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Influences on compliance with standard precautions among operating room nurses
Influences on compliance with standard precautions among operating room nurses Sonya Osborne, RN, BSN, MNurs Canberra, Australia
Background: Occupational exposures of health care workers occur because of inconsistent compliance with standard precautions. The purpose of this study was to develop national estimates of compliance with standard precautions and occupational exposure reporting among operating room nurses (specifically, scrub nurses) in Australia and to assess variables that influence compliance. Methods: A descriptive correlation design was used to investigate relationships between variables and compliance, using a theoretical framework, the Health Belief Model, to give meaning to the variables. Data collection was done through mail-out surveys to members of the Australian College of Operating Room Nurses. Results: This article reports the results of compliance with the following 2 specific self-protective behaviors: double-gloving and wearing adequate eye protection. Mean compliance rates were 55.6% with always double-gloving during surgical procedures and 92% with always wearing adequate eye protection. In addition, the variable that had the most influence on compliance was the perception of barriers to compliance, specifically, that adhering to standard precautions interfered with duties. Conclusion: These results have implications for the development of multifaceted perioperative infection control programs, including strategies for prevention, education, and policy development, to improve practices aimed at reducing occupational exposures among this high-risk group. (Am J Infect Control 2003;31:415-23.)
The focus of infection control since the discovery of the mechanism of disease transmission by Lister and others in the 1800s has been on the prevention of patient-acquired nosocomial infections.1 Throughout the years, health care workers have become increasingly aware of their risks of contracting diseases from patients, especially bloodborne infections such as hepatitis B virus (HBV); human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS); and more recently, hepatitis C virus (HCV). Global statistics on occupational exposures of health care workers to bloodborne pathogens are startling. Transmission rates after occupational exposure for HIV, HBV, and HCV are estimated at 0.3%, 6% to 30%, and 1% to 10%, respectively.2-4
From the University of Canberra, School of Nursing. Reprint requests: Sonya Osborne, RN, BSN, MNurs, The Canberra Hospital and University of Canberra Research Centre for Nursing Practice, Woden, ACT 2606 Australia. Copyright ª 2003 by the Association for Professionals in Infection Control and Epidemiology, Inc. 0196-6553/2003/$30.00 + 0 doi:10.1067/mic.2003.68
HISTORY OF STANDARD PRECAUTIONS IN AUSTRALIA In the mid-1980s, in response to the increase in prevalence of HIV/AIDS and the increased concern for the protection of the health care worker, the Centers for Disease Control and Prevention proposed the concept of universal precautions. Universal precautions guidelines involved treating the blood and body fluids from all patients as potentially infectious. However, certain body fluids (ie, feces, nasal secretions, sputum, sweat, tears, urine, and vomitus, unless they visibly contained blood) were not included in these guidelines.5 This definition of universal precautions was adopted in Australia, albeit in an expanded form. Work practices in Australia have the underlying assumption that all blood and body substances, without exception, are a potential risk of disease transmission. In Australia, the principle of ‘‘confine and contain’’ applies to all patients and all procedures in the operating room, and universal precautions are mandated by state departments of health as the policy of infection control in public hospitals. Universal precautions are limited in that they focus only on disease transmission through blood and body fluids and do not incorporate precautions for transmission by other means. It was recognized in Australia that the term ‘‘universal precautions’’ was ambiguous, caused confusion in its 415
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interpretation, and led to a false sense of security.6 This was evident in reports of health care workers substituting glove-wearing for appropriate handwashing. It was at this time that the National Health and Medical Research Council and the National Council on AIDS recommended a change in terminology. This change in terminology reflects a 2-tiered approach to infection control and is in line with the changes in terminology adopted by the Centers for Disease Control and Prevention in 1996.6 Universal precautions has been broken down to reflect a 2-tiered approach. The first tier, standard precautions, is the first line of defense in infection control and assumes that all blood and body fluids are potentially infectious. Standard precautions include diligent hygiene practices (eg, handwashing and drying), use of personal protective equipment (PPE) (eg, gloves, gowns, masks, and eye protection), and appropriate handling and disposal of sharps (eg, safe transfer, no needle recapping, immediate disposal after use). Standard precautions are used when handling nonintact skin; mucous membranes; blood; and all other body fluids, even if dried, except sweat.6 In 1996, ‘‘the Infection Control Working Party in Australia recommended adoption of the term ‘‘standard precautions’’ as the basic risk minimisation strategy . . . to prevent transmission of infection.. . .’’6 The second tier, additional precautions, is the second line of defense in infection control. It is used in addition to standard precautions in situations in which standard precautions may be insufficient to prevent transmission of infection, in cases in which the patient has a known or suspected infection or colonization with an epidemiologically important or highly transmissible pathogen.6 The modes of transmission of these significant pathogens is usually by airborne transmission, droplet transmission, or transmission via direct or indirect contact with intact skin or contaminated surfaces.6 By consistently incorporating this 2-tiered approach of standard precautions and additional precautions into work practices, a high level of protection against occupational exposure of diseases from the patient to the health care worker can be obtained. Breaches in these guidelines, designed to protect the health care worker, may result in an increased risk of occupational exposure and subsequent disease transmission.
AIM OF THE STUDY The efficacy of using specific standard precautions behaviors—such as double-gloving and wearing protective eyewear—in particular circumstances in the operating room in decreasing the risk of disease transmission has been well supported in the literature. Research continues to report a less than 100% compli-
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ance rate with standard precautions among health care professionals, despite the demonstrated benefits of compliance with standard precautions, including a decrease in disease transmission by the reduction of risk of exposure. It is therefore necessary to explore factors that influence whether a health care professional will comply with standard precautions. Once these influences are identified, appropriate programs can be implemented with the aim of improving compliance and reducing the risk of occupational exposures. A study was conducted with the following aims: (1) assessing the attitudes, beliefs, and level of compliance with standard precautions and occupational exposure reporting and (2) identifying influences on compliance with standard precautions and occupational exposure reporting among operating room nurses in the scrub role in Australia. The focus of this article is on compliance with standard precautions. Thus, research questions guiding this study included the following: What is the self-reported compliance rate with standard precautions among operating room nurses? What factors influence compliance? This article focuses on 2 standard precautions behaviors, that is, double-gloving during surgical procedures and the wearing of adequate eye protection by operating room nurses in the scrub role.
STANDARD PRECAUTIONS IN THE OPERATING ROOM ENVIRONMENT In the operating room, the wearing of gloves, gowns, and masks by operating room personnel is a necessary requirement to establish and maintain an aseptic environment for the patient, thus helping to decrease the chance of wound infection for the patient. However, more diligent use of these barriers, as well as other self-protective health behaviors, can be used in the operating room to decrease the operating room nurses’ chance of occupational exposure and risk of acquiring bloodborne infections from patients. Several measures, some in excess of the minimal standard precautions, have been demonstrated to be effective in decreasing occupational exposures in the operating room. Two of these measures are double-gloving7-10 and wearing adequate protective eyewear.11-13 Paramount to the use of any of these standard precautions is a comprehensive education and training program on infection control. Studies14,15 have shown that it is possible to improve compliance with standard precautions through strategies such as regular education and mandated policies. Previous research focusing on operating room personnel—specifically, operating room nurses—reported incidence of occupational exposure but not necessarily
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incidence of compliance with standard precautions to prevent occupational exposure.15-18
SAMPLE/STUDY POPULATION The target population for the study was operating room nurses selected from the accessible population of current members of the Australian College of Operating Room Nurses (ACORN), a professional organization representing operating room nurses in Australia. To obtain a study sample that reflected the state representation in ACORN, subjects were chosen from the sampling frame of ACORN membership with use of a stratified random sampling method on the basis of the proportion of ACORN members per state in Australia. The only sampling criteria for inclusion in the study sample were current membership in ACORN and a mailing address in Australia at the time of questionnaire distribution. Five hundred questionnaires were distributed. Sample size calculations determined that at least 176 members needed to be surveyed for the study sample to be representative of the total ACORN membership (n = 1710 members). Two hundred twenty-seven of the 230 questionnaires returned were included in the analysis. This 45% response rate represents 13% of the total membership of ACORN. Demographic distribution of respondents is shown in Table 1.
