- Email: [email protected]
Perceptions that Influence Occupational Exposure Reporting
Osbome
AUGUST 2003,VOL 78, NO 2
Perceptions that Influence
Occupational Exposure Reporting Sonya Osbome, RN
S
tatistics on occupational exposures of health care workers to bloodbome pathogens are disturbing. In 1996, the estimated total annual occupational exposures to blood or other body substances in the United States was 786,885 exposures, at a rate of 30 exposures per 100 hospital beds occupied daily.’ In Australia, national monitoring of occupational exposures to bloodborne pathogens began in 1995, and the estimated total exposures in Australia in 1998 was 1,718, at a rate of 25 exposures per 100 hospital beds occupied daily2In addition, from the analysis of documented cases, disease transmission rates for HIV and hepatitis C after occupational exposure are estimated at 0.3%and 1%to lo%, respectively, in the United States,s” and 0.32% and l.6%, respectively, in Australia? Although, standard precautions
ABSTRACT 0 STATISTICS on health care worked occupational exposures to bloodborne pathogens underestimate the true extent of the problem because of a tendency for underreporting. 0 A DESCRIPTIVE CORRELATIONAL DESIGN was used to investigate compliance with standard precautions and occupational exposure reporting practices among perioperative nurses in Australia. 0 THE STUDY found that although intention to report both percutaneous and mucocutaneous exposures was relatively high, mean compliance rates for actually reporting exposures incurred were considerablylower. 0 THE PERCEPTION of barrien to reporting significantly influenced compliance.AORN] 78 (August unl3)262-272.
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were introduced in the 1980s, research continues to report less than 100% compliance among health care professionals with measures demonstrated to decrease disease transmi~sion.~-’~ The consequences of an occupational exposure to bloodborne pathogens extend beyond transmission of infection. Consequences related to health can include liver disease and subsequent transplantation complications, chronic disabilities, and premature death.’ Consequences related to employment can include punitive disciplinary action, job discrimination, denial of worker’s compensation claims, and loss of employment potential.’ Personal consequences can include anxiety, alteration in sexual practices, or postponement of pregnancy.’ The possibility of incurring these consequences emphasizes the need for prevention of exposure to bloodborne infections in high-risk environments. The focus of this article is compliance with occupational exposure reporting. It is anticipated that results from this study will be used to inform the development of appropriate strategic measures to improve perioperative nurses’ compliance with occupational exposure reporting.
OCCUPATIONAL EXPOSURE IN
THE
OR
Perioperative nursing is a high-risk nursing specialty. The nature of the work environment and the conditions in which surgical procedures take place put perioperative nurses at increased risk for occupational exposure and occupationally acquired disease transmission. The incidence of cutaneous and mucocutaneous exposure in the OR far exceeds that of percutaneous exposure and may occur in 30% to 50%
AUGUST 2003, VOL 78, NO 2
Osbome
of surgical procedure^.'^,'^ The greatest risk for occupational transmission of bloodborne infections, however, is from exposure by percutaneous injury from needles and other sharp objects, which occurs in up to 15% of surgical
procedure^.'"'^ The occupational exposure risk in the OR is considered low compared to hospital-wide risk, probably because of inadequate reporting of exposures in the OR.’* In the early 1990s, studies were conducted on risk of exposure, compliance with standard precautions and infection control policies and procedures, and lack of reporting of occupational exposures in ORs in the United state^.'^.'^,'^,^^ Previous research also compared both self-reported and observed data and questioned the reliability of self-reported data.I5 Occupational exposures among health care workers have been substantially underreported,721-25 and OR personnel underreport by as much as 25%.Unfortunately, hospitals typically rely on incident reports to determine the frequency of exposures and the need for improving measures to decrease or prevent them.= Reporting occupational exposures provides several benefits for perioperative nurses, including early initiation of prophylactic treatment and possible prevention of future social,’ and financialz’,’”problems associated with acquiring a bloodborne infection. Studies have concluded that treatment with prophylactic agents within 24 hours of exposure decreases the risk of some disease transmission.26Reporting also may decrease the anxiety associated with an occupational exposure. In light of these benefits, it is in the best interest of perioperative nurses to report all occupational exposures promptly to put in motion a process of future protection for themselves and their family members.
PURPOSE OF THE STUDY
There has been a significant amount of international research on benefits of and compliance with standard precautions as well as some research, though not as much, on types, frequency, and risk of occupational exposures among different categories of health care workers in a variety of clinical settings. Hospitals There is a dearth of research about perioperative nurses‘ compliance typically rely rates for reporting occuon incident pational exposures, however, and no studies have been found that investireports to gate the sigruficance of specific influences on determine the iompliance with reportfreWeWY ing in general or, specifically, among perioperastaff members‘ tive nurses in Australia. The purpose of this exposures to studv was to assess attitud&, beliefs, and level of bloodborne compliance with stan-
of
d a d precautions and occupational exposure reporting. Two research questions guided the study. What is the level of compliance with standard mecautions and
pathogens; unfortunately, these occurrences often are not reported.
occupational exposure reporting among perioperative nurses? What factors influence compliance with standard precautions and occupational exposure reporting among perioperative nurses in Australia?
METHOD A descriptive correlational design was used to describe variables and examine relationships between variables. Data were collected via a mailed survey. A AORN JOURNAL
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theoretical framework, the Health Belief Model,% was used to guide questionnaire development. By using a theoretical framework, the variables were given meaning so that logical conclusions could be made about which variables had the greatest influence on a health behavior. United States public health researchers began to-develop models to idenidy targets for health education .~ programs in the 1950sand 1 9 6 0 ~Early research suggests that health beliefs were correlated with behavior and Variables could be used to differenbetween those who included in this tiate did and did not underthese behaviors.** study included take The Health Belief Model describes specific variperception of ables that influence whether an individual risk, severity, will undertake particular self-protective behaviors. and benefits These variables include 0 perception of risk or and barriers susceptibility to the illn€!SS, 0 perception of severity of the illness, exposure 0 perception of benefits of undertaking a recreporb'ng. ommended health behavior, 0 perception of barriers or costs of undertaking a particular health behavior, and 0 cues to action that trigger the health behavior? The Health Belief Model is based 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.30 Readiness depends on perceptions of risk and severity of acquiring a bloodborne infection, as well as perceived
of to occupational
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benefits of undertaking the self-protective behaviors. Motivating and enabling factors include the individual's personal characteristics, previous experience, social pressure, 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 and other modifying variables, such as demographics, that allow for the prediction of health behaviors. The variables under investigation in this study are perception of 0
risk,
0
severity, benefits, and barriers.
