Highlights
- •Non-percutaneous body fluid exposure reports indicate poor compliance with use of personal protective equipment.
- •Nurses risk assess activities to select appropriate personal protective equipment yet report non-compliance in use.
- •A positive safety culture could improve compliance with use of personal protective equipment.
Abstract
Background
Selection and use of personal protective equipment (PPE) to prevent non-percutaneous body fluid exposure (NP BFE) is determined by a clinical assessment of risk. The aim of this study was to explore the selection and use of PPE, particularly masks and eye protection to prevent NP BFE, by nurses.
Methods
This quantitative single-site two-phased study was guided by the Health Belief Model (HBM). Phase 1 was a retrospective electronic database audit of body fluid exposure surveillance data. Phase 2 included a cross-sectional survey.
Results
The highest incidence of reported NP BFE to non-intact skin and mucous membranes during the study period were identified in the emergency department (ED) at 51.3% (20/39), intensive care unit (ICU) at 30.8% (12/39), operating theatre (OT) with 12.9% (5/39), and inpatient renal ward with 5.1% (2/39). Reported PPE use during NP BFE was: 0% face shields or masks, 10% gown/apron, and 15% goggles.
Survey results related to Prevention of mucocutaneous exposures were similar across all high-risk units, though ED nurses reported poorer compliance with the use of PPE to prevent exposure. Risk assessment for prevention of NP BFE was reported, yet there was a lack of compliance. The ICU results indicated a positive safety culture in contrast to the ED.
Conclusion
The findings are consistent with research identifying inadequate prevention of NP BFE, although nurses are aware of the importance of risk assessment. The HBM has the potential to increase understanding of the differences in nurses’ perceptions of risk in safety culture.
Keywords
Introduction
Standard precautions (SP) to prevent the transmission of pathogens, primarily from blood and other body substances (vomit, urine, faeces, etc.), in healthcare settings have evolved since 1987 [
[1]
] to current practice [[2]
]. These precautions include, but are not limited to, hand hygiene and the use of personal protective equipment (PPE) such as gloves, eye protection, gowns/aprons, and masks to prevent exposure to blood or body substances during clinical care. The use of PPE has been a critical aspect of clinical practice in healthcare delivery for decades, and with the recent COVID-19 pandemic, PPE became a household term receiving significant attention worldwide. The use of SP in clinical practice ensures healthcare worker (HCW) safety and patient safety and is dependent upon assessment of risk of transmission of pathogens, as noted by the National Health and Medical Research Council [[2]
]:“Selection of protective equipment must be based on assessment of the risk of transmission of infectious agents to the patient or carer, and the risk of contamination of the clothing or skin of healthcare workers or other staff by patients' blood, body substances, secretions or excretions.”
Whilst the use of SP is mandated globally as best practice, failure to comply with these precautions, has been noted in the literature [
[3]
,[4]
]. An Australian study identified that non-compliance appears to be based on the individual judgement of HCW as to whether to implement elements of SP, including PPE [[3]
]. Of the PPE that is selected, glove use has been identified internationally to have the highest compliance in several studies [4
, 5
, 6
, 7
, 8
, 9
, 10
, - Haile T.G.
- Engeda E.H.
- Abdo A.A.
Compliance with standard precautions and associated factors among healthcare workers in gondar university comprehensive specialized hospital, northwest Ethiopia.
J. Environ. Public Health. 2017; 2017doihttps://doi.org/10.1155/2017/2050635
11
, 12
, 13
, 14
, 15
, 16
, 17
, 18
]. The poorest compliance reported for SP, pre-COVID-19, is in the selection and use of eye protection, masks, and aprons/gowns [4
, 5
, 6
, 7
, 8
, 9
, 10
, - Haile T.G.
- Engeda E.H.
- Abdo A.A.
Compliance with standard precautions and associated factors among healthcare workers in gondar university comprehensive specialized hospital, northwest Ethiopia.
J. Environ. Public Health. 2017; 2017doihttps://doi.org/10.1155/2017/2050635
11
, 12
, 13
, 14
, 15
,17
, 18
, 19
, 20
, - Aluko O.O.
- Adebayo A.E.
- Adebisi T.F.
- Ewegbemi M.K.
- Abidoye A.T.
- Popoola B.F.
Knowledge, attitudes and perceptions of occupational hazards and safety practices in Nigerian healthcare workers.
