JOURNAL OF BUSINESS AND PSYCHOLOGY Vol. 15, No. 1, Fall 2000

FACTORS AFFECTING UNIVERSAL PRECAUTIONS COMPLIANCE Patricia M. McGovern Donald Vesley Laura Kochevar University of Minnesota

Robyn R.M. Gershon Johns Hopkins University

Frank S. Rhame Elizabeth Anderson University of Minnesota

ABSTRACT: This study characterizes levels of self-reported compliance with Universal Precautions (UP) among health care workers (HCWs) at risk of bloodborne exposure. A convenience survey was conducted of 1135 health care workers, expected to be at high risk for transmission of bloodborne pathogens. Using a crosssectional design and a theoretical model by Gershon et al. (1995) data were analyzed with logistic regression. Factors associated with at least one of the two measures of HCW compliance with UP included longer tenure in one’s job, increased knowledge of human immunodeficiency virus (HIV) transmission, a conservative attitude toward risky behaviors, a perception of a strong organizational safety climate, and having had some training in the use of personal protective equipment. Knowledge of factors associated with compliance helps to explain why health care workers sometimes exhibit poor compliance despite the real occupational hazard posed by exposure to bloodborne pathogens.

This study was funded, in part, by ERC, Inc. Address correspondence to Patricia McGovern, University of Minnesota, School of Public Health, Mayo Building, Box 807, 420 Delaware St., SE, Minneapolis, MN 55455. 149

 2000 Human Sciences Press, Inc.

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INTRODUCTION In response to the threat of exposure to bloodborne pathogens, the Centers for Disease Control and Prevention (CDC) developed a set of work practice guidelines, referred to as Universal Precautions (UP). The realization that occupational exposures and subsequent infection with the human immunodeficiency virus (HIV) could occur among health care workers (HCW) resulted in the development of these safe work practices. The subsequent promulgation of the OSHA Blood-Borne Disease Standard codified the adoption of UP and mandated compliance. Subsequent reports that percutaneous exposure to HIV positive blood yielded an infection rate approaching 0.3% added to the concern, given the nearly 100% fatality rate for AIDS (Ipolito, 1993). The comparable risk for hepatitis B in unvaccinated individuals is known to be much higher (around 30%) (CDC, 1989). The Centers for Disease Control and Prevention (CDC) has reported 51 episodes of occupationally acquired HIV infections in the United States using unpublished data from 1996 (as cited in CDC, 1997). Several reports have indicated that overall compliance with UP has been relatively poor both before and after the enactment of the OSHA standard (Gershon, Karkashian & Felknor, 1994; Hersey & Martin, 1994). Reasons for poor compliance have been incompletely investigated. While drug therapy such as zidovudine (ZDV) postexposure prophylaxis (PEP) may reduce the risk for HIV transmission after occupational exposure to HIV-infected blood, prevention of blood exposures is the primary means of preventing occupational transmission of HIV infection (MDH, 1996). In 1992, the National Institute for Occupational Safety and Health (NIOSH) initiated a multi-center study through its Educational Resource Centers (ERC) to explore the risk factors for poor compliance. The participating centers were located in a high HIV prevalence city (Baltimore), a moderate prevalence city (Houston), and a low prevalence city (Minneapolis). The study included a questionnaire survey of 3000 HCW including physicians, nurses and technicians having direct patient or specimen contact, in large teaching hospitals in those three cities. One conclusion which emerged from Gershon et al.’s study was that the low incidence location was associated with the lowest UP compliance rates overall (1995). The objective of this study is to determine factors associated with compliance using data from the one site with the lowest incidence rates where workers presumably have less motivation to comply with UP. METHODS Sample This study is a secondary analysis of a data set created by Gershon et al. (1995), in association with a cross-sectional study designed to assess

