Factors Influencing Attitudes and Adherence to Recommendations for Pressure Injury Prevention: Insights From a Cross–Sectional Study of Registered Nurses in Saudi Arabia

Abstract

Introduction

Registered nurses’ attitudes are integral to ensuring stringent adherence with pressure injury prevention (PIP), making their attitudes and adherence to PIP critical to patient outcomes, yet require comprehensive assessment to evaluate their relationship and effectiveness. Nevertheless, there is a notable absence of national prevalence data in the Kingdom of Saudi Arabia (KSA), indicating a shortfall in the application of established PIP strategies. Hence, research focused on evaluating the impact of nurses’ attitudes and adherence to PIP within the KSA has been limited.

Objective(s)

The aim of this study was to assess the attitudes of nurses towards PIP and their adherence with its recommendations, and how sociodemographic factors and attitudes influence their adherence to the recommendations for PIP.

Methods

A descriptive–correlational design was used. The study was conducted in a military medical city in Riyadh, KSA. Data were collected between 26 February and 03 March 2026, and analyzed using IBM SPSS Statistics (version 30). Multiple linear regression analyses were performed separately for the attitudes towards and adherence to recommendations for preventing pressure injuries (PIs) as dependent variables. For the first two regression models, the sociodemographic variables were considered predictor variables of attitudes towards and adherence to recommendations for PIP, and the level of attitudes was assigned as the predictor of adherence for the third model.

Results

A total convenience sample of 524 nurses participated and demonstrated overall positive attitudes towards PIP and positive adherence to PIP recommendations. Three sociodemographic variables were found as significant predictors of attitudes towards PIP, including age, highest education, and having read an article, book, or guideline pertaining to the PIP within the last year or less. In addition, two sociodemographic variables also demonstrated as significant predictors of adherence to the recommendations for PIP, namely: gender, and having read an article, book, or guideline pertaining to PIP within the last year or less.

Conclusions

The findings demonstrated that registered nurses displayed favorable attitudes towards PIP alongside positive adherence to its recommendations. These findings may suggest a shared commitment and consistent engagement in PIP practices. Numerous sociodemographic factors and attitudes towards PIP emerged as significant predictors of nurses’ adherence to the recommendations for PIP.

Keywords

adherence attitude registered nurse pressure injury pressure ulcer prevention

Introduction

Pressure injuries (PIs), commonly referred to as pressure ulcers (PUs) or bedsores, denote localized harm to the skin and the underlying tissues that arise from sustained pressure during hospital stays (Bhattacharya & Mishra, 2015). PIs associated with healthcare are widespread, with global incidence rates reported to be between 4.7% and 31% (Li et al., 2020). Research has underscored the significant financial implications of PIs for both individual patients and healthcare systems. For example, Padula and Delarmente (2019) reported that the total costs associated with hospital-acquired PIs in the United States of America (USA) in 2019 surpassed $26.8 billion. PIs represent a major issue within healthcare settings due to their serious impacts on patient morbidity, mortality, and the economic strain on healthcare systems (Wassel et al., 2020).

Registered nurses play a crucial role in ensuring adherence to pressure injury prevention (PIP), making their attitudes towards and adherence to recommendations for PIP vital to patient safety outcomes (Gillespie et al., 2021; Thomas & Nain, 2023). Nurses’ attitudes towards and adherence to PIP are essential but need thorough evaluation to determine their relationship and effectiveness (Salam, 2023). Exploring this topic would enable the recognition of educational deficiencies, formulate innovative strategies, and subsequently enhance quality of patient care in the study setting and across the Kingdom of Saudi Arabia (KSA). In the context of the KSA, focused educational and training initiatives can improve registered nurses’ adherence with PIP recommendations, while attitudinal strategies ensure that nurses’ perspectives are in harmony with optimal preventive practices. This study emphasizes the execution of effective measures and support frameworks to convert attitudes into reliable preventive actions concerning adherence to recommendations for PIP, thus aiding in the transformation of healthcare in accordance with Saudi Vision 2030 (Mani & Goniewicz, 2024).

For the initial construct examined in this study, Beeckman et al. (2010) cited that an attitude can be characterized as a relatively stable organization of interconnected beliefs (Rockeach, 1966) and may suggest what one can anticipate from others (Petty & Cacioppo, 1996). An individual who perceives that engaging in specific behavior will probably result in predominantly positive outcomes is likely to maintain a more favorable attitude towards that behavior, and vice versa (Ajzen, 1991; Ajzen & Fishbein, 1977; Ajzen & Madden, 1986). A reliable and robust tool was used, the Attitudes towards Pressure ulcer Prevention (APuP), for assessing attitudes of registered nurses in this study. The other construct investigated is adherence, which can be described as the degree to which nurses report that their preventive measures correspond with evidence-based PIP recommendations and institutional protocols (Moya-Suárez et al., 2017). Within the context of PIP guidelines, adherence is generally characterized by the level of compliance and concordance with the suggested preventive interventions (Moya-Suárez et al., 2017). In this study, the Questionnaire to evaluate nurses’ Adherence to Recommendations for Preventing Pressure Ulcers (QARPPU) was employed to measure the respondents’ adherence to PIP recommendations.

