the responsibility dimension of attitudes, and post-training knowledge in staging and wound description remained suboptimal compared with some previous reports. These findings suggest that, in addition to improving knowledge and general attitudes, future interventions should focus on clarifying responsibility within multidisciplinary teams, strengthening feedback mechanisms, and reinforcing training on injury staging and wound assessment.\u003c/p\u003e \u003cp\u003eDespite its limitations, this study provides empirical support for implementing hybrid, small-group, interactive MDRPI training programs tailored to OR nurses. Such programs may serve as a practical framework for hospital-wide MDRPI prevention strategies and as a basis for future multi-center studies linking nurse education with patient outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/h2\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eFZ reviewed and edited the manuscript. ZLC, QLE, XYW, LZ collected and analyzed the data. FZ, JZ and PW conceived the study, participated in the study design, interpreted the data, and coordinated the study. All authors have read and approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003e The authors would like to thank the operating room nurses at Xuzhou Central Hospital for their participation and support in this study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEdsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. J Wound Ostomy Cont Nurs. 2016;43:585\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu J, Nan M, Yu C, Yao D. 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Effect of Implementing Educational Program about Preventive Nursing Measures of Medical devices related Pressure Injuries on Nurses' Performance and Patients' Clinical Outcome. Tanta Sci Nurs J.2022;(4): S119\u0026ndash;139.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErbay Dallı \u0026Ouml;, Kelebek Girgin N. Medical Device-Related Pressure Injury Care and Prevention Training Program (DevICeU): Effects on intensive care nurses\u0026rsquo; knowledge, prevention performance and point prevalence. Intensive Crit Care Nurs. 2024;82:103622.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePieper B, Zulkowski K. Pressure Ulcer Knowledge Assessment Tool (PUKAT): Translation and Cultural Adaptation. J Wound Ostomy Cont Nurs. 2016;43(4):351\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNie WB. Evidence-Based Care Practice for the Prevention and Management of Medical Device-Related Pressure Injuries in Critically Ill Patients. Jilin University; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeeckman D, Defloor T, Demarr\u0026eacute; L, Van Hecke A, Vanderwee K. Pressure ulcers: development and psychometric evaluation of the attitude towards pressure ulcer prevention instrument (APuP). Int J Nurs Stud. 2010;47(11):1432\u0026ndash;41. Epub 2010 May 14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHill JE, Edney S, Hamer O, Williams A, Harris C. Interventions for the treatment and prevention of pressure ulcers. Br J Community Nurs. 2022;27(Sup6):S28-S36. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.12968/bjcn.2022.27.Sup6.S28\u003c/span\u003e\u003cspan address=\"10.12968/bjcn.2022.27.Sup6.S28\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Erratum in: Br J Community Nurs. 2022;27(7):314.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarakat-Johnson M, Lai M, Wand T, Li M, White K, Coyer F. The incidence and prevalence of medical device-related pressure ulcers in intensive care: a systematic review. J WoundCare. 2019;28(8):512\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDang W, Liu Y, Zhou Q, et al. Risk factors of medical devicerelated pressure injury in intensive care units. J Clin Nurs. 2022;31(9\u0026ndash;10):1174\u0026ndash;11830.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao W, He L, Deng W, Zhu J, Su A, Zhang Y. The effectiveness of the combined problem-based learning (PBL) and case-based learning (CBL) teaching method in the clinical practical teaching of thyroid disease. BMC Med Educ. 2020;20(1):381.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGonzalez AE, Pineda Gutierrez A, Kern AM, Takahashi KZ. Association between foot thermal responses and shear forces during turning gait in young adults. PeerJ. 2021;9:e10515.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchaefer SM, Dominguez M, Moeller JJ. The future of the lecture in neurology education. Semin Neurol. 2018;38(4):418\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuo L, Wen X, Wang J, Xiao Q, Su L, Zhou M. Analysis of the Current Status of Nurses' Knowledge of Pressure Injuries and Factors Influencing It in Shaanxi Province, China: A Cross-Sectional Study. Risk Manag Healthc Policy. 2024;17:1451\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhojastehfar S, Najafi Ghezeljeh T, Haghani S. Factors related to knowledge, attitude, and practice of nurses in intensive care unit in the area of pressure ulcer prevention: a multicenter study. J Tissue Viability. 2020;29(2):76\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarakat-Johnson M, Barnett C, Wand T, White K. Knowledge and attitudes of nurses toward pressure injury prevention: across-sectional multisite study. J Wound Ostomy Cont Nurs. 2018;45(3):233\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLotfi M, Aghazadeh AM, Asgarpour H, Nobakht A. Iranian nurses' knowledge, attitude and behaviour on skin care, prevention and management of pressure injury: a descriptive cross-sectional study. Nurs Open. 2019;6(4):1600\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAwoke N, Tekalign T, Arba A, Lenjebo TL. Pressure injury prevention practice and associated factors among nurses at Wolaita Sodo University Teaching and Referral Hospital, South Ethiopia: a cross-sectional study. BMJ Open. 2022;12(3):e047687.