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and characterize levels of compliance with universal precautions (UP) among hospital-based personnel. This secondary analysis is restricted to health care workers (HCW) employed at one large teaching hospital (approximately 548 beds) in Minneapolis, Minnesota. A convenience sample of volunteer HCWs completed questionnaires in 1992 on their knowledge, attitudes and behaviors related to HIV/AIDS, and compliance with universal precautions. The study population included personnel expected to be in direct patient care or having specimen contact from departments hypothesized to be at high risk for transmission of bloodborne pathogens, e.g., critical care, emergency, laboratory, surgery, and phlebotomy. A sample of 1135 employees was identified by selected departments and job classifications from hospital personnel records and sent a confidential, self-administered 210-item questionnaire designed by Gershon et al. (1995), upon giving informed consent. The response rate for health care workers was 53%. Theoretical Model While several theories gave rise to the study model, they were limited in explaining the role that “care giving” plays when analyzing self-protective behaviors. Exposure to bloodborne pathogens presents a potentially difficult dilemma to health care workers as some situations can place the workers’ commitment to patient care at odds with the need to protect themselves. The final project model (see Figure 1) was guided by the Figure 1 Model of Determinants of Compliance Behavior

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PRECEDE model of health education of Green and associates (1980), and modified by DeJoy (1986) for application to self-protective behavior at work. A general model for studying associations between perceived job stresses and injuries was also used (Murphy, Dubois & Joseph, 1986). As depicted in Figure 1 the study model has three major constructs. Personal traits represent the individual’s social and demographic characteristics, knowledge, education, attitudes, values and beliefs. Work-related factors represent individual’s work experience, skills, perceived workload, work stress and associated cognitive demands. Organizational factors represent the administrative support, safety climate, employee training and peer review processes as perceived by the worker. These constructs are hypothesized to play a major role as either barriers or facilitators of employee compliance with Universal Precautions. Instrument To translate the theoretical model into constructs and questionnaire items content was taken from UP guidelines issued by the Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA). Selection of scales and questionnaire items was for the most part from established, well defined instruments. Additional input from health care workers was obtained through focus groups. The final instrument went through extensive pilot testing and psychometric analysis. Two dependent variables addressing the compliance behaviors of health care workers were constructed as two distinct subsets from an 11item scale (see Table 1). The first variable assessed general compliance behaviors, e.g., disposal of sharp objects in sharps containers and handwashing after glove removal. This 7-item scale achieved an internal consistency reliability score of 0.49 approaching recommended reliability criterion of 0.50 for group comparisons (Stewart, Hays & Ware, 1992). The second variable assessed compliance behaviors specific to the use of Personal Protective Equipment (PPE), e.g., wearing disposal outer garments or gloves whenever the chance for exposure to blood or body fluids existed. This four item scale achieved an internal consistency reliability score of 0.59. Each dependent variable was scored 0, (noncompliant) or 1 (compliant). Each questionnaire item concerning compliance behaviors was originally scaled on a five point likert scale (always, often, sometimes, rarely, never). Item responses were collapsed so that behaviors occurring “always” or “often” were scored as compliant; behaviors occurring “sometimes,” “rarely” or “never” were scored as noncompliant. The independent variables were operationalized as measures of personal traits, characteristics of one’s work, and organizational factors hypothesized to play an important role in association with compliance

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Table 1 Adherence to Compliance Behaviors Among Health Care Workers

General Compliance Behaviors Take special precaution with scalpels/sharp objects Dispose of sharp objects in sharps container Properly dispose of potentially contaminated materials Wash hands after removing gloves Don’t eat or drink where chance of contamination Adequately wipe up all spills with a disinfectant Don’t recap needles Personal Protective Equipment (PPE) Wear disposable gloves whenever chance of exposure to blood or other body fluids exists Wear disposable outer garment whenever chance of soiling work clothes exists Wear protective eye shields whenever possibility of splash or splatter to eyes exists Wear disposable face mask whenever chance of splash or splatter to the mouth exists Total Compliance General Compliance (7 items) PPE Compliance (4 items) Total Compliance (11 items)

