Hello
Thank you for the opportunity to review this manuscript. Pressure injury prevention education for patients is an important topic that requires further exploration.

I have made some comments for you to consider below. Please note these comments aim to be constructive in nature and I will leave you and the authorship team to make decisions about which comments you may find useful to support the future development of the manuscript.

Abstract
- The abstract is appropriate based on the findings from the study

Introduction
- Page 3, Lines 7-16. This is a very long and complex sentence. I would suggest revising this sentence to improve readability.
- Page 3, Lines 22-26. Revise this sentence for word choice. "Pressure injury prevention (PIP) is a healthcare priority [4] in mitigating the harmful physical, mental, and emotional impacts on patients and the economic burden on healthcare institutions [1, 2, 4]."
("in mitigating") doesn't quite work here.
Background
- Page 3, Lines 32-36. I am not sure why Waterlow has been singled out here (especially since research using the Braden scale is discussed later in the background). Perhaps refer to the use of validated risk assessment tools. Note however that much research recommends the use of validated risk assessment tools AND clinical judgement of Registered Nurses.
- Page 3, Lines 37-41. Consider reframing this. "Patient education in PIP delivered by nurses aims to ..." Might be better expressed as Pressure injury prevention education for patients aims to ...
- Page 3, Lines 41-45. This statement has references to support it but I do not think the literature supports such a strong statement. Your statement is ... " Patient benefits from receiving PIP education include shorter hospital stays, improved outcomes, and greater patient satisfaction [7, 8] and confidence [9]." To my knowledge there is no equivocal evidence to support such a strong statement. Patient PIP education has been linked to improved satisfaction and confidence. You may need to moderate this.
- Page 4, Paragraph beginning line 29. This paragraph could benefit from revision. The content is disjointed and you skip between different foci in different sentences.
- Reference 20 is from a study conducted in 1996. Immediately after this reference is the sentence .... " An earlier study [21] found Braden Scale score, hospital length of stay, and clinical unit (geriatric care and intensive care unit (ICU)) to predict the implementation of regular repositioning and use of alternating pressure mattresses [21]. This needs to be revised as obviously the reference 21 is from a study conducted in 2015.
- Page 4, Paragraph beginning line 29. The logic in this paragraph requires review. There are many studies on factors that predict PIs. You have highlighted a few but also state they may not be relevant in the Australian context. This diminishes the Australian studies that have explored this topic. Its complex to ensure the content you explore is global in focus and then highlights the local gap that your study aims to fill but this requires additional revision in my opinion.
- Page 4/5. Lines 60 to 5. "A 2017 observational study [25] reported patients’ “at-risk” Waterlow © score predicted the number of prevention strategies implemented, use of support surfaces and receipt of PIP education during hospitalisation." Your meaning here is clear ... what does "at-risk" Waterlow score mean?
Also, wouldn't we expect Waterlow score to predict PI intervention and education. It would not be an effective risk-assessment tool if it did not.

Methods
Study Sample
- Page 6, Lines 31-32. This sentence is redundant. "The accuracy of analysis was influenced by sample size [26]."
Inclusion Criteria
- Please provide additional detail about how mobility was used in the inclusion criteria. The table states "Independent or limited mobility". It is not clear to me what you mean by this. For example, excluding all immobile patients may have a significant impact on findings.
- If I read this section (and section 4.1 correctly), patients must have been "at-risk" of developing a PI to be included in the study. What cut-off value was used? If I read this section correctly, this risk assessment was performed by the staff looking after the patient (as part of screening). It was then verified by the research assistants to confirm eligibility. Given that a participant had to be "at-risk " of PI to be screened how sure are we that the RNs and ward staff were accurately assessing all patients. That is, were some patients excluded who shouldn't have been? This may not matter.
Section 4.5
- This could be synthesised into a table (if you have room for any additional tables). If it remains text, then it could be more succinct.
- There are a range of other predictive variables e.g. mobility, nutritional status. These have not been collected or analysed. I am not sure why. Some justifications of how the variables for data collection were chosen is required.
Data Collection
- Good Clinical Practice training may not have specific meaning for international readers. I would revise this to state that all research assistants had training in XXXXXX.
- If all measures are in a table (see comment on Section 4.5) you could refer to how they were collected in the same table, and this may reduce some duplication that is evident in the methods. I note that Table 2 could be expanded to include this information so there may not be a need for an additional table.