Purpose of the Study

The purpose of this study was to assess the levels of attitudes and adherence to recommendations for PIP among registered nurses, and the sociodemographic factors influencing their attitudes and adherence to PIP.

Review of Literature

The current literature suggests that nurses generally possess baseline knowledge regarding PIP strategies, but the translation of this knowledge into practice varies (Dalvand et al., 2018). Despite the availability of clinical guidelines, studies have revealed discrepancies between theoretical knowledge, as well as attitudinal influence, and actual bedside practice. For instance, a recent systematic review and meta-analysis encompassing 10 studies revealed that the relationships between knowledge, attitudes, and practices regarding PIP exhibit both positive and negative aspects from a global standpoint. These relationships are influenced by a range of confounding and mediating factors, which include sociodemographic, nursing-related, and hospital-related factors (Asiri et al., 2025). The review conducted by Asiri et al. (2025) suggested that enhancing the knowledge base of registered nurses and fostering positive attitudes towards PIP would improve their practice levels. Comparable results were observed in another systematic review and meta-analysis, which indicated that both registered nurses and nursing students held moderate levels of attitudes towards PIP and underscored the importance of delivering adequate training to these groups (Rostamvand et al., 2022).

In addition, several studies have indicated that adherence to various PIP recommendations remains suboptimal in Western nations (Barker et al., 2013; Chaboyer et al., 2017; Latimer et al., 2016). Building on this, in a cross-sectional study conducted in China, the compliance rate for repositioning among immobile patients was found to be 90% (Liu et al., 2019), significantly surpassing the figures reported in Sweden (44.3%; Baath et al., 2014) and Australia (66.4%; Chaboyer et al., 2017). Furthermore, a recent observational study also revealed high rates of completion for repositioning and risk assessment in a tertiary hospital in China; however, the adoption of strategies by nurses, such as providing suitable support surfaces, skin care, and nutrition, was found to be less than ideal (Li et al., 2021). Additionally, prior study conducted across 33 adult intensive care units within 16 tertiary general hospitals located in five major cities of Liaoning Province, China, revealed that the adherence of critical care nurses with the clinical practice guidelines for PIP was deemed satisfactory (Song et al., 2024). However, Song et al. (2024) indicated that there are low-to-moderate barriers affecting nurses’ adherence with clinical practice guidelines for PIP, with the strongest barrier being the low priority given to PIP by the nurses themselves. Consequently, The study highly recommended that healthcare organizations should consider offering training to nurses and addressing the identified barriers to enhance their adherence to evidence-based guidelines for PIP (Song et al., 2024).

Moreover, Vaismoradi et al.’s (2020) systematic review on the adherence of registered nurses to patient safety principles, including PIP, revealed reports from six studies conducted in various countries, including Australia (Graan et al., 2016), Finland (Laurikainen et al., 2016), Norway (Fålun et al., 2020), South Korea (Lim et al., 2019), Sweden (Förberg et al., 2014), and the United Kingdom (Alsulami et al., 2014). The findings indicated that nurses’ attitudes, along with other contributing factors, significantly impacted their adherence to patient-safety principles (Vaismoradi et al., 2020). Other various factors influencing adherence to PIP include workload, staffing levels, training, and institutional support (Tayyib et al., 2016). In addition, evidence shows a positive correlation between comprehensive education on adherence to PIP and better patient outcomes (Li et al., 2022aLi, Marshall, et al., 2022). However, there is an existing gap in the literature highlighting the need for research focusing on registered nurses’ attitudes and adherence to identify barriers to and facilitators for implementing adherence to PIP measures effectively (Peters et al., 2022). Notably, a strong sense of responsibility may enhance adherence to hospital protocols and clinical practice guidelines (Tan et al., 2020). However, there is no direct or indirect relationship that has been established in the literature between attitudes and adherence to PIP recommendations among registered nurses. A previous qualitative investigation carried out in China indicated that nurses who are significantly integrated into a strict organizational culture prioritizing PIP tend to place high value to adhering recommendations for PIP (Li et al., 2022bLi, Zhu, et al., 2022).

