Chronic kidney disease (CKD) is an increasing global health concern, with a prevalence of approximately 9.5% worldwide (1). It has risen from the 25th leading cause of death in 1990 to the 16th leading cause in 2017, and it is projected to become the 5th leading cause of death by 2040 (2, 3). Hemodialysis (HD) is a life sustaining intervention for CKD patients, but HD units carry a high risk for healthcare-associated infections (HAIs) due to frequent vascular access, environmental factors, and patient susceptibility (4). HAIs significantly worsen patient outcomes and are the second leading cause of death (5).

Nurses are central to HD care and are essential for implementing infection prevention and control (IPC) measures (6). However, adherence to IPC guidelines remains inconsistent, particularly in resource-limited settings such as the Gaza Strip (GS). Challenges include limited supplies, high patients loads, instability, and insufficient training, (7–9). Regular training, management support, and supervision are key to increasing knowledge and reducing HAIs and antimicrobial resistance (10, 11).

The number of patients undergoing HD continues to rise, accompanied by high mortality rates compared with those of other diseases. Infection remains the second leading cause of death among HD patients (12, 13). Ensuring patient safety is a key nursing goal, necessitating regular educational interventions to enhance nurses' knowledge and practice in IPC (14). Yet, in GS, many nurses have not received recent IPC training, and systemic barriers hinder sustained adherence. Therefore, this study aimed to evaluate the effect of a structured IPC training program on the knowledge and practices of HD nurses in governmental hospitals in GS, with the goal of informing sustainable strategies to enhance patient safety and care quality in this high-risk, constrained setting.

The study included a total of 112 HD nurses, who were evenly divided into control and intervention groups (n = 56 each). The highest proportion of participants were from Al Shifa Hospital (29.5%), followed by Nasser Al Ka'bey and Helal Al Daghma Hospitals (19.6% each). The mean age of the participants was 35.76 ± 7.31 years, with the majority (54.5%) aged between 31 and 40 years. Male nurses comprised 71.4% of the sample, and 78.6% held a bachelor's degree. Most participants (91%) were working in adult HD units, and the average duration of work experience was 5.79 ± 5.12 years. More than half of the nurses (50.9%) reported never having received IPC training, whereas among those who had, 77.7% had received training more than five years prior, highlighting the critical need for updated and regular IPC refresher courses (see Table 1).

The results in Table 2 reveal significant variations in IPC knowledge and practices across different hospitals, HD units, age groups, genders, education levels, professional experience, and prior training. post-hoc Least Significant Difference (LSD) tests, conducted following significant ANOVA results, identified specific pairwise differences among hospitals and education levels. For IPC practice in the intervention group, Al Rantesy Hospital (reference) demonstrated significantly higher adherence compared to Al Shifa (p = 0.001), Al Aqsa (p = 0.001), and Al Najjar (p = 0.001). No significant differences were observed between Al Rantesy and N. Al Ka'bey (p = 0.001) or H. Al Daghma (p = 0.001). In the control group, Al Najjar Hospital (reference) had significantly lower practice scores compared to all other hospitals (all p < 0.05). For IPC knowledge in the intervention group, Al Rantesy (reference) scored significantly higher than N. Al Ka'bey (p = 0.217), Al Shifa (p = 0.004), Al Aqsa (p = 0.016), and Al Najjar (p = 0.030), while no significant difference was found compared to H. Al Daghma (p = 0.189). Regarding education level, master's degree holders (reference) in the intervention group had significantly higher knowledge scores compared to those with a diploma (p = 0.047) or bachelor's degree (p = 0.015).

Overall, among hospitals, Al Najjar Hospital's control group presented lower IPC practice scores, whereas nurses from Al Rantesy Hospital in the intervention group presented significantly greater IPC knowledge and practices (P = 0.001). Pediatric HD nurses consistently outperformed adult HD nurses in both knowledge and practice post-intervention (P = 0.022, P = 0.001), which is a trend that is consistent with the findings of Mohamed and Fashafsheh (19) and the World Health Organization (20), who attributed this to the high acuity of care in pediatric units. While no significant age-related differences were found in IPC knowledge (P = 0.091, P = 0.181) or practice (P = 0.112, P = 0.657), younger nurses scored higher in IPC practice (≤30 years: 50.15 vs. >40 years: 40.60), which aligns with findings by Trifunovic-Koenig, Bushuven, Gerber, Otto, Dettenkofer, Salm and Fischer (21) on adaptability to evolving protocols. Gender differences in IPC adherence were statistically insignificant, although female nurses slightly outperformed male nurses in practice (P = 0.253), which is consistent with the findings of Trifunovic-Koenig, Bushuven, Gerber, Otto, Dettenkofer, Salm and Fischer (21) but contradicts the findings of Alsulami, Sacgaca, Pangket, Pasay-An, Al Amoudi, Alreshidi, Alrashedi, Mostoles Jr, Buta and Areola Jr (22), suggesting that external factors such as workload distribution play a role. Education level was a significant determinant of IPC knowledge, with master's degree holders scoring higher than diploma or bachelor-level nurses (P = 0.047, P = 0.015), yet practice scores did not show a corresponding increase (P = 0.112), underscoring the persistent “know-do gap” (23). Professional experience did not significantly impact IPC knowledge (P = 0.941, P = 0.391) or practice (P = 0.211, P = 0.603), reinforcing findings from Savul, Ikram, Khan and Khan (24) that structured training, rather than experience, determines compliance. Similarly, prior training had no significant influence on IPC knowledge (P = 0.142, P = 0.381) or practice (P = 0.312, P = 0.067), suggesting that one-time training is insufficient for sustained adherence and emphasizing the need for continuous, structured IPC programs (20, 24). The observed variations across hospitals, unit types, and demographic groups highlight the need for IPC training tailored to specific institutional and workforce contexts. Although post-intervention knowledge improved significantly, the persistent knowledge practice gap indicates that systemic barriers such as limited resources, high workload, and institutional policies continue to hinder IPC adherence. These findings support the need for sustained mentorship, periodic refresher training, and stronger policy enforcement to promote long-term IPC compliance across hemodialysis settings.