Number

Percent

561/563 550/585 536/580 517/589 490/574 481/567 365/538

99.6% 94.0% 92.4% 87.8% 85.4% 84.8% 67.8%

567/591

96.0%

356/572

62.2%

332/555

59.8%

266/548

48.5%

268/592 197/592 119/592

45.1% 33.3% 20%

behavior. Table 2 displays the independent variables. Generally, each independent variable was composed of a multi-item scale which was scored on a four or five point likert scale. Final assessment of internal consistency reliability of all multi-item scales used in this study as independent variables revealed a range of scores for Cronbach’s alpha from 0.65 to 0.88. Measures assessing hours of training in universal precautions, protection confidence, perceived risk of contracting occupational related HIV, and perceived knowledge of universal precautions were constructed as single item variables. Analysis The two multi-item scales of general compliance and PPE compliance were not combined into one overall compliance score, but treated as two distinct variables because individuals may think about and act on the two types of behaviors differently. Moreover, the descriptive statistics show different compliance rates suggesting this (see Table 1). All theoretically relevant independent variables were entered into a multivariate logistic regression model. The analysis was run using data from individu-

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Table 2 Variables in the Model Personal Traits Demographics: Gender, Age, Education Job characteristics: Hours/day, Profession, Clinical or non-clinical role, and Tenure in this position Knowledge: General knowledge of HIV, Knowledge of HIV transmission, alternative modes of transmission of HIV, and of Universal Precautions Attitudes and Perceptions: Attitudes toward HIV, Perception of one’s risk to HIV on the job, of universal precautions as a barrier to job performance, and of the efficacy of Universal Precautions, and Attitude toward risky behaviors Mental Health Index Confidence (in one’s ability to protect oneself from HIV on the job) Work-Related Factors Cognitive demands Job ambiguity Workload Work-related stress Organizational Factors Safety climate Availability of Personal Protective Equipment (PPE) Training in the use of PPE Training in Universal Precautions

als with observed values for all variables in the model. Statistical significance of factors associated with the dependent variables was determined by assessing the odds ratio (greater than 1.25), and the 95% confidence interval (CI) on the estimated coefficient. If the 95% CI excluded the value of 0, the null hypothesis, that there was no difference on the incidence of compliance between two groups of HCWs on the independent variable of interest, was rejected. For example, there is no significant difference between male and female HCWs in association with general compliance, controlling for the effects of all the other variables in the model, as the odds ratio of 1.17 is less than 1.25, and the 95% CI on the estimated regression coefficient of −0.42 to 0.49 includes 0.

RESULTS Characteristics of the study samples are displayed in Table 3. On average, respondents were 36 years of age. The majority of respondents were female (78.5%). Most subjects had earned a baccalaureate or graduate degree (54.8%). The majority of respondents were nurses (50.2%); physicians represented 14.9% of the respondents. Most respondents worked in a clinical setting (67.1%), although a substantial minority

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Table 3 Descriptive Statistics

Variable Gender Female Male Missing Total Age Education Vo-tech or some college College graduate Post graduate Other Missing Total Profession Nurse Physician Technologist, Phlebotomist Ancillary, other Missing Total Job Category Administrative/Management Clinical Technical Other or Missing Total Tenure in Position Work Time per Week <40 hours 40 to 50 hours >50 hours Missing Total

Statistic

Mean (Standard Deviation)

Mean (Standard Deviation)

Subjects Number (Percentage)

476 (78.5%) 120 (19.8%) 10 ( 1.7%) 606 (100%) 36.1 yrs (8.8 yrs) 107 322 166 1 10 606

(17.6%) (53.1%) (27.4%) ( 0.2%) ( 1.0%) (100%)

304 90 135 68 9

(50.2%) (14.9%) (22.3%) (11.3%) ( 1.5%) (100%)

31 (5.1%) 400 (67.1%) 154 (25.8%) 20 ( 3.4%) 606 (100%) 7 yrs (6.8 yrs) 277 226 92 11 606