METHOD AND DESIGN The research design chosen for this study was a descriptive correlational design. This design allows inter-relationships that exist between variables to be examined to identify problems with current practice and provide knowledge about the variables. Through use of a theoretical framework, these variables are given meaning, and thus logical conclusions can be drawn about which variables have the greatest influence on the health behavior. The theoretical framework used to guide development of the data collection instrument and analysis of the data was the Health Belief Model (HBM).
HEALTH BELIEF MODEL The Health Belief Model19 describes specific variables that influence whether an individual will undertake particular self-protective health behaviors. These variables include the following: (1) perception of risk or susceptibility to the illness, (2) perception of severity or degree of consequence of the illness, (3) perception of the benefits of undertaking a recommended health behavior, (4) perception of barriers or costs of undertaking a particular health behavior, and (5) cues to action that trigger the health behavior. The first 4 variables have been tested and demonstrated in subsequent research, but the difficulty in testing cues
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Table 1. Demographics of the sample Nursing education Hospital trained University and/or hospital trained No answer
Age range of participants 74.3% 24.3%
20–29 y 30–39 y
5.8% 30.8%
1.3%
40–49 y 50–59 y [60 y
75.4% 23.7% 0.9%
Years postregistration nursing experience \2 y 2–5 y 5–10 y [10 y
Scrub nurse experience 0.9% 4.4% 11.0% 83.8%
Type of facility Private/day hospital Public hospital No, or both answers
7.9% 10.1% 15.0% 67.0%
Employment status 31.4% 65.0% 3.6%
No. beds \100 101–300 301–600 [600
\2 y 2–5 y 5–10 y [10 y
Full time Part time/casual No answer
59.7% 38.9% 3.6%
No. operating rooms 22.8% 37.1% 30.4% 9.8%
1–2 3–5 6–8 [8
16.4% 37.6% 23.5% 22.6%
to action was recognized, especially in retrospective studies, because of the individuality of this variable.19 In later versions of the HBM, the construct of health motivation or the desire to undertake the particular health behavior was added.20 The HBM is a model that has its basis on the interaction of the individual’s readiness to comply with the behavior and the motivating and enabling factors that determine what the individual will do.21 Readiness depends on perceptions of risk and severity of acquiring a bloodborne infection as well as perceived benefits of undertaking the self-protective behaviors. Motivating and enabling factors include the individual’s personal characteristics, previous experience, social pressures, and barriers to undertaking the behavior. This interaction determines the likelihood of compliance with recommended self-protective behaviors. It is the interaction of these variables that allows for the prediction of health behaviors.
DATA COLLECTION Data collection was done through a self-report mail-out survey. This study attempted to establish relationships between variables (ie, influences) and compliance with standard precautions. Therefore, a 96-item questionnaire was developed to test and explore relationships between compliance with standard
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precautions and the variables described in the HBM. The questionnaire included items that were previously tested for internal consistency and reliability in application of the HBM in the prediction of undertaking self-protective health behaviors.20 Additional questions were added to determine level of compliance with standard precautions and occupational exposure reporting behavior and to gather basic demographic information. The questionnaire was checked for content validity by review from 4 operating room nurses with at least 5 years of operating room experience (total of 43 years of experience). These nurses were employed at the clinical nurse specialist/nurse educator level or higher and were considered to be experts by their peers. Comments and suggestions were taken into account, and appropriate changes were made. The university’s Human Research Ethics Committee approved the study before the questionnaire was pilot-tested among a small sample (n = 50) of operating room nurses in the Australian Capital Territory. On the basis of the quality of data and the comments obtained from the pilot study, the questionnaire was revised before distribution to the study sample. Instrument revision included changes to questionnaire item wording and format on the basis of preliminary analysis of data and comments by pilot study respondents. The majority of questions were changed to Likert response questions with the same 5 responses (ie, strongly agree, agree, neutral, disagree, strongly disagree) for ease of response. Questions about reasons why a study participant would not undertake certain behaviors were changed from open-ended to Likerttype responses to facilitate coding. Questions on frequencies were changed so that ‘‘none’’ was a category on its own. This was done because of the difficulty in separating ‘‘no’’ exposures from a small number of exposures (ie,‘‘1 or 2’’) when analyzing the pilot survey data. Although the exclusion of open-ended questions may be considered a limitation in the quality of data collected (ie, qualitative), for the purposes of this study (ie, to gain baseline data), closed-ended questions were considered suitable by the researcher for this study. The Cronbach a coefficient was used to test reliability for each questionnaire item within the construct scales of the HBM. The construct scales of perception of risk and perception of severity demonstrated consistency coefficients of 0.71 and 0.70, respectively. The scales for perception of benefits of standard precautions demonstrated a consistency coefficient of 0.51. Scales for perception of barriers to standard precautions were subgrouped into doublegloving and wearing adequate eye protection, yielding consistency coefficients of 0.78 and 0.76, respectively. For well-developed instruments, the lowest acceptable
reliability coefficient is usually 0.80, although for a new instrument, 0.70 is considered acceptable.22 Therefore, scales with a Cronbach a coefficient of less than 0.70 were not included in the analysis, unless otherwise indicated. Internal reliability was comparable with that demonstrated in the original instrument by Champion20 (Table 2). After the university’s Human Research Ethics Committee approved the study, 500 questionnaires were mailed to a stratified random sample of ACORN members. The questionnaires, accompanied by a participant information sheet, were sent to a council representative of ACORN who received the questionnaires in sealed, stamped envelopes, which also included a prepaid return envelope. Mailing labels were generated from ACORN’s membership list on the basis of randomization parameters set forth by the investigator. The ACORN councilor affixed the mailing labels and mailed the questionnaires. Although an organizational mailing list was used for questionnaire distribution, the researcher did not have access to this mailing list. Completed questionnaires were returned directly to the study investigator anonymously via the prepaid return envelope enclosed with each questionnaire. Respondents were given a return date to allow 4 weeks for completion and return of the questionnaire to the investigator. The questionnaires were distributed in this way to ensure the anonymity of the sample population from the researcher and to ensure that the personal information of the members was protected by ACORN.