The variability in adherence to PIP recommendations highlights the necessity for a more profound understanding of the approaches taken by Saudi Arabian nurses regarding PIP. In the KSA, a recent cross-sectional study specifically revealed that nurses’ low prioritization of PIP correlates with negative attitudes (Mostafa et al., 2024). This finding implies that nurses who assign low priority to PIP might also exhibit a negative attitude towards prevention initiatives (Mostafa et al., 2024). Despite this recent study finding, research focusing on evaluating the connection between attitudes and adherence to recommendations for PIP among registered nurses in KSA within inpatient settings remains scarce (Al Mutairi et al., 2020). Additionally, there is a lack of national prevalence data in the KSA, suggesting a deficiency in the implementation of established strategies regarding PIP. Finally, there exists a significant gap in the research evidence regarding nurses’ adherence to recommendations for PIP, specifically in relation to attitudes that influence such adherence or non-adherence. While existing studies often explore components of PIP, comprehensive assessments that link these components to adherence to PIP among registered nurses are limited. This gap underscores the need for more focused research to better understand how attitudes impact adherence to PIP and to identify effective strategies to enhance compliance with evidence-based prevention protocols (Ghazanfari et al., 2022). Consequently, this study was undertaken to enhance the understanding of how registered nurses engage with the recommendations for PIP. Specifically, it explored how the sociodemographic characteristics and attitudes of registered nurses towards PIP influence their adherence with the recommendations for PIP.

Methods

Research Design

This study employed a descriptive, correlational, cross-sectional design, and adhered to the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines.

Research Questions

To achieve the purpose of the present study, the following research questions were addressed.

1. What is the extent of registered nurses’ attitudes towards PIP?

2. What is the degree of adherence among registered nurses to the recommendations for PIP?

3. How do registered nurses’ attitudes and various sociodemographic factors influence their adherence to the recommendations for PIP?

Study Setting and Sample

The study was conducted in a military medical city in Riyadh, KSA. A convenience sampling method was used to ensure the inclusion of nurses from various departments. The study included 524 registered nurses who were employed in the nursing departments of the medical city, particularly in medical, surgical, and intensive care units, and had worked in the same healthcare facility for over one year. The exclusion criteria for this study were being a registered nurse enrolled in the general nursing orientation, working in units with no reported cases of PI, and those who were on official leave of absence during the time of data collection.

In this study, the sample size was established utilizing the G-Power 3.1 software with 5% margin of error, a power level of 0.80 and a small effect size of 0.2, with a minimum sample size of 265. The minimum sample size was increased twofold, leading the researchers to invite 530 registered nurses in the medical city to take part in the online survey. By increasing the sample size in survey studies like the one conducted in the current study, the researchers were able to achieve more precise predictions and a greater probability of detecting significant differences or trends within the data (Verma & Verma, 2020). Furthermore, by increasing the sample size, the researchers were able to minimize the margin of error associated with the study’s results, thereby ensuring that the findings were more dependable and less susceptible to random sampling variations (Verma & Verma, 2020).

Research Instruments

This study employed a questionnaire for the online survey, which consists of three parts, as detailed here. The first part identified eight sociodemographic and work-related characteristics of nurses that include: (1) age, (2) gender, (3) nationality, (4) highest education, (5) unit patient population, (6) having information about PIP in the past year, (7) certification as wound care specialist, and (8) frequency of reading an article, book or guideline related to PIP.

The second part of the study’s questionnaire is the APuP instrument (Beeckman et al., 2010), with permission obtained from the copyright holder on September 19, 2023. The APuP consists of 13 items in five subscales, detailed as follows: personal competency to prevent PUs (3 items), priority of PUP (3 items), impact of PUs (3 items), responsibility in PUP (2 items), and confidence in the effectiveness of prevention (2 items). According to Beeckman et al. (2010), the APuP instrument demonstrated an internal consistency of Cronbach’s alpha = 0.79, indicating its sound psychometric properties. In the current study, each item on the instrument was rated utilizing a four-point Likert rating scale (1 = strongly agree, 2 = agree, 3 = disagree, and 4 = strongly disagree). Negatively worded items were reverse-coded to compute the average mean scores, which were then used to determine the overall attitude mean score. A mean score of 2.0 or lower indicated a positive attitude, while a score greater than 2.0 reflected a negative attitude towards PIP.

The third part of the questionnaire employed the QARPPU tool, which comprises 18 items (Moya-Suárez et al., 2017). This instrument features response options that are evaluated on a five-point Likert scale to measure the level of adherence to each guideline for patients who are at a high risk of developing PIs. The response categories on the scale ranged from 5 (never) to 1 (always). The content validity index was 0.80 and Cronbach’s alpha was 0.89 (Moya-Suárez et al., 2017). The scoring of the scale is determined by calculating the mean scores for each individual item and the overall mean score for adherence. Scores below the mean score of 2.5 were categorized as indicative of higher or positive adherence, while scores above the mean represent lower or negative adherence.

A pilot study was conducted to test the tools’ reliability by assessing its internal consistency with Cronbach’s alpha, as well as examining its predictive validity to verify the accuracy of future results on the basis of the initial assessment. A small cohort of registered nurses (n = 25) who met the criteria for inclusion in the study, but were excluded from the final sample, took part in a pilot test. The internal consistency values, determined using Cronbach’s alpha coefficient, was 0.87 for the overall APuP, higher than the alpha value of 0.79 reported in Beeckman’s (2010) study, and for the adherence to recommendations for PIP was 0.91, surpassing Moya-Suárez et al.’s (2017) reported Cronbach’s alpha value of 0.89.