0 0
POPULATION AND SAMPLE
Perioperative nurses in Australia were the target population for this investigation; therefore, a sample was selected from the accessible population of current members of the Australian College of Operating Room Nurses (ACORN), the professional nursing organization representing perioperative nurses in Australia. The total membership at the time of questionnaire distribution was 1,710 members. Based on calculations using a 95% confidence level and a confidence interval of 7, a minimum of 176 members needed to be surveyed for the study sample to be representative of the total ACORN membership; therefore, 500 questionnaires were distributed in anticipation of the 25% to 30% return rate expected from a mailed survey3' To obtain a study sample that reflected state representation in ACORN, participants were chosen from the sampling frame of ACORN membership using a stratified random sampling method based on the proportion of ACORN members per state in Australia (Figure 1).The only criteria for inclusion in the study sample were current membership in
ACORN and a mailing address in Australia at the time of questionnaire distribution. Questionnaires were distributed and returned in a way that maintained the privacy and anonymity of respondents. To ensure that respondent information was treated anonymously, only general demographic data were solicited on the questionnaire. No other personal information was required. The questionnaires were sent to a council representative of ACORN who had agreed to assist in distributing the questionnaires. The ACORN representative received the questionnaires in sealed, stamped envelopes. The representative generated mailing labels from ACORN'S membership list based on randomization parameters set forth by the researcher, affixed the mailing labels, and mailed the questionnaires. Although an organizational mailing list was used to distribute the questionnaire, the researcher did not have access to this mailing list. Completed questionnaires were returned directly to the researcher anonymously via prepaid return envelopes enclosed with each questionnaire. Questionnaires were distributed in this way to ensure anonymity of the sample from the researcher and to ensure that the personal information of the members was protected by ACORN.
previously for internal consistency and reliability in application of the Health Belief Model in the prediction of undertaking self-protective health behaviors. 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 reviewed for content validity by four perioperative nurses, each of whom had at least five years of OR experience and who CUTrently were employed at the clinical nurse specialist/nurse educator level or above. Comments and suggestions were taken into account, and appropriate changes were made. Cronbach's alpha was used to test all questionnaire items for internal consistency and reliability. The university human research ethics committee approved the study before the questionnaire was pilot tested among 50 perioperative nurses. SURVEYINSTRUMENT Based on the quality of data and the A 96-item questionnaire was devel- comments obtained from the pilot, the oped to test and explore relationships questionnaire was revised before distribetween compliance with standard pre- bution to the sample population. cautions and occupational exposure reporting and the variables described in RESULTS the Health Belief Model. The questionAlthough this study investigated naire included items adapted from compliance with standard precautions another instrument,32which were tested and occupational exposure reporting
Figure 1 Surveys returned compared to Australian College of Operating Room Nurses membership distribution by state.
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TABLE1
Demographics of the Sample (n = 227) Gender Female Male Nurse classification
Number
Percent
218
96
9
4
hundred twenty-seven questionnaires were inRN 220 %.9 cluded in the analysis for Enrolled nurse* 7 3.1 a response rate of 45%, Nursinq traininq/education representing 13% of the Hospital trained 166 73 ACORN membertotal Uniiersity trained 20.7 47 ship. Demographic data Both 13 5.7 and frequency tables No answer 1 0.4 were compiled from the Years of scrub nu- experience returned questionnaires. Less than 2 years 19 8.4 The typical respondent 2 to 5 years 22 9.7 was a female, hospital6 to 10 years 34 15 trained RN with more More than 10 vears 152 67 than 10 years scrub nurse Employment ‘atus experience who was emFull time 135 59.5 Part time 76 33.5 ployed fulltime in a pubCasual 11 4.8 lic hospital (Table 1). No longer working/not a scrub nurse 2 0.9 Relationships between More than one answer/no answer 3 1.3 demographic data and Type of facility self-reported compliance Public hospital 147 64.8 with occupational expoPrivate hospital 62 27.3 sure reporting were anaDay surgery hospital 9 4 lyzed using frequency More than one answer 6 2.6 tables and chi square Other 2 0.9 analysis. Statistical sigrufNo answer 1 0.4 icance was assumed at Size of facility the .05 level. The analysis Lessthan1oobeds 51 22.5 was performed using 101 to 300 beds 84 37 SES-Statistical Package 301 to 600 beds 68 30 for Social Sciences verMore than 600 beds 21 9.3 sion 9.1. No answer 3 1.3 Of the 227 perioperaSize of OR suite 1t020Rs 37 16.3 tive nurses who respond3to50Rs 85 37.4 ed to the questionnaire, 6to80Rs 52 22.9 27% acknowledged inMore than 8 ORs 52 22.9 curring a percutaneous No answer 1 0.4 occupational exposure, and 5% acknowledged Totals my not equal 200% due to rounding. incurring a mucocutaneous exposure in the * An enrolled nurse in Australia is equivalent to a licensed practical nurse or licensed vocational nurse in the United States. past 12 months (Figure 2). Although intention to report both percutaneous and the relationships among perceptions exposures and mucocutaneous expoof risk,severity, and benefits of and bar- sures was high (92% and 87%, respecriers to compliance, the results present- tively), the mean compliance rates for ed in this article focus only on compli- actually reporting exposures incurred ance with and variables influencing was considerably lower (Figure 3). occupational exposure reporting. Two Additionally, when conditions were
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added, a small number of respondents were identified who would only report percutaneous or mucocutaneous exposures under certain conditions, for example if they considered the patient to be high risk or the exposure to be serious (Figure 4). Contingency tables and chi square analysis were used to determine whether a relationship existed between demographic variables and compliance with occupational exposure reporting. There was no sigruficant difference in reporting either percutaneous or mucocutaneous exposures between genders, nurse classifications, education, years of postregistration experience, or years of scrub nurse experience. Compliance with mucocutaneous exposure reporting was sigruficantly lower for nurses working in smaller, private facilities and those working in facilities with fewer ORs (Table 2). Sigruficant low to moderate correlations were found between perceptions of risk of acquiring a bloodbome infection and compliance with occupational exposure reporting. This was particularly true when respondents were asked about the high chance of acquiring hepatitis B or C and the likelihood of acquiring hepatitis B or C if an occupational exposure occurred. A sigruficant low correlation was found between the perception of severity of problems following disease transmission lasting a long time and reporting a mucocutaneous exposure. A sigruficant low correlation also was found between reporting an occupational exposure and the perception of benefits of reporting to prevent futureproblems (Table 3). The most consistently sigruficant correlations were found between reporting occupational
Figure 2 Incidence of occupational exposures in the past 12 months (figures rounded).
Figure 3 Intention to report percutaneous and mucocutaneous exposures compared to actual reporting (figures rounded).
exposures and the perception of barriers, particularly with reporting mucocutaneous exposures. Sigruficant low to moderate correlations were found between reporting exposures and the time consuming nature of reporting, embarrassment of reporting, paperwork involved, and inconvenience involved.
