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Abstract

Introduction

Central line-associated bloodstream infections (CLABSIs) are a significant contributor to hospital-acquired infections, increasing patient morbidity and mortality. Nurses in intensive care units (ICUs) and dialysis departments play a vital role in CLABSI prevention through adherence to evidence-based practices. Understanding their knowledge and behavior is critical to reducing infection rates.

Aim

To assess the level of knowledge and behavior among ICU and dialysis nurses in Hebron governorate hospitals regarding the prevention of CLABSIs and to examine the relationship between knowledge and preventive behavior.

Methods

A cross-sectional descriptive study was conducted from January to May 2024 across five hospitals. A total of 131 nurses completed a structured questionnaire measuring knowledge (11 items) and behavior (8 items) regarding CLABSI prevention. Data were analyzed using descriptive statistics, Pearson correlation, and regression analysis.

Results

Participants demonstrated a medium level of knowledge (M = 5.65) and medium behavioral adherence (M = 3.39) to CLABSI prevention practices. Nearly half (49.6%) exhibited low knowledge levels. The behavior with the highest adherence was the use of sterile transparent dressings (M = 3.55), while the lowest was timely dressing replacement (M = 3.28). A statistically significant positive correlation (r = 0.233, p = .007) was found between knowledge and behavior. Regression analysis confirmed knowledge as a significant predictor of behavior (p = .007).

Conclusion

There is a moderate but significant relationship between nurses’ knowledge and their behavior in preventing CLABSIs. Interventions focusing on continuous education and training are essential to improve compliance with prevention guidelines and enhance patient safety.

Keywords

central venous catheters ICU CLABSI nurse knowledge infection prevention Hebron hospitals

Introduction

Central line-associated bloodstream infections (CLABSIs) are among the most serious and preventable healthcare-associated infections (HAIs), posing significant threats to patient safety and clinical outcomes. They occur when microorganisms enter the bloodstream through a central venous catheter, resulting in prolonged hospitalization, increased morbidity, elevated healthcare costs, and preventable mortality (Centers for Disease Control and Prevention; CDC, 2024). Globally, CLABSI remains a major concern, particularly in critical care environments such as intensive care units (ICUs) and dialysis departments, where central venous access is frequently required for therapeutic and monitoring purposes. However, the relative burden of CLABSI compared with other HAIs varies according to healthcare setting and patient population. For instance, in some facilities, ventilator-associated pneumonia or surgical site infections may surpass CLABSI in incidence, particularly in surgical or postoperative care units (Alqaissi, 2025; Qtait & Alekel, 2019; Qtait, 2025). Therefore, while CLABSI prevention remains a global priority, its significance should be understood in the local epidemiological context, especially within healthcare systems facing resource limitations and inconsistent infection control infrastructure, such as those in low- and middle-income countries (LMICs).

In the context of Palestine and other developing health systems, infection prevention remains a persistent challenge due to multiple contextual constraints. These include inadequate nurse-to-patient ratios, limited access to sterile equipment, and the absence of continuous infection control training programs. According to Qtait (2025), Palestinian hospitals face increasing risks of hospital-acquired infections due to systemic shortages and workload pressures, which can undermine adherence to evidence-based infection control practices. This is particularly concerning in high-dependency settings such as ICUs and dialysis units, where patients are highly susceptible to infection due to compromised immunity and the frequent use of invasive devices. Consequently, the prevention of CLABSI in these clinical environments depends not only on the availability of resources but also on the professional competence and compliance of the nursing staff with standardized clinical guidelines.