Ethical Considerations

This study received ethical approvals from the Institutional Review Board (IRB) at Prince Sultan Military Medical City (PSMMC) under IRB Approval Number: E-2824, dated 16 February 2026, and from the Research Ethics Committee at King Saud University (KSU) with Reference Number: 26-0192, dated 26 February 2026. Respondents were provided with comprehensive information regarding the objectives and methods of the study, highlighting the voluntary nature of their involvement, as detailed in the informed consent form and preliminary part of the online survey. Furthermore, they were assured that their confidentiality would be strictly maintained and their participation was completely anonymous. Consent was secured before the submission of the properly filled questionnaires, and participation in the online survey conducted through Google Form was completely voluntary.

Data Collection

After obtaining ethical approvals, the data collection involved administering online survey to eligible registered nurses. The surveys were distributed electronically via institutional email and messaging applications such as WhatsApp, as well as posting of QR codes on bulletin boards within the unit to ensure ease of access and completion. For the survey instructions, respondents were given the option to choose “Agree” to proceed with answering the survey or “Disagree” to be redirected to an exit page. The wound care nurse leader provided support and encouragement to enhance participation during visits to the nursing unit. The researchers held the responsibility of reviewing the submitted forms and consistently overseeing the Google Form for any updates in responses. The survey was structured to be compatible with Google Sheets, ensuring that the responses from nurses remained confidential and reducing the need for manual data entry, thus promoting complete anonymity of their participation. Data collection happened from 26 February 2025 to 03 March 2026. Registered nurses took an average time of eight minutes to complete the survey.

Statistical Analysis

Data cleaning was conducted to manage missing data. The data were analyzed using IBM SPSS Statistics (Version 30) with a significance level of 0.05. The analysis included both descriptive and inferential statistics to effectively summarize the data and draw meaningful conclusions. Descriptive statistics (mean, standard deviation, and frequency) summarized the attitude towards and adherence to recommendations for PIP, as well as the sociodemographic characteristics of registered nurses. Normality tests were conducted to determine a suitable test for relationships among registered nurses’ sociodemographic characteristics, attitudes towards and adherence to recommendations for PIP. The tests revealed non-normal distribution, as indicated by p-values < .001, for both the Kolmogorov-Smirnov and Shapiro-Wilk tests. Hence, Spearman’s rho correlation test was utilized. Multiple linear regression analyses determined the predictors of registered nurses’ adherence to PIP. In the analysis, three regression models were computed. The initial two regression models incorporated sociodemographic characteristics that were dummy coded, which served as predictor variables for attitudes and adherence to the PIP recommendations. In the third regression model the level of attitudes served as the predictor of adherence to the recommendations for PIP.

Results

Sociodemographic Characteristics

Table 1 presents descriptive statistics about the demographic characteristics of 524 registered nurses. The mean age of the nurse respondents was 36.40 years (SD = 6.91) that ranged from 24 to 60 years old, with majority of them were females (n = 456, 87.0%) and Filipinos (n = 281, 53.6%). Most of them held a bachelor’s degree (n = 494, 94.3%) and were employed in nursing units caring for adult patients (n = 465, 88.8%). Furthermore, most respondents were certified wound care specialists (n = 498, 95.0%) and had actively sought information on the prevention of PIs within the previous year (n = 503, 96.0%). Lastly, 90.3% (n = 473) of the respondents reported having read an article, book, or guideline pertaining to PIP within the last year or less.

Table 1.

Sociodemographic Characteristics

Sociodemographic characteristics	Mean (SD)	Range
Age (In years)	36.40 (6.91)	24–60
	f	%
Gender
Male	68	13.0
Female	456	87.0
Nationality
Saudi	19	3.6
Indian	207	39.6
Filipino	281	53.6
Others	17	3.2
Highest education
Diploma	13	2.5
Bachelor	494	94.3
Post-graduate	17	3.2
Unit patient population
Adult	465	88.8
Pediatric	28	5.3
Neonate	31	5.9
Information about PIP in the past year
Yes	503	96.0
No	21	4.0
Wound care specialist certification
Yes	26	5.0
No	498	95.0
Last time reading an article, book or guideline about PIP
Never	9	1.7
One year or less	473	90.3
More than one year but less than 2 years	38	7.2
2–4 years or greater	4	.8

Note. SD = Standard deviation; f = frequency; % = Percentage; PIP = Pressure injury prevention.

