Better training can boost HCW compliance with UP
Study finds low compliance rates
Health care workers' compliance with universal precautions (UP) can be improved through training programs that address organizational safety management, the use of barrier equipment, routes of bloodborne pathogen transmission, and self-protective behavior, according to a recent study of hospital-based HCWs.
A recent study of health care workers with direct patient care or specimen contact at three large, geographically distinct, acute care hospitals showed a low overall UP compliance rate of 23.7%. Compliance was defined as "always" or "often" adhering to protective work practices such as proper use of needles, proper disposal of sharps, and use of barrier protection.1
Robyn R. M. Gershon, MHS, DrPH, a research associate in the Department of Environmental Health Sciences of the School of Public Health at Johns Hopkins University in Baltimore and lead author of the study, says although the compliance rate is "not good," it is comparable to rates found in other studies.1
Although that may be bad news, the good news is that appropriate HCW training can address many of the causes of poor compliance uncovered in Gershon's study, she says.
"We were interested in finding out why some people comply with universal precautions and why others don't. Given the seriousness of the threat of exposure, we were really surprised to find out from the literature and from our own experience that people were not complying. We wanted to identify barriers to compliance and then to develop strategies to help them comply," she explains.
The study and data analysis took place from 1992 to 1995. A confidential survey containing more than 300 questions was sent to 3,000 employees (1,000 at each hospital). Some 1,716 usable questionnaires were returned (a 57% response rate).
The hospitals were: a mid-Atlantic facility with a high prevalence of bloodborne infection; a Southwestern facility with a moderate rate; and a Midwestern facility with a low rate.
HCWs were randomly selected from critical care, emergency, laboratory, surgery, and
phlebotomy departments. The study population included 902 nurses, 322 physicians, 247 medical
technologists, 64 nurse practitioners, 53 nurses' aides, 39 phlebotomists, 24 clinical assistants, 18
laboratory scientists, 11 autopsy technicians, seven dentists, and 29 others.
Most respondents were female nurses. Respondents had worked in the health care field for a mean of 11 years and in their present jobs for a mean of 6.1 years. More than 80% of respondents had at least an undergraduate education. Most workers were employed full time (40-50 hours per week); 20% worked more than 50 hours per week.
The highest compliance levels reported for specific tasks were for wearing gloves, and for properly disposing of sharps and other contaminated waste. Lowest compliance levels were associated with recapping needles, wearing protective eyewear and clothing, and cleaning spills.
Among the hospitals, the highest compliance rates (28%) were reported at the mid-Atlantic site,
where the prevalence of bloodborne
infection was highest. Twenty percent of the Southwestern and Midwestern HCWs reported
compliance with all 11 items on the questionnaire, which were related to sharps disposal, needle use
and care, barrier protection use, and eating or drinking in potentially contaminated areas.
Compliance lowest among physicians
The study's purpose was not only to assess and characterize UP compliance rates of HCWs at risk for exposure to bloodborne pathogens, but also to identify both individual and organizational factors correlated with compliance and noncompliance.
Factors correlated with compliance were
categorized as follows: sociodemographic and individual factors, psychosocial factors, and
organizational management factors.
In the first category, some results were predictable. Compliance rates were highest among nurses (26.5%) and lowest among physicians (16.2%).
Physicians' poor compliance was "not surprising," Gershon says. "The data show they are not getting the interventions that have been implemented in the hospitals, such as anti-needlestick devices. A lot of hospitals are switching to them, but they don't train the doctors. Consequently, when [doctors] get up on the floors, they don't know how to use the new device. They hoard the old device and try to use it instead of the new device, and that creates a real problem for other people coming after them because they might not know how to use the old device."
Physicians are "out of the loop" for training and supervision, she adds. "Nurses will often turn to one another and say, 'You should be putting on some goggles,' whereas doctors don't really want to be told what to do, especially by nurses."