Nurses play a central role in CLABSI prevention because they are responsible for multiple phases of catheter management, including insertion assistance, maintenance, and continuous monitoring. Their knowledge and adherence to evidence-based practices are critical to reducing infection risk and improving patient outcomes (Chi et al., 2020; Griffing & Overcash, 2023). Nevertheless, international and regional studies continue to highlight notable gaps between knowledge and actual practice among nurses. For instance, Alqaissi (2025) found that despite nurses in Middle Eastern hospitals demonstrating moderate awareness of CLABSI prevention guidelines, their behavioral adherence to maintenance bundles and aseptic techniques was inconsistent. The study attributed these discrepancies to heavy workload, lack of refresher training, and insufficient institutional support. Similarly, Chi et al. (2020) reported that fewer than half of ICU nurses in China consistently adhered to maximum barrier precautions or timely removal of unnecessary catheters, despite acknowledging the importance of such practices. These findings illustrate a persistent and concerning disconnect between theoretical understanding and practical implementation of infection control measures, a phenomenon often influenced by systemic and organizational barriers.

In many clinical environments, particularly in LMICs, educational and infrastructural limitations further complicate adherence to CLABSI prevention protocols. Nurses frequently rely on outdated or incomplete knowledge due to limited access to continuing professional education and up-to-date clinical guidelines (Rawashda, 2020). Furthermore, organizational culture and leadership commitment significantly affect the sustainability of infection prevention practices. Studies have demonstrated that institutional factors, such as supportive supervision, adequate staffing, and the provision of infection control resources, are essential for improving adherence to evidence-based practice (Goldman et al., 2021; Jose et al., 2022). Without consistent managerial reinforcement and adequate resources, individual nurse competence alone is insufficient to achieve sustained improvements in CLABSI reduction.

The global literature also underscores the necessity of periodic training and multidimensional interventions to bridge the gap between knowledge and behavior. Alqaissi (2025) and Griffing and Overcash (2023) emphasize that knowledge-oriented educational sessions, when coupled with behavioral reinforcement strategies such as audits, peer feedback, and visual reminders, can significantly enhance compliance with CLABSI prevention bundles. Nonetheless, sustained improvements require a supportive institutional culture, regular monitoring, and the integration of CLABSI prevention into broader patient safety initiatives.

Despite substantial international attention to CLABSI prevention, there remains a paucity of data from Palestine, particularly the Hebron governorate, regarding nurses’ knowledge and behavior toward CLABSI prevention. This knowledge gap limits the ability of policymakers and nurse educators to design contextually appropriate interventions. Given that Palestinian nurses come from diverse educational and experiential backgrounds, variations in their understanding and adherence to best practices are likely. Moreover, the high patient acuity and workload pressures within Palestinian ICUs and dialysis units make adherence to CLABSI prevention bundles especially challenging (Qtait, 2025). Therefore, it is crucial to assess the current level of knowledge and behavioral adherence among nurses in these settings to identify specific educational and institutional priorities.

In summary, while CLABSI is a globally recognized challenge, its prevention relies on the integration of evidence-based knowledge, behavioral compliance, and systemic support. Understanding how nurses in Hebron's ICUs and dialysis departments apply preventive measures is essential to informing targeted interventions, enhancing professional competence, and improving patient outcomes. This study thus aims to evaluate nurses’ knowledge and behavior toward CLABSI prevention and explore the relationship between these two constructs, providing a foundation for policy development, educational planning, and sustainable infection control strategies in the Palestinian healthcare context.

Review of the Literature

The prevention of CLABSIs continues to be a major global health priority, particularly in intensive care and dialysis settings where patients are at increased risk. While many efforts have been made to implement evidence-based guidelines, a persistent gap exists between knowledge acquisition and behavioral application among nursing professionals. Research from the past 5 years highlights critical insights into the underlying challenges and potential solutions for improving nursing compliance with CLABSI prevention protocols.

One central issue is the disconnect between theoretical knowledge and clinical behavior. Esposito et al. (2017) found that although nurses in oncological ICUs demonstrated moderate-to-high awareness of CLABSI guidelines, their practical implementation remained suboptimal. This mismatch was attributed to a lack of periodic training, reliance on outdated habits, and insufficient supervision. Similarly, Dube et al. (2020) identified inconsistencies in adherence to catheter maintenance protocols in American ICUs, noting that while nurses understood procedural recommendations, time constraints and high workloads impeded strict compliance.