Attitudes Towards Pressure Injury Prevention

As presented in Table 2, the registered nurses exhibited generally positive attitudes towards PIP, with an overall mean score of 1.92 out of 4. The highest positive attitude was observed in subscale 2, which pertains to the priority of in PIP (Mean = 1.70, SD = .053), whereas the lowest favorable (negative) attitude was noted in subscale 5, which relates to confidence in the effectiveness of prevention (Mean = 2.23, SD = .56). Three specific items received negative ratings from the nurses: the item ‘PIs are almost never preventable’ (Mean = 2.87, SD = 0.58), followed by the item ‘The financial impact of PIs on a patient should not be exaggerated’ (Mean = 2.52, SD = 0.78), and the item ‘PIP is too difficult. Others are better than I am’ (Mean = 2.13, SD = 0.78). Nevertheless, two items received the highest positive ratings: ‘I feel confident in my ability to prevent PIs’ (Mean = 1.55, SD = 0.53) and ‘PIP should be a priority’ (Mean = 1.48, SD = 0.91).

Table 2.

Attitudes Towards Pressure Injury Prevention

Attitudes towards PIP	Mean	SD
Subscale 1: Personal competency to prevent PIs	1.81	.60
I feel confident in my ability to prevent PIs.	1.55	.53
I am well trained to prevent PI.	1.74	.55
PIP is too difficult. Others are better than I am.^r	2.13	.78
Subscale 2: Priority of PIP	1.70	.53
Too much attention goes to the prevention of PIs.^r	1.82	.65
PIP is not that important.^r	1.81	.91
PIP should be a priority.	1.48	.91
Subscale 3: Impact of PI	2.14	.75
A PI almost never causes discomfort for a patient.^r	1.96	.92
The financial impact of PIs on a patient should not be exaggerated.^r	2.52	.78
The financial impact of PIs on society is high.	1.94	.63
Subscale 4: Responsibility in PIP	1.76	.57
I am not responsible if a PI develops in my patients.^r	1.92	.86
I have an important task in PIP.	1.59	.57
Subscale 5: Confidence in the effectiveness of prevention	2.23	.56
PIs are preventable in high-risk patients.	1.59	.57
PIs are almost never preventable.^r	2.87	.58
Overall Mean Score	1.92	.85

Note. SD = Standard deviation; f = frequency; % = Percentage;^r = reverse-coded; PI = Pressure injury; PIP = Pressure injury prevention.

Adherence to Recommendations for Preventing Pressure Injuries

Overall, the registered nurses demonstrated a positive adherence to the recommendations for PIP, achieving a mean score of 1.56 out of 5, as shown in Table 3. Three items garnered the highest positive ratings: the item ‘I ensure the patient’s skin is kept clean and dry’ (Mean = 1.26, SD = 0.68), followed by the item ‘I ensure the patient’s skin is protected from excessive moisture, using a barrier product’ (Mean = 1.27, SD = 0.65), and the item ‘I perform a daily evaluation of the patient’s skin with respect to its integrity, possible changes in color or variations in temperature, firmness and moisture/dryness’ (Mean = 1.33, SD = 0.67). Only one item received a negative rating from the nurses: ‘To assess the risk of PIs forming, I rely exclusively on my clinical judgment as a nurse (without the support of risk evaluation instruments)’ (Mean = 2.88, SD = 1.45).

Table 3.

Adherence to Recommendations for Preventing Pressure Injuries

Adherence to recommendations for preventing pressure injuries	Mean	SD
To assess the risk of PIs forming, I rely exclusively on my clinical judgment as a nurse (without the support of risk evaluation instruments).	2.88	1.45
To assess the risk of PIs forming, I take into account my clinical judgement as a nurse and also apply a validated risk evaluation instrument (Braden, Emina, Norton, Waterlow or similar).	1.56	.88
I conduct risk evaluation when the patient is admitted, always within six hours of admission.	1.85	1.26
I perform a further examination in response to any change in the patient’s clinical status (for example, after surgery, the worsening of an underlying disease or a change in mobility).	1.46	.80
I perform a daily evaluation of the patient’s skin with respect to its integrity, possible changes in color or variations in temperature, firmness and moisture/dryness.	1.33	.67
I try to avoid reclining the patient on areas with non-blanching erythema.	1.89	1.13
I ensure the patient’s skin is kept clean and dry.	1.26	.68
I ensure the patient’s skin is protected from excessive moisture, using a barrier product.	1.27	.65
I hydrate dry skin with a moisturizer.	1.38	.72
Provided it is not contraindicated by the patient’s clinical status, I apply postural changes, according to the risk of a PI forming.	1.81	.95
Provided the patient’s clinical status allows, I encourage him/her to change position frequently, depending on the risk presented.	1.44	.72
When the patient must be moved, I take care to avoid friction and shear (using slide sheets, transfer boards, hoists, etc.).	1.35	.70
When the patient is sitting in a chair, I ensure that the feet are well supported, either directly on the floor or raised on a footrest or stool.	1.38	.77
When the patient is in bed, I maintain the 30° position, unless it is contraindicated by the health situation or is not tolerated.	1.49	.81
I place high-risk patients on a special surface for pressure redistribution (e.g., a dynamic pressure-relieving mattress, or alternating overlay, or a high specification foam mattress).	1.48	.74
I avoid placing the patient directly on treatment devices such as catheters, drainage systems, etc., unless it is unavoidable.	1.48	.80
I ensure that pressure is relieved from the heel by lifting it such that the weight of the leg is distributed along the calf, without putting pressure on the Achilles tendon (e.g., by placing a foam pillow or cushion under the calf, leaving the heel suspended).	1.47	.74
I use dressings (hydrocolloids, foam, silicone, etc.) in risk areas to avoid friction and shear forces.	1.35	.68
Overall Mean Score	1.56	.56

Note. SD = Standard deviation; f = frequency; % = Percentage; PI = Pressure injury.