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSun XX, Chen RB, Fang PP, Yu R, Wang XX, Liu JQ, Chen Y, Ling H. Model construction of factors influencing intensive care unit nurses' medical device-related pressure injury knowledge, attitude, and practice. Int Wound J. 2023;20(7):2582\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim G, Park M, Kim K. The effect of pressure injury training for nurses: A systematic review and meta-analysis. Adv Skin Wound Care. 2020;33(3):1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParisod H, Holopainen A, Kielo-Viljamaa E, Puukka P, Beeckman D, Haavisto E. Attitudes of nursing staff towards pressure ulcer prevention in primary and specialised health care: A correlational cross-sectional study. Int Wound J. 2022;19(2):399\u0026ndash;410.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"medical device–related pressure injury, operating room nurses, problem-based learning, simulation training, knowledge, attitude","lastPublishedDoi":"10.21203/rs.3.rs-8382431/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8382431/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e \u003cb\u003eObjective\u003c/b\u003e: To evaluate the effectiveness of a medical device\u0026ndash;related pressure injury (MDRPI) care and prevention training program on the knowledge and attitudes of operating room (OR) nurses.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMethods\u003c/b\u003e: A prospective, single-group, pretest\u0026ndash;posttest quasi-experimental study was conducted in the OR of a tertiary hospital from March to June 2025. A total of 80 OR nurses who met the inclusion criteria were enrolled. The intervention consisted of eight small-group training sessions integrating problem-based learning (PBL), case discussions, and scenario-based simulation. Each theoretical PBL/case session lasted 2 hours and each simulation session 1 hour. MDRPI-related knowledge and attitudes were assessed before and after the intervention using the validated Chinese versions of the Pieper\u0026ndash;Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT) and the Attitude towards Pressure Ulcer Prevention instrument (APuP).\u003c/p\u003e \u003cp\u003e \u003cb\u003eResults\u003c/b\u003e: The mean total PZ-PUKT score significantly increased from 40.58\u0026thinsp;\u0026plusmn;\u0026thinsp;9.00 to 53.23\u0026thinsp;\u0026plusmn;\u0026thinsp;6.78 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and the overall knowledge accuracy improved from 56.35% to 73.92%. Significant gains were observed in all subdomains, with accuracy increasing from 64.55% to 78.88% for risk factors/prevention, from 50.75% to 68.88% for staging, and from 51.46% to 72.33% for wound description. The total APuP score also significantly increased from 40.06\u0026thinsp;\u0026plusmn;\u0026thinsp;3.33 to 44.60\u0026thinsp;\u0026plusmn;\u0026thinsp;2.49 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), corresponding to an accuracy improvement from 76.97% to 85.77%. Significant improvements were found in personal prevention capability, prioritization of prevention, perceived impact of pressure injuries, and confidence in the effectiveness of prevention (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). No statistically significant change was observed in the responsibility dimension (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.157).\u003c/p\u003e \u003cp\u003e \u003cb\u003eConclusion\u003c/b\u003e: The hybrid training program integrating PBL-based theoretical teaching with scenario-based simulation significantly improved OR nurses\u0026rsquo; MDRPI-related knowledge and attitudes. These findings support the implementation of structured, small-group, interactive education to strengthen MDRPI prevention in the operating room.\u003c/p\u003e","manuscriptTitle":"Effects of a Problem-Based and Simulation-Based Training Program on Operating Room Nurses’ Knowledge and Attitudes Toward Medical Device–Related Pressure Injuries","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-08 09:57:07","doi":"10.21203/rs.3.rs-8382431/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-27T04:34:34+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-23T14:35:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"296087950598291146872432914660564549850","date":"2026-01-15T08:47:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"336726922114019115408120213179361637718","date":"2026-01-13T16:19:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-11T08:23:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"250791660722601097794060732789205381471","date":"2026-01-09T05:12:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-06T17:59:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-01T15:40:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-23T04:50:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-23T00:36:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-12-23T00:31:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0aba1584-b27d-45f3-993c-08b8309bc669","owner":[],"postedDate":"January 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T16:02:58+00:00","versionOfRecord":{"articleIdentity":"rs-8382431","link":"https://doi.org/10.1186/s12909-026-09147-1","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2026-04-17 15:58:47","publishedOnDateReadable":"April 17th, 2026"},"versionCreatedAt":"2026-01-08 09:57:07","video":"","vorDoi":"10.1186/s12909-026-09147-1","vorDoiUrl":"https://doi.org/10.1186/s12909-026-09147-1","workflowStages":[]},"version":"v1","identity":"rs-8382431","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8382431","identity":"rs-8382431","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}