DISCUSSION Previous studies have used varying methods to analyze data on compliance with occupational exposure reporting. Consequently, there is little agreement in the literature on actual compliance AORN JOURNAL
267
Figure 4 Conditions that influence occupational exposure reporting (figures rounded).
rates. One fact that pervades previous Although this study revealed high studies and is supported by this study is mean compliance rates with intention that compliance with occupational to report occupational exposures, the exposure reporting is less than 100%. mean compliance rate for actually An additional finding of this study is reporting exposures incurred was conthe significanceof the perception of bar- siderably lower. This low rate of actual riers to occupationalexposure reporting reporting is cause for concern. Without among this high-risk group. accurate data on the incidence of occupational exposures, the incidence of exposures may be inaccurately perceived as low and, thus, not treated as a priority in the development of strategic infection control plans.” It also must be reiterated here that previous research comparing self-report data and observed data questions the reliability of self-report data;I5thus, the self reported data here may be an overestimation of actual reporting in practice. A large number of respondents in this study agreed with the perception of benefits of compliance with occupational exposure reporting; however, perception of barriers-or what a person perceives to be interfering with his or her undertaking or continuing a self-
TABLE2
Relationship Between Demographic Variables and Occupational Exposure Repotting Percutaneous exposures X
P
Mucocutaneous exposures X
P
Gender
0.725
0.696
0.94
0.625
Nurse classification
0.663
0.718
1.282
0.527
Nurse training/education
2.998
0.558
1.859
0.762
Years of scrub nurse experience
4.377
0.629
8.627
0.1%
Employment status
2.536
0.638
3.689
0.450
Type of faality Size of facility Size of OR suite * P < 0.05= signi@nce
3.083
0.544
10.02
O.W*
4.072
0.667
13.153
0.041*
7.498
0.277
14.7
0.0239
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AUGUST 2003, VOL 78, NO 2
TABU
3
Correlations Between Health Belief Constructs and Compliance with Reporting Occupational Exposures Percutaneoue exposures r P
M n ~ t a n e o a exposures s r P
Perception of risk My chance of getting hepatitis B (HBV)or hepatitis C (HCV) is high.
0.377
O.ooo*
0.246
O.OOO*
There is a possibility that I will get HBV or HCV.
-0.09
0.177
-0.01
0.876
I worry a lot about getting HBV or HCV.
-0.003
0.959
0.029
0.663
My work activities put me at risk for HBV or HCV.
0.031
0.646
0.098
0.141
If I have an exposure, then HBV or HCV is likely.
0.241
O.OOO*
0.162
0.015*
HBV or HCV would endanger my career.
0.057
0.397
0.107
0.108
HBV or HCV would endanger a significant relationship.
0.084
0.207
0.013
0.845
Perception of severity
HBV or HCV would endanger my financial security.
-0.025
0.710
0.122
0.066
Problems after HBV or HCV would last a long time.
0.038
0.571
0.165
0.013,
Perception of benefits Reporting prevents future problems for me.
0.222
0.001,
0.227
0.0019
Reporting would benefit me and my family members.
0.031
0.642
0.090
0.175
Reporting may lead to early disease transmission protection.
-0.042
0.527
0.012
0.863
If I reported, I would not be so anxious about HBV or HCV.
-0.021
0.756
-0.017
0.804
0.202
0.002*
0.385
O.ooo*
Perception of barriers
Reporting is lengthy and time consuming.
Reporting is embarrassing. Reporting involves too much paperwork.
-0.017
0.801
0.25
O.OO0'
-0.024
0.720
0.385
O.OOO*
Reporting is inconvenient.
-0.015
0.822
0.36
O.OO0'
High correlation (r = 0.5-1), moderate correlation (r = 0.3-0.49), low correlation (r = 0.10-0.29) * Sign$ant
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Systems and processes should make occupational exposure reporting as easy as possible. Reporting mechanisms need to be convenient and less time consuming to encourage compliance. protective behavior-demonstrated the most substantial relationships. The significance of barriers to compliancewith standard precautions is noted extensively in the literature, and correlations have been demonstrated between perception of barriers and compliance with standard pre~autions.’~ This study correlated barriers to occupational exposure reporting that previously were associated with noncompliance with standard precautions. The most significant barriers to occupational exposure reporting in this study were the time-consuming nature of reporting, the inconvenience of reporting, and the excessive paperwork involved in reporting. The barrier to reporting agreed upon by most of the respondents (72%) was the time-consuming nature of reporting. The hindrance to compliance with occupational exposure reporting caused by what perioperative nurses perceive as barriers may be overcome through the development of systems and processes that strongly encourage and support perioperative nurses to report exposures. Systems and processes must be in place to encourage compliance with occupational exposure reporting. Perioperative nurses need a reporting mechanism that is convenient and less time consuming and that involves less paperwork to make reporting as easy as possible. Accurate reporting also will be useful in generating better data on the actual occupational exposure rate among perioperative nurses, which then can be incorporated into a national strategic plan for the reduction of disease transmission among this high-risk nursing group in Australia.
the generalizability of findings should be limited to members of ACORN. Future studies also will need to include nurses who are not members of this professional body to obtain a more representative sample of all perioperative nurses in Australia. Another limitation is the inability to compare compliance rates of responders with nonresponders, producing a potentially biased sample. One way to make adjustments for this bias is to compare characteristics of the sample with those of the sampling frame. The researcher did not have direct access to characteristicsof the sampling frame, so it was not possible to determine how closely the characteristics of the sample reflected the sampling frame. Finally, there is a tendency for overestimation of compliance via a selfreport method of data collection. Future studies may need to use a combination of self-reporting instruments with prospective observation to improve estimates and collect valuable qualitative and quantitative data. Although the assumption has been made that conditions and risks faced by Australian perioperative nurses are similar to those in other countries, further research may reveal that differences between countries’ health care systems, disease prevalence, and technology may affect the general level of compliance with occupational exposure reporting in individual countries.
CONCLUSION
Consequences of an occupational exposure to bloodborne pathogens extend beyond short-term and longterm physical consequences and can affect other aspects of health care workers’ lives, such as the emotional, social, LIMlTATIONS OF THE STUDY One limitation of this study is that and financial domains. The possibility perioperative nurses who are members of incurring these consequencesstresses of ACORN represent only 12.7%of all the need for prevention of exposure to perioperative nurses in Australia? thus, bloodborne infections.