Results of the Correlation and Multiple Linear Regression Analyses

In this study, three correlation analyses were conducted using the Spearman rho correlations test, together with three linear regression analyses (see Table 4). The correlation test showed that there were four sociodemographic variables: age (ρ = -.232, p = < .001), nationality (ρ = -.213, p = < .001), highest education (ρ = -.154, p = .010), and having read an article, book, or guideline pertaining to PIP within the last year or less (ρ =.139, p = .020) exhibited significant relationships with the attitude to PIP. Meanwhile, the regression model of attitude to PIP was statistically significant (F [9, 268] = 4.895, p = < .001), explaining approximately 14.1% of the variance (R² =.141, Adjusted R² =.112). The model identified three sociodemographic variables as significant predictors of attitude to PIP, including age (β = -.010, p = .001, 95% confidence interval [CI] = -.017, -.004), highest education (β = -.206, p = .005, 95% CI = -.349, -.063), and having read an article, book, or guideline pertaining to PIP within the last year or less (β = .099, p = .019, 95% CI = .016, .181).

Table 4.

Results of the Correlation and Multiple Linear Regression Analyses

Study variables		ρ	p	Unstandardized coefficients		Standardized coefficients	t	p	95% Confidence interval
Study variables		ρ	p	β	SE-b	Beta	t	p	Lower limit	Upper limit
Attitudes towards PIP	Age	-.232	<.001***	-.010	.003	-.216	-3.361	.001***	-.017	-.004
	Gender	-.105	.079	-.065	.058	-.065	-1.117	.265	-.179	.050
	Nationality	-.213	<.001***	-.058	.034	-.106	-1.678	.095	-.125	.010
	Highest education	-.154	.010**	-.206	.073	-.172	-2.834	.005**	-.349	-.063
	Unit patient population	-.065	.277	-.066	.039	-.099	-1.700	.090	-.142	.010
	PI information	.093	.120	.069	.103	.040	.669	.504	-.134	.272
	Wound specialist certification	.017	.784	-.010	.090	-.007	-.114	.909	-.187	.166
	Reading about PI	.139	.020*	.099	.042	.145	2.360	.019*	.016	.181
Adherence to the Recommendations for PIP	Age	.061	.309	-.004	.005	-.048	-.728	.467	-.014	.007
	Gender	-.115	.050*	-.242	.100	-.146	-2.419	.016*	-.438	-.045
	Nationality	.208	<.001***	.026	.059	.029	.449	.654	-.090	.143
	Highest education	-.005	.929	-.100	.125	-.050	-.799	.425	-.345	.146
	Unit patient population	.014	.821	.074	.066	.067	1.118	.265	-.056	.205
	PI information	.051	.401	.298	.177	.104	1.682	.094	-.051	.647
	Wound specialist certification	.064	.288	-.020	.154	-.008	-.131	.896	-.324	.283
	Reading about PI	.033	.058	.138	.072	.122	1.924	.050*	-.003	.280
Attitudes and Adherence to the Recommendations for PIP		.152	.011*	-.156	.038	-.239	-4.084	<.001***	-.231	-.081

Note. The dependent variable was the overall mean score of the adherence to recommendations for pressure injury prevention (PIP).

PI = Pressure injury; ρ = Spearman’s rho correlation value; p = p-value; β = unstandardized coefficients; SE-b = standard error; t = t-value.

*Significance level at 0.05.

**Significance level at 0.01.

***Significance level at 0.001.

For the adherence to recommendations for PIP, the correlation test revealed that there were two sociodemographic variables: gender (ρ = -.232, p = < .001) and nationality (ρ = -.213, p = < .001) exhibited significant relationships. Moreover, the regression model of adherence to the recommendations for PIP was statistically significant (F [9, 268] = 2.483, p = .010), explaining approximately 7.7% of the variance (R² =.077, Adjusted R² =.046). The model identified two sociodemographic variables as significant predictors of adherence to the recommendations for PIP, namely: gender (β = -.010, p = .001, 95% CI = -.017, -.004), and having read an article, book, or guideline pertaining to the PIP within the last year or less (β = .099, p = .019, 95% CI = .016, .181).

