Reasons and consequences of low adherence to standard precautions by the nursing team

Porto, Janete Silva; Marziale, Maria Helena Palucci

doi:10.1590/1983-1447.2016.02.57395

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Integrative Review • Rev. Gaúcha Enferm. (Online) 37 (02) • 2016 • https://doi.org/10.1590/1983-1447.2016.02.57395 linkcopy

Reasons and consequences of low adherence to standard precautions by the nursing team

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Standard precautions (SP) are recommendations to prevent infection and protect health care workers during the provision of care, however, still exists low adherence to these recommendations.

Objective To analyze the reasons and consequences of low adherence to standard precautions by the nursing staff.

Method integrative literature review, search in seven databases, from 2005 to 2014.

Results 30 articles were selected for analysis. The reasons for low adherence evidenced relate to deficient practices of lifelong learning, risk behaviors of workers, inadequate provision of equipment and protective equipment and inadequate working conditions. The consequences are accidents and occupational diseases. There are few intervention studies, which merely provide guidance to professionals.

Conclusions The low adhesion to standard precautions is linked to individual aspects of workers, employers and educational institutions. Intervention strategies carried out have shown little efficient by only focusing on the worker.

Standard precautions; Universal precautions; Occupational health; Accident prevention; Nursing, team

Citation/Database/Country	Title	Methodological design	Results on adherence to SP	Reasons for low and/or no adherence to SP	Consequences of low and/or no adherence to SP and recommended interventions
Silva et al, 2012 / SCIELO / Brasil	Knowledge and use of standard precautions by health professionals	Descriptive cross- -sectional study	Most professionals recognize and adopt standard precautions, but a significant part of them show low or no-adherence to SP.	Insufficient training in biosafety to promote changes of habits that many health workers find it difficult to handle.	The occurrence of occupational accidents, and accidents are trivialized, poorly reported and monitored.
Chan MF, 2010 / MEDLINE / Singapura	Factors affecting the compliance of operating room nursing staff toward standard and transmission based precautions in an acute care hospital	Descriptive cross- -sectional study	Higher education and recent training in the service were not sufficient to establish a strong correlation between attitude and compliance, but there was a significant correlation between knowledge and compliance.	The reasons may be specific to the different groups of workers.	Exposure of workers to diseases and accidents and risk to patient safety. Identify the reasons for low adherence and provide the appropriate intervention.
Nowak et al, 2013 / SCOPUS / Brasil	Risk factors for accidents with sharp materials	Retrospective study	Low adherence to standard precautions, particularly incorrect use of PPE and improper handling and disposal of sharp materials .	Excessive work, double shifts, reduced teams were reported as possible reasons for low adherence to SP and causes of accidents.	Occurrence of occupational accidents. Preventive measures such as immunization, availability of PPE and appropriate sizing of personnel are recommended.
Amin T, Al Wehedy A, 2009 / SCOPUS / Arabia Saudita	Healthcare providers knowledge of standard precautions at the primary healthcare level in Saudi Arabia	Descriptive cross- -sectional study	Lack of knowledge on the PP, especially related to handwashing, waste disposal, accident management and environment cleaning.	Lack of resources and opportunities of training (due to excessive work).	Occurrence of occupational accidents and mistakes in post-accident conducts. It is suggested that contents on epidemiology of transmissible infections, ergonomy and risk perception are included in nursing curricula.
Askarian et al, 2015 / SCOPUS / Irã	Knowledge, practice, and attitude among iranian nurses, midwives, and students regarding standard isolation precautions	Descriptive cross- -sectional study	Despite the lack of resources and increased exposure, characteristics observed in Iran, there is a positive linear correlation between knowledge, practice and scores of attitude for the nursing groups, instructors and students of obstetrics, indicating proper adherence to standard precautions.	Adherence is no yet ideal due to unavailability of resources.	Contamination by pathogens, accidents with sharp materials. Increasing the supply of resources to meet the demands is recommended.