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AORN JOURNAL
Perioperative nursing is considered a high-risk nursing specialty because of the increased likelihood of occupational exposure to blood and other body substances. One way to decrease the risk of transmission of a bloodborne infection following an occupational exposure and subsequently to decrease or avoid unwanted consequences is for perioperative nurses to report all occupational exposures promptly. Prompt reporting and early prophylactic treatment have been successful in preventing disease transmission following an exposure. This study contributes to the body of nursing knowledge by idenbfymg perception of barriers to compliance as a sigruficantinfluence on compliance. The results of this study can be used to provide a basis upon which to develop and implement strategic measures to improve compliance practices through a change in systems and processes for reporting, ultimately minimizing disease transmission rates among perioperative nurses. *:*
Sonya Osborne, RN, MNurs, CNOR, is a nurse researcher, Royal Brisbane and Women’s Hospital, Nursing and Women’s Health Research Centre, Herston, Queensland, Australia. Editor’s note: Additional data from this study will be published in S Osborne, ”Injluenceson compliance with standard precautions among operating room nurses,” American Journal of Infection Control, in press.
NOTES 1.International Health Care Worker Safety Center, University of Virginia Health Sciences Center, ”Estimated annual number of US occupationalpercutaneous in’uries and mucocutaneous exposures to blood or at-risk biological substances,”Advances in Exposure Prevention 4 (January1998) 3. 2. National Centre in HIV Epidemiology and C l i c a l Research, Australian HIV Surveillance Report 15 (April 1999) 1-6.
3. Centers for Disease Control and Prevention, “Public health service guidelines for the management of health-care worker exposures to HIV and recornendations for postexposure prophylaxis,“ Morbidity and Mortality Weekly Report 47 (May 15,1998) 1-33. 4. Centers for Disease Control and Prevention, ”Recommendationsfor prevention and control of he atitis C virus (HCV) infection and HCV-re ated chronic disease,” Morbidity and Mortality Weekly Report 47 (Oct 16,1998) 1-39. 5. A R Tait et al, ”Compliance with standard guidelines for the revention of occupational transmission o bloodborne and airborne pathogens: A survey of postanaesthesia nursing Practice,” Journal of Continuing Education in Nursing 31 (January/ February 2000) 38-44. 6. D Akduman et al, “Use of personal protective equipment and operating room behaviors in four surgical subspecialties: Personal protective equipment and behaviors in surgery,” Infection Control and Hospital Epidemiology 20 (February 1999) . 110-114. 7. J M Patterson et al, ”Surgeons‘concern and practices of protection against bloodborne pathogens,” Annals of Surgery 228 (Aua;st 1998) 266-272. 8. S elsin T L Nielsen, J 0 Nielsen, “Noncompfancewith Universal precautions and the associated risk of mucocutaneous blood ex osure among Danish hysicians,” lnjction Control and Hospital [prdemiolp 18 (October 1997) 692-698. 9. D B Je e et al, “Healthcare workers’ atti-
P
P
Epidemiology 18 (October 1997) 710-712. 10. V M Knight, N J Bodsworth, “Perceptions and ractice of Universal blood and body flui] recautions by registered nurses at a major dney teaching hospital,” Journal of Adlanced Nursing 27 (April 1998) 746-751. 11. J L Tokars et al, ’’Skin and mucous membrane contacts with blood during surgical procedures: Risk and prevention,” Infection Control and Hospital Epidemiology 16 (December 1995) 703-711. 12. J C Herse ,L S Martin, “Useof infection control guideLes by workers in healthcare facilitiesto revent occupational transmission of HBfand HIV Results from a national survey,“ Infection Control and Hospital Epidemiology 15 (April 1994) 243-252.
!?
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13.K Henry et al, "Compliance with universal precautions and needle handling and disposal practices among emerency department staff at two community Rospitals," American Journal o lnfection Control 22 (June 1994) 129-13i 14.C 0Williams et al, "Variables influencing worker compliance with universal precautions in the emergency department, ' American Journal of lnfection Control 22 (June 1994) 138-148. 15. K Henry, S Campbell, M Maki, "A comparison of observed and self-reported compliance with universal precautions among emergency de artment personnel at a Minnesota putlic teaching hospital: Implications for assessing infection control rograms," Annals of Emergency Medicine 21 t 1992) 940-946. Wright, "Mechanisms of glove tears and sharp in'uries among SUT 'cal ersonnel," JAMA 166 (Sept 25,199fld-1671. 17.G Pugliese, "Should blood e osures in the o erating room be ConsidereTpart of the jo;?" American Journal of lnfection Control 21 (December 1993) 337-342. 18.J Jag er, E H Hunt, R D Pearson, "Sharp o%jectinjuries in the hospital: Causes and strate 'es for prevention," American Journal oflnfection Control 18 (August 1990) 227-231. 19.G L Telford, E J Quebbeman, "Assessing the risk of blood ex osure in the operating room," American ~ u r n aofl lnfection Control 21 (December 1993) 351-356. 20. L J Short, D M Bell, "Risk of occupational infection with bloodbome pathogens in operating and delivery room settings," American Journal of lnfection Control 21 (December 1993) 343-350. 21. S R Osborne, "Occupational exposures: Balancing the costs of prevention vs treatment in o erating theatres, with particular focus on ouble gloving practices," ACORN 14 (Winter 2001) 16-21. 22. P Lynch, M C White, "Perioperative blood contact and exposures: A comparison of incident reports and focused studes," American Journal of lnfection Control 21 (December 1993) 357-363. 23. C M Mangione, J L Gerberding, S R
B
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Cummings, "Occupational exposure to HIV Frequency and rates of underreporting of percutaneous and mucocutaneous housestaff," American
26. D M Cardo et al, "A case-control stud of HIV seroconversion in health care ,or{ers after percutaneous ex osure. Centers for Disease Control and revention Needlestick Surveillance Grou '' The Nau England Journal of Medicine 337 &ov 20,1997) 14851490. 27. Occupational Exposure to Blood: Clinical lmplicatwns and the Financial Impact of Accidental Occupational Exposure to Blood (Arlington,Tex: Johnson &Johnson Medical, Inc, 1997). 28. I M Rosenstock, "Historical origins of the health belief model," Health Education Monographs 2 (Winter 1974) 328-335. 29. R Davidhizar, "Critique of the healthbelief model," Journal of Advanced Nursing 8 (November 1983) 467-472. 30. H S Ross, P R Mico, Theory and Practice in Health Education (Palo Alto, Calif: Mayfield P u b l i s h Co, 1980) 58. 31. N Bums, S% Grove, The Practice of Nursing Research: Conduct, Critique b Utilization, third ed (Philadelphia:WB Saunders Co, 1997). 32. V L Cham ion, "Instrument development for heal& belief model constructs," Advances in Nursing Science 6 (April 1984) 73-85. 33. S R Osbome, "Compliance with standard precautions and occupationalexposure reporting among operating room nurses in Australia" (Master's thesis, University of Canberra, Australia, 2001). 34. Nursing Labour Force 1997 (Canberra, Australia: Australian Institute of Health and Welfare, 1999).