Work environment conditions have also been shown to play a critical role in influencing nurse behavior. In a multicenter observational study, Baier et al. (2020) discovered that hospitals with lower nurse-to-patient ratios and stronger infection control leadership demonstrated significantly lower CLABSI rates. These findings underscore that systemic and organizational factors—not just individual knowledge—impact adherence to infection prevention guidelines.

Moreover, recent research emphasizes the effectiveness of bundled interventions but cautions against passive implementation. A study by Simoneaux and Guerra (2022) showed that introducing CLABSI maintenance bundles alone was not sufficient to improve outcomes. Success was only achieved when the intervention was paired with ongoing feedback loops, peer accountability systems, and visual reminders within the unit. The researchers concluded that behavior change requires a combination of structural reinforcements and educational engagement.

Another relevant factor is the impact of initial and continuing education on knowledge retention and behavioral adaptation. In a quasi-experimental study in Malaysia, Sham et al. (2023) reported a statistically significant improvement in both knowledge and practice after an intensive, hands-on training module on CLABSI prevention. However, 6 months post-training, knowledge scores declined slightly, suggesting that periodic refreshers are needed to sustain gains.

Interestingly, the role of attitudes and perceptions is gaining attention in this field. A qualitative study by Welter and Villanueva (2022) explored ICU nurses’ views on CLABSI protocols and found that those who viewed the guidelines as bureaucratic or impractical were less likely to adhere consistently, despite being well-informed. Conversely, nurses who saw the protocols as patient safety tools demonstrated higher compliance. This aligns with theories of behavior change, which emphasize that attitudes, perceived norms, and self-efficacy are strong predictors of health-related behavior.

Technological supports have also emerged as facilitators of improved performance. Kelada et al. (2023) evaluated the impact of digital checklists and real-time electronic reminders on catheter care compliance. The study found that incorporating these tools into nurses’ workflows reduced CLABSI rates by enhancing procedural accuracy and standardization. These results suggest that technology, when thoughtfully integrated, can bridge knowledge-to-practice gaps.

In resource-constrained settings, challenges become more pronounced. Jose et al. (2022) examined hemodialysis nurses in low-resource clinics and identified the absence of updated guidelines, limited availability of antiseptic agents, and inadequate staffing as primary barriers to CLABSI prevention. Despite possessing reasonable knowledge, nurses often had to improvise due to the lack of essential supplies. The authors called for context-specific policy development that accounts for practical limitations while reinforcing core safety principles.

Lastly, recent reviews have reinforced the importance of leadership and institutional accountability. A systematic review by Sachan and Manu (2022) analyzed data from multiple countries and concluded that multidisciplinary engagement, leadership commitment, and staff empowerment are indispensable to sustaining low CLABSI rates. The review argued that education alone is insufficient unless reinforced by consistent policy enforcement and performance monitoring.

In sum, the literature reveals that nurses’ knowledge about CLABSI prevention is necessary but not sufficient. Behavioral change is influenced by a combination of factors including workload, organizational support, continuous training, personal attitudes, and resource availability. Future efforts should adopt a holistic approach that integrates clinical education with behavioral science, policy alignment, and infrastructural support to improve and sustain nursing practice related to CLABSI prevention.

Aim of the Study

The primary aim of this study was to evaluate the level of knowledge and behavior of nurses working in ICUs and dialysis departments in Hebron Governorate hospitals regarding the care and maintenance of inserted central lines. Specifically, the study sought to assess nurses’ adherence to evidence-based maintenance precautions and infection control practices that are essential for minimizing the risk of CLABSIs. Furthermore, the study aimed to examine the relationship between nurses’ knowledge and their self-reported behaviors related to central line care, thereby identifying potential areas for targeted educational interventions and institutional support to enhance clinical practice and patient safety within critical care and dialysis settings.