Table 3 shows that the intervention and control groups were comparable at baseline, with no significant differences in mean knowledge (49.12% vs. 46.61%; p = 0.299) or practice adherence (49.70% vs. 48.20%; p = 0.560). One week after implementation of the IPC training program, the intervention group demonstrated markedly higher knowledge scores compared with the control group (79.91% vs. 49.40%; p = 0.001), reflecting a 62.68% improvement from baseline. A similar pattern was observed for IPC practice, where the intervention group achieved significantly greater adherence than the control group (68.90% vs. 47.65%; p = 0.001), corresponding to a 38.63% improvement. Paired analyses confirmed significant pre–post gains only in the intervention group, whereas the control group showed no meaningful change. Overall, these findings confirm that the IPC training program produced substantial and statistically significant short-term improvements in both knowledge and observed practice among hemodialysis nurses.

Despite these gains, certain practices, such as routine disinfection, showed only marginal improvement, likely reflecting persistent challenges such as limited resources and high patient-to-nurse ratios. These findings are consistent with prior research by Tabash, Kashkash and Eljedi (25) and Eljedi and Dalo (9), who reported similar post-training improvements in IPC adherence among Palestinian HD nurses. Additionally, the results align with those of Singh, Kaur, Saini, Singh, Aggarwal and Chandra (26), who reported a 50% increase in IPC compliance following training interventions in northern India.

Noteworthy improvements were observed in specific clinical procedures, including arteriovenous fistula/graft cannulation (P = 0.001) and catheter disconnection care (P = 0.001), supporting the results of Tannous, El-Saed, Ameer, Khalaf, Mohammad, Molaeb and Alshamrani (27) and Kadium (28). However, other domains, such as medication administration (P = 0.393) and linen management (P = 0.234), showed minimal gains, suggesting the need for supplementary strategies beyond training, such as workflow optimization and strict policy enforcement, to achieve sustained IPC compliance. This is supported by Tu, Elling, Behnke, Tseka, Kafanikhale, Mofolo, Hoffman and Cronk (29), who emphasized that nurses in high-pressure environments may prioritize task efficiency over protocol adherence, despite adequate training.

Overall, the study shows that hands-on IPC training improves knowledge and practical skills; however, sustained compliance requires addressing systemic barriers through ongoing education, simulated practice, and structured feedback to reinforce behavior change.

This study has several limitations. First, although the study included a control group, and pre-post measurement, the allocation was non-random and based on a systemic roster method. Formal allocation concealment was not implemented, as the researcher was aware of group assignment during recruitment, which represents a common limitation of quasi-experimental studies conducted in operational clinical settings. Second, assessor blinding was not feasible, as the same researcher delivered training and conducted evaluations, though standardized protocols, repeated unannounced visits, and a tool with established reliability (Cronbach's α = 0.921) to mitigate observation bias. Inter-rater reliability statistics (e.g., ICC or Kappa) were not calculated, as observations were conducted by a single trained assessor. Third, the short post-intervention assessment period limits conclusions regarding long-term retention of IPC knowledge and practices. Finally, contextual systemic barriers such as limited resources, high patient-to-nurse ratios, and operational disruptions in the Gaza Strip may affect the sustainability of improved practices. Future studies would benefit using centralized randomization systems, blinded independent assessors, and longer follow-up periods to strengthen causal inference and evaluate sustained compliance.

The Quasi-experimental study demonstrates that a structured IPC training program led to significant improvement in HD nurses' knowledge and practices in governmental hospitals in the Gaza Strip. These short-term gains underscore the value of targeted educational interventions in resource constrained setting. However, considering the study's limitations, sustained IPC compliance will require more than training alone and must address the persistent systemic barriers highlighted in this context. To translate these improvements into practice change, we recommend: (1) implementing regular and mandatory IPC training for HD nurses, (2) integrating IPC into nursing curricula, (3) ensuring consistent availability of essential IPC supplies, (4) fostering multidisciplinary collaboration, and (5) enforcing IPC guidelines through continuous supervision and clear accountability measures. Future research should employ longer follow-up periods and blinded assessment to better evaluate the sustainability of training effects.

SOA and OMOK supported tool development, training implementation, hospital coordination, and data collection. MK conceptualized and led the study. MJAN supervised the methodology, and contributed to data analysis and interpretation. SAZ contributed to data analysis and interpretation. YFF provided statistical support and assisted in manuscript preparation. All authors reviewed and approved the final manuscript.