Finally, the attitudes towards PIP exhibited significant relationship with adherence to the recommendations for PIP (ρ = .152, p = .011). The regression model for the third model yielded a statistically significant result (F [1, 276] = 22.962, p = < .001), explaining approximately 7.7% of the variance (R² =.077, Adjusted R² =.073). The model exhibited registered nurses’ attitudes towards PIP (β = -.156, p = < .001, 95% CI = -.231, -.081) was a significant predictor of their adherence to the recommendations for PIP.

Discussion

The PIP is chiefly nursing responsibility; consequently, the attitudes towards and adherence to the recommendations for preventing such injuries were investigated in this study. The study findings revealed that registered nurses exhibited overall positive attitudes towards the prevention of PIs. This result aligns with an earlier cross-sectional study carried out in public general hospitals in Kuwait, where nurses similarly reported a favorable attitude towards the prevention of PIs (ALFadhalah et al., 2025). Comparably, the results of a systematic review indicated that, in general, nurses exhibit relatively favorable attitudes towards PIP, with studies conducted in the Middle East showing the lowest average attitudes score, while those from Europe demonstrated the highest average attitudes score (Avsar et al., 2023). However, it was reported in an earlier systematic review and meta-analysis that utilized the APuP instrument, that the attitudes of nurses towards PIP were slightly unfavorable (Rostamvand et al., 2022).

In the current study, the registered nurses also demonstrated a positive adherence to the recommendations for PIP. This finding is consistent with a previous cross-sectional study among critical care nurses (n = 473) in China where nurses’ adherence to PIP clinical practice guideline was satisfactory (Song et al., 2024). However, this particular result could not be compared or interpolated within Saudi Arabian context, as this marks the first investigation, to date, on adherence to PIP recommendations among registered nurses in the KSA.

The correlation test showed that there were four sociodemographic variables: age, nationality, highest education, and having read an article, book, or guideline pertaining PIP within the last year or less exhibited significant relationships with the attitudes towards PIP. For the adherence to the recommendations for PIP, the correlation test conducted in the current study revealed that there were two sociodemographic variables: gender and nationality that exhibited significant relationships. These results suggest that the relationship between nurses’ gender and nationality and their positive attitudes towards PIP may also correlate with a favorable or positive adherence to PIP recommendations. In a culturally diverse healthcare workplace such as that in the KSA, registered nurses of all gender identities and cultural backgrounds, particularly the predominantly expatriate nurses from the Philippines and India in the study setting, must possess cultural competence to deliver high-quality care services, including delivery of nursing interventions related to PIP. Failing to provide culturally safe services can lead to significant adverse outcomes (Latif, 2020), which may encompass the occurrence of PIs. Additionally, the attitudes towards PIP exhibited significant relationship with adherence to the recommendations for PIP. Comparably, several factors have been identified in earlier research that demonstrate a significant correlation with a positive attitudes towards PIP. These include PIP training and work experience among Iranian nurses (Lotfi et al., 2019), increased work experience noted in another Iranian study (Khojastehfar et al., 2020), as well as the higher age of nurses as indicated in a previous study conducted in Cyprus (Charalambous et al., 2019).

Three sociodemographic variables were found as significant predictors of attitude to PIP, including age, highest education, and having read an article, book, or guideline pertaining to the prevention of PIs within the last year or less. These findings are comparable with a previous study among critical care nurses in the KSA where the factors associated with knowledge of PIP include age, clinical nursing experience, and experience in intensive care units (Alshahrani et al., 2023). Furthermore, possessing a bachelor’s degree or a higher qualification was a predictor of improved knowledge and attitudes regarding PIP (Alshahrani et al., 2023). Additionally, comparable results were reported in a previous study among nursing staff in Finland that the following background factors, namely: working as a wound care nurse, working experience after graduation, self-reported PIP and early detection skills, and views about the realization of their unit’s PIP practices remained independent determinants of the attitudes total scores (Parisod et al., 2022). In the current study, two sociodemographic variables also demonstrated as significant predictors of adherence to the recommendations for PIP, namely: gender, and having read an article, book, or guideline pertaining to the prevention of PIs within the last year or less. Similarly, having participated in training on PIP clinical practice guideline statistically predicted better adherence of critical care nurses in China (Song et al., 2024). Finally, the attitudes of registered nurses towards PIP served as predictor of their adherence to the recommendations for PIP. This finding aligns with a previous study conducted in Kuwait, which concluded that nurses’ positive attitudes were mirrored in their adherence to PIP practices (ALFadhalah et al., 2025). Similarly, a recent review indicated that fostering positive attitudes towards PIP could enable healthcare organizations to improve upon the already commendable standards of practice and adherence to PIP (Asiri et al., 2025).