Methods

Study Design

A descriptive cross-sectional quantitative design was adopted to assess the knowledge and self-reported behavior of nurses working in ICUs and dialysis departments regarding the care and maintenance of inserted central lines. This design enabled the examination of existing practices and perceptions within a defined period, providing a snapshot of nurses’ adherence to evidence-based maintenance protocols.

Study Setting

The study was conducted in hospitals located in the Hebron Governorate, Palestine, including both governmental institutions—Alia Governmental Hospital, Dura Governmental Hospital, and Abu Hassan Al-Qasem Hospital—and one nongovernmental facility, Al-Mizan Specialized Hospital. These hospitals were selected because they contain active ICUs and dialysis units where central venous catheters are commonly used for critically ill and renal failure patients.

Population and Sampling

The study population comprised all registered nurses working in the ICUs and dialysis departments of the selected hospitals. A total of 141 nurses were identified as the accessible population, and all were invited to participate using a total population sampling approach to maximize representativeness and reduce sampling bias. Of these, 131 nurses completed the questionnaire, yielding a response rate of 92.9%. Ten nurses were excluded due to incomplete responses or unavailability during the data collection period.

Inclusion and Exclusion Criteria

Inclusion criteria:

Registered nurses with at least 6 months of experience in ICU or dialysis departments.

Nurses who provided informed consent and were available during the study period.

Exclusion criteria:

Nurses on extended leave during data collection.

Nurses working temporarily or on rotation outside ICU or dialysis units.

Data Collection Instrument

Data were gathered using a structured, self-administered questionnaire consisting of three sections:

Demographic data—including age, gender, marital status, education level, years of experience, department, and prior training on central line care or infection prevention.

Knowledge scale—comprising 11 multiple-choice items adapted from the CDC guidelines and previously validated tools (Labeau et al., 2009; Chi et al., 2020), assessing evidence-based maintenance practices. Each correct answer received one point, with total scores categorized as low (0–4), moderate (4.1–7.9), and high (8–11).

Behavior scale—consisting of eight items rated on a five-point Likert scale (1 = never, 5 = always), evaluating nurses’ adherence to maintenance practices such as aseptic technique, dressing changes, and timely catheter removal. Mean scores were categorized as low (1.00–2.33), medium (2.34–3.67), and high (3.68–5.00) adherence levels.

Validity, Reliability, and Data Accuracy

The questionnaire underwent content and face validity evaluation by a panel of five infection control experts and senior nursing educators. Based on their recommendations, minor revisions were made to ensure cultural appropriateness and clarity. Internal consistency was assessed through a pilot test involving 15 nurses drawn from the same hospitals but different departments (i.e., medical and surgical wards). These participants were not included in the final sample of 141 nurses to prevent contamination and response bias. The pilot test yielded acceptable Cronbach's alpha values of 0.82 for the behavior scale and 0.76 for the knowledge scale, confirming internal reliability.

Data Collection Procedure

Data collection was carried out over 4 weeks between January and February 2024. Following ethical approval, paper-based questionnaires were distributed to eligible nurses during their shifts. Participation was voluntary and anonymous, with respondents returning completed forms in sealed envelopes. While self-administered questionnaires allowed broad participation with minimal workflow disruption, the authors acknowledge that self-reported measures may be prone to bias. Actual clinical behaviors might differ from reported ones due to social desirability or recall limitations. Ideally, behavioral practices observed directly through structured observation checklists, whereas attitudes and perceptions may be more appropriately assessed using self-report instruments. However, due to time constraints, staffing shortages, and ethical considerations regarding direct observation in ICU and dialysis settings, self-reported behavior was adopted as a practical and ethical alternative.