RESULTS The results of this study revealed a compliance rate with standard precautions of less than 100%, with a mean compliance rate of 72.1% for all study behaviors (Table 3). There was no significant difference between some demographic characteristics, such as sex, nurse education, nurse status, years of post registration nursing experience, and type of facility and compliance with either double-gloving or wearing adequate eye protection. However, other demographic characteristics, such as age, years of scrub nurse experience, size of facility and operating room complex, type of employment, and state of employment, demonstrated significant difference with either compliance with double-gloving, compliance with wearing adequate eye protection, or both. A significant relationship was present between double-gloving and several demographic variables. Compliance rates were significantly greater for nurses with fewer than 2 years of scrub experience (x2= 16.415, df = 3, P \ .05) and significantly less for nurses working in small facilities (x2 = 15.761, df = 6, P \ .05) with few operating rooms (x2 =
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Table 2. Examples of items evidencing internal consistency for HBM scales Item number
Survey item
Corrected item total correlation
Cronbach’s a
Cronbach’s a (Champion)20
0.39 0.34 0.36 0.35 0.59
0.71
0.78
0.49 0.47 0. 59
0.70
0.78
0.21 0.27 0.30 0.57 0.30
0.51
0.61
0.62 0.71 0.46 0.64 0.44
0.78
0.76
0.52 0.68 0.39 0.70
0.76
0.76
Risk scale Q12 My chance of getting hep B or C is high Q15 There is a possibility that I will get hep B or C Q16 I worry a lot about getting hep B or C Q23 My work related activities put me at risk of contracting hep B or C Q24 If I sustain a perc. exposure. . .it is likely I would contract hep B or C Severity scale Q18 If I get hep B or C my career would be endangered Q19 Hep B or C would endanger a significant relationship Q20 My financial security would be endangered if I got hep B or C Benefits scale Q26 Wearing protective eye wear decreases my risk of acquiring hep B or C Q27 Double gloving when scrubbed for surgical procedures decreases my risk... Q28 Not recapping needles decreases my risk . . . Q29 Announcing sharps transfers decreases my risk . . . Q30 Using a hands free sharps passage technique decreases my risk... Barriers scale (double gloving) Q60 Double gloves produce hand numbness and tingling Q61 Double gloves interfere with duties Q62 Double gloves are too expensive Q63 Double gloves are a poor fit Q64 Double gloves are in limited supply at my facility Barriers scale (wearing adequate protective eyewear) Q52 Protective eyewear interferes with my duties Q53 Protective eyewear is uncomfortable Q54 Protective eyewear is expensive Q55 Protective eyewear impairs vision
14.025, df = 6, P \ .05). Differences in compliance rates across states also was significant (x2 = 57.69, df =10, P \ .05), with nurses in New South Wales demonstrating the highest compliance rates with double-gloving (81.8%). A significant relationship was present between wearing protective eyewear and state of employment (x2 = 40.47, df = 10, P \ .05). The compliance rate (69.2%) for nurses employed in South Australia was significantly lower than compliance rates for nurses in other states. In addition, 30.8% of the South Australian nurses were neutral on the subject of wearing protective eyewear. Results of the analysis of the constructs of the HBM also are differential, depending on which construct was examined and against which standard precautions behavior (Table 4). No significant difference was found between the construct perception of severity and either compliance with double-gloving or compliance with wearing adequate eye protection. However, the constructs of perception of risks, benefits, and barriers demonstrated significant correlations with compliance, to varying degrees, depending on the standard precautions behavior with which they were correlated.
DISCUSSION To better assess the level of compliance with standard precautions among operating room nurses in Australia, the results of this study must be viewed in context with other published results to first determine where on the continuum the compliance rates of operating room nurses in Australia lie. The results support the findings of previous studies that reported a less than 100% compliance rate with standard precautions among operating room nurses in Australia. An assumption can be made at this time that conditions and risks faced by Australian operating room nurses are similar to those faced in other countries, such as the United States, the United Kingdom, Spain, and Denmark. It also must be reiterated here that previous research comparing self-report data and observed data questioned the true reliability of self-report surveys and demonstrated that self-reported data might be an overestimate of actual compliance in practice.23 Although this study supports previous studies in reporting a less than 100% compliance rate with standard precautions, a trend toward improved compliance is evident. The mean compliance rates of 55.6% for double-gloving and 92% for wearing adequate protective eyewear are considerably greater than those reported previously in the literature.24 Although, there
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Table 3. Compliance rates with standard precautions behaviors among operating room nurses in Australia Survey items related to standard precautions behaviors Q33 I always wear protective eyewear when scrubbed Q34 I always double glove while scrubbed for surgical procedures Q35 I always recap hypodermic needles after use Q36y I always announce sharps transfers when passing sharps Q37y I always pass sharps using hands-free technique Average compliance for the 5 study behaviors (Q33, Q34, Q35, Q36, and Q37)
c/n
%
206/224 125/225 186/227* 133/225 161/224 184/230
92.0 55.6 81.9 59.1 71.9 72.1
c/n, Number of self-reported compliant respondents per number of respondents answering question. *Q35 was a negatively worded question, therefore c/n = noncompliant responders, which indicates compliance with not recapping. y Q36, Q37, and Q38 are subcategories of the study behavior ‘‘safe sharps handling.’’
Table 4. Significant findings (P \.05) between compliance and HBM constructs
Double gloving Risk if percutaneous injury occurred Severity Benefits in decreasing risk Barriers Interferes with duties Too expensive Causes hand tingling or numbness Poor fit Limited supply Adequate eye protection Risk Severity Benefits in decreasing risk Barriers Interferes with duties Too expensive Impairs vision Uncomfortable
Perception* (%)
Compliancey(%)
r
36%
70%
78%
Relationship
df
0.1
Negligible
2
62%
0.4
Substantial
2
14% 4% 23%
6% 33% 8%
0.5 0.2 0.5
Substantial Weak Substantial
2 2 2
9% 1%
15% 33%
0.3 0.2
Weak Weak
2 2
Not significant
Not significant Not significant 98%
86%
0.2
Weak
2
8% 6% 18% 24%
50% 77% 63% 73%
0.4 0.2 0.4 0.2
Substantial Weak Substantial Weak
2 2 2 2
r, Correlation; df, degrees of freedom. *Perception (percentage of respondents who agreed with perception). y Compliance (percentage of those who agreed with perception and complied with standard precautions behavior).
was no significant differences found among demographic groups in their compliance rates with standard precautions, there was a difference in the mean age of nurses who were noncompliant versus compliant with standard precautions. The mean age for noncompliance with always double-gloving for surgical procedures (44.8 6 8.23) was greater than the mean age for compliance (41.8 6 8.64). Similarly, the mean age for noncompliance (47.50 6 8.49) with always wearing protective eyewear was greater than the mean age for compliance (42.31 6 8.24). Further studies on age and compliance may assist in strategy development aimed at older nurses who, because of years of experience and tradition, may be resistant to changing their behavior. The differences in compliance between states may be attributed to the differences in infection control polices mandated by each state, which is reflected in the fact that the state with the highest
compliance rate (New South Wales) mandates compliance and enforces strong penalties (eg, deregistration) for noncompliance. This study partially supports the findings of earlier studies that demonstrated that constructs of the HBM are appropriate to identify attitudes of nurses regarding standard precautions.20,25,26 Barriers to compliance are reported extensively in the literature. Some of these include lack of time (71% to 74%), perceived ‘‘low risk’’ of patient (50% to 57%), PPE interfering with care (55%), and PPE not available (19.3-41%).13,23,26 Previous studies26 also have concluded that a correlation exists between barriers and compliance. This study demonstrates that perception of barriers has a significant influence on compliance. Other perceptions, including perceptions of risk, severity, and benefits, also are influential. It is clear from the data analysis and discussion that measures must be imple-
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mented to increase operating room nurses’ compliance with standard precautions. Standard precautions are guidelines developed to protect the health care worker from occupational exposure. Operating room infection control programs must therefore aim for compliance with Standard precautions through a multifaceted program of prevention, education, and policy.
