Breaking Barriers: Compliance with Standard Precautions, PPE Needs Improvement

By Kelly M. Pyrek

Fewer than one-fifth of ambulatory-care nurses surveyed in a recent study reported compliance with all nine components of Standard Precautions, indicating a continuing need for identifying barriers to compliance and emphasizing patient and healthcare personnel safety.  As Powers, et al. (2016) emphasize, "Exposure to blood and bodily fluids represents a significant occupational risk for nurses. The most effective means of preventing bloodborne pathogen transmission is through adherence to Standard Precautions (SP). Despite published guidelines on infection control and negative health consequences of noncompliance, significant issues remain around compliance with SP to protect nurses from bloodborne infectious diseases, including hepatitis B virus, hepatitis C virus (HCV), and HIV."

Donna Powers, DNP, RN, of Kransoff Quality Management Institute, North Shore Long Island Jewish Health System in New York, N.Y., and her colleagues conducted a descriptive, correlational study to measure self-reported compliance with SP, knowledge of HCV, and perceived susceptibility and severity of HCV, as well as perceived benefits and barriers to SP use.

"The findings were not a huge surprise," Powers says. "We know from the literature that healthcare worker compliance with Standard Precautions is a problem and although the study found that only 17.4 percent of the respondents reported compliance with all nine SP items, this is higher than what has been previously reported."

The authors say they concentrated on SP and HCV because more than 5 million people in the United States and 200 million worldwide are infected with HCV, making it one of the most significant public health threats.

"My experience in talking with clinical nurses indicated that knowledge of hepatitis C was poor, however I was surprised by the high percentages of nurses who thought hepatitis C was sexually transmitted (26 percent) and that most people with hepatitis C will die of the disease (14 percent)," Powers adds.
 Employing the Health Belief Model (HBM) for the theoretical framework, the study explored reasons why nurses fail to adopt behaviors that protect them. Essentially, the HBM asserts that perceptions of reality, rather than objective reality, influence behavior. According to Powers, et al. (2016), "An assumption of the HBM is that an individual will engage in a recommended health action if he or she believes that a negative health condition can be avoided and that the presence of illness has at least a moderate threat to some aspect of his or her life."

Rosenstock (1974) explains that the HBM model includes four constructs: perceived susceptibility, severity, benefits, and barriers: "In the HBM, the likelihood that a person will follow a preventive behavior is influenced by their subjective weighing of the costs and benefits of the action." The  perception involves the following elements:
- Perceived susceptibility: the person’s judgment of his or her risk of contracting the condition.
- Perceived seriousness of the condition: the severity of the condition (its clinical consequences, disability, pain or death) and its impact on lifestyle (working ability, social relationships, etc.).

As Rosenstock (1974) observes, "The combination of perceived susceptibility and seriousness is termed perceived threat. The perceived threat has a cognitive component and is influenced by information. It creates a pressure to act, but does not determine how the person will act. That is influenced by the balance between the perceived efficacy and cost of alternative courses of action."

The perceived benefits of an action cause the individual to ask, will the proposed action be effective in reducing the health risk? Does this course of action have other benefits? Again, it is the person’s beliefs, rather than factual evidence, that is influential. The beliefs will reflect social and cultural influences.

As Rosenstock (1974) notes, "The balance between benefits and costs may suggest the person’s likelihood of acting and their preferred course of action, but do not necessarily determine that they will act. Indeed, if benefits are closely balanced against costs the person may vacillate, perhaps experiencing anxiety. The final ingredient in the HBM is therefore a stimulus or cue to action. When a person is motivated and can perceive a beneficial action to take, actual change often occurs when some external or internal cue (e.g., a change in health, the physician’s advice, or a friend’s death) triggers action. As cues may be fleeting events they are elusive to record. The magnitude of the cue required to trigger action would depend on the motivation to change and the perceived benefit to cost ratio for the action."