Ethical Considerations

The study obtained approval from the Institutional Review Board of the affiliated university (approval no. 235) and the Palestinian Ministry of Health. Participation was voluntary, and informed consent was obtained from all respondents. Confidentiality was strictly maintained, and participants were informed of their right to withdraw at any time without consequence.

Data Analysis

Data were coded and analyzed using IBM SPSS Statistics (Version 26.0). Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to summarize demographic characteristics and scores on knowledge and behavior scales. Inferential tests included:

Independent sample t-tests and one-way analysis of variance (ANOVA) to identify differences across demographic variables.

Pearson's correlation coefficient to examine the relationship between knowledge and behavior scores.

Simple linear regression analysis to determine the predictive effect of knowledge on behavior.

A p-value of <.05 was considered statistically significant.

Results

Out of the 141 nurses identified in the accessible population, 131 completed the questionnaire, resulting in a response rate of 92.9%. The remaining 10 nurses were excluded because of incomplete responses or unavailability during data collection due to shift changes and workload constraints. These missing responses were not statistically imputed to maintain data integrity.

Table 1 presents the sociodemographic characteristics of the study participants. The majority were male nurses (58.0%), and most participants were married (63.4%). The largest age group ranged from 25 to 29 years (38.2%), and 63.4% of respondents held a bachelor's degree in nursing. Approximately 84.0% of the nurses were employed in governmental hospitals, primarily within Alia ICU (45.0%), followed by Al-Mizan ICU (16.0%). The number of dialysis nurses was consistent across hospitals (n = 20, 15.3%), confirming equal representation from each dialysis unit.

Table 1.

Sociodemographic Characteristics of Participants (N = 131).

Characteristic	Category	n (%)	Mean (SD)	t/F	p-Value
Age (years)	25–29	50 (38.2%)	5.12 (2.65)
	30–34	34 (26.0%)	5.76 (3.53)	0.942	.33
	35–39	21 (16.0%)	6.42 (3.23)
	≥40	26 (19.8%)	5.92 (3.73)
Sex	Male	76 (58.0%)	5.14 (2.99)	2.176	.035*
	Female	55 (42.0%)	6.36 (3.40)
Marital status	Single	37 (28.2%)	5.43 (3.01)	0.702	.55
	Married	83 (63.4%)	5.59 (3.28)
	Divorced/Widowed	11 (8.4%)	6.72 (2.89)
Education level	Diploma	26 (19.8%)	5.50 (3.43)	2.741	.068
	Bachelor	83 (63.4%)	5.32 (3.11)
	Master's+	22 (16.8%)	7.09 (3.07)
Work experience	1–5 years	53 (40.5%)	5.52 (3.05)	0.810	.447
	6–10 years	40 (30.5%)	6.17 (3.30)
	>10 years	38 (29.0%)	5.28 (3.34)
Hospital type	Governmental	110 (84.0%)	5.53 (3.23)	0.980	.329
	Nongovernmental	21 (16.0%)	6.28 (3.08)
Hospital name	Alia ICU	59 (45.0%)	4.88 (3.21)	4.268	.001**
	Dura ICU	13 (9.9%)	8.46 (2.67)
	Dura dialysis	13 (9.9%)	6.38 (3.15)
	Yatta dialysis	7 (5.3%)	7.42 (1.72)
	Halhul ICU	8 (6.1%)	3.12 (1.36)
	Al-Mizan ICU	21 (16.0%)	6.28 (3.08)
Training on CLABSI prevention	Yes (official/workshop)	41 (31.3%)	5.31 (2.99)	1.708	.416
	No	90 (68.7%)	5.81 (3.31)

Note. p < .05; p < .01. CLABSI= Central line-associated bloodstream infections; ICU=intensive care unit.

Regarding professional experience, 40.5% had between 1 and 5 years of service, and 29.0% had more than 10 years. Only 31.3% of the respondents had previously attended a training session or workshop related to central line care or CLABSI prevention. Most of these training programs were official institutional workshops conducted by infection control committees, focusing on catheter maintenance, aseptic technique, and dressing protocols, rather than CLABSI case identification.