Prevention The most logical way to decrease occupational transmission of bloodborne infections in the operating room is by prevention of occupational exposure in the first instance. The literature has already demonstrated that double-gloving, especially during procedures longer than 2 hours and with expected blood loss of greater than 100 mL, and the wearing of adequate eye protection significantly decrease the incidence of occupational exposure. It would be in the best interest of the employer to enact measures to eliminate or at least attempt to decrease barriers to the use of PPE. Employers must make PPE available and accessible to all employees. A cost-benefit analysis of double-gloving versus treatment of occupational exposures can justify the use of 2 pairs of gloves by scrub staff.27 Adequate eye protection—in the form of face shields, masks with face shields, and/or goggles with side shields—must be made available to operating room staff. Staff members who wear prescription glasses must be provided with side-shield attachments or goggles with side shields that fit comfortably over their glasses or goggles that incorporate their prescription. The costs of these modifications to prescription glasses may be covered by the hospital or through private insurance. If these modifications are required in the workplace, the cost also may be recoverable through personal income tax deductions. This is an area that needs to be investigated further and available options offered to employees. This study found that compliance rates were significantly less for double-gloving among nurses working in small facilities with fewer operating rooms. Further investigation may find that cost and supply could be major factors for smaller facilities with understandably smaller budgets in the provision of a wide enough range of glove sizes as well an adequate supply available for double-gloving.
Education Another component of a successful infection control program is education. The program must incorporate initial and ongoing training and education. The core principles of adult learning must be incorporated into the education component to ensure learning takes place. Individuality within the group also must be taken into consideration so that the program addresses the
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needs and preconceived perceptions of all learners. This study found that the mean age for noncompliance was greater than the mean age for compliance with double-gloving. Motivation and readiness to learn vary according to life span development28; therefore, any education program must take into account the age and experience of the participants. The education program must tailor the material to focus on the HBM constructs so that material is presented in a way that will reach all participants, no matter which construct influences them, as individuals, the most.
Policy Another component of an effective infection control program is the development of policies mandating the use of standard precautions, including the enforcement of these policies. Implementing stringent policies on mandatory compliance with standard precautions may help to decrease occupational exposures. The difference in levels of compliance between states found in this study, specifically with double-gloving, is noteworthy. New South Wales, the state demonstrating the highest compliance rate with double-gloving, is the only state in Australia with mandated infection control guidelines for health professionals that link compliance to professional registration. Policies can be general at the organizational level but can be more specific at the unit level. Specific policies on the use of goggles or masks with side shields can be implemented on the unit level. The best way to help the staff to comply with written policies is to let the staff develop the policy. The more input that staff members have into policies on the unit, the more likely they are to comply. Improved compliance with standard precautions has resulted from involving operating room personnel in identifying high-risk behaviors and situations and in developing strategies for improving compliance.17 Each operating room unit can establish working parties for the review of standard policies within the unit. Working parties from facilities in geographically close areas can network and share information on currently available literature.
LIMITATIONS OF THE STUDY One of the limitations of the study is the sampling frame used. The sampling frame used was operating room nurses with membership in the professional organization, ACORN. According to the Australian Institute of Health and Welfare,29 of the 192,711 registered and enrolled nurses working in Australia, 14,002 (7.1%) worked in operating rooms. Thus, the number of operating room nurses belonging to ACORN (n = 1710) represents only 12.2% of all operating room nurses in Australia. Therefore, the
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generalizability of findings of this study should be limited to members of the professional organization. Future studies also will need to include nurses who are not members of the professional organization to obtain a more representative sample of all operating room nurses in the country. A second limitation of the design of the study is the tendency for overestimation of compliance via selfreport method. Previous studies that used observation and self-reporting mechanisms found that by comparing self-reported with observed compliance of standard precautions, health care workers tend to overestimate their compliance with protective barriers.23 Future studies may need to use a combination of self-reporting instruments with prospective observation to improve estimates as well as to collect valuable qualitative data in addition to quantitative data.
CONCLUSIONS Studies in the past have used varying methods and have looked at different groups in analyzing data on health care workers’ compliance with standard precautions. As a result, a range of compliance rates has been reported in the literature. One fact that pervades throughout all previous studies, and is supported by this study, is that there is still a less than 100% compliance rate with guidelines developed to protect the health care worker from occupational exposure to bloodborne pathogens. Operating room infection control programs aimed at improving compliance with standard precautions must address the variety of perceptions (eg, risk, severity, benefits, and barriers) that may influence compliance with standard precautions. Prevention strategies that include provision and accessibility of adequate supplies of PPE and instructions in their use are necessary. Issues of inadequate supply, discomfort with use, and expense must be addressed and corrected. Education strategies must acknowledge the perceptions that operating room nurses bring with them to a unit and the degree to which these perceptions are influential in compliance with specific self-protective behaviors. Evidence-based policies aimed at compliance with standard precautions must be implemented and enforced. Data from this study can provide a basis to develop and implement measures to improve these practices, thus minimizing occupational exposure and disease transmission rates among the high-risk specialty of operating room nursing.
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Osborne 2. Centers for Disease Control and Prevention. Public health service guidelines for the management of health care worker exposures to HIV and recommendations for postexposure prophylaxis. Morb Mortal Wkly Rep MMWR 1998;47:1-33. 3. Centers for Disease Control and Prevention. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. Morb Mortal Wkly Rep MMWR 1998;47:1-39. 4. National Centre in HIV. Epidemiology and Clinical Research. Australian health surveillance report. 1999;15:1-6. 5. Centers for Disease Control and Prevention. Draft guidelines for isolation precautions in hospitals. Federal Register 1994;59:214. 6 National Health and Medical Research Council (NHMRC). Infection control in the health care setting. Canberra, Australia: Commonwealth of Australia; 1996. 7. Dodds RDA, Barker SGE, Donaldson DR, Thomas MH. Self protection in surgery: the use of double gloves. Br J Surg 1990;77:219-20. 8. Telford GL, Quebbeman EJ. Assessing the risk of blood exposure in the operating room. Am J Infect Control 1993;21:351-6. 9. Marin-Bertolin S, Gonzales-Martinez MD, Gimenez CN, Vila PM, Amorrortu-Velayos J. Does double gloving protect surgical staff from skin contamination during plastic surgery. Plastic Reconstructive Surg 1996;99:956-60. 10. Jensen SL, Kristensen B, Fabrin K. Double gloving as self protection in abdominal surgery. Eur J Surg 1997;163:163-6. 11. Geberding JL. Procedure-specific infection control for preventing intraoperative blood exposures. Am J Infect Control 1993;21:364-7. 12. Tokars JL, Culver DH, Mendelson MH, Sloan EP, Farber BF, Fligner DJ, et al. Skin and mucous membrane contacts with blood during surgical procedures: risk and prevention. Infect Control Hosp Epidemiol 1995;16:703-11. 13. Nelsing S, Nielsen TL, Nielsen JO. Noncompliance with Universal Precautions and the associated risk of mucocutaneous blood exposure among Danish physicians. Infect Control Hosp Epidemiol 1997;18: 692-8. 14. Sahdev P, Lacqua MJ, Harrigan N, Evans JT, Vaish AK. Barrier precautions in trauma resuscitations: multivaried analysis of factors affecting use. Ann Emerg Med 1994;23:823-7. 15. Lynch P, White MC. Perioperative blood contact and exposures: a comparison of incident reports and focused studies. Am J Infect Control 1993;21:357-63. 16. White MC, Lynch P. Blood contact and exposures among operating room personnel: a multicenter study. Am J Infect Control 1993;21:243-8. 17. White MC, Lynch P. Blood contacts in the operating room after hospital-specific data analysis and action. Am J Infect Control 1997; 25:209-14. 18. Mujeeb SA, Khatri Y, Khanani R. Frequency of parenteral exposure and seroprevalence of HBV, HCV, and HIV among operation room personnel. J Hosp Infect 1998;38:133-7. 19. Rosenstock IM. Historical origins of the Health Belief Model. Health Educ Monographs 1974;4:328-35. 20. Champion VL. Instrument development for Health Belief Model constructs. Adv Nurs Sci 1984;6:73-85. 21. Ross HS, Mico PR. Theory and practice in health education. Palo Alto (CA): Mayfield Publishing; 1980. p. 58. 22. Polit DF, Hungler BP. Nursing research principles and practice. Philadelphia: JB Lippincott; 1995. 23. Henry K, Campbell S, Collier P, Williams C. Compliance with Universal Precautions and needle handling and disposal practices among emergency department staff at two community hospitals. Am J Infect Control 1994;22:129-37. 24. Akduman D, Kim LE, Parks RL, L’Ecuyer PB, Mutha S, Jeffe DB, et al. Use of personal protective equipment and operating room behaviors in four surgical subspecialties: personal protective equipment and behaviors in surgery. Infect Control Hosp Epidemiol 1998;20:110-4.