BMC Res Notes. 2016; 9https://doi.org/10.1186/s13104-016-1880-2
21
]. This leads to the question as to why compliance with protective behaviours to prevent non-percutaneous body fluid exposure (NP BFE) is so poor amongst HCW. To date there has been limited research describing nurses’ PPE practices and the reasons for poor compliance in relation to PPE use to prevent NP BFE as part of SP.Objectives
The overall objective of this study was to identify and describe current nursing staff practices in the selection and use of PPE, particularly masks, eye protection and gowns/aprons to prevent NP BFE, as part of SP. This quantitative two-phased study was guided by the Health Belief Model (HBM) which explores HCW perceptions of: 1) risk susceptibility, 2) risk severity, 3) benefits to action, 4) barriers to action, 5) cues to action, and 6) self-efficacy in embracing preventative practices [
22
, 23
, 24
]. The HBM provides a theoretical framework for understanding the barriers to clinician engagement in behaviours that protect them from exposure to potentially infectious pathogens.Methods
Study design
This study was undertaken in two phases. The first phase was a retrospective electronic database audit of body fluid exposure surveillance data including the incidence, location (department) and type of muco-cutaneous exposures reported, and the circumstances in which they occurred, from September 2013–September 2019 (prior to the COVID-19 pandemic). This study focuses on nurses, as preliminary unpublished data from the study site indicated that nursing staff accounted for the highest proportion of NP BFE. The information was de-identified and presented in aggregate form.
The second phase of this study included a cross-sectional self-administered paper-based survey using a combination of two measures previously validated and reported in nursing populations, see measures below.
Setting
This single-site study was conducted at the Gold Coast University Hospital, a 750-bed acute tertiary care facility located in South-East Queensland, Australia.
Measures
The measures used in Phase 2 of this study were the psychometrically validated: 1) Compliance with Standard Precautions Scale (CSPS) [
[25]
] which assessed overall compliance with SP, and, 2) the Factors Influencing Adherence to Standard Precautions Scale (FIASPS) [[3]
,[26]
] which assessed attitudinal and workplace factors that influence adherence to SP. Permission to use these tools was given by the creators of the tools.The CSPS [
[25]
] identified particular practices associated with poor compliance using a Likert–style scale of 1–4 (‘never’ to’ always') for each item. The results of this scale were clustered into key IPC practices: 1) Prevention of mucocutaneous exposure, 2) Safe handling and disposal of sharps, 3) Hand hygiene, 4) Glove use, and 5) Waste and environmental management.The FIASPS [
[26]
] also uses a Likert-type scale of 1–5 (‘not at all’ to ‘very much’) for each item clustering results into the key constructs of the Health Belief Model: 1) Susceptibility, 2) Severity, 3) Benefits, 4) Barriers, 5) Cue to action, and 6) Self-efficacy.Participants and data collection
Phase 1 data were collected by Infection Control Department staff from the pre-existing database of occupational exposures. For the purposes of this study, the four units identified as having the highest incidence of NP BFE reported by nurses and midwives were: 1) intensive care unit (ICU), 2) Emergency Department (ED), 3) Operating Theatre (OT), and 4) the inpatient renal ward. Nursing staff from these four ‘high-risk’ units were invited to participate in Phase 2.
Phase 2 survey data were collected during staff meetings and handover sessions at shift changeovers for each department. Information sheets were provided to all participants and completion of the survey implied consent. Permission parameters for the CSPS [
[25]
] and FIASPS [[26]
] were limited to 1000 copies per project. This data was collected primarily in late 2019, prior to the COVID-19 pandemic. Due to the impact of COVID-19 in early 2020, the data collection phase was suspended and although data collection had commenced in the OT, it had not been completed and not included in the analysis.Data analysis
All data were analysed using the Statistical Package for the Social Sciences Version 27 (SPSS) [
[27]
]. The audit data analyses were descriptive: means (m), standard deviation (SD), and frequencies (%), depending on the level and distribution of the data. The retrospective audit identified four high-risk departments where surveys were distributed, for cross departmental comparisons, OT responses were excluded due to the small sample size and incomplete data collection (n = 9). Chi squared, fishers exact test, and t-tests were used to compare differences in survey responses between different departments; statistical significance was set at p < 0.05.The HBM [
22
, 23
, 24
], in conjunction with the work of Pereira and colleagues [[4]
] who used the CSPS [[25]
] to measure compliance with standard precautions in both Hong Kong and Brazil, guided the clustering of items from the surveys and the interpretation of the results.Results
Phase 1: body fluid exposure audit
For the period September 2013 until September 2019, a total of 223 NP BFE were recorded by nurses/midwives (including students): 93 (41.7%) mucous membrane exposure, 105 (47.1%) non-intact skin exposure, and 25 (11.2%) not classified. The most common substance involved with exposures was blood or blood products, both overall (54.3% n = 121) and in all identified high-risk units (56.4% n = 57). The clinical units with the highest number of NP mucous membrane BFE were the ICU (38.6% n = 39), ED (27.7% n = 28), OT (23.8% n = 24), and the inpatient renal ward (9.9% n = 10). The highest incidence of reported NP BFE to non-intact skin during the study period was identified in the ED at 51.3% (20/39), ICU at 30.8% (12/39), OT with 12.9% (5/39), and renal ward with 5.1% (2/39) (Table 1). Of all reported NP BFE, 45.3% (100/223) were nurses with most sustained by Registered Nurses (RN) both overall (84.4% n = 92) and in the high-risk units.