Strengths and Limitations

This study had certain limitations that must be acknowledged. The self-reported attitudes towards and adherence to recommendations for preventing PIs, along with the utilization of a convenience sampling method, may introduce a level of bias in the responses provided by registered nurses in the survey. Consequently, the results should be interpreted with caution, as the reported ratings from registered nurses may not accurately reflect the attitudes towards and adherence to PIP recommendations among nurses in various healthcare institutions across the KSA, including private hospitals. Therefore, these limitations restrict the generalizability of the study’s findings.

Implications for Practice

Based on the study findings, targeted interventions can play a crucial role in improving attitudes towards and adherence to PIP recommendations. These may encompass educational initiatives and ongoing training for registered nurses conducted by the wound care team within the medical city. Additional interventions could involve enhancing nursing education, improving the quality of data reporting, increasing the documentation of adverse events, and boosting satisfaction levels among nursing staff. Other measures may also pertain to attitudinal strategies that guarantee alignment between nurses’ viewpoints and the best preventive practices, as well as adherence to the recommendations for PIP. These measures can also be adopted by other hospitals where nursing personnel exhibit negative attitudes towards PIP and demonstrate unfavorable adherence to PIP recommendations, both throughout the kingdom and in other Arab Gulf countries, as well as on an international level. Finally, future research should take into account additional confounding variables including experience, prior PIP training, or other relevant factors, and a larger sample size of respondents across multiple centers throughout the kingdom, encompassing both public and private healthcare facilities. Furthermore, employing various qualitative methodologies could provide insights into the reasons behind nurses’ negative attitudes towards and adherence to recommendations regarding PIP for certain items on the APuP and QARPPU scales.

Conclusions

The findings of this study revealed that the registered nurses' attitudes towards PIP were favorable or positive, and their adherence to recommendations for PIP was also positive. This positive disposition among registered nurses was evident in their overall positive adherence to the recommendations aimed at preventing PIs. The alignment of positive attitudes and adherence may reflect a shared commitment and consistent engagement in PIP practices among the registered nurses. Furthermore, registered nurses’ adherence was significantly influenced by their sociodemographic characteristics and their attitudes towards PIP. While these results are encouraging, there exists an opportunity to enhance registered nurses’ attitudes towards PIP, specifically related to their proficiency in preventing PIs, impact of PIs, and confidence in the efficacy of PIP. Additional improvements may also be warranted in adherence to specific components of PIP recommendations, particularly those concerning the risk assessment of PIs based on the clinical judgment of registered nurses.

Supplemental Material

Supplemental material - Factors Influencing Attitudes and Adherence to Recommendations for Pressure Injury Prevention: Insights From a Cross–Sectional Study of Registered Nurses in Saudi Arabia

Supplemental material for Factors Influencing Attitudes and Adherence to Recommendations for Pressure Injury Prevention: Insights From a Cross–Sectional Study of Registered Nurses in Saudi Arabia by Mousa Yahya Asiri, Regie Buenafe Tumala, Homoud Ibrahim Alanazi, Homood A. Alharbi, Sahar Abdulkarim Al-Ghareeb, Badr Ayed Alenazy, Yahya Al Rashed, and Mesfer Alotaibi in Sage Open Nursing.

Footnotes

Acknowledgments

The authors are thankful to the Deanship of Graduate Studies and Scientific Research at King Saud University, Riyadh, Saudi Arabia.

ORCID iDs

Mousa Yahya Asiri

Regie Buenafe Tumala

Sahar Abdulkarim Al-Ghareeb

Badr Ayed Alenazy

Ethical Considerations

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board at Prince Sultan Military Medical City (PSMMC) with Approval Number: E-2824, dated 16 February 2026 and from the Research Ethics Committee at King Saud University (Approval Number: 26-0192, dated 26 February 2026).

Consent to Participate

Informed consent was obtained from all subjects involved in the study.

Author Contributions

Conceptualization, M.Y.A. and R.B.T.; methodology, M.Y.A., R.B.T., H.I.A. and H.A.A.; software, M.Y.A. and R.B.T.; validation, H.I.A., S.A.A. and B.A.A.; formal analysis, M.Y.A. and R.B.T.; investigation, M.Y.A., H.I.A., H.A.A., S.A.A., B.A.A., Y.A. and M.A.; resources, H.I.A., S.A.A., B.A.A., Y.A. and M.A.; data curation, M.Y.A. and R.B.T.; writing—original draft preparation, M.Y.A., H.I.A., H.A.A., S.A.A., B.A.A., Y.A. and M.A.; writing—review and editing, M.Y.A., H.I.A., H.A.A., S.A.A., B.A.A., Y.A. and M.A.; visualization, H.I.A., Y.A. and M.A.; supervision, R.B.T., H.A.A., Y.A. and M.A.; project administration, M.Y.A., S.A.A. and B.A.A.; funding acquisition, M.Y.A. M.Y.A. and R.B.T. equally contributed to this manuscript. All authors have read and agreed to the published version of the manuscript.

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.

Data Availability Statement

The data presented in this study are all included in the paper.*

Supplemental Material

Supplemental material for this article is available online.

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