The solution is to make physician training mandatory. They must be taught from the outset that safety precautions, such as wearing goggles and gloves, are an essential part of medical procedures. Physicians also should receive annual updates on UP. "Every effort must be made by senior management and safety specialists" to involve physicians in safety programs and safety committees, she advises.
It also was no surprise that compliance was lower among employees working more than 50 hours per week (17%) than among those working fewer than 50 hours per week (25%).
"Employees with long work hours may simply be too tired to make the effort to comply," the study states. "Overwork puts the worker at risk for work stress, as well as for occupational injuries and accidents. Supervisors should be alert to this potential problem among their staff members."
More education, lower compliance
Less predictably, compliance rates were lower for employees with higher levels of education than for
those with fewer than 16 years of
education.
Gershon says the tendency for health care professionals who work in the emergency room or the operating room to be less worried about their own safety than housekeepers or food service workers is called "optimistic bias."
"When people are at risk, it's so hard to think about it all the time that they start to think they're not at risk," she explains. "It's really self-protective thinking, because if you worried about [your safety] all the time, you'd go crazy."
UP compliance scores were higher (27%) for workers with higher scores on a set of questions designed to test their knowledge about modes of HIV transmission than for those with lower knowledge scores (22%).
Workers who don't know that HIV is not transmitted by mosquitoes or toilet seats probably don't know how to protect themselves from actual exposures, either. "It's a lack of knowledge all the way around," and an indicator of the need for training, Gershon says.
"Because knowledge scores related to alternate (casual contact) modes of transmission were generally
low . . . information about
the routes of transmission of bloodborne pathogens and information on ways in which HIV is not
transmitted are important to include in training and educational programs," the report states.
The survey showed that although most workers were extremely knowledgeable about UP, their knowledge was not associated with compliance. "It is therefore unlikely that simply lecturing HCWs on UP practices will help improve compliance," the study notes.
Instead, Gershon says training should address key factors identified in the study as being correlated with compliance. These include:
* Conflict of interest. Compliance was higher (25%) among employees reporting a low conflict of interest between the need to protect themselves and the need to provide patient care than among those with a high conflict (10%).
Gershon says this attitude stems from the training most HCWs receive.
"If you think that your patient's needs come before your own, because of the way we're trained as care providers, in most cases you will go with the patient. There are so many cases now of health care workers who were exposed during emergency procedures," she says.
Workers must be retrained to understand that "their lives are important to us, too," she explains. She recommends a three-part training approach:
-- Workers must understand the organization's commitment to both patient care and worker safety.
-- Personal protective equipment must be immediately accessible, comfortable, and must not interfere with providing medical care.
-- In interactive training sessions, workers should be encouraged to role-play how they would provide patient care and protect themselves in emergency situations.
* Risk-taking. Compliance was lower (16%) among respondents scoring high on a risk-taking personality scale (for example, "I enjoy taking risks in life") than among respondents less inclined toward risk-taking (25%).
Gershon says this is an important variable. "If you're a risk taker, you are a risk taker all the way around," she says. This is not a trait that leads to self-protection.
New hires could be given a short questionnaire designed to identify risk-takers, she says. Those who score high could be given several extra hours of training with the explanation, "We recognize you have this tendency, and we really want you to have some extra training because we don't want anything to happen to you." Targeting risk-takers would not be illegal, as long as risk behavior is not made a condition of employment.
* Perception of risk. Compliance was higher among workers who perceived that their exposure risk would be low if they followed UP (24%) than among workers who did not believe that compliance would lower their risk (10%).
HCW training should emphasize that the effort of using UP is worth it, Gershon advises.
Telling workers they are at low risk of HIV infection is a practice that has "backfired," she states.
"Why should workers want to take precautions if they believe they are at low risk? And that statement isn't true," she says.
The 0.3% risk of HIV infection after percutaneous exposure to HIV-contaminated blood1 is a risk most people never would take if they really thought about it, Gershon maintains.