Osborne 25. Grady MM, Shortridge LA, Davis LS, Klinger CS. Occupational exposure to blood-borne diseases and Universal Precautions: measurement of health care workers’ self-reported attitudes. AAOHN Journal 1993;41:533-40. 26. Williams CO, Campbell S, Henry K, Collier P. Variables influencing worker compliance with Universal Precautions in the emergency department. Am J Infect Control 1994;22: 138-148.
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27. Osborne SR. Occupational exposures: balancing the costs of prevention vs treatment in operating theatres, with particular focus on double gloving practices. ACORN Journal 2001;14:16-21. 28. Knowles MS. The adult learner. 5th ed. Houston: Gulf Publishing; 1998. p. 4. 29. Australian Institute of Health and Welfare (AIHW). Nursing labour force 1997. AIHW Cat. No. HWL 14. Canberra, Australia: AIWH (National Health Labour Force Series); 1999.
Background: Occupational exposures of health care workers occur because of inconsistent compliance with standard precautions. The purpose of this study was to develop national estimates of compliance with standard precautions and occupational exposure reporting among operating room nurses (specifically, scrub nurses) in Australia and to assess variables that influence compliance. Methods: A descriptive correlation design was used to investigate relationships between variables and compliance, using a theoretical framework, the Health Belief Model, to give meaning to the variables. Data collection was done through mail-out surveys to members of the Australian College of Operating Room Nurses. Results: This article reports the results of compliance with the following 2 specific self-protective behaviors: double-gloving and wearing adequate eye protection. Mean compliance rates were 55.6% with always double-gloving during surgical procedures and 92% with always wearing adequate eye protection. In addition, the variable that had the most influence on compliance was the perception of barriers to compliance, specifically, that adhering to standard precautions interfered with duties. Conclusion: These results have implications for the development of multifaceted perioperative infection control programs, including strategies for prevention, education, and policy development, to improve practices aimed at reducing occupational exposures among this high-risk group. (Am J Infect Control 2003;31:415-23.)
The focus of infection control since the discovery of the mechanism of disease transmission by Lister and others in the 1800s has been on the prevention of patient-acquired nosocomial infections.1 Throughout the years, health care workers have become increasingly aware of their risks of contracting diseases from patients, especially bloodborne infections such as hepatitis B virus (HBV); human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS); and more recently, hepatitis C virus (HCV). Global statistics on occupational exposures of health care workers to bloodborne pathogens are startling. Transmission rates after occupational exposure for HIV, HBV, and HCV are estimated at 0.3%, 6% to 30%, and 1% to 10%, respectively.2-4
From the University of Canberra, School of Nursing. Reprint requests: Sonya Osborne, RN, BSN, MNurs, The Canberra Hospital and University of Canberra Research Centre for Nursing Practice, Woden, ACT 2606 Australia. Copyright ª 2003 by the Association for Professionals in Infection Control and Epidemiology, Inc. 0196-6553/2003/$30.00 + 0 doi:10.1067/mic.2003.68
HISTORY OF STANDARD PRECAUTIONS IN AUSTRALIA In the mid-1980s, in response to the increase in prevalence of HIV/AIDS and the increased concern for the protection of the health care worker, the Centers for Disease Control and Prevention proposed the concept of universal precautions. Universal precautions guidelines involved treating the blood and body fluids from all patients as potentially infectious. However, certain body fluids (ie, feces, nasal secretions, sputum, sweat, tears, urine, and vomitus, unless they visibly contained blood) were not included in these guidelines.5 This definition of universal precautions was adopted in Australia, albeit in an expanded form. Work practices in Australia have the underlying assumption that all blood and body substances, without exception, are a potential risk of disease transmission. In Australia, the principle of ‘‘confine and contain’’ applies to all patients and all procedures in the operating room, and universal precautions are mandated by state departments of health as the policy of infection control in public hospitals. Universal precautions are limited in that they focus only on disease transmission through blood and body fluids and do not incorporate precautions for transmission by other means. It was recognized in Australia that the term ‘‘universal precautions’’ was ambiguous, caused confusion in its 415
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interpretation, and led to a false sense of security.6 This was evident in reports of health care workers substituting glove-wearing for appropriate handwashing. It was at this time that the National Health and Medical Research Council and the National Council on AIDS recommended a change in terminology. This change in terminology reflects a 2-tiered approach to infection control and is in line with the changes in terminology adopted by the Centers for Disease Control and Prevention in 1996.6 Universal precautions has been broken down to reflect a 2-tiered approach. The first tier, standard precautions, is the first line of defense in infection control and assumes that all blood and body fluids are potentially infectious. Standard precautions include diligent hygiene practices (eg, handwashing and drying), use of personal protective equipment (PPE) (eg, gloves, gowns, masks, and eye protection), and appropriate handling and disposal of sharps (eg, safe transfer, no needle recapping, immediate disposal after use). Standard precautions are used when handling nonintact skin; mucous membranes; blood; and all other body fluids, even if dried, except sweat.6 In 1996, ‘‘the Infection Control Working Party in Australia recommended adoption of the term ‘‘standard precautions’’ as the basic risk minimisation strategy . . . to prevent transmission of infection.. . .’’6 The second tier, additional precautions, is the second line of defense in infection control. It is used in addition to standard precautions in situations in which standard precautions may be insufficient to prevent transmission of infection, in cases in which the patient has a known or suspected infection or colonization with an epidemiologically important or highly transmissible pathogen.6 The modes of transmission of these significant pathogens is usually by airborne transmission, droplet transmission, or transmission via direct or indirect contact with intact skin or contaminated surfaces.6 By consistently incorporating this 2-tiered approach of standard precautions and additional precautions into work practices, a high level of protection against occupational exposure of diseases from the patient to the health care worker can be obtained. Breaches in these guidelines, designed to protect the health care worker, may result in an increased risk of occupational exposure and subsequent disease transmission.