In the study by Powers, et al. (2016), fewer than one-fifth (17.4 percent) of nurses reported that they are “always compliant” with all nine SP behaviors; 92 percent reported always wearing gloves, and 70 percent reported always using a face mask. More than 16 percent of study respondents reported that they sometimes or seldom avoid placing foreign objects on their hands.

As Powers, et al. (2016), note, "An assumption can be made that the perception of risk among ambulatory care nurses is lower than what has been reported in acute and tertiary care settings. Self-reported data might be an overestimate of actual compliance and the homogeneity of the ambulatory nurses group, years of experience, and training may have contributed to the higher compliance rate as well. Overall the ambulatory care nurses chose to implement some behaviors and not others and this behavior puts them at risk for acquiring a bloodborne infection."

The researchers add, "Understanding reasons for noncompliance will help determine a strategy for improving behavior and programs that target the aspects that were less than satisfactory to improve overall compliance. It is critical to examine factors that influence compliance to encourage those that will lead to total compliance and eliminate those that prevent it. The results of this study reveal that rings and artificial fingernails need to be addressed and stricter enforcement of policy must take place so that nurse managers, educators, and infection control staff can develop educational and monitoring programs aimed at problem areas to increase the use of all SP behaviors. Gaps in knowledge regarding transmission, treatment, and progression of HCV can affect nurses’ perception of risk and severity of illness. If an assumption of the HBM is that a nurse engages in a recommended health action if he or she believes that a negative health condition can be avoided and the presence of illness poses at least a moderate threat to some aspect of his or her life, then adequate knowledge will provide a more realistic perception of the risk involved."

Powers says the study helps raise awareness of occupational hazards and the need for clinicians to protect themselves by following all components of SP.
"I don’t think that nurses consciously disregard their own safety," Powers says, but I do think that they are unaware of the risks in some cases due to lack of knowledge,  as evidenced  by this study.  I think that when they are busy or overwhelmed they create work-arounds and ignore evidence based practices. I think that people believe that the 'unthinkable' will never happen to them, and take unnecessary risks.

Powers adds, "Everyone is a stakeholder in this. The data speak volumes and should and can be used to change culture. Infection preventionists can assess knowledge and create educational programs that target deficient areas. Staff will not only  better understand their risk , but be prepared to educate patients and families about Hepatitis C. Employee health and risk managers can share information as well by providing data regarding occupational exposures including type, reason, and outcome. Managers should be aware of the depth and scope of the problem. Finally, healthcare organizations must provide the tools necessary for employees to comply. Lack of access or ease of access to PPE is simply unacceptable."

PPE Compliance
Although personal protective equipment (PPE) is one of the best lines of protection against hazardous exposures, many healthcare workers either shun this protective apparel or do not wear it in an appropriate manner at the appropriate time. The Occupational Safety & Health Administration (OSHA) requires the use of PPE to reduce employee exposure to hazards when engineering and administrative controls are not feasible or effective. Yet, data from the Bureau of Labor Statistics (BLS) show that of the workers who sustained a variety of on-the-job injuries, the vast majority were not wearing PPE. Seventy-eight percent of survey respondents said workplace accidents and injuries were top concerns. Worker compliance with safety protocols was also cited as the top workplace safety issue. Twenty-eight percent of respondents chose this, while 21 percent selected "fewer workers." "Insufficient management support for health and safety functions" and "meeting the safety needs of an aging workforce" tied at 18 percent. Lack of funds to implement safety programs was last at 8 percent.

Barriers to PPE compliance are numerous, and include healthcare workers thinking that PPE wasn't needed, or viewing PPE as being uncomfortable, too hot, a poor fit, not available near work task, and unattractive-looking.