$
AUGUST 2003,VOL 78, NO 2
Perceptions that Influence
Occupational Exposure Reporting Sonya Osbome, RN
S
tatistics on occupational exposures of health care workers to bloodbome pathogens are disturbing. In 1996, the estimated total annual occupational exposures to blood or other body substances in the United States was 786,885 exposures, at a rate of 30 exposures per 100 hospital beds occupied daily.’ In Australia, national monitoring of occupational exposures to bloodborne pathogens began in 1995, and the estimated total exposures in Australia in 1998 was 1,718, at a rate of 25 exposures per 100 hospital beds occupied daily2In addition, from the analysis of documented cases, disease transmission rates for HIV and hepatitis C after occupational exposure are estimated at 0.3%and 1%to lo%, respectively, in the United States,s” and 0.32% and l.6%, respectively, in Australia? Although, standard precautions
ABSTRACT 0 STATISTICS on health care worked occupational exposures to bloodborne pathogens underestimate the true extent of the problem because of a tendency for underreporting. 0 A DESCRIPTIVE CORRELATIONAL DESIGN was used to investigate compliance with standard precautions and occupational exposure reporting practices among perioperative nurses in Australia. 0 THE STUDY found that although intention to report both percutaneous and mucocutaneous exposures was relatively high, mean compliance rates for actually reporting exposures incurred were considerablylower. 0 THE PERCEPTION of barrien to reporting significantly influenced compliance.AORN] 78 (August unl3)262-272.
262
AORN JOURNAL
were introduced in the 1980s, research continues to report less than 100% compliance among health care professionals with measures demonstrated to decrease disease transmi~sion.~-’~ The consequences of an occupational exposure to bloodborne pathogens extend beyond transmission of infection. Consequences related to health can include liver disease and subsequent transplantation complications, chronic disabilities, and premature death.’ Consequences related to employment can include punitive disciplinary action, job discrimination, denial of worker’s compensation claims, and loss of employment potential.’ Personal consequences can include anxiety, alteration in sexual practices, or postponement of pregnancy.’ The possibility of incurring these consequences emphasizes the need for prevention of exposure to bloodborne infections in high-risk environments. The focus of this article is compliance with occupational exposure reporting. It is anticipated that results from this study will be used to inform the development of appropriate strategic measures to improve perioperative nurses’ compliance with occupational exposure reporting.
OCCUPATIONAL EXPOSURE IN
THE
OR
Perioperative nursing is a high-risk nursing specialty. The nature of the work environment and the conditions in which surgical procedures take place put perioperative nurses at increased risk for occupational exposure and occupationally acquired disease transmission. The incidence of cutaneous and mucocutaneous exposure in the OR far exceeds that of percutaneous exposure and may occur in 30% to 50%
AUGUST 2003, VOL 78, NO 2
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of surgical procedure^.'^,'^ The greatest risk for occupational transmission of bloodborne infections, however, is from exposure by percutaneous injury from needles and other sharp objects, which occurs in up to 15% of surgical
procedure^.'"'^ The occupational exposure risk in the OR is considered low compared to hospital-wide risk, probably because of inadequate reporting of exposures in the OR.’* In the early 1990s, studies were conducted on risk of exposure, compliance with standard precautions and infection control policies and procedures, and lack of reporting of occupational exposures in ORs in the United state^.'^.'^,'^,^^ Previous research also compared both self-reported and observed data and questioned the reliability of self-reported data.I5 Occupational exposures among health care workers have been substantially underreported,721-25 and OR personnel underreport by as much as 25%.Unfortunately, hospitals typically rely on incident reports to determine the frequency of exposures and the need for improving measures to decrease or prevent them.= Reporting occupational exposures provides several benefits for perioperative nurses, including early initiation of prophylactic treatment and possible prevention of future social,’ and financialz’,’”problems associated with acquiring a bloodborne infection. Studies have concluded that treatment with prophylactic agents within 24 hours of exposure decreases the risk of some disease transmission.26Reporting also may decrease the anxiety associated with an occupational exposure. In light of these benefits, it is in the best interest of perioperative nurses to report all occupational exposures promptly to put in motion a process of future protection for themselves and their family members.
PURPOSE OF THE STUDY
There has been a significant amount of international research on benefits of and compliance with standard precautions as well as some research, though not as much, on types, frequency, and risk of occupational exposures among different categories of health care workers in a variety of clinical settings. Hospitals There is a dearth of research about perioperative nurses‘ compliance typically rely rates for reporting occuon incident pational exposures, however, and no studies have been found that investireports to gate the sigruficance of specific influences on determine the iompliance with reportfreWeWY ing in general or, specifically, among perioperastaff members‘ tive nurses in Australia. The purpose of this exposures to studv was to assess attitud&, beliefs, and level of bloodborne compliance with stan-
of
d a d precautions and occupational exposure reporting. Two research questions guided the study. What is the level of compliance with standard mecautions and
pathogens; unfortunately, these occurrences often are not reported.
occupational exposure reporting among perioperative nurses? What factors influence compliance with standard precautions and occupational exposure reporting among perioperative nurses in Australia?
METHOD A descriptive correlational design was used to describe variables and examine relationships between variables. Data were collected via a mailed survey. A AORN JOURNAL
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theoretical framework, the Health Belief Model,% was used to guide questionnaire development. By using a theoretical framework, the variables were given meaning so that logical conclusions could be made about which variables had the greatest influence on a health behavior. United States public health researchers began to-develop models to idenidy targets for health education .~ programs in the 1950sand 1 9 6 0 ~Early research suggests that health beliefs were correlated with behavior and Variables could be used to differenbetween those who included in this tiate did and did not underthese behaviors.** study included take The Health Belief Model describes specific variperception of ables that influence whether an individual risk, severity, will undertake particular self-protective behaviors. and benefits These variables include 0 perception of risk or and barriers susceptibility to the illn€!SS, 0 perception of severity of the illness, exposure 0 perception of benefits of undertaking a recreporb'ng. ommended health behavior, 0 perception of barriers or costs of undertaking a particular health behavior, and 0 cues to action that trigger the health behavior? The Health Belief Model is based 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.30 Readiness depends on perceptions of risk and severity of acquiring a bloodborne infection, as well as perceived
of to occupational
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benefits of undertaking the self-protective behaviors. Motivating and enabling factors include the individual's personal characteristics, previous experience, social pressure, 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 and other modifying variables, such as demographics, that allow for the prediction of health behaviors. The variables under investigation in this study are perception of 0
risk,
0
severity, benefits, and barriers.