AIM OF THE STUDY The efficacy of using specific standard precautions behaviors—such as double-gloving and wearing protective eyewear—in particular circumstances in the operating room in decreasing the risk of disease transmission has been well supported in the literature. Research continues to report a less than 100% compli-
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ance rate with standard precautions among health care professionals, despite the demonstrated benefits of compliance with standard precautions, including a decrease in disease transmission by the reduction of risk of exposure. It is therefore necessary to explore factors that influence whether a health care professional will comply with standard precautions. Once these influences are identified, appropriate programs can be implemented with the aim of improving compliance and reducing the risk of occupational exposures. A study was conducted with the following aims: (1) assessing the attitudes, beliefs, and level of compliance with standard precautions and occupational exposure reporting and (2) identifying influences on compliance with standard precautions and occupational exposure reporting among operating room nurses in the scrub role in Australia. The focus of this article is on compliance with standard precautions. Thus, research questions guiding this study included the following: What is the self-reported compliance rate with standard precautions among operating room nurses? What factors influence compliance? This article focuses on 2 standard precautions behaviors, that is, double-gloving during surgical procedures and the wearing of adequate eye protection by operating room nurses in the scrub role.
STANDARD PRECAUTIONS IN THE OPERATING ROOM ENVIRONMENT In the operating room, the wearing of gloves, gowns, and masks by operating room personnel is a necessary requirement to establish and maintain an aseptic environment for the patient, thus helping to decrease the chance of wound infection for the patient. However, more diligent use of these barriers, as well as other self-protective health behaviors, can be used in the operating room to decrease the operating room nurses’ chance of occupational exposure and risk of acquiring bloodborne infections from patients. Several measures, some in excess of the minimal standard precautions, have been demonstrated to be effective in decreasing occupational exposures in the operating room. Two of these measures are double-gloving7-10 and wearing adequate protective eyewear.11-13 Paramount to the use of any of these standard precautions is a comprehensive education and training program on infection control. Studies14,15 have shown that it is possible to improve compliance with standard precautions through strategies such as regular education and mandated policies. Previous research focusing on operating room personnel—specifically, operating room nurses—reported incidence of occupational exposure but not necessarily
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incidence of compliance with standard precautions to prevent occupational exposure.15-18
SAMPLE/STUDY POPULATION The target population for the study was operating room nurses selected from the accessible population of current members of the Australian College of Operating Room Nurses (ACORN), a professional organization representing operating room nurses in Australia. To obtain a study sample that reflected the state representation in ACORN, subjects were chosen from the sampling frame of ACORN membership with use of a stratified random sampling method on the basis of the proportion of ACORN members per state in Australia. The only sampling criteria for inclusion in the study sample were current membership in ACORN and a mailing address in Australia at the time of questionnaire distribution. Five hundred questionnaires were distributed. Sample size calculations determined that at least 176 members needed to be surveyed for the study sample to be representative of the total ACORN membership (n = 1710 members). Two hundred twenty-seven of the 230 questionnaires returned were included in the analysis. This 45% response rate represents 13% of the total membership of ACORN. Demographic distribution of respondents is shown in Table 1.
METHOD AND DESIGN The research design chosen for this study was a descriptive correlational design. This design allows inter-relationships that exist between variables to be examined to identify problems with current practice and provide knowledge about the variables. Through use of a theoretical framework, these variables are given meaning, and thus logical conclusions can be drawn about which variables have the greatest influence on the health behavior. The theoretical framework used to guide development of the data collection instrument and analysis of the data was the Health Belief Model (HBM).
HEALTH BELIEF MODEL The Health Belief Model19 describes specific variables that influence whether an individual will undertake particular self-protective health behaviors. These variables include the following: (1) perception of risk or susceptibility to the illness, (2) perception of severity or degree of consequence of the illness, (3) perception of the benefits of undertaking a recommended health behavior, (4) perception of barriers or costs of undertaking a particular health behavior, and (5) cues to action that trigger the health behavior. The first 4 variables have been tested and demonstrated in subsequent research, but the difficulty in testing cues
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Table 1. Demographics of the sample Nursing education Hospital trained University and/or hospital trained No answer
Age range of participants 74.3% 24.3%
20–29 y 30–39 y
5.8% 30.8%
1.3%
40–49 y 50–59 y [60 y
75.4% 23.7% 0.9%
Years postregistration nursing experience \2 y 2–5 y 5–10 y [10 y
Scrub nurse experience 0.9% 4.4% 11.0% 83.8%
Type of facility Private/day hospital Public hospital No, or both answers
7.9% 10.1% 15.0% 67.0%
Employment status 31.4% 65.0% 3.6%
No. beds \100 101–300 301–600 [600
\2 y 2–5 y 5–10 y [10 y
Full time Part time/casual No answer
59.7% 38.9% 3.6%
No. operating rooms 22.8% 37.1% 30.4% 9.8%
1–2 3–5 6–8 [8
16.4% 37.6% 23.5% 22.6%
to action was recognized, especially in retrospective studies, because of the individuality of this variable.19 In later versions of the HBM, the construct of health motivation or the desire to undertake the particular health behavior was added.20 The HBM is a model that has its basis on the interaction of the individual’s readiness to comply with the behavior and the motivating and enabling factors that determine what the individual will do.21 Readiness depends on perceptions of risk and severity of acquiring a bloodborne infection as well as perceived benefits of undertaking the self-protective behaviors. Motivating and enabling factors include the individual’s personal characteristics, previous experience, social pressures, and barriers to undertaking the behavior. This interaction determines the likelihood of compliance with recommended self-protective behaviors. It is the interaction of these variables that allows for the prediction of health behaviors.
DATA COLLECTION Data collection was done through a self-report mail-out survey. This study attempted to establish relationships between variables (ie, influences) and compliance with standard precautions. Therefore, a 96-item questionnaire was developed to test and explore relationships between compliance with standard
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precautions and the variables described in the HBM. The questionnaire included items that were previously tested for internal consistency and reliability in application of the HBM in the prediction of undertaking self-protective health behaviors.20 Additional questions were added to determine level of compliance with standard precautions and occupational exposure reporting behavior and to gather basic demographic information. The questionnaire was checked for content validity by review from 4 operating room nurses with at least 5 years of operating room experience (total of 43 years of experience). These nurses were employed at the clinical nurse specialist/nurse educator level or higher and were considered to be experts by their peers. Comments and suggestions were taken into account, and appropriate changes were made. The university’s Human Research Ethics Committee approved the study before the questionnaire was pilot-tested among a small sample (n = 50) of operating room nurses in the Australian Capital Territory. On the basis of the quality of data and the comments obtained from the pilot study, the questionnaire was revised before distribution to the study sample. Instrument revision included changes to questionnaire item wording and format on the basis of preliminary analysis of data and comments by pilot study respondents. The majority of questions were changed to Likert response questions with the same 5 responses (ie, strongly agree, agree, neutral, disagree, strongly disagree) for ease of response. Questions about reasons why a study participant would not undertake certain behaviors were changed from open-ended to Likerttype responses to facilitate coding. Questions on frequencies were changed so that ‘‘none’’ was a category on its own. This was done because of the difficulty in separating ‘‘no’’ exposures from a small number of exposures (ie,‘‘1 or 2’’) when analyzing the pilot survey data. Although the exclusion of open-ended questions may be considered a limitation in the quality of data collected (ie, qualitative), for the purposes of this study (ie, to gain baseline data), closed-ended questions were considered suitable by the researcher for this study. The Cronbach a coefficient was used to test reliability for each questionnaire item within the construct scales of the HBM. The construct scales of perception of risk and perception of severity demonstrated consistency coefficients of 0.71 and 0.70, respectively. The scales for perception of benefits of standard precautions demonstrated a consistency coefficient of 0.51. Scales for perception of barriers to standard precautions were subgrouped into doublegloving and wearing adequate eye protection, yielding consistency coefficients of 0.78 and 0.76, respectively. For well-developed instruments, the lowest acceptable
reliability coefficient is usually 0.80, although for a new instrument, 0.70 is considered acceptable.22 Therefore, scales with a Cronbach a coefficient of less than 0.70 were not included in the analysis, unless otherwise indicated. Internal reliability was comparable with that demonstrated in the original instrument by Champion20 (Table 2). After the university’s Human Research Ethics Committee approved the study, 500 questionnaires were mailed to a stratified random sample of ACORN members. The questionnaires, accompanied by a participant information sheet, were sent to a council representative of ACORN who received the questionnaires in sealed, stamped envelopes, which also included a prepaid return envelope. Mailing labels were generated from ACORN’s membership list on the basis of randomization parameters set forth by the investigator. The ACORN councilor affixed the mailing labels and mailed the questionnaires. Although an organizational mailing list was used for questionnaire distribution, the researcher did not have access to this mailing list. Completed questionnaires were returned directly to the study investigator anonymously via the prepaid return envelope enclosed with each questionnaire. Respondents were given a return date to allow 4 weeks for completion and return of the questionnaire to the investigator. The questionnaires were distributed in this way to ensure the anonymity of the sample population from the researcher and to ensure that the personal information of the members was protected by ACORN.