(45.7%) (37.3%) (15.1%) ( 1.8%) (100%)

worked in a technical (i.e., laboratory) setting (25.8%). On average respondents had been in their present job 7 years, and in their line of work for 12 years. Most respondents (73.8%) were employed full-time. Compliance varied substantially across specific behaviors (see Table 1). Behaviors most frequently complied with include: taking special caution when using scalpels or other sharp objects (99.6%); wearing disposable gloves whenever a chance of exposure to blood and body fluids exists (95.9%); disposing of sharp objects in sharps containers (94%); and dispos-

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ing of all potentially contaminated materials properly, i.e., into a “red” (and/or labeled) bag for disposal as infectious waste (92.4%). Behaviors less frequently complied with include: wearing disposable face masks whenever a chance of splash or splatter to the mouth exists (48.5%) and wearing protective eye shields whenever the possibility of a splash or splatter to the eyes exists (59.8%). Results of the multivariate analysis are summarized in Table 4. Factors associated with general compliance include longer tenure in one’s current position, accurate knowledge of disease transmission, and a less tolerant attitude toward high risk behaviors. Health care workers who

Table 4 Multivariate Results

Variable Gender Age Hours/Day Education M.D./Else Clinical/Else Tenure in Position General Knowledge Knowledge of Transmission Knowledge of UP Knowledge of Alternative Modes of Transmission Attitudes Perceived Risk UP as a Barrier Efficacy of UP Attitude/Risky Behaviors MHI Confidence Cognitive Demands Job Ambiguity Workload Work Stress Safety Climate Availability of PPE Training in PPE Training in UP

General Compliance Odds Ratio (N = 435)

General Compliance 95% Confidence interval

PPE Compliance Odds Ratio (N = 435)

1.17 1.03 0.59 1.45 1.44 0.89 1.69* 3.30

−0.51 to 0.82 −0.42 to 0.49 −1.38 to 0.33 −0.23 to .97 −0.49 to 1.22 −0.57 to 0.34 0.07 to 0.99* −1.26 to 3.66

0.68 2.12 0.73 0.60 0.71 1.59 0.39 1.18

−1.08 −0.25 −1.24 −1.14 −1.25 −0.04 −0.11 −2.16

1.58* 2.19

0.02 to 0.89* −0.44 to 2.01

1.11 0.77

−0.36 to 0.58 −1.47 to 0.95

1.39 0.96 1.36 1.75 0.86 1.85* 1.37 1.24 0.99 0.96 0.73 .74 0.92 0.93 1.36 1.19

−0.25 to 0.91 −0.48 to 0.39 −.15 to .76 −1.26 to 2.38 −0.95 to 0.65 0.03 to 1.23* −0.23 to 0.88 −0.35 to 0.78 −0.59 to 0.56 −0.80 to 0.71 −0.79 to 0.15 −1.11 to 0.51 −0.67 to 0.49 −1.51 to 1.37 −0.45 to 1.07 −0.25 to 0.61

0.92 0.87 1.70 0.32 1.13 1.48 0.90 1.39 0.76 1.52 0.57 1.20 2.87* 0.33 5.67* 1.15

−0.71 to 0.53 −0.63 to 0.30 0.03 to 1.03 −2.96 to 0.68 −0.78 to 1.02 −0.27 to 1.06 −0.70 to 0.48 −0.31 to 0.96 −0.94 to 0.40 −0.44 to 1.28 −1.08 to −0.05 −0.73 to 1.10 0.31 to 1.80* −2.70 to 0.51 0.67 to 2.80* −0.33 to 0.60

*The asterick denotes a statistically significant finding.