Table 1Use of PPE during non-percutaneous body fluid exposure by high-risk unit.
| ICU (n = mucous membrane/non-intact) | ED (n = mucous membrane/non-intact) | OT (n = mucous membrane/non-intact) | RW (n = mucous membrane/non-intact) | Percentage of total high-risk units % (n = mucous membrane/non-intact) | |
|---|---|---|---|---|---|
| Faceshield | 0/0 | 0/0 | 2/0 | 0/0 | 2% (2/101)/0% (0/39) |
| Goggles | 10/4 | 1/1 | 3/1 | 0/0 | 13.9% (14/101)/15% (6/39) |
| Mask | 1/0 | 0/0 | 4/0 | 0/0 | 5% (5/101)/0% (39) |
| Gown/apron | 11/2 | 2/2 | 5/0 | 2/0 | 19.8% (20/101)/10% (4/39) |
Where NP BFE occurred, the use of PPE ranged from 0% (n = 0) for face shields and masks, with goggles the most common at 15% (n = 6). Based on these results, the ICU utilised PPE more than any other unit (Table 1).
Phase 2: high risk department nursing survey
181 nurses participated in the survey, of which 165 (91.2%) were female and 16 (8.8%) were male. The average age was 36 years old (SD = 11.32). Most respondents were RNs (n = 136, 74.2%). The largest proportion of responses were from the ED (n = 101, 55.5%), with only nine surveys being completed in the OT, but these were excluded from analysis due to suspension of data collection due to the COVID-19 pandemic (4.9%) (Table 2).
Table 2Survey participant demographics.
| Item | n | % | |
|---|---|---|---|
| Gender | Female | 165 | 91.2% |
| Male | 16 | 8.8% | |
| Total | 181 | ||
| Age (mean) | 36.08 years | SD = 11.32 | |
| Infection control training (last 24 months) | Hospital | 126 | |
| University | 1 | ||
| None | 47 | ||
| Position | Nurse Unit Manager | 3 | 1.6% |
| Clinical Nurse Consultant | 7 | 3.8% | |
| Nurse Practitioner | 1 | 0.5% | |
| Clinical Nurse | 27 | 14.8% | |
| Registered Nurse | 135 | 74.2% | |
| Enrolled Nurse | 4 | 2.2% | |
| Specialty Unit | Emergency Department | 101 | 55.5% |
| Intensive Care Unit | 44 | 24.2% | |
| Renal Ward | 27 | 14.8% | |
| Operating Theatres | 9 | 4.9% |
Compliance with Standard Precautions Scale
A strong ceiling effect was evident in the results of the CSPS [
[25]
], meaning most of the respondents scores for these items were on the upper limit of the scale, with responses trending towards the ‘always’ answer or ‘4/4’. Across the three departments, the ED tended to score lower, with some variation on specific items as outlined in Table 3.Table 3Difference between the compliance with clustered Standard Precautions between departments.