RESULTS The results of this study revealed a compliance rate with standard precautions of less than 100%, with a mean compliance rate of 72.1% for all study behaviors (Table 3). There was no significant difference between some demographic characteristics, such as sex, nurse education, nurse status, years of post registration nursing experience, and type of facility and compliance with either double-gloving or wearing adequate eye protection. However, other demographic characteristics, such as age, years of scrub nurse experience, size of facility and operating room complex, type of employment, and state of employment, demonstrated significant difference with either compliance with double-gloving, compliance with wearing adequate eye protection, or both. A significant relationship was present between double-gloving and several demographic variables. Compliance rates were significantly greater for nurses with fewer than 2 years of scrub experience (x2= 16.415, df = 3, P \ .05) and significantly less for nurses working in small facilities (x2 = 15.761, df = 6, P \ .05) with few operating rooms (x2 =
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Table 2. Examples of items evidencing internal consistency for HBM scales Item number
Survey item
Corrected item total correlation
Cronbach’s a
Cronbach’s a (Champion)20
0.39 0.34 0.36 0.35 0.59
0.71
0.78
0.49 0.47 0. 59
0.70
0.78
0.21 0.27 0.30 0.57 0.30
0.51
0.61
0.62 0.71 0.46 0.64 0.44
0.78
0.76
0.52 0.68 0.39 0.70
0.76
0.76
Risk scale Q12 My chance of getting hep B or C is high Q15 There is a possibility that I will get hep B or C Q16 I worry a lot about getting hep B or C Q23 My work related activities put me at risk of contracting hep B or C Q24 If I sustain a perc. exposure. . .it is likely I would contract hep B or C Severity scale Q18 If I get hep B or C my career would be endangered Q19 Hep B or C would endanger a significant relationship Q20 My financial security would be endangered if I got hep B or C Benefits scale Q26 Wearing protective eye wear decreases my risk of acquiring hep B or C Q27 Double gloving when scrubbed for surgical procedures decreases my risk... Q28 Not recapping needles decreases my risk . . . Q29 Announcing sharps transfers decreases my risk . . . Q30 Using a hands free sharps passage technique decreases my risk... Barriers scale (double gloving) Q60 Double gloves produce hand numbness and tingling Q61 Double gloves interfere with duties Q62 Double gloves are too expensive Q63 Double gloves are a poor fit Q64 Double gloves are in limited supply at my facility Barriers scale (wearing adequate protective eyewear) Q52 Protective eyewear interferes with my duties Q53 Protective eyewear is uncomfortable Q54 Protective eyewear is expensive Q55 Protective eyewear impairs vision
14.025, df = 6, P \ .05). Differences in compliance rates across states also was significant (x2 = 57.69, df =10, P \ .05), with nurses in New South Wales demonstrating the highest compliance rates with double-gloving (81.8%). A significant relationship was present between wearing protective eyewear and state of employment (x2 = 40.47, df = 10, P \ .05). The compliance rate (69.2%) for nurses employed in South Australia was significantly lower than compliance rates for nurses in other states. In addition, 30.8% of the South Australian nurses were neutral on the subject of wearing protective eyewear. Results of the analysis of the constructs of the HBM also are differential, depending on which construct was examined and against which standard precautions behavior (Table 4). No significant difference was found between the construct perception of severity and either compliance with double-gloving or compliance with wearing adequate eye protection. However, the constructs of perception of risks, benefits, and barriers demonstrated significant correlations with compliance, to varying degrees, depending on the standard precautions behavior with which they were correlated.
DISCUSSION To better assess the level of compliance with standard precautions among operating room nurses in Australia, the results of this study must be viewed in context with other published results to first determine where on the continuum the compliance rates of operating room nurses in Australia lie. The results support the findings of previous studies that reported a less than 100% compliance rate with standard precautions among operating room nurses in Australia. An assumption can be made at this time that conditions and risks faced by Australian operating room nurses are similar to those faced in other countries, such as the United States, the United Kingdom, Spain, and Denmark. It also must be reiterated here that previous research comparing self-report data and observed data questioned the true reliability of self-report surveys and demonstrated that self-reported data might be an overestimate of actual compliance in practice.23 Although this study supports previous studies in reporting a less than 100% compliance rate with standard precautions, a trend toward improved compliance is evident. The mean compliance rates of 55.6% for double-gloving and 92% for wearing adequate protective eyewear are considerably greater than those reported previously in the literature.24 Although, there
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Table 3. Compliance rates with standard precautions behaviors among operating room nurses in Australia Survey items related to standard precautions behaviors Q33 I always wear protective eyewear when scrubbed Q34 I always double glove while scrubbed for surgical procedures Q35 I always recap hypodermic needles after use Q36y I always announce sharps transfers when passing sharps Q37y I always pass sharps using hands-free technique Average compliance for the 5 study behaviors (Q33, Q34, Q35, Q36, and Q37)
c/n
%
206/224 125/225 186/227* 133/225 161/224 184/230
92.0 55.6 81.9 59.1 71.9 72.1
c/n, Number of self-reported compliant respondents per number of respondents answering question. *Q35 was a negatively worded question, therefore c/n = noncompliant responders, which indicates compliance with not recapping. y Q36, Q37, and Q38 are subcategories of the study behavior ‘‘safe sharps handling.’’