0 0
POPULATION AND SAMPLE
Perioperative nurses in Australia were the target population for this investigation; therefore, a sample was selected from the accessible population of current members of the Australian College of Operating Room Nurses (ACORN), the professional nursing organization representing perioperative nurses in Australia. The total membership at the time of questionnaire distribution was 1,710 members. Based on calculations using a 95% confidence level and a confidence interval of 7, a minimum of 176 members needed to be surveyed for the study sample to be representative of the total ACORN membership; therefore, 500 questionnaires were distributed in anticipation of the 25% to 30% return rate expected from a mailed survey3' To obtain a study sample that reflected state representation in ACORN, participants were chosen from the sampling frame of ACORN membership using a stratified random sampling method based on the proportion of ACORN members per state in Australia (Figure 1).The only criteria for inclusion in the study sample were current membership in
ACORN and a mailing address in Australia at the time of questionnaire distribution. Questionnaires were distributed and returned in a way that maintained the privacy and anonymity of respondents. To ensure that respondent information was treated anonymously, only general demographic data were solicited on the questionnaire. No other personal information was required. The questionnaires were sent to a council representative of ACORN who had agreed to assist in distributing the questionnaires. The ACORN representative received the questionnaires in sealed, stamped envelopes. The representative generated mailing labels from ACORN'S membership list based on randomization parameters set forth by the researcher, affixed the mailing labels, and mailed the questionnaires. Although an organizational mailing list was used to distribute the questionnaire, the researcher did not have access to this mailing list. Completed questionnaires were returned directly to the researcher anonymously via prepaid return envelopes enclosed with each questionnaire. Questionnaires were distributed in this way to ensure anonymity of the sample from the researcher and to ensure that the personal information of the members was protected by ACORN.
previously for internal consistency and reliability in application of the Health Belief Model in the prediction of undertaking self-protective health behaviors. 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 reviewed for content validity by four perioperative nurses, each of whom had at least five years of OR experience and who CUTrently were employed at the clinical nurse specialist/nurse educator level or above. Comments and suggestions were taken into account, and appropriate changes were made. Cronbach's alpha was used to test all questionnaire items for internal consistency and reliability. The university human research ethics committee approved the study before the questionnaire was pilot tested among 50 perioperative nurses. SURVEYINSTRUMENT Based on the quality of data and the A 96-item questionnaire was devel- comments obtained from the pilot, the oped to test and explore relationships questionnaire was revised before distribetween compliance with standard pre- bution to the sample population. cautions and occupational exposure reporting and the variables described in RESULTS the Health Belief Model. The questionAlthough this study investigated naire included items adapted from compliance with standard precautions another instrument,32which were tested and occupational exposure reporting
Figure 1 Surveys returned compared to Australian College of Operating Room Nurses membership distribution by state.
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TABLE1
Demographics of the Sample (n = 227) Gender Female Male Nurse classification
Number
Percent
218
96
9
4
hundred twenty-seven questionnaires were inRN 220 %.9 cluded in the analysis for Enrolled nurse* 7 3.1 a response rate of 45%, Nursinq traininq/education representing 13% of the Hospital trained 166 73 ACORN membertotal Uniiersity trained 20.7 47 ship. Demographic data Both 13 5.7 and frequency tables No answer 1 0.4 were compiled from the Years of scrub nu- experience returned questionnaires. Less than 2 years 19 8.4 The typical respondent 2 to 5 years 22 9.7 was a female, hospital6 to 10 years 34 15 trained RN with more More than 10 vears 152 67 than 10 years scrub nurse Employment ‘atus experience who was emFull time 135 59.5 Part time 76 33.5 ployed fulltime in a pubCasual 11 4.8 lic hospital (Table 1). No longer working/not a scrub nurse 2 0.9 Relationships between More than one answer/no answer 3 1.3 demographic data and Type of facility self-reported compliance Public hospital 147 64.8 with occupational expoPrivate hospital 62 27.3 sure reporting were anaDay surgery hospital 9 4 lyzed using frequency More than one answer 6 2.6 tables and chi square Other 2 0.9 analysis. Statistical sigrufNo answer 1 0.4 icance was assumed at Size of facility the .05 level. The analysis Lessthan1oobeds 51 22.5 was performed using 101 to 300 beds 84 37 SES-Statistical Package 301 to 600 beds 68 30 for Social Sciences verMore than 600 beds 21 9.3 sion 9.1. No answer 3 1.3 Of the 227 perioperaSize of OR suite 1t020Rs 37 16.3 tive nurses who respond3to50Rs 85 37.4 ed to the questionnaire, 6to80Rs 52 22.9 27% acknowledged inMore than 8 ORs 52 22.9 curring a percutaneous No answer 1 0.4 occupational exposure, and 5% acknowledged Totals my not equal 200% due to rounding. incurring a mucocutaneous exposure in the * An enrolled nurse in Australia is equivalent to a licensed practical nurse or licensed vocational nurse in the United States. past 12 months (Figure 2). Although intention to report both percutaneous and the relationships among perceptions exposures and mucocutaneous expoof risk,severity, and benefits of and bar- sures was high (92% and 87%, respecriers to compliance, the results present- tively), the mean compliance rates for ed in this article focus only on compli- actually reporting exposures incurred ance with and variables influencing was considerably lower (Figure 3). occupational exposure reporting. Two Additionally, when conditions were
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added, a small number of respondents were identified who would only report percutaneous or mucocutaneous exposures under certain conditions, for example if they considered the patient to be high risk or the exposure to be serious (Figure 4). Contingency tables and chi square analysis were used to determine whether a relationship existed between demographic variables and compliance with occupational exposure reporting. There was no sigruficant difference in reporting either percutaneous or mucocutaneous exposures between genders, nurse classifications, education, years of postregistration experience, or years of scrub nurse experience. Compliance with mucocutaneous exposure reporting was sigruficantly lower for nurses working in smaller, private facilities and those working in facilities with fewer ORs (Table 2). Sigruficant low to moderate correlations were found between perceptions of risk of acquiring a bloodbome infection and compliance with occupational exposure reporting. This was particularly true when respondents were asked about the high chance of acquiring hepatitis B or C and the likelihood of acquiring hepatitis B or C if an occupational exposure occurred. A sigruficant low correlation was found between the perception of severity of problems following disease transmission lasting a long time and reporting a mucocutaneous exposure. A sigruficant low correlation also was found between reporting an occupational exposure and the perception of benefits of reporting to prevent futureproblems (Table 3). The most consistently sigruficant correlations were found between reporting occupational
Figure 2 Incidence of occupational exposures in the past 12 months (figures rounded).
Figure 3 Intention to report percutaneous and mucocutaneous exposures compared to actual reporting (figures rounded).
exposures and the perception of barriers, particularly with reporting mucocutaneous exposures. Sigruficant low to moderate correlations were found between reporting exposures and the time consuming nature of reporting, embarrassment of reporting, paperwork involved, and inconvenience involved.