| ED mean (S.D.) (sample size varied from n = 78–101) | ICU mean (S.D.) (sample size varied from n = 26–44) | Renal Ward mean (S.D.) (sample size varied from n = 14–27) | Chi-squared statistic (P value) | |
|---|---|---|---|---|
| Prevention of mucocutaneous exposure | ||||
| B8. I would take a shower in case of extensive splashing even after I have put on PPE | 3.1 (1.2) | 3.6 (0.7) | 3.4 (1.0) | 10.627 (0.084) |
| B9. I would cover my wound(s) or lesion(s) with waterproof dressing before patient contacts | 3.8 (0.5) | 3.8 (0.5) | 3.9 (0.3) | 6.518 (0.123) |
| B13. I wear a surgical mask alone or in combination with goggles, face shield and apron whenever there is a possibility of a splash or splatter | 3.2 (0.6) | 3.4 (0.7) | 3.3 (0.8) | 7.351 (0.24) |
| B14. My mouth and nose are covered when I wear a mask | 3.9 (0.3) | 4.0 (0.3) | 4.0 (0) | same |
| B15. I reuse a surgical mask or disposable PPE | 3.7 (0.9) | 3.7 (0.7) | 3.7 (0.7) | 7.514 (0.227) |
| B16. I wear a gown or apron when exposed to blood, body fluids or any patient excretions | 3.4 (0.7) | 3.9 (0.3) | 3.9 (0.4) | 30.11 (0.001∗) |
| Safe handling and disposal of sharps | ||||
| B4. I recap used needles after giving an injection | 3.6 (0.7) | 3.6 (0.8) | 3.5 (0.9) | 5.573 (0.439) |
| B5. I put used sharp articles into a sharps container | 3.9 (0.5) | 4.0 (0.2) | 4.0 (0) | same |
| B6. The sharps container is disposed of when its contents reach the full line on the container | 3.3 (0.7) | 3.8 (0.4) | 3.7 (0.5) | 22.936 (0.001∗) |
| Hand hygiene | ||||
| B1. I wash my hands between patient contacts | 3.7 (0.4) | 4.0 (0) | 3.9 (0.4) | 17.689 (0.001∗) |
| B2. I only use water for hand washing | 3.2 (1.1) | 2.9 (1.1) | 3 (1.0) | 11.894 (0.049∗) |
| B3. I use alcohol-based hand rubs as an alternative to soap and water if my hands are not visibly soiled | 3.3 (0.9) | 3.3 (0.7) | 3.4 (0.7) | 3.97 (0.683) |
| Glove use | ||||
| B10. I wear gloves when I am exposed to body fluids, blood products, and any excretion of patients | 3.9 (0.3) | 4.0 (0.2) | 3.9 (0.3) | 1.172 (0.536) |
| B11. I change gloves between patient contacts | 4.0 (0) | 4.0 (0) | 4.0 (0) | same |
| B12. I decontaminate my hands immediately after removal of gloves | 3.7 (0.5) | 3.9 (0.3) | 3.9 (0.4) | 4.394 (0.112) |
| B19. I wear gloves to decontaminate used equipment with visible soils | 3.7 (0.5) | 4.0 (0.2) | 4.0 (0) | 13.384 (0.003∗) |
| Waste and environmental management | ||||
| B7. I remove PPE in a designated area | 3.3 (0.8) | 3.5 (0.7) | 3.8 (0.4) | 13.591 (0.002∗) |
| B17. Waste contaminated with blood, body fluids, secretion and excretion is placed in yellow plastic bags irrespective of the patient's infection status | 3.6 (0.6) | 3.9 (0.3) | 4.0 (0.2) | 15.583 (0.002∗) |
| B18. I decontaminate surfaces and equipment after use | 3.4 (0.6) | 3.9 (0.3) | 3.7 (0.5) | 36.091 (0.001∗) |
| B20. I clean up spillage of blood or body fluids immediately with disinfectants | 3.7 (0.5) | 3.9 (0.4) | 4.0 (0) | 15.166 (0.002∗) |
There were statistically significant differences among departments relative to the four “Waste and environmental management” items (B7, B17, B18, and B20). The ED had consistently lower scores on these four items compared to the other two departments.
For B7 renal ward respondents were more likely to remove PPE in a designated area (m = 3.8, SD = 0.4, p = 0.002) and (B20) and clean up body fluid spills immediately (m = 4, SD = 0, p = 0.002). Responses to the question about appropriate disposal of contaminated waste (B17), were comparable between the ICU (m = 3.9, SD = 0.3) and the renal ward (m = 4.0, SD = 0.2, p = 0.002). ICU respondents were most likely to decontaminate surfaces and equipment after use (B18) - m = 3.9, SD = 0.3, p = 0.001.
Two of three of the “Hand hygiene” questions were also significantly different across the departments. Responses to B1 differed significantly between units indicating hand hygiene between patients was less frequent in ED (m = 3.7, SD = 0.4), compared to the renal ward (m = 3.9, SD = 0.4) and ICU (m = 4, SD = 0, p = 0.001).
ED respondents ranked lowest when questioned about prevention of mucocutaneous exposure including the use of gowns/aprons (B16) where ED scored (m = 3.4, SD = 0.7, p = 0.001). All departments scored unanimously high in relation to appropriate mask wearing (B14), with no significant differences.
In the section “Safe handling and disposal of sharps” ICU scored highest (B6) in relation to disposal of full sharps containers (m = 3.8, SD = 0.4, p = 0.001).
