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“Knowing is not doing”: knowledge, misconceptions and perceived barriers to pressure ulcer prevention practice among nursing students at a tertiary institution in the United Arab Emirates

This study of nursing students in the UAE reveals that while their knowledge of pressure ulcer prevention improves with clinical exposure, it remains insufficient in rejecting outdated practices, creating a significant "knowing is not doing" gap driven by barriers such as time scarcity and workforce constraints that necessitate curriculum reforms focused on simulation and deconstructing legacy methods.

Original authors: Doreen Mukona, Rutendo Felicity Mukona, Mathilda Zvinavashe, Augustine Ndaimani

Published 2026-08-11

📖 6 min read🧠 Deep dive

CC BY 4.0

Original authors: Doreen Mukona, Rutendo Felicity Mukona, Mathilda Zvinavashe, Augustine Ndaimani

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

Imagine you are learning to drive a car. In driving school, you sit in a classroom, memorize the rules of the road, and learn exactly how to steer, brake, and signal. You pass your written test with flying colors. But then, you get behind the wheel for the first time in real traffic. Suddenly, the textbook rules feel different. Maybe you forget to check your blind spot because you're nervous, or maybe you were taught an old trick by a friend that actually isn't safe anymore. This gap between what you know you should do and what you actually do when the pressure is on is a problem that shows up in many jobs, but especially in nursing.

In the world of healthcare, there is a specific danger called a "pressure ulcer" (also known as a bedsore). Think of your skin like a delicate garden. If you leave a heavy rock sitting on a patch of grass for too long, the grass turns brown and dies because it can't get air or water. Similarly, if a person stays in one position for too long, their skin and the tissue underneath can get squished so hard that blood can't flow, causing the skin to break down. The good news is that nurses have a very clear "rulebook" on how to prevent this: move the patient often, use special cushions, keep the skin clean and dry, and check for red spots early. But just like the new driver, knowing the rules doesn't always mean you can follow them perfectly when you are tired, busy, or working with limited tools. This is the story of a group of future nurses trying to figure out why they sometimes struggle to turn their classroom knowledge into real-world action.

The Paper: "Knowing is Not Doing"

This study takes a deep dive into the minds of nursing students in the United Arab Emirates to see if they are ready to stop these painful sores before they start. The researchers, led by Doreen Mukona and her team, wanted to answer a simple but tricky question: Do these students actually know the right way to prevent bedsores, and if they do, what stops them from doing it?

They surveyed 133 nursing students (mostly Emirati, with an average age of 21.9 years) at a health sciences college. They gave the students a 31-question quiz about pressure ulcer prevention. The quiz wasn't just about knowing the right things to do; it was also a trap to see if they could spot the wrong things that people used to do but shouldn't anymore.

The Scoreboard: Good News and Bad News

The results were a mix of hope and a reality check. On average, the students scored 19.9 out of 31, which translates to about 64.1%.

The Good: Only about 20.3% of the students had "good" knowledge (scoring 80% or higher).
The Middle: 42.1% had "moderate" knowledge.
The Struggle: A significant chunk, 37.6%, had "poor" knowledge (below 60%).

The most interesting part of the findings was what they got wrong. The students were great at answering questions about the right things to do, like "Use a special mattress" or "Check the skin often." But they stumbled badly when asked to reject old, outdated habits.

Only 14.3% correctly said that putting special fatty acids on the skin to protect it from moisture is not the right move.
Only 17.3% knew that propping a patient's head up at a steep angle (30–45°) is actually bad advice.
Only 19.5% realized that wrapping heels in bandages doesn't help.
Only 36.8% knew that "donut-shaped" cushions (the kind with a hole in the middle) are a bad idea.

It's as if the students learned the new rules of the road but kept driving with the old map in their glovebox. The study suggests that while they learned the "do's," they didn't unlearn the "don'ts" that are still floating around in textbooks or from older habits.

The "Why" Behind the Struggle

The researchers didn't just stop at the test scores; they asked the students, "What stops you from doing the right thing?" The students answered with open-ended questions, and the researchers grouped these answers into six main themes.