Efstathiou et al, 2011 / LILACS / Sul da Turquia – Cyprus	Factors influencing nurses’ compliance with standard precautions in order to avoid occupational exposure to microorganisms: a focus group study	Qualitative study with a focus group	In general, health professionals recognize the importance of precautions, but adherence is low or nonexistent.	Lack of knowledge, lack of time, forgetfulness, lack of resources, negative impact of PPE on nursing skills, PPE is uncomfortable, causes skin irritation, conflict between the need to provide care and use of self-protection.	Exposure to potentially contaminated material, occurrence of occupational diseases and accidents. Further studies are needed to understand the lack of compliance with standard precautions.
Melo et al, 2006/ LILACS / Brasil	Nurses’ understanding of standard precautions at a public hospital in Goiania – GO, Brazil	Qualitative descriptive study	Knowledge consistent with the implementation of SP by professionals, but there are distorted perceptions on its comprehensiveness. There is also the selection of use according to the patient’s diagnosis.	Cognitive, emotional and behavioral aspects directly related to non-implementation of SP.	Occurrence of occupational accidents and diseases. It is necessary to invest in training in nursing skills using appropriate strategies for training in the service.
Rezende et al, 2012/ LILACS / Brasil	Adherence to handwashing and the use of personal protective equipment by nursing professionals in basic health care	Descriptive cross- -sectional study	Low adherence to handwashing and the use of PPE.	Few educational actions and lack of na effective management regarding adherence to SP.	Inappropriate behavior poses risk to workers and users. It is necessary to implement educational programs related to adherence to SP.
Costa et al, 2012/ LILACS / Brasil	The nursing team is informed on a mobile care on precautions	Descriptive cross- -sectional study	Most professionals provided incorrect answers on the importance of SP. None of the nurses recognizes the disposal of sharp materials as a SP measure. None of the professionals described all the SP, safety practices, nor explained what to do in the event of an accident.	Lack of knowledge on the importance of use of SP, on educational actions and on biosafety and post-accident conducts.	Occurrence of occupational accidents with sharp materials, inappropriate post-accident conducts. It is important to disseminate the principles of the SP during training and maintain regular education programs in the service.
Campos et al, 2011/ LILACS / Brasil	Biosafety: knowledge and adherence to standard precaution measures in a hospital	Descriptive cross- -sectional study	Low level of knowledge on the SP, occupational hazards and reporting services. Adherence is greater among professionals who had accidents.	Little knowledge on SP and lack of dissemination of standards.	Occurrence of accidents, inappropriate post-accident conducts and underreporting. It is important to implement educational actions and a manual for dissemination of SP .
Pereira et al, 2013 / PUBMED / Brasil	Adherence to standard precautions by nursing professionals who perform their activities in intensive care of a university hospital	Descriptive cross- -sectional study	Adherence to SP is not sufficient.	Individual factors such as personality and perception of risk and factors related to work such as the perception of obstacles and long working hours	Occurrence of occupational accidents and diseases. Activities aimed to increase the perception of risks, reduce obstacles and provide training of professionals on SP are recommended.
Brevidelli MM, Cianciarullo TI, 2009/ PUBMED / Brasil	Psychosocial and organizational factors relating to adherence to standard precautions	Descriptive cross- -sectional study	The global rate of adherence to SP was 38.5%. The involved factors were: belonging to the group of physicians, trained in the implementation of standard precautions (SP), reduced perception of the obstacles to be overcome to adhere to SP, more accurate perception of workloadl feedback from safety practices and support to safety management.	Individual and organizational factors: level of knowledge, training, perception of obstacles and workloead and management and safety practices.	Exposure of workers and patients to biological agents. It is important to consider the individual and organizational factors in prevention programs.