Factors Influencing Adherence to Standard Precautions Scale
The FIASPS [
[26]
] was clustered into the constructs of the Health Belief Model: 1) susceptibility, 2) severity, 3) benefits, 4) barriers, 5) cue to action, and 6) self-efficacy (Table 4). This scale was scored 1 = not at all, to 5 = very much. A ceiling effect was again evident in many of the items for the FIASPS [[26]
], with responses trending towards the ‘very much’ answer or ‘5/5’. This ceiling effect was not as pronounced when compared to the CSPS [[25]
]. Different departments also scored differently across the survey, with no single department trended towards highest or lowest scores for the entire survey, it varied based on item (Table 4).Table 4Difference between the compliance with Standard Precautions between departments grouped by Health Belief Model elements.
| ED mean (S.D.) (sample size varied from n = 78–101) | ICU mean (S.D.) (sample size varied from n = 26–44) | Renal Ward mean (S.D.) (sample size varied from n = 14–27) | Chi-squared statistic (P value) | |
|---|---|---|---|---|
| Susceptibility | ||||
| C5. I assess what is wrong with a patient before deciding whether or not to implement standard precautions | 3.1 (1.4) | 2.4 (1.5) | 2.8 (1.5) | 12.982 (0.104) |
| C13. Most nurses adhere to standard precautions | 3.7 (0.9) | 4.1 (0.8) | 4.1 (0.9) | 10.062 (0.207) |
| C20. I am more likely to follow standard precautions if I am dealing with needles | 3.9 (1.4) | 3.6 (1.6) | 4.0 (1.4) | 4.969 (0.771) |
| C23. I am educated and able to weigh up risks/benefits of not using standard precaution when needed | 2.7 (1.5) | 2.8 (1.7) | 3.0 (1.7) | 13.312 (0.172) |
| C24. Most doctors typically adhere to standard precautions | 2.7 (1.1) | 2.8 (1.1) | 2.4 (1.0) | 4.195 (0.852) |
| C25. I don't need to wear gloves when taking blood/cannulating as I am skilled at what I do | 4.7 (0.8) | 4.6 (1.0) | 4.9 (0.2) | 4.892 (0.787) |
| Severity | ||||
| C14. My assessment of a patient's status will indicate if I need to follow standard precautions guidelines | 2.8 (1.3) | 2.3 (1.4) | 2.9 (1.7) | 18.474 (0.014∗) |
| C15. It is my choice not to wear gloves when taking blood/cannulating as I am only putting myself at risk | 4.3 (1.3) | 4.6 (1.0) | 3.7 (1.9) | 17.517 (0.021∗) |
| C16. I am able to decide whether or not to use personal protective equipment based on the clinical risk to me | 2.6 (1.4) | 3 (1.6) | 2.5 (1.7) | 13.913 (0.044∗) |
| Benefits | ||||
| C9. I use role-modelling to increase use of standard precautions by others | 3.5 (1.1) | 4.1 (1.0) | 4.2 (0.9) | 19.764 (0.006∗) |
| C10. I have a responsibility to encourage people to protect themselves | 3.9 (1.0) | 4.6 (0.7) | 4.7 (0.6) | 32.288 (0.001∗) |
| Barriers | ||||
| C4. People interpret standard precautions guidelines differently | 3.1 (1.2) | 3.0 (0.9) | 2.7 (1.1) | 8.467 (0.38) |
| C8. In some workplaces it is standard practice not to follow guidelines | 4.2 (1.0) | 4.2 (1.1) | 4.1 (1.2) | 5.679 (0.67) |
| C11. The culture in the organisation allows for people not to follow standard precaution guidelines | 2.7 (1.2) | 2.3 (1.3) | 2.4 (1.5) | 15.366 (0.044∗) |
| C17. I am clumsier when I wear gloves and risk having to repeat the procedure | 4.1 (1.2) | 4.6 (0.7) | 4.0 (1.1) | 12.64 (0.09∗) |
| C21. I don't wear gloves when cannulating/taking blood as I cannot feel veins | 4.3 (1.1) | 4.6 (0.9) | 4.6 (1.1) | 6.873 (0.485) |
| C22. I am less likely to wear gloves as I was taught procedures without them | 4.7 (1.1) | 4.8 (0.6) | 4.5 (1.0) | 5.404 (0.694) |
| Cue to action | ||||
| C1. I feel the need to confront people I see not adhering to standard precautions | 2.9 (0.9) | 3.6 (1.0) | 3.5 (0.9) | 24.429 (0.001∗) |
| C3. I am more likely to wear personal protective equipment if I see my colleagues wearing it | 3.5 (1.4) | 3.0 (1.6) | 3.7 (1.6) | 17.879 (0.017∗) |
| C6. I am more likely to follow standard precautions if I am dealing with sharp instruments | 3.9 (1.4) | 2.8 (1.7) | 3.5 (1.7) | 19.466 (0.008∗) |
| C7. When I witness others' non-adherence with standard precautions, I use that as an education opportunity | 2.7 (1.2) | 3.4 (1.2) | 3.5 (1.3) | 15.258 (0.048∗) |