Table 1 demonstrates balanced demographic representation, with most nurses being young professionals possessing bachelor's degrees and moderate clinical experience. The significant difference between male and female knowledge means (p = .035) suggests gender-related variance in training exposure or compliance with infection control education.

Figure 1 presents the distribution of knowledge levels among participating nurses. Nearly half of the nurses (49.6%) demonstrated low knowledge (≤4 points), 22.9% had moderate knowledge (4.1–7.9 points), and 27.5% achieved high knowledge (≥8 points).

Figure 1.

Distribution of nurses’ knowledge levels on central line care and maintenance.

A further cross-tabulation revealed that nurses who attended formal training sessions or workshops scored significantly higher than those who did not (p = .021), indicating a positive correlation between structured education and knowledge level.

Nearly half of the participants had low knowledge levels, while less than one-third achieved high knowledge. Nurses who attended official infection control training programs demonstrated notably higher knowledge scores than those without prior exposure.

Table 2 indicates that while participants demonstrated adequate knowledge in some areas (e.g., blood administration set replacement and aseptic hub cleaning), deficiencies persisted in others—particularly dressing care, antiseptic use, and catheter change frequency. These results confirm partial adherence to CDC recommendations (2024) for catheter maintenance and highlight the need for continuous professional education.

Table 2.

Distribution of Participants’ Correct Responses on Knowledge Items (N = 131).

Question	Correct n (%)	Incorrect n (%)
Routine replacement of CVCs	74 (56.5)	57 (43.5)
Use of antiseptic-coated catheters	74 (56.5)	57 (43.5)
Dressing change frequency	61 (46.6)	70 (53.4)
Use of sterile dressing	60 (45.8)	71 (54.2)
Antiseptic disinfection at insertion site	64 (48.9)	67 (51.1)
Use of antibiotic ointment	62 (47.3)	69 (52.7)
Replacement of blood administration sets	84 (64.1)	47 (35.9)
Replacement of other infusion sets	47 (35.9)	84 (64.1)
Cleaning access hub before connection	78 (59.5)	53 (40.5)
Aseptic technique and sterile gloves use	76 (58.0)	55 (42.0)
Pressure transducer replacement	61 (46.6)	70 (53.4)

CVC = central venous catheter.

Behavioral Adherence to Central Line Care

The behavior scale evaluated nurses’ self-reported adherence to maintenance practices. Table 3 presents the mean scores for each behavior item.

Table 3.

Mean Scores of Nurses’ Behavioral Adherence to Central Line Care (N = 131).

Behavioral practice	Mean (SD)	Adherence level
Use of sterile transparent dressing	3.55 (1.08)	Moderate
Maximal barrier precautions	3.42 (1.09)	Moderate
Asepsis with 2% chlorhexidine	3.38 (0.96)	Moderate
Routine catheter replacement	3.41 (1.08)	Moderate
Prompt catheter removal when not essential	3.38 (1.00)	Moderate
Use of suture-less securement devices	3.32 (1.07)	Moderate
Administration set replacement	3.35 (0.99)	Moderate
Dressing replacement every 7 days	3.28 (1.10)	Moderate

Table 3 reveals an overall medium level of adherence (mean = 3.39, SD = 0.70). The highest adherence was observed for use of sterile transparent dressings, while routine dressing replacement scored lowest. This suggests that nurses are more consistent in daily care procedures but may overlook periodic maintenance requirements.

Pearson's correlation test indicated a significant positive relationship between knowledge and behavior scores (r = 0.233, p = .007). Nurses with higher knowledge levels exhibited better adherence to central line maintenance practices. Regression analysis confirmed that knowledge significantly predicted behavior (β = 0.233, p = .007), implying that a one-unit increase in knowledge is associated with a 0.051 increase in behavioral adherence.