Jeong et al, 2008/ PUBMED / Coréia do Sul	Compliance with standard precautions among operating room nurses in South Korea	Descriptive cross- -sectional study	All investigated hospitals have educational programs for new employees, but not on a regular basis for all of them. Only 12% of the respondents always wear protective gloves , 2% always wear glasses and 10% are not always concerned with needle recapping.	Lack of regular training for all the workers.	Occupational exposure to biological agents that may result in accidents and diseases. The implementation of regular training programs for all employees is suggested.
Oliveira et al, 2009/ PUBMED / Brasil	Knowledge and attitude regarding standard precautions in a Brazilian public emergency service: a cross-sectional study	Descriptive cross- -sectional study	Different levels of knowledge among the team members. The drivers showed a lower level of knowledge on SP. Although the other professionals had adequate knowledge of SP, adherence was low.	Level of knowledge on SP and characteristics of work can be reasons for low adherence.	Contamination by infectious agents and occupational accidents. The implementation of educational programs for different groups of professionals is recommended.
Cirelli et al, 2007/ PUBMED / Brasil	Adherence to standard precautions in peripheral vascular access o	Prospective study	It was found that 84.4% of the punctures were performed without gloves and previous handwashing, in 29.7% of the cases needles were recapped and in 93.2% of the cases professionals reported that material supply was adequatel.	Urgency procedure, rush, low-risk patient, disagreement with precaution and unpredictable situations.	Exposure of professionals and patients to risk of infections. Innovative interventions that arouse the team’s attention to increased adherence to SP is recommended.
Zhou et al, 2014 / ISI / China	Healthcare-Associated Infections and Shanghai Clinicians: A Multicenter Cross-Sectional Study	Descriptive cross- -sectional study	The self reporting of professionals regarding practices and adherence to SP showed less than satisfactory results.	Lack of knowledge on standard precautions.	Occupational exposure and inappropriate post-accident conducts. Innovative interventions based on strategies targeted to the promotion of a culture of safety and health are suggested.
Atif et al, 2013/ ISI / França	Awareness of standard precautions for 4439 healthcare professionals in 34 institutions in France	Multicentric cross-sectional study	The study showed a range of correct answers regarding SP of 37.1-91%. Regarding handwashing, the percentage of correct answers was 72.6%, but only 7,3% provided correct answers to questions on the use of barriers and disposal of needles. The nurses were found to have greater knowledge than the other professionals.	Lack of knowledge on SP, particularly regarding the disposal of needles and the use of appropriate protective barriers.	Occupational exposure to possible accidents and diseases. Investment in educational programs on SP for all professionals is recommended.
Cutter J, Jordan S, 2012/ ISI / País de Gales	Inter-professional differences in compliance with standard precautions in operating theatres: A multi-site, mixed methods study	Descriptive cross- -sectional study	The results showed an unsatisfactory level of adherence: 10% always adhere to all available precautions; 0.003% (1) reported never adhering to precautions; the others have low adherence to SP according to their risk perception. The groups of professionals have different perceptions of exposure to risk.	Risk perception varies among the professions and this may cause distorted views on the use of SP.	The occurrence of occupational accidents. It is important to include content on risk perception in the curricula and invest in health and safety at work policies .
Paiva MHRS, Oliveira AC, 2011/ ISI / Brasil	Knowledge about the attitudes of workers from a public emergency service on the adoption of standard precautions	Descriptive cross- -sectional study	Nurses and drivers showed the highest and the lowest level of knowlege regarding SP, respectively. Non-adherence to precaution measures was greater among professionals older than 31 years.	Being older than 31 years appeared as a factor that may interfere with non-adherence to SP.	Occurrence of occupational accidents and diseases in workers and patients. It is necessary to invest in educational programs targeted on SP.
Sreedharan et al, 2011/ ISI / Emirados Arabes Unidos	Knowledge about standard precautions among university hospital nurses in the United Arab Emirates	Descriptive cross- -sectional study	Although 97% of the respondents were familiar with the concept of SP, a significant part of them reported that only diagnosed patients or suspected cases of infectious diseases pose risk, and less than half of respondents aggreed that the SP are aimed to protect health professionals and patients (45.9%).	Lack of knowledge on control of infections and SP.	Possibility of accidents and diseases due to occupational exposure and improper use of precautions. The implementation of a program aimed to improve knowledge on SP is recommended.