DISCUSSION Previous studies have used varying methods to analyze data on compliance with occupational exposure reporting. Consequently, there is little agreement in the literature on actual compliance AORN JOURNAL
267
Figure 4 Conditions that influence occupational exposure reporting (figures rounded).
rates. One fact that pervades previous Although this study revealed high studies and is supported by this study is mean compliance rates with intention that compliance with occupational to report occupational exposures, the exposure reporting is less than 100%. mean compliance rate for actually An additional finding of this study is reporting exposures incurred was conthe significanceof the perception of bar- siderably lower. This low rate of actual riers to occupationalexposure reporting reporting is cause for concern. Without among this high-risk group. accurate data on the incidence of occupational exposures, the incidence of exposures may be inaccurately perceived as low and, thus, not treated as a priority in the development of strategic infection control plans.” It also must be reiterated here that previous research comparing self-report data and observed data questions the reliability of self-report data;I5thus, the self reported data here may be an overestimation of actual reporting in practice. A large number of respondents in this study agreed with the perception of benefits of compliance with occupational exposure reporting; however, perception of barriers-or what a person perceives to be interfering with his or her undertaking or continuing a self-
TABLE2
Relationship Between Demographic Variables and Occupational Exposure Repotting Percutaneous exposures X
P
Mucocutaneous exposures X
P
Gender
0.725
0.696
0.94
0.625
Nurse classification
0.663
0.718
1.282
0.527
Nurse training/education
2.998
0.558
1.859
0.762
Years of scrub nurse experience
4.377
0.629
8.627
0.1%
Employment status
2.536
0.638
3.689
0.450
Type of faality Size of facility Size of OR suite * P < 0.05= signi@nce
3.083
0.544
10.02
O.W*
4.072
0.667
13.153
0.041*
7.498
0.277
14.7
0.0239
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TABU
3
Correlations Between Health Belief Constructs and Compliance with Reporting Occupational Exposures Percutaneoue exposures r P
M n ~ t a n e o a exposures s r P
Perception of risk My chance of getting hepatitis B (HBV)or hepatitis C (HCV) is high.
0.377
O.ooo*
0.246
O.OOO*
There is a possibility that I will get HBV or HCV.
-0.09
0.177
-0.01
0.876
I worry a lot about getting HBV or HCV.
-0.003
0.959
0.029
0.663
My work activities put me at risk for HBV or HCV.
0.031
0.646
0.098
0.141
If I have an exposure, then HBV or HCV is likely.
0.241
O.OOO*
0.162
0.015*
HBV or HCV would endanger my career.
0.057
0.397
0.107
0.108
HBV or HCV would endanger a significant relationship.
0.084
0.207
0.013
0.845
Perception of severity
HBV or HCV would endanger my financial security.
-0.025
0.710
0.122
0.066
Problems after HBV or HCV would last a long time.
0.038
0.571
0.165
0.013,
Perception of benefits Reporting prevents future problems for me.
0.222
0.001,
0.227
0.0019
Reporting would benefit me and my family members.
0.031
0.642
0.090
0.175
Reporting may lead to early disease transmission protection.
-0.042
0.527
0.012
0.863
If I reported, I would not be so anxious about HBV or HCV.
-0.021
0.756
-0.017
0.804
0.202
0.002*
0.385
O.ooo*
Perception of barriers
Reporting is lengthy and time consuming.
Reporting is embarrassing. Reporting involves too much paperwork.
-0.017
0.801
0.25
O.OO0'
-0.024
0.720
0.385
O.OOO*
Reporting is inconvenient.
-0.015
0.822
0.36
O.OO0'
High correlation (r = 0.5-1), moderate correlation (r = 0.3-0.49), low correlation (r = 0.10-0.29) * Sign$ant
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Systems and processes should make occupational exposure reporting as easy as possible. Reporting mechanisms need to be convenient and less time consuming to encourage compliance. protective behavior-demonstrated the most substantial relationships. The significance of barriers to compliancewith standard precautions is noted extensively in the literature, and correlations have been demonstrated between perception of barriers and compliance with standard pre~autions.’~ This study correlated barriers to occupational exposure reporting that previously were associated with noncompliance with standard precautions. The most significant barriers to occupational exposure reporting in this study were the time-consuming nature of reporting, the inconvenience of reporting, and the excessive paperwork involved in reporting. The barrier to reporting agreed upon by most of the respondents (72%) was the time-consuming nature of reporting. The hindrance to compliance with occupational exposure reporting caused by what perioperative nurses perceive as barriers may be overcome through the development of systems and processes that strongly encourage and support perioperative nurses to report exposures. Systems and processes must be in place to encourage compliance with occupational exposure reporting. Perioperative nurses need a reporting mechanism that is convenient and less time consuming and that involves less paperwork to make reporting as easy as possible. Accurate reporting also will be useful in generating better data on the actual occupational exposure rate among perioperative nurses, which then can be incorporated into a national strategic plan for the reduction of disease transmission among this high-risk nursing group in Australia.
the generalizability of findings should be limited to members of ACORN. Future studies also will need to include nurses who are not members of this professional body to obtain a more representative sample of all perioperative nurses in Australia. Another limitation is the inability to compare compliance rates of responders with nonresponders, producing a potentially biased sample. One way to make adjustments for this bias is to compare characteristics of the sample with those of the sampling frame. The researcher did not have direct access to characteristicsof the sampling frame, so it was not possible to determine how closely the characteristics of the sample reflected the sampling frame. Finally, there is a tendency for overestimation of compliance via a selfreport method of data collection. Future studies may need to use a combination of self-reporting instruments with prospective observation to improve estimates and collect valuable qualitative and quantitative data. Although the assumption has been made that conditions and risks faced by Australian perioperative nurses are similar to those in other countries, further research may reveal that differences between countries’ health care systems, disease prevalence, and technology may affect the general level of compliance with occupational exposure reporting in individual countries.
CONCLUSION
Consequences of an occupational exposure to bloodborne pathogens extend beyond short-term and longterm physical consequences and can affect other aspects of health care workers’ lives, such as the emotional, social, LIMlTATIONS OF THE STUDY One limitation of this study is that and financial domains. The possibility perioperative nurses who are members of incurring these consequencesstresses of ACORN represent only 12.7%of all the need for prevention of exposure to perioperative nurses in Australia? thus, bloodborne infections.