Table 4. Significant findings (P \.05) between compliance and HBM constructs
Double gloving Risk if percutaneous injury occurred Severity Benefits in decreasing risk Barriers Interferes with duties Too expensive Causes hand tingling or numbness Poor fit Limited supply Adequate eye protection Risk Severity Benefits in decreasing risk Barriers Interferes with duties Too expensive Impairs vision Uncomfortable
Perception* (%)
Compliancey(%)
r
36%
70%
78%
Relationship
df
0.1
Negligible
2
62%
0.4
Substantial
2
14% 4% 23%
6% 33% 8%
0.5 0.2 0.5
Substantial Weak Substantial
2 2 2
9% 1%
15% 33%
0.3 0.2
Weak Weak
2 2
Not significant
Not significant Not significant 98%
86%
0.2
Weak
2
8% 6% 18% 24%
50% 77% 63% 73%
0.4 0.2 0.4 0.2
Substantial Weak Substantial Weak
2 2 2 2
r, Correlation; df, degrees of freedom. *Perception (percentage of respondents who agreed with perception). y Compliance (percentage of those who agreed with perception and complied with standard precautions behavior).
was no significant differences found among demographic groups in their compliance rates with standard precautions, there was a difference in the mean age of nurses who were noncompliant versus compliant with standard precautions. The mean age for noncompliance with always double-gloving for surgical procedures (44.8 6 8.23) was greater than the mean age for compliance (41.8 6 8.64). Similarly, the mean age for noncompliance (47.50 6 8.49) with always wearing protective eyewear was greater than the mean age for compliance (42.31 6 8.24). Further studies on age and compliance may assist in strategy development aimed at older nurses who, because of years of experience and tradition, may be resistant to changing their behavior. The differences in compliance between states may be attributed to the differences in infection control polices mandated by each state, which is reflected in the fact that the state with the highest
compliance rate (New South Wales) mandates compliance and enforces strong penalties (eg, deregistration) for noncompliance. This study partially supports the findings of earlier studies that demonstrated that constructs of the HBM are appropriate to identify attitudes of nurses regarding standard precautions.20,25,26 Barriers to compliance are reported extensively in the literature. Some of these include lack of time (71% to 74%), perceived ‘‘low risk’’ of patient (50% to 57%), PPE interfering with care (55%), and PPE not available (19.3-41%).13,23,26 Previous studies26 also have concluded that a correlation exists between barriers and compliance. This study demonstrates that perception of barriers has a significant influence on compliance. Other perceptions, including perceptions of risk, severity, and benefits, also are influential. It is clear from the data analysis and discussion that measures must be imple-
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mented to increase operating room nurses’ compliance with standard precautions. Standard precautions are guidelines developed to protect the health care worker from occupational exposure. Operating room infection control programs must therefore aim for compliance with Standard precautions through a multifaceted program of prevention, education, and policy.
Prevention The most logical way to decrease occupational transmission of bloodborne infections in the operating room is by prevention of occupational exposure in the first instance. The literature has already demonstrated that double-gloving, especially during procedures longer than 2 hours and with expected blood loss of greater than 100 mL, and the wearing of adequate eye protection significantly decrease the incidence of occupational exposure. It would be in the best interest of the employer to enact measures to eliminate or at least attempt to decrease barriers to the use of PPE. Employers must make PPE available and accessible to all employees. A cost-benefit analysis of double-gloving versus treatment of occupational exposures can justify the use of 2 pairs of gloves by scrub staff.27 Adequate eye protection—in the form of face shields, masks with face shields, and/or goggles with side shields—must be made available to operating room staff. Staff members who wear prescription glasses must be provided with side-shield attachments or goggles with side shields that fit comfortably over their glasses or goggles that incorporate their prescription. The costs of these modifications to prescription glasses may be covered by the hospital or through private insurance. If these modifications are required in the workplace, the cost also may be recoverable through personal income tax deductions. This is an area that needs to be investigated further and available options offered to employees. This study found that compliance rates were significantly less for double-gloving among nurses working in small facilities with fewer operating rooms. Further investigation may find that cost and supply could be major factors for smaller facilities with understandably smaller budgets in the provision of a wide enough range of glove sizes as well an adequate supply available for double-gloving.
Education Another component of a successful infection control program is education. The program must incorporate initial and ongoing training and education. The core principles of adult learning must be incorporated into the education component to ensure learning takes place. Individuality within the group also must be taken into consideration so that the program addresses the
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needs and preconceived perceptions of all learners. This study found that the mean age for noncompliance was greater than the mean age for compliance with double-gloving. Motivation and readiness to learn vary according to life span development28; therefore, any education program must take into account the age and experience of the participants. The education program must tailor the material to focus on the HBM constructs so that material is presented in a way that will reach all participants, no matter which construct influences them, as individuals, the most.
Policy Another component of an effective infection control program is the development of policies mandating the use of standard precautions, including the enforcement of these policies. Implementing stringent policies on mandatory compliance with standard precautions may help to decrease occupational exposures. The difference in levels of compliance between states found in this study, specifically with double-gloving, is noteworthy. New South Wales, the state demonstrating the highest compliance rate with double-gloving, is the only state in Australia with mandated infection control guidelines for health professionals that link compliance to professional registration. Policies can be general at the organizational level but can be more specific at the unit level. Specific policies on the use of goggles or masks with side shields can be implemented on the unit level. The best way to help the staff to comply with written policies is to let the staff develop the policy. The more input that staff members have into policies on the unit, the more likely they are to comply. Improved compliance with standard precautions has resulted from involving operating room personnel in identifying high-risk behaviors and situations and in developing strategies for improving compliance.17 Each operating room unit can establish working parties for the review of standard policies within the unit. Working parties from facilities in geographically close areas can network and share information on currently available literature.
LIMITATIONS OF THE STUDY One of the limitations of the study is the sampling frame used. The sampling frame used was operating room nurses with membership in the professional organization, ACORN. According to the Australian Institute of Health and Welfare,29 of the 192,711 registered and enrolled nurses working in Australia, 14,002 (7.1%) worked in operating rooms. Thus, the number of operating room nurses belonging to ACORN (n = 1710) represents only 12.2% of all operating room nurses in Australia. Therefore, the
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generalizability of findings of this study should be limited to members of the professional organization. Future studies also will need to include nurses who are not members of the professional organization to obtain a more representative sample of all operating room nurses in the country. A second limitation of the design of the study is the tendency for overestimation of compliance via selfreport method. Previous studies that used observation and self-reporting mechanisms found that by comparing self-reported with observed compliance of standard precautions, health care workers tend to overestimate their compliance with protective barriers.23 Future studies may need to use a combination of self-reporting instruments with prospective observation to improve estimates as well as to collect valuable qualitative data in addition to quantitative data.
CONCLUSIONS Studies in the past have used varying methods and have looked at different groups in analyzing data on health care workers’ compliance with standard precautions. As a result, a range of compliance rates has been reported in the literature. One fact that pervades throughout all previous studies, and is supported by this study, is that there is still a less than 100% compliance rate with guidelines developed to protect the health care worker from occupational exposure to bloodborne pathogens. Operating room infection control programs aimed at improving compliance with standard precautions must address the variety of perceptions (eg, risk, severity, benefits, and barriers) that may influence compliance with standard precautions. Prevention strategies that include provision and accessibility of adequate supplies of PPE and instructions in their use are necessary. Issues of inadequate supply, discomfort with use, and expense must be addressed and corrected. Education strategies must acknowledge the perceptions that operating room nurses bring with them to a unit and the degree to which these perceptions are influential in compliance with specific self-protective behaviors. Evidence-based policies aimed at compliance with standard precautions must be implemented and enforced. Data from this study can provide a basis to develop and implement measures to improve these practices, thus minimizing occupational exposure and disease transmission rates among the high-risk specialty of operating room nursing.
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