Racing the Clock (51% of responses): The biggest complaint was simply a lack of time. Students felt overwhelmed by other tasks, leaving no time to reposition patients or check their skin carefully.
Knowing and Doing (54% of responses): This was the biggest theme. Students admitted there was a gap between what they were taught in class and what they could actually do in the hospital. They felt they knew the theory but lacked the hands-on experience to feel confident.
Stretched Too Thin (43% of responses): There weren't enough nurses for the number of patients. When one nurse is responsible for too many people, everyone gets less attention.
Without the Right Tools (26% of responses): Sometimes the special mattresses or cushions just weren't available.
The Patient in the Equation (12% of responses): Some patients were too heavy, in too much pain, or just wouldn't cooperate with being moved.
Falling Through the Cracks (13% of responses): Sometimes the team didn't talk to each other, or the notes weren't written down properly, so important warnings were missed.

The Path Forward

When asked how to fix these problems, the students had clear ideas. They wanted:

Regular training (suggested by 58.9% of respondents).
Simulation practice (where they can practice on mannequins or in fake scenarios), suggested by 35.7%.
Updated guidelines and checklists, suggested by 22.3%.

The study found that students who had been in school longer and had done more clinical placements (internships) generally knew more. However, even the senior students hadn't quite reached the level of "good knowledge" needed to be fully confident. The data suggests that simply getting older or spending more time in a hospital isn't enough; you need specific, guided practice to bridge the gap.

The Bottom Line

The paper concludes that "knowing is not doing." The students in this study have a decent foundation, but they are still tripping over old myths and facing real-world hurdles like time pressure and lack of equipment. The authors suggest that nursing schools need to do more than just teach the right answers; they need to actively teach students how to unlearn the wrong ones. By using more simulation (practice runs) and making sure the hospitals where students train have the right tools and enough staff, we can help these future nurses turn their knowledge into action, ensuring that the patients they care for stay safe and comfortable. The study doesn't claim to have solved the problem, but it has mapped exactly where the roadblocks are, offering a clear guide for how to clear the path.

Technical Summary: "Knowing is not doing": Knowledge, Misconceptions and Perceived Barriers to Pressure Ulcer Prevention Practice Among Nursing Students in the UAE

Problem Statement

Pressure ulcers (pressure injuries) remain a significant, largely preventable burden in acute care settings across the United Arab Emirates (UAE) and the broader Gulf region, with prevalence rates in the Eastern Mediterranean reaching 16.6% in intensive care units. While the theoretical framework for prevention is well-established—encompassing risk assessment, repositioning, nutrition, and support surfaces—a persistent "theory–practice gap" exists where nursing curricula fail to translate into competent clinical action.

Previous literature indicates that nursing students and qualified nurses often possess suboptimal knowledge regarding pressure ulcer prevention, particularly in distinguishing evidence-based practices from outdated or harmful interventions. However, specific data regarding the knowledge levels, misconceptions, and perceived barriers among pre-registration nursing students in the UAE has been anecdotal or limited. This study addresses the critical question of whether current nursing education in the UAE equips the future workforce to effectively prevent pressure ulcers, specifically investigating the divergence between what students know and what they perceive they can do in practice.

Methodology

The study employed a descriptive, cross-sectional design with an embedded qualitative component conducted at Fatima College of Health Sciences (FCHS) in the UAE.

Participants: 133 nursing students enrolled in clinical phases (Years 2, 3, and 4) of their program. The sample was predominantly Emirati (99.2%) with a mean age of 21.9 years.
Instrumentation:
- Quantitative: An adapted, validated 31-item Pressure Injury Prevention Knowledge (PIPK) questionnaire. Items were scored as True, False, or "Don't know," with a maximum score of 31. Knowledge was categorized as Good (≥80%), Moderate (60–79%), or Poor (<60%).
- Qualitative: Two open-ended questions solicited perceived barriers to prevention practice and suggestions for improvement.
Data Analysis:
- Quantitative: Descriptive statistics, t-tests, ANOVA, chi-square tests, and Spearman correlations were used to analyze knowledge scores against demographic and academic variables.
- Qualitative: Reflexive thematic analysis (following Braun and Clarke's six-phase approach) was applied to 112 substantive barrier responses. Content analysis was used for improvement suggestions.