Discussion

This study examined nurses’ knowledge and behavioral adherence regarding the care and maintenance of inserted central lines in ICUs and dialysis departments in Hebron Governorate hospitals. The findings revealed that nurses demonstrated a moderate level of knowledge and medium behavioral adherence, with a statistically significant yet modest correlation between knowledge and behavior. This suggests that while knowledge is an essential precursor to safe clinical performance, it alone does not ensure consistent adherence to infection control standards.

Nearly half of the participating nurses exhibited low knowledge levels regarding evidence-based central line care, a finding that aligns with previous studies reporting comparable deficiencies among nurses in critical care environments (Alqaissi, 2025; Almalki et al., 2023). Jose et al. (2022) similarly observed that although nurses in hemodialysis units possessed adequate theoretical awareness of catheter-related infections, challenges such as high patient loads, limited resources, and irregular training undermined effective practice. These convergent findings indicate that the gap between knowledge and clinical behavior is influenced not only by individual competence but also by institutional and environmental constraints.

The present study also found that nurses demonstrated better compliance with routine maintenance behaviors—such as the use of sterile transparent dressings—than with periodic or protocol-driven practices, including timely dressing replacement or catheter change. This discrepancy mirrors the findings of Chi et al. (2020) and Griffing and Overcash (2023), who noted that repetitive tasks are more likely to be maintained in daily routines, whereas less frequent procedures are often overlooked under time pressure or staffing limitations. These behavioral inconsistencies highlight the need for structured, ongoing, and competency-based training programs that emphasize both cognitive reinforcement and skill mastery.

It is also important to distinguish between education and training as complementary yet distinct determinants of nursing competence. Education primarily enhances theoretical understanding and knowledge acquisition, whereas training develops psychomotor and procedural skills necessary for translating knowledge into consistent clinical practice (Sham et al., 2023). Therefore, comprehensive CLABSI prevention strategies should integrate both didactic instruction and experiential learning approaches—such as simulation-based training, clinical mentorship, and periodic evaluation—to achieve sustained improvements in practice. This dual model of education and skill reinforcement has proven effective in improving adherence to infection control bundles and reducing bloodstream infection rates (Goldman et al., 2021).

In the Palestinian context, the moderate knowledge and adherence levels observed in this study likely reflect systemic and resource-related barriers common to developing healthcare systems. As Rawashda (2020) noted, challenges such as nurse understaffing, limited infection control resources, and the absence of continuous professional development opportunities significantly hinder the consistent application of evidence-based guidelines. These findings emphasize the need for institutional leadership to strengthen infection prevention programs through policy standardization, resource provision, and supportive supervision. Furthermore, the modest correlation between knowledge and behavior reinforces that sustainable improvements depend not only on individual learning but also on the organizational culture of patient safety and accountability (Esposito et al., 2017).

Overall, this study contributes important baseline data on CLABSI-related nursing practices in Palestine and underscores the need for systemic, multidisciplinary interventions aimed at improving infection control performance and patient outcomes.

Implications for Practice and Policy

The results have several implications for clinical nursing practice, education, and health policy in Palestine. The findings highlight the need for institutionalized infection prevention programs that extend beyond theoretical instruction to include structured, hands-on, and simulation-based training modules. Hospitals should integrate standardized CLABSI maintenance bundles into daily workflows and reinforce compliance through regular audits, visual reminders, and feedback systems. Strengthening the role of infection control teams and nurse educators is essential to maintaining adherence and ensuring continuous performance improvement. At the policy level, the Palestinian Ministry of Health should develop a national CLABSI prevention framework to unify standards, establish monitoring indicators, and promote interhospital collaboration. Nursing curricula should also be updated to emphasize infection prevention competencies as core learning outcomes for both undergraduate and postgraduate students.