The importance of PPE and its inherent compliance challenges are summed up nicely by a 2008 report from the National Academies: "Personal protective equipment is one of the vital components of a system of safety controls and preventive measures used in healthcare facilities. The recent heightened awareness of patient safety issues has opened up opportunities to improve worker safety with the potential to benefit workers, patients, family members and others who interact in the healthcare setting. Because PPE works by acting as a barrier to hazardous agents, healthcare workers face challenges in wearing PPE that include difficulties in verbal communications and interactions with patients and family members, maintaining tactile sensitivity through gloves, and physiological burdens such as difficulties in breathing due to respirators. For healthcare workers this may affect their work and the quality of interpersonal relationships with patients and family members. As manufacturers continue to develop PPE that can reduce the job-related constraints, healthcare institutions and individual healthcare workers need to improve their adherence to appropriate PPE use. Healthcare employers need to provide a work environment that values worker safety, including provision of PPE that is effective against the hazards faced in the healthcare workplace. In turn, healthcare workers need to take responsibility to properly use PPE, and managers should ensure that the staff members they supervise also make proper use of PPE."

Despite recommendations in numerous guidelines and the prevalence of high-risk conditions, healthcare workers still exhibit low rates of PPE use, and the National Academies (2008) says that "assessments of the explanations for noncompliance and the solutions to these issues need to focus beyond the individual and address the institutional issues that prevent, allow or even favor non-compliance."
A number of studies have documented the barriers to PPE compliance:
- Lack of time
- Perception that using PPE interferes with the ability to perform the job
- Physical discomfort/difficulty communicating when wearing masks
- PPE not available when needed

While healthcare workers should demonstrate personal responsibility for donning PPE when needed, the legal responsibility for employee PPE usage and adherence falls to the employer. OSHA states that the employer is responsible for designing and implementing a respiratory protection program, monitoring and evaluating program effectiveness, and maintaining proper records regarding the program. This responsibility is part of a larger culture of safety, conceivably an organization-wide dedication to the creation, implementation, evaluation and maintenance of effective and current safety practices. According to the National Academies (2008), "An organization that has a functional and healthy safety culture is one in which all employees show a concern for safety issues within the infrastructure and act to maintain or update safety standards. Further, the organizational commitment to safety is evidenced by the organization’s policies, procedures, management support, and resources dedicated to safety, which include access to effective, appropriate, and state-of-the-art safety equipment. An institutional commitment to a culture of safety establishes systems, policies, and practices to ensure that safety is the highest priority of the organization. If need be, productivity or efficiency are willingly sacrificed in order to maintain safety… In the healthcare setting, a strong culture of safety has been shown to result in a higher rate of adherence to standard infection control precautions among employees, a decreased incidence of exposure mishaps in hospitals, and fewer workplace injuries among employees. In order to establish an effective culture of safety, responsibility for both personal safety and the safety of others should be a joint employer-employee responsibility. Although much of the responsibility for creating and monitoring a safety program is managerial, staff members should be responsible for applying the safety practices to their work environment."

PPE compliance does not happen in a vacuum; instead, it is part of a number of other safety-related interventions including environmental and engineering controls, administrative or work practice controls (such as protocols to ensure early disease recognition, vaccination policies, disease surveillance, infection control guidelines for patients and visitors, decontamination of healthcare equipment and patient-care rooms, risk assessment education programs for healthcare workers). According to the National Academies (2008), "The hierarchy of controls is meant to address hazards through direct control at the source of the infection and along the path between the infectious source and the employee. PPE is implemented at the individual level and is one component of effective infection prevention and control measures that particularly emphasize hand hygiene as a critical action for reducing disease transmission. When all of these measures are integrated and implemented, a continuum of safety exists; deploying evidence-based improvements at any level can enhance the safety culture."

References:

National Academies Press. Preparing for an Influenza Pandemic: Personal Protective Equipment for Healthcare Workers (2008). Committee on Personal Protective Equipment for Healthcare Workers During an Influenza Pandemic. Goldfrank LR and Liverman CT, eds. Washington, D.C.

Institute of Medicine (IOM). Preventing Transmission of Pandemic Influenza and other Viral Respiratory Diseases: Personal Protective Equipment for Healthcare Personnel, Update 2010.

Powers D, Armellino D, Dolansky M and Fitzpatrick J. Factors influencing nurse compliance with Standard Precautions. Am J Infect Control. 44 (2016) 4-7.

Rosenstock I. Historical origins of the health belief model. Health Educ Monogr. 1974;2:175-83.