| C18. I am more likely to wear Personal Protective Equipment if it is located nearby patients | 3.9 (1.4) | 3.6 (1.6) | 4.0 (1.3) | 3.941 (0.876) |
| C19. I am more careful if I know that a patient has a blood-borne pathogen | 4.5 (0.9) | 4.0 (1.2) | 4.2 (1.3) | 9.327 (0.258) |
| Self-efficacy | ||||
| C2. The more experienced I become, the more likely I am to be able to decide when I need to use standard precautions | 3.5 (1.4) | 3.6 (1.6) | 3.6 (1.6) | 11.442 (0.152) |
| C12. I feel comfortable challenging nurses or doctors when I see them not adhering to standard precautions | 2.9 (1.2) | 3.7 (1.2) | 3.5 (1.3) | ∗∗insufficient memory to compute |
Using the HBM constructs as a clustering mechanism there were significant differences in all “Severity and Benefits” questions.
For Severity, decisions about PPE use were based on HCW decisions about a patient's infectious status (C14) less frequently in ICU (m = 2.3, SD = 1., p = 0.014), while nurses in the renal inpatient unit were less likely to base PPE selection on their perception of their own clinical risk (C16) – m = 2.5, SD = 1.7, p = 0.021 - or their own personal preference (C15) – m = 3.7, SD = 1.9, p = 0.044.
Within the Benefits questions, ED respondents were less likely to use role modelling (C9) - m = 3.5, SD = 1.1, p = 0.006 – to influence the behaviour of others or to accept responsibility for encouraging protective behaviour in others (C10) - m = 3.9, SD = 1.0, p = 0.001.
Of note within the Barriers question (C11), ED respondents indicated the organizational culture supported poor compliance with SP (m = 2.7, SD = 1.2, p = 0.044), while ICU respondents disagreed (m = 2.3, SD = 1.3).
There were statistically significant differences in responses across departments in the “Cue to action” section. In relation to question (C1) ICU respondents were more likely to confront non-adherence with SP (m = 3.6, SD = 1.0, p = 0.001) and less likely to rely on colleagues wearing appropriate PPE (C3) to comply themselves (m = 3.0, SD = 1.6, p = 0.017). ICU respondents indicated they were not as reliant on dealing with sharp instruments to promote compliance with SP (C6) - m = 2.8, SD = 1.7, p = 0.008. Respondents from ED were less likely to educate colleagues demonstrating non-compliance with SP (C7) - ED (m = 2.7, SD = 1.2), compared with those from ICU (m = 3.4, SD = 1.2) and the renal ward (m = 3.5, SD = 1.3, p = 0.048).
There were no significant group differences noted in the elements of “Susceptibility” or “Self-efficacy”.
Discussion
This study aimed to identify and describe current practice for nursing staff in the selection and use of PPE, particularly masks, eye protection, and gowns/aprons, to prevent NP BFE as part of SP. Reported exposures were designated as being associated with mucous membranes, or non-intact skin.
Appropriate selection and use of PPE was highest among ICU nurses who reported more mucous membrane NP BFE than non-intact skin exposures, with ED reporting the most non-intact skin NP BFE. Such a difference between the two units may be specifically related to workplace culture because previous studies have identified that a positive safety culture encourages reporting of BFE [
[28]
]. Such a culture is also associated with a lower incidence of BFE generally [[28]
]. The ED environment is considered to be a challenging patient care environment for IPC due to reported issues including, staffing, inadequate in-service training, workload, and critically ill patients who may require resuscitation, and other stressors [[29]
,[30]
]. Added to this is the well reported overcrowding that impacts all Australian EDs, with presentations increasing by 2.6% each year [[31]
].Several blood-borne viruses can be contracted by HCWs during their routine duties through occupational exposures [
[32]
]. Key viruses acquired through NP BFE include hepatitis B, hepatitis C, and human immunodeficiency virus (HIV) [[33]
] therefore the use of appropriate PPE to reduce exposure is essential. In this study the use of face shields or masks during NP BFE was not reported in any of the high-risk units, with the use of goggles the highest, at 15% across reported NP BFE. This is particularly low in comparison to other studies where it is reported closer to 50% [[10]
] and 57.4% [- Haile T.G.