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Perioperative nursing is considered a high-risk nursing specialty because of the increased likelihood of occupational exposure to blood and other body substances. One way to decrease the risk of transmission of a bloodborne infection following an occupational exposure and subsequently to decrease or avoid unwanted consequences is for perioperative nurses to report all occupational exposures promptly. Prompt reporting and early prophylactic treatment have been successful in preventing disease transmission following an exposure. This study contributes to the body of nursing knowledge by idenbfymg perception of barriers to compliance as a sigruficantinfluence on compliance. The results of this study can be used to provide a basis upon which to develop and implement strategic measures to improve compliance practices through a change in systems and processes for reporting, ultimately minimizing disease transmission rates among perioperative nurses. *:*
Sonya Osborne, RN, MNurs, CNOR, is a nurse researcher, Royal Brisbane and Women’s Hospital, Nursing and Women’s Health Research Centre, Herston, Queensland, Australia. Editor’s note: Additional data from this study will be published in S Osborne, ”Injluenceson compliance with standard precautions among operating room nurses,” American Journal of Infection Control, in press.
NOTES 1.International Health Care Worker Safety Center, University of Virginia Health Sciences Center, ”Estimated annual number of US occupationalpercutaneous in’uries and mucocutaneous exposures to blood or at-risk biological substances,”Advances in Exposure Prevention 4 (January1998) 3. 2. National Centre in HIV Epidemiology and C l i c a l Research, Australian HIV Surveillance Report 15 (April 1999) 1-6.
3. Centers for Disease Control and Prevention, “Public health service guidelines for the management of health-care worker exposures to HIV and recornendations for postexposure prophylaxis,“ Morbidity and Mortality Weekly Report 47 (May 15,1998) 1-33. 4. Centers for Disease Control and Prevention, ”Recommendationsfor prevention and control of he atitis C virus (HCV) infection and HCV-re ated chronic disease,” Morbidity and Mortality Weekly Report 47 (Oct 16,1998) 1-39. 5. A R Tait et al, ”Compliance with standard guidelines for the revention of occupational transmission o bloodborne and airborne pathogens: A survey of postanaesthesia nursing Practice,” Journal of Continuing Education in Nursing 31 (January/ February 2000) 38-44. 6. D Akduman et al, “Use of personal protective equipment and operating room behaviors in four surgical subspecialties: Personal protective equipment and behaviors in surgery,” Infection Control and Hospital Epidemiology 20 (February 1999) . 110-114. 7. J M Patterson et al, ”Surgeons‘concern and practices of protection against bloodborne pathogens,” Annals of Surgery 228 (Aua;st 1998) 266-272. 8. S elsin T L Nielsen, J 0 Nielsen, “Noncompfancewith Universal precautions and the associated risk of mucocutaneous blood ex osure among Danish hysicians,” lnjction Control and Hospital [prdemiolp 18 (October 1997) 692-698. 9. D B Je e et al, “Healthcare workers’ atti-
P
P
Epidemiology 18 (October 1997) 710-712. 10. V M Knight, N J Bodsworth, “Perceptions and ractice of Universal blood and body flui] recautions by registered nurses at a major dney teaching hospital,” Journal of Adlanced Nursing 27 (April 1998) 746-751. 11. J L Tokars et al, ’’Skin and mucous membrane contacts with blood during surgical procedures: Risk and prevention,” Infection Control and Hospital Epidemiology 16 (December 1995) 703-711. 12. J C Herse ,L S Martin, “Useof infection control guideLes by workers in healthcare facilitiesto revent occupational transmission of HBfand HIV Results from a national survey,“ Infection Control and Hospital Epidemiology 15 (April 1994) 243-252.
!?
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13.K Henry et al, "Compliance with universal precautions and needle handling and disposal practices among emerency department staff at two community Rospitals," American Journal o lnfection Control 22 (June 1994) 129-13i 14.C 0Williams et al, "Variables influencing worker compliance with universal precautions in the emergency department, ' American Journal of lnfection Control 22 (June 1994) 138-148. 15. K Henry, S Campbell, M Maki, "A comparison of observed and self-reported compliance with universal precautions among emergency de artment personnel at a Minnesota putlic teaching hospital: Implications for assessing infection control rograms," Annals of Emergency Medicine 21 t 1992) 940-946. Wright, "Mechanisms of glove tears and sharp in'uries among SUT 'cal ersonnel," JAMA 166 (Sept 25,199fld-1671. 17.G Pugliese, "Should blood e osures in the o erating room be ConsidereTpart of the jo;?" American Journal of lnfection Control 21 (December 1993) 337-342. 18.J Jag er, E H Hunt, R D Pearson, "Sharp o%jectinjuries in the hospital: Causes and strate 'es for prevention," American Journal oflnfection Control 18 (August 1990) 227-231. 19.G L Telford, E J Quebbeman, "Assessing the risk of blood ex osure in the operating room," American ~ u r n aofl lnfection Control 21 (December 1993) 351-356. 20. L J Short, D M Bell, "Risk of occupational infection with bloodbome pathogens in operating and delivery room settings," American Journal of lnfection Control 21 (December 1993) 343-350. 21. S R Osborne, "Occupational exposures: Balancing the costs of prevention vs treatment in o erating theatres, with particular focus on ouble gloving practices," ACORN 14 (Winter 2001) 16-21. 22. P Lynch, M C White, "Perioperative blood contact and exposures: A comparison of incident reports and focused studes," American Journal of lnfection Control 21 (December 1993) 357-363. 23. C M Mangione, J L Gerberding, S R
B
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Cummings, "Occupational exposure to HIV Frequency and rates of underreporting of percutaneous and mucocutaneous housestaff," American
26. D M Cardo et al, "A case-control stud of HIV seroconversion in health care ,or{ers after percutaneous ex osure. Centers for Disease Control and revention Needlestick Surveillance Grou '' The Nau England Journal of Medicine 337 &ov 20,1997) 14851490. 27. Occupational Exposure to Blood: Clinical lmplicatwns and the Financial Impact of Accidental Occupational Exposure to Blood (Arlington,Tex: Johnson &Johnson Medical, Inc, 1997). 28. I M Rosenstock, "Historical origins of the health belief model," Health Education Monographs 2 (Winter 1974) 328-335. 29. R Davidhizar, "Critique of the healthbelief model," Journal of Advanced Nursing 8 (November 1983) 467-472. 30. H S Ross, P R Mico, Theory and Practice in Health Education (Palo Alto, Calif: Mayfield P u b l i s h Co, 1980) 58. 31. N Bums, S% Grove, The Practice of Nursing Research: Conduct, Critique b Utilization, third ed (Philadelphia:WB Saunders Co, 1997). 32. V L Cham ion, "Instrument development for heal& belief model constructs," Advances in Nursing Science 6 (April 1984) 73-85. 33. S R Osbome, "Compliance with standard precautions and occupationalexposure reporting among operating room nurses in Australia" (Master's thesis, University of Canberra, Australia, 2001). 34. Nursing Labour Force 1997 (Canberra, Australia: Australian Institute of Health and Welfare, 1999).
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