Key Results

1. Knowledge Levels and Misconceptions

Overall Performance: The mean knowledge score was 19.9/31 (64.1% ± 16.6%). Only 20.3% of students demonstrated "Good" knowledge, while 37.6% scored in the "Poor" category (<60%).
The "Knowing vs. Doing" Gap: Students performed significantly better on items requiring the affirmation of correct practices (e.g., using devices to reduce friction, reassessing risk) than on items requiring the rejection of outdated practices.
- Top Misconceptions (Lowest Correct Rates):
  - Using hyper-oxygenated fatty acids for moisture protection: 14.3% correct.
  - Keeping bedridden patients with head-of-bed elevation at 30–45°: 17.3% correct.
  - Using cotton/elastic heel bandages to redistribute pressure: 19.5% correct.
  - Allowing up to 48 hours for admission skin assessment: 24.8% correct.
  - Using doughnut-shaped devices for pressure relief: 36.8% correct.
Correlates: Knowledge scores showed a positive correlation with the year of study ( $\rho=0.245, p=0.006$ ) and the number of clinical placements completed ( $\rho=0.220, p=0.014$ ). However, even final-year students averaged only 67%, indicating that clinical exposure narrows but does not close the gap to proficiency. Age and marital status showed no significant association with knowledge.

2. Perceived Barriers (Qualitative Themes)
Analysis of 112 barrier responses generated six primary themes:

Knowing and Doing (54%): The largest theme, describing a two-sided gap between formal education and the hands-on experience required to apply it confidently.
Racing the Clock (51%): Time scarcity and competing clinical duties preventing regular repositioning and skin assessment.
Stretched Too Thin (43%): Structural workforce constraints, including staff shortages and high patient-to-nurse ratios.
Without the Right Tools (26%): Lack of access to pressure-relieving equipment (mattresses, cushions).
Falling Through the Cracks (13%): Breakdowns in documentation and interprofessional communication.
The Patient in the Equation (12%): Patient-specific factors such as weight, mobility, and cooperation.

3. Suggested Improvements
Students proposed remedies that directly addressed the identified barriers:

Regular training and continuing education (58.9%).
Hands-on practice and simulation (35.7%).
Access to updated guidelines and checklists (22.3%).
Mentorship and improved staffing.

Key Contributions

Identification of Specific Misconceptions: The study provides granular evidence that while students learn what to do, they struggle significantly to unlearn what not to do. The high retention of harmful practices (e.g., doughnut devices, heel bandaging, excessive head elevation) suggests curricula may prioritize additive knowledge over the deconstruction of legacy practices.
Student Self-Diagnosis: The qualitative data reveals that students are acutely aware of the theory–practice gap, identifying it not merely as a lack of information but as a systemic issue involving time, staffing, and the lack of supervised repetition.
Regional Context: This research fills a data gap regarding nursing education in the UAE, confirming that the theory–practice gap observed globally is also present in this specific demographic, with implications for the region's rising pressure ulcer burden.

Significance and Claims

The paper concludes that the current nursing curriculum in the studied institution does not fully equip students to prevent pressure ulcers upon graduation. The authors claim that:

Curricular Reform is Necessary: Education must move beyond simply transmitting correct guidelines to explicitly deconstructing outdated practices, likely through case-based and simulation formats where students must actively choose against incorrect interventions.
Clinical Placements Must Reinforce Theory: The gap is not closed by clinical exposure alone; placements must be supported by adequate staffing, equipment, and supervision to allow students to practice guideline-concordant care.
Simulation is Critical: The students' own suggestions for simulation align with evidence that it improves decision-making and confidence by forcing engagement with practical application.
Systemic Nature of Barriers: The barriers are compounding and systemic (e.g., understaffing leads to time pressure, which prevents training and documentation), requiring a holistic approach to education and clinical environment design rather than isolated interventions.

The study asserts that bridging the gap from "knowing" to "doing" requires a curriculum explicitly designed to address the specific shape of these misconceptions and barriers, ensuring the future workforce is prepared to deliver evidence-based prevention before entering the clinical workforce.