Results
- Page 10, Lines 28-30. If the Waterlow score was used to screen for eligibility and patients who were at risk of PI were included in the study how did only 87% have a Waterlow score recorded within 24 hours. Did the others have theirs done after 24 hours? If so, then 100% had it recorded but only 87% had it recorded within 24 hours. Make sure the intext description is clear.
- I don't understand how Waterlow risk score is a predictor variable. Didn't all patients have a Waterlow score completed to be eligible? Is it a score of a certain value? Did you dichotomise this? Revise so this is clear.
- In reading the results I think there were missed opportunities to collect data about mobility status, nutritional status, presence of a preexisting PI etc. I am left wondering if a person was immobile, malnourished or had an existing PI whether they would also have received PIP education. At the moment having a higher BMI is the only predictive variable but it's not really telling the full story (or maybe it is - but its hard to assess this based on the data collected).
- Some more detail is needed about the anecdotal comments. Was this documented verbatim from participants? Were comments received only from patients who received PIP education? If so there is a discrepancy between number of patients who received PIP and number of participants who provided anecdotal comments

Discussion
- Each paragraph makes important points but some of the feedback already provided needs to be considered when developing the logical arguments that are presented.
E.g. Is BMI in isolation enough to predict PIP education, or is perhaps immobility a better predictor of nurses delivering PIP to patients at risk of PI? Given that mobility and other potential risk factors were not collected then we cant answer this question.
- The discussion of organisation, clinical and nurse related factors is quite superficial. Comparing organisation A to organisation B is not really comparing orghanisational factors. The readers knows nothing about the organisational context of each facility and can not apply this knowledge to there own context.
- For example, you state ... "These results contrast with research suggesting organisational culture impacts the delivery of PIP education." It is important to comment here that you do not appear to have explored organisational culture in your study,
- Similarly, you do not appear to have explored nursing knowledge or skill in relation to PI prevention or PI prevention education. Therefore statements exploring other studies that have done so can only be used to contextualise your findings and make recommendations.

Recommendations
- Your opening sentence states BMI and Waterlow score are predictors of developing a PI. This is an oversimplification. For example, impaired mobility is the largest predictor.

Conclusions
- May need to be revised based on feedback above.

Thank you for the opportunity to review your manuscript.

Regards
The Reviewer

Hello

Thank you for the opportunity to review this revised version of your manuscript. Please review all references and ensure that they are relevant for the specific context in your paper where they are used.
The background section of your manuscript still requires significant revision. The logical development of your argument requires improvement as much of the new writing makes this disjointed and difficult to follow.
The flow of writing in many sections of the manuscript has not been improved with the addition of new content and the revisions made. Please review and reassess to improve the presentation of the content.

Introduction:
Page 3, Lines 26-31. Review this sentence - "Whilst PI development is multi-factorial, risk factors such as reduced mobility, poor nutrition, incontinence, advancing age, hospitalisation, recent surgery, certain medical conditions and a history of prior pressure injuries predispose patients to PI development [5]."
I want to highlight that while PI development is multifactorial in nature, immobility is an independent predicator of risk, and this is not sufficiently highlighted in your writing on this.
Page 3, Lines 31-43. Revise this new writing to improve clarity. "Accordingly, pressure injury prevention (PIP) is a healthcare priority [5] aimed at providing patients with strategies to improve participation in their PIP care during hospitalisation. Moreover, patient education as a PIP strategy is recommended by the National Pressure Injury Advisory Panel (NPIAP), the European Pressure Ulcer Advisory Panel (EPUAP) and the Pan Pacific Pressure Injury Alliance (PPPIA) in the international clinical practice guidelines [5]. Increasing patient participation in their own PIP care may reduce the economic burden on healthcare institutions associated with treatment costs [1, 2, 5]. "
The object of sentence 1 in this quote is PIP but it involves more than "providing patients with strategies to improve participation in their PIP care during hospitalisation".