- Engeda E.H.
- Abdo A.A.
Compliance with standard precautions and associated factors among healthcare workers in gondar university comprehensive specialized hospital, northwest Ethiopia.
J. Environ. Public Health. 2017; 2017doihttps://doi.org/10.1155/2017/2050635
[34]
]. This low use of any type of eye protection to prevent NP BFE has similarly been reported in studies in France [[9]
], Brazil [[4]
], Ethiopia [[35]
], and Hong Kong [- Adal O.
- Abebe A.
Occupational exposure to blood and body fluids among nurses in public hospitals of the emergency department and intensive care unit, addis ababa, Ethiopia: cross-sectional study.
Reserch Square. 2022; (Online)https://doi.org/10.21203/rs.3.rs-1272527/v1
[25]
], identifying this as an area in need of improvement in practice globally.Within the five elements of the CSPS the most relevant to this study is “Prevention of mucocutaneous exposures”. Generally, all units were similar across the included items, apart from ED which was particularly low in items related to the active selection and use of PPE to prevent exposure. Additionally, the ED scored lower than ICU or renal ward in the elements of “Waste and environmental management” and “Hand hygiene”. This poor compliance in the use of PPE, and IPC generally, in the ED setting has been reported elsewhere [
[29]
] and provides opportunities for further research.Although the use of masks was low in all reported NP BFE, all units surveyed scored unanimously high, with no significant differences in the item related to appropriate mask use. This, and within the context of the previous discussion, is an example of how implementation of SP overall is both selective and inconsistent and appears to be influenced by factors not identified in this study. Similar to the findings of Pereira and colleagues [
[4]
], items in this study related to hand hygiene (B1, B2), waste disposal (B17), and decontamination of used items (B18, B19, B20) demonstrated a significant difference between clinical units, with ED generally reported to be the poorer performer possibly again due to the difficulties experienced in that environment.Using the HBM, this study has identified potential impediments to nursing staff (from ICU, ED, and renal ward) engaging in behaviours that protect them from exposure to potentially infectious pathogens. This is in line with the work of Efstathiou et al. [
[36]
] and Powers et al. [[37]
] who's studies used the HBM to elucidate some of the barriers to adoption of SP. They both found that in case of a life-threatening situation with their patient, nurses always made the choice to provide immediate care without taking time to wear PPE. They were willing to neglect their own safety to save the patient's life. Another barrier to SP compliance was the lack of easy accessibility to and non-availability of PPE. In their study the risk of interference with clinical skills (reduced dexterity and sensitivity of touch due to gloves when performing venepuncture) impacted on adopting SP according to the requirements of safe care. Concerns about reduced dexterity and sensitivity associated with glove use are also reported in our study though were not found to be statistically significant. Respondents from the renal unit and ED indicated the location of PPE influenced its use. The survey questions in this study did not examine the impact of life-threatening situations on compliance with SP.Severity
The findings in this study indicated inconsistencies across the clinical units for Severity. There was strong support from all units about the right of the nurse to choose whether to wear gloves during cannulation or venepuncture (C15) but varying support across the units regarding the nurses' ability to decide whether to use PPE (C16). ICU was most supportive while the renal unit was least supportive. One item where responses from all units were close, and relatively high, was the ability to clinically risk assess the need to wear PPE. Given that the appropriate selection and use of PPE for SP is based upon risk assessment this is somewhat reassuring, yet inconsistent with the ED results in the CSPS where it is indicated that PPE may not actually be worn in these situations (B19). This may be due to the risk assessment being related to the nurses' perception of the status of the patient, the nurses’ right of professional autonomy, or the clinical risk to themselves rather than the potential for exposure to blood and other body substances as required for SP [
[2]
].Benefits
This study identified that nurses in ED had a low perception of any Benefits associated with intervening to improve compliance in SP amongst colleagues through role-modelling good IPC practice or encouraging others to protect themselves. Whether this perception is the result of the specific nuances of the ED work environment and culture is unclear but remains an opportunity for further research [
[30]
].Barriers
In relation to Barriers, the findings demonstrate that nurses feel less dexterous when wearing gloves (ICU highest score), resulting in no glove use during cannulation or venepuncture, which possibly reflects their training where the teacher was not wearing gloves for specific procedures. The organisational culture in ICU appears to support compliance with SP more than the culture in ED. This may reflect the finding previously described where ICU reported more mucous membrane NP BFE and hence possibly demonstrates a positive workplace safety culture [
[28]
].Cue to action
All items related to the Cue to action construct demonstrated significant differences between the clinical departments. Like items in Benefits, wherever there was an option to actively intervene such as confronting poor SP practice and using poor SP practice as a teaching moment to improve compliance, ED nurses were far less likely to engage. ICU and the renal ward were nearly equal in these two items and more likely to engage. Again, this suggests that the cultural differences across these three areas have an impact on not only risk assessment of the use of PPE to prevent NP BFE but also promotion of healthcare worker safety.