PPE Compliance 95% Confidence interval to to to to to to to to

0.31 1.25 0.61 0.12 0.57 0.97 0.89 2.48

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had worked at their present position for more than 5 years were 1.7 times more likely to comply with UP than those who had worked in their position 5 years or less. Subjects’ knowledge of HIV transmission was measured with an 8item scale score. Examples of items constituting this scale included: touching the skin, cleaning or dressing a wound, and drawing blood of an HIV infected person without wearing gloves; getting splashed or sprayed in the eyes or mouth with blood or other body fluid from a patient who is HIV positive; and getting stuck or cut with a sharp object that was contaminated with blood or body fluids. Respondents who correctly answered all 8 items were 1.6 times as likely to be compliant with UP as those HCWs who answered one or more items incorrectly. Individuals’ attitudes toward risky behaviors was assessed using a five item scale score. Examples of items constituting this scale include statements such as, “I prefer an exciting, unpredictable life”; “I enjoy taking risks in life”; and “I prefer new and exciting experiences even if they might be dangerous.” Health care workers whose scores indicated less tolerance or affinity for risky behaviors were 1.9 times more likely to comply with UP practices. Factors associated with PPE compliance include workers perception of a strong organizational safety climate and some vs. no training on the use of PPE. Organizational safety climate was measured as a multi-item scale score. Examples of items included statements such as, “employees, supervisors, and managers work together to insure the safest possible working conditions”; “unsafe work practices are corrected by supervisors”; and “there is a safety committee where I work.” Health care workers who perceived their safety culture was strong were 2.9 times more likely to be compliant with UP. To assess the impact of PPE training for HCWs, subjects were asked to respond to the following item, “I have been trained to use personal protective equipment (e.g., goggles, gloves, etc.).” Workers who had some PPE training were 5.7 times more likely to be compliant with UP compared to workers without any training.

DISCUSSION Health care worker compliance with universal precautions at a large teaching hospital in Minnesota varied across specific behaviors, but overall was low for both general and PPE compliance. Consistent with the findings of the overall health care worker survey mentioned earlier (Gershon et al., 1995), a high level of HCW compliance was noted for the following: taking special precaution with scalpels and sharp objects, disposing of sharp objects in sharps containers, wearing disposable gloves

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whenever the chance of exposure to blood or body fluid existed, and properly disposing of potentially contaminated materials. Behaviors with lower levels of HCW compliance, consistent with findings of Gershon et al., included wearing a face mask whenever the chance of splash or splatter to the mouth exists, wearing protective eye shields whenever the chance of splash or splatter to the eye exists, and wearing a disposable outer garment whenever the chance of soiling work clothes exists. Specific factors found to be associated with general compliance included longer tenure in one’s position, increased knowledge of HIV transmission, and a more conservative attitude toward risky behaviors, although the strength of these associations was modest, with odds ratios in the range of 1.6 to 1.7. The independent and positive effect of tenure on the job in association with compliance suggests that health care workers with more time on the job (greater than 5 years) have had the opportunity to incorporate experience and judgment into their clinical practice which could promote the use of appropriate preventive behaviors. The independent and positive effect of knowledge of HIV transmission on compliance distinct from general knowledge of HIV, or knowledge of alternative modes of transmission, lends support for the study model, and if future studies reveal consistent findings, these results could be easily translated into a curriculum for health care workers and tested in an intervention study. In contrast, the finding on the positive association between the variable, “attitude toward risky behaviors” and compliance, while theoretically plausible, and consistent with the findings of Gershon et al. (1995), appears more challenging to address in a practical manner. It may be that occupational health and safety, or risk management personnel could explicitly address the issue of individual personality differences in relation to preventative behaviors such that compliance with UP may be more challenging for some personalities (i.e., risk takers) than others. An intervention study could assess if increased self awareness among such individuals could enhance their willingness to listen to information about UP, and consider the implications for their clinical practice. Specific factors associated with PPE compliance included a perception of a stronger organizational safety climate and having had some as opposed to no training in PPE. The significant association between the organization’s safety climate to PPE compliance is consistent with the findings of Michalsen et al. (1997). On average, health care workers who perceived their management to be more safety oriented were 2.9 times more likely to be compliant with UP governing the use of PPE. Safety climate is a subset of the organizational climate, or the social and organizational circumstances in which employees work (Coyle, Sleeman & Adams, 1995). It has been defined by DeJoy (1986) and others as an organized set of perceptions and expectations held by workers in regards to the