Background:
Page 4, Lines 8-12. Revise grammar. Comma's are needed between referenced concepts
Page 4, Line 17. Full stop at end of sentence
Page 4, Lines 20-24. Revise this content to ensure a broader discussion of the following important questions related to your study. Do patients who are not at risk of developing a PI require PIP education? Is it reasonable to assume that this can even be provided at the time of risk assessment (or in the first 24 hours of admission)?
Page 4, Paragraph commencing Line 32. Revise this paragraph to improve logic and flow.
Page 4, Paragraph commencing Line 58. Revise this paragraph to improve logic and flow.
Page 5 - Reference 32 is from 1996. Is it even relevant in 2025?
Page 5, Lines 46-55. Revise this writing. "A 2017 observational study found that patients with "at-risk" Waterlow © scores (10-14) despite being the least implemented strategy, patients were more likely to receive PIP education, which was provided four times more to "at-risk" than "no risk" patients [35], despite being the least implemented strategy. Despite this, there is a lack of research on predictors of PIP education in acute care, prompting this study to investigate contextual, clinical, and patient factors predicting its delivery." It is very difficult to follow your logic here.

Design
Page 6. The new detail provided in this section is helpful. Thank you. I would recommend revision to ensure it is more succinct. A more logical approach to presenting this information could improve flow. Perhaps start with how this is a study from a larger RCT that sought to XXXXX.
You need to be careful with language otherwise reference to study and sub-sample becomes confusing for the reader.

Study sample
Page 6, Lines 29-31. Consider revising this to improve clarity. "A consecutive sub-sample of the first 150 control group participants was drawn from hospital sites A & B of the parent trial [36] (for a total of 300 participants). "
e.g. The study sample consisted of the first 150 participants (300 participants in total) who were randomly allocated to the control group at hospital sites A and B from within the parent trial (Ref).

Inclusion & Exclusion criteria
Page 7, Line 52/53. I am not sure what you mean by this sentence: "PI risk assessment score is a known precursor to PI prevention [5]."

Measures
Page 8, Line 22-25. Revise this sentence. Your meaning is unclear. "Predictor variables were selected based on clinical experience, prior research [35], and known PI risk factors [5, 7] informed the selection of the predictor variables."
Page 8, Lines 25-27. You state: "Table 2 details data collection methods for variables such as age, sex, and BMI—key PI risk factors [5, 7]." Age, sex and BMI are not what I would describe as key PI risk factors.
Page 8, Lines 27-32. You state: "BMI is a numerical measure of body size and nutritional status [41], increases PI risk in both under or overweight individuals [5]." How was a BMI score that indicates that a person was either overweight and underweight used and modelled in your study. I note that mean and % are used in Table 3. But a range, or SD, is provided rather than %. Given that the literature tells us that those with a low BMI and those with a high BMI are at increased risk of developing a PI I am not sure how this was managed, and it is not clear in your findings or in the model-building that was conducted. I naote that you have indicated BMI was a continuous variable. Please note this comment also needs to be addressed in the findings section of your paper.

Results
Page 12, Lines 12-33. Please see earlier comments about BMI and risk at low and high BMI scores. How was this modelled?

Discussion
You have explored literature on studies in your discussion that identify patients with low and high BMIs. This data was not reported in your study which makes it very hard to interpret your findings in this context. Only mean and either range or SD. This makes interpretation of your findings difficult.

Final comments.
While I think this is an important study, and I look forward to reading more about your findings, further revision and clarification is required in many sections of the manuscript.

Regards
The Reviewer

Hello

Thank you for the opportunity to review a revised version of this manuscript.

You appear to have diligently addressed feedback from previous peer review. I believe that all major comments and feedback have been addressed.

There are two versions of the manuscript in your submission. The first manuscript does not appear to be the final version associated with the track changes as the references and text are different in many places throughout. I am not sure if this is the previous version, or not, or perhaps the incorrect file.

I have therefore based my comments on the second manuscript with the track changes. Reviewing the manuscript with these track changes can introduce some typographical and editorial issues - or make it harder to identify them. Your previous revisions used coloured text to highlight changes made - and I think this is much easier to review. You may want to consider this in the future.

As a result of reviewing the track-changes version of the manuscript, I have identified quite a few typographical and editorial issues in the manuscript. This will need to be reviewed, and a comprehensive edit undertaken. I have not listed these due to the nature of them.

Please also take care with how abbreviations are being used. PIP appears as an abbreviation at a point in the manuscript but is written out in full for all uses prior to this. Given you are abbreviating PI then perhaps 'PI prevention' is clearer, but I will leave this for you to decide. I have no specific preference but would encourage you to be consistent.

Thanks again for the opportunity to review.

Kind regards
The Reviewer