Susceptibility and Self-efficacy
Within the context of this study the HBM constructs of Susceptibility and Self-efficacy there were no significant differences between clinical units for each item. What this means in the context of this study is unable to be established given the method and warrants further investigation.
Limitations
As a preliminary investigation, this was a single-site study, and therefore may be not generalizable across other settings. Sampling was purposive and therefore results are most relevant to the specific high-risk units identified. The results are only able to be interpreted from a quantitative perspective and must consider the limitations of self-reported data yet were considered alongside existing literature to contextualise the findings. One notable contextual limiter was the COVID-19 pandemic and the impact it had upon this project. Phase 2 of the study commenced just prior to the World Health Organization declaring COVID-19 as a Public Health Emergency of International Concern. The impact of COVID-19 changed healthcare across the world, including PPE use, and resulted in changes to the study, cancellation of the planned qualitative component of the study. As a result of the pandemic, there was a greater focus on the use of PPE by staff which could have biased results. This study was specific to SP, not the transmission-based precautions required for COVID-19, although the healthcare delivery environment and PPE use are thought to have changed significantly since the declaration of the Public Health Emergency.
Implications for practice and research
This study provides a pre-pandemic baseline of SP for three high-risk units for NP BFE which can be used for future study. Next steps from this research will include a post-pandemic review of reported SP practice and perceptions of the HBM constructs. This will include a qualitative exploration of the impact of safety culture on reporting and prevention of NP BFE in these high-risk units with development of an action plan to address identified issues. Comparing this pre-pandemic data to more recent data, which will capture the influence of COVID-19 on PPE use and safety culture [
[38]
], will be vital to further our understanding of health beliefs and safety procedures, and to inform behavior change practices to ensure the highest standards of healthcare.- Salome G.
- Dutra R.
Prevention of facial injuries caused by personal protective equipment during the COVID-19 pandemic.
Rev Bras Enferm. 2021; 74https://doi.org/10.1590/0034-7167-2020-1219
Conclusion
The findings of this study are consistent with other research which highlights the selection and use of “other” PPE to prevent NP BFE is inadequate, although nurses are aware of the need to risk assess for this. The HBM constructs assist in explaining nurses' perceptions of this risk with an apparent difference in safety culture across the three high-risk units. The different culture is particularly evident in ED where there is a reported reluctance to challenge others’ poor practice or use these as teaching opportunities to improve practice and therefore healthcare worker safety. This points to the need for further research to explore these departmental cultures in more detail with follow-up qualitative exploration.
Ethics
This study was approved by the Gold Coast Health Ethics Committee (LNR/2019/QGC/52551) and the Griffith University Human Research Ethics Committee (2019/673). No individual identifiers were collected through any phase of this study, therefore there was no requirement to seek a Public Health Act application.
CRediT authorship contribution statement
PZ: Conceptualization, Funding acquisition, Formal analysis, Data curation, Methodology, Project administration, Resources, Writing – original draft, review & editing, Investigation. DM: Conceptualization, Funding acquisition, Investigation, Formal analysis, Data curation, Methodology, Writing - review & editing. JB: Formal analysis, Data curation, Methodology, Writing – original draft, review & editing, Investigation. BG: Conceptualization, Funding acquisition, Writing - review & editing.
Conflict of interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Funding
This project was supported by the Cardinal Health Infection Control Scholarship.
Provenance and peer review
Not commissioned, externally peer reviewed.
Acknowledgements
The authors wish to thank and acknowledge all participants for sharing their honest views and experiences. They all wish to acknowledge the support from the Infection Control Department staff of the study site for their support and assistance with data collection.
Appendix A. Supplementary data
The following is/are the supplementary data to this article.
- Multimedia component 1
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Article info
Publication history
Published online: April 15, 2023
Accepted:
March 20,
2023
Received in revised form:
March 14,
2023
Received:
November 9,
2022
Publication stage
In Press Corrected ProofIdentification
Copyright
© 2023 The Author(s). Published by Elsevier B.V. on behalf of Australasian College for Infection Prevention and Control.
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