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safety of their work environment. Although the concept of safety climate has been in the literature for over 20 years (Brown & Holmes, 1986; Coyle et al., 1995; Dedobbeleer & Beland, 1991; Zohar, 1980), Gershon et al.’s (1995) study is unique in explicitly applying this construct into a model for HCW compliance with UP. Thus, subsequent studies are needed to assess the validity and reliability of this finding in other studies of HCW compliance with UP. For administrators and risk managers concerned with workplace safety, the construct of safety climate can be translated into principles that guide workplace safety efforts. For example, management should demonstrate a consistent commitment toward clearly defined safety goals and objectives and appropriately allocate resources. In addition, management must establish a visible partnership with health and safety specialists and employees in working toward such goals (Walker, 1994). Examples of practical strategies for enhancing organizational safety climate that could be tested in intervention studies include the following: involving front line workers in identifying safe work practices and strategies for reducing exposure; creating opportunities for peer teaching or inspection teams within departments and units; and including staff on institutional safety committees. The positive association between training in PPE and PPE compliance is logically consistent and theoretically plausible. On average, health care workers who received some training in the use of PPE were 5.7 times more likely to be compliant than their peers without such training. This finding suggests that training, i.e., the practical application of knowledge to a context, is important and different than knowledge per se. It lends credence to worker training by occupational health and safety specialists despite ambiguous findings in the literature, as some studies show no effect of training on compliance (Krasinski, LaCouture & Holzman, 1987; Edmond, Khakoo, McTaggert & Solomon, 1988), some show mixed effects (McCormick, Meisch, Ircink, & Maki, 1991), and others show mild (Wehman, Short, Mendleson, Lilenfield & Rodriguez, 1995) or strong, positive effects (Wong et al., 1991). The ambiguity in the literature reveals the need for additional research on the content and methods of employee UP training. Study results are internally valid although they may not be generalized to all hospital settings as the findings are from a convenience sample obtained from one teaching hospital in Minnesota with a study response rate of 53%. Also, subject recall and social desirability bias may be a problem given the total reliance on self report data for this study. However, questionnaire items were worded to capture health care workers current perceptions and knowledge. Additionally, a cross-sectional study design is limited in revealing contemporaneous associations as opposed to causal relations. Moreover, there is always a question as to whether a given

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outcome (i.e., compliance behavior) might have influenced the exposure of interest (e.g., worker knowledge or perceived organizational safety climate). However, inferences from this study can be used to add to the existing knowledge base and to generate hypotheses for future, more rigorous and resource intensive studies such as those employing a prospective, longitudinal design. While the theoretical model displayed in Figure 1 is complex, it provides insight into the dynamics of health care worker compliance with UP. Study findings suggest the relevance of personal traits such as tenure on the job, specific knowledge such as HIV transmission, and organizational factors such as worker training in PPE and the institution’s safety climate; selected factors could be targeted for intervention studies. The institution studied has yet to report one confirmed case of occupationally acquired HIV. Factors which may contribute to this situation include the relatively low risk of exposure in Minnesota, as well as the compliance which exists with specific UP behaviors. Risk management professionals need to continue to work closely with hospital administrators to apply engineering control strategies (e.g., safer devices) which minimize the need for reliance on HCW behavior while they simultaneously facilitate labor-management collaborative efforts to improve institutional safety climate.

ACKNOWLEDGMENTS We thank and acknowledge Polly Dubbel, MPH, the research assistant who conducted the data collection and provided key logistical support for this study, and George Maldonado, Ph.D., Assistant Professor, who provided invaluable statistical consultation and editorial support.

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