Strengths and Limitations

This study has several methodological strengths. It is among the few empirical investigations exploring central line maintenance practices among Palestinian nurses, thus contributing locally relevant evidence to a globally important issue. The inclusion of nurses from multiple hospitals and both ICU and dialysis settings enhances the representativeness of the sample. The use of validated instruments adapted from international guidelines (CDC, 2024; Labeau et al., 2009) and expert-reviewed for contextual appropriateness ensures reliability and construct validity. Furthermore, the study achieved a high response rate (92.9%), minimizing selection bias and reflecting strong engagement among clinical nurses.

Several limitations should be acknowledged. First, the reliance on self-reported behavioral data may introduce social desirability bias, as participants could overestimate their compliance with recommended practices. Observational assessments would yield a more objective evaluation of actual behavior but were not feasible due to ethical and logistical constraints. Second, the cross-sectional design captures associations between knowledge and behavior at one point in time, limiting causal interpretation. Longitudinal or interventional studies are recommended to examine how educational interventions influence performance over time. Third, the study's geographical scope was limited to Hebron Governorate hospitals; while diverse, these institutions may not fully represent other Palestinian healthcare contexts. Finally, heterogeneity in prior training experiences among nurses could have influenced results, as no standardized national program currently exists. These factors should be considered when interpreting the findings and planning future research.

Conclusion

This study revealed moderate knowledge and behavior levels among nurses working in ICUs and dialysis departments regarding the care and maintenance of central lines in Hebron Governorate hospitals. The statistically significant but modest correlation between knowledge and behavior underscores that while educational enhancement is essential, it must be complemented by organizational reinforcement and systemic support.

Improving infection control performance requires an integrated approach that combines education, clinical training, institutional policy development, and adequate resource provision. Hospital administrations should prioritize continuous professional development and ensure that nurses have the structural and material resources necessary to apply evidence-based practices effectively.

At the national level, establishing standardized CLABSI prevention frameworks and competency-based training programs could substantially strengthen the quality of patient care, reduce infection rates, and enhance patient safety. Future research should adopt observational and longitudinal methodologies to evaluate the sustained impact of educational and institutional interventions.

By addressing the intersection of knowledge, behavior, and institutional context, this study provides valuable insights for advancing infection prevention and control within Palestine's critical care and dialysis settings, contributing to safer clinical environments and improved health outcomes.

Supplemental Material

sj-docx-1-son-10.1177_23779608251402958 - Supplemental material for Assessment of Nurses’ Knowledge and Behavior Toward Preventing Central Line-Associated Bloodstream Infections in Intensive Care Units and Dialysis Units

Supplemental material, sj-docx-1-son-10.1177_23779608251402958 for Assessment of Nurses’ Knowledge and Behavior Toward Preventing Central Line-Associated Bloodstream Infections in Intensive Care Units and Dialysis Units by Mohammad Qtait, Nesreen Alqaissi and Yousef Jaradat in SAGE Open Nursing

Supplemental Material

sj-docx-2-son-10.1177_23779608251402958 - Supplemental material for Assessment of Nurses’ Knowledge and Behavior Toward Preventing Central Line-Associated Bloodstream Infections in Intensive Care Units and Dialysis Units

Supplemental material, sj-docx-2-son-10.1177_23779608251402958 for Assessment of Nurses’ Knowledge and Behavior Toward Preventing Central Line-Associated Bloodstream Infections in Intensive Care Units and Dialysis Units by Mohammad Qtait, Nesreen Alqaissi and Yousef Jaradat in SAGE Open Nursing

Footnotes

Acknowledgments

We would like to express our sincere gratitude to all individuals who have contributed to this research. We are grateful to the participants for their cooperation.

ORCID iD

Mohammad Qtait

Ethics Approval

Ethical approval for this study was obtained from the Institutional Review Board (IRB) at University (the IRB approval no. 235).

Informed Consent

Written informed consent was obtained from each participant. Participation remained anonymous and data were treated with confidentiality.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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