'3 in 1,000 is a terrible risk'
"Most people won't do anything with a risk of more than one fatality in 10,000, such as driving a car. In training sessions, I put it in the context of other risks. Even one chance in 1,000 of dying from doing anything is horrible. It's [the risk associated with] bungee jumping and scuba diving, and a lot of people won't do that. This is three times riskier. Three in 1,000 is a terrible risk," she states.
HCWs who didn't believe they were at risk and who had a risk-taking personality on top of that were the least likely to comply, the study found.
* Tolerant attitudes. Another psychosocial factor, tolerance toward patients with HIV/ AIDS, affected compliance rates. Workers reporting tolerant attitudes were more likely to comply (25%) than were workers reporting less tolerant attitudes.
An earlier study identified several factors associated with tolerant attitudes toward people with AIDS. These were: acquaintance with someone with AIDS, high level of knowledge regarding transmission routes, low level of fear, and accurate risk perceptions.2
The "maladaptive response to fear" is easy to address in training, Gershon says.
"You can change this by introducing them personally to someone with AIDS, even using a video in which [people] with AIDS tell their story," she says. "Just one viewing is enough to get them to flip the switch."
* Hospital's safety climate. Compliance rates were higher for workers who perceived the hospital as having a strong commitment to safety (26%) than for those who did not perceive a strong safety climate (9%).
Gershon emphasizes that management must take safety seriously, providing effective safety programs with strong safety committees and policies. Infection control manuals should be readily available to workers, who should be evaluated on their safety compliance.
"The more seriously safety is taken, the better employees will adhere to safe work practices and the lower exposure rates and worker injuries will be," she says.
Because the study found the highest UP compliance rates were associated with receiving six or more hours of safety training annually, the one or two hours of training a year most hospitals provide is not enough, she notes.
Work stress was another problem related to several variables, such as organizational and individual factors. Compliance levels were higher among those reporting low levels of work stress (26%) than among those reporting higher levels of work-related stress (19%).3
Most work-related stress was associated with employees' relationships to supervisors and the organization.
"Workers have to feel that supervisors care about them; they have to have a voice and be empowered," says Gershon, who is working on another study to determine whether hospitals that use total quality management (TQM) teams have lower needlestick rates. "In hospitals with TQM, every worker has a voice and there is a conduit to be heard by higher management. Those places are much more productive and safer."
Hospital work generally is associated with high levels of job stress, but it doesn't have to be that way, she states.
"Supervisor training is the key -- getting supervisors to understand that workers should be treated with respect as people, not as children. Many times, workers are treated like dirt. It costs nothing to treat workers with respect, and it improves their quality of work," she says.
To reduce worker stress and improve productivity, administrators also must identify and minimize a variety of other stressors reported in the study. Those include verbal abuse from patients, patients' families, co-workers, and supervisors, as well as environmental bothers, such as loud noise, poor air quality, uncomfortable temperatures, unpleasant odors, overcrowding, poor lighting, and fear of bodily harm.
Such factors affect the quality of work, Gershon says, and "in this day and age when there is so much competition for patients, I would think [administrators] would want the happiest workers providing the best product. It's good business."
References
1. Gershon RRM, Vlahov D, Felknor SA, et al. Compliance with universal precautions among health care workers at three regional hospitals. Am J Infect Control 1995; 23:225-36.
2. Gershon RRM, Curbow B, Kelen G, et al. Correlates of attitudes concerning human immunodeficiency virus and acquired immunodeficiency syndrome among hospital workers. Am J Infect Control 1994; 22:293-9.
3. Gershon RRM, Karkashian CD, Kasting CH. The correlation between workstress, organizational factors and bloodborne exposures. Presented at Frontline Healthcare Workers: National Conference on Prevention of Sharps Injuries and Bloodborne Exposures. Atlanta; August 1995. Abstract No. S95-01-030. *
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