Efstathiou et al, 2011/ ISI /	Compliance of Cypriot nurses with standard precautions to avoid exposure to pathogens	Descriptive cross- -sectional study	The results showed unsatisfactory adherence to SP. Only 9.1% reported full adherence. Exposed professionals who participated in trainings reported greater adherence.	Probably not all the professionals are being benefitted by educational programs, generating deficit of knowledge and lower adherence to SP.	Exposure of professionals and patients to biological risks. Educational strategies targeted to all the professionals to improve knowledge and practices related to SP are recommended.
Reda et al, 2010 / ISI / Etiópia	Standard Precautions: Occupational Exposure and Behavior of Health Care Workers in Ethiopia	Descriptive cross- -sectional study	Practices unfavorable to SP such as needle recapping and discriminatory attitudes towards patients with HIV/AID; insufiicient supply of PPE.	Discriminatory attitudes can be related to lack of knowledge and impact adherence to SP, insufficient supply of PPE.	Risk of sickening and occupational accidents and hospital infections by patients. I Investment on the training of professionals, adequated supply of PPE, prevention of hospital infections and assessment and communication of occupational exposures are recommended.
Luo et al, 2010 / ISI / China	Factors impacting compliance with standard precautions in nursing, China	Descriptive cross- -sectional study	Low adherence to SP among the nurses who participated in the study.	Low level of knowledge on SP, work characteristics, experience of exposure and availability of container for disposal of sharp materials.	Exposure of health personnel and patients.It is important that the authorities involved become concerned with adherence to SP and provide the personal protective equipment (PPE). Training should include information on SP.
Parmeggiani et al, 2010 / ISI /	Healthcare workers and health care-associated infections: knowledge, attitudes, and behavior in emergency departments in Italy	Descriptive cross- -sectional study	Health professionals have high levels of knowledge but show low adherence to SP. Nurses have greater knowledge, perception of risks and take more adequante measures of control of infections compared to physicians.	Low level of knowledger was a key fctor in adherence to SP.	Occupational exposure with possible occurrence of accidents and diseases. Investment in education, perception of risks and supply of PPE is suggested.
Ferrer et al, 2009 / ISI / Chile	Observed use of standard precautions in Chilean Community Clinics	Observacional study	The study showed inconsistency in the use of SP, particularly regarding handwashing, cleaning of surfaces and general materials.	Lack of materials was the most commonly observed reason, which made it difficult to adhere to SP in many situations.	Exposure to risks may result in accidents and disease in professionals and patients. The delivery of training to the professionals involved in care is recommended.
Kagan et al, 2009 / ISI / Israel	Perceived knowledge of blood-borne pathogens and avoidance of contact with infected patients	Descriptive cross- -sectional study	Adherence to SP differs according to the patient’s disease. Knowledge on SP has little impact on adherence to these measures.	Existence of bias and values that interfere with the use of SP.	Occurrence of accidents and diseases. It is necessary to introduce psychological and educational aspects in educational programs to health professionals.
Souza Lopes et al, 2008 / ISI / Brasil	Adherence to standard precautions by the mobile prehospital care team from Belo Horizonte, Minas Gerais, Brasil	Descriptive cross- -sectional study	The professionals reported not obtaining satisfactory results for use of facial masks, goggles and other PPE; the drivers reported inadequate attitudes for all the items.	Lack of training on biosafety and SP, of periodical meetings with the teams, of a center for materials (cleaning, disinfection and sterilization).	Occurrence of accidents and diseases. The implementation of educational programs on biosafety and PPE, a calendar of periodical meetings and the creation of a center for materials.
Chan et al, 2007 / ISI / China	Investigating the knowledge, attitudes and practice patterns of operating room staff towards standard and transmission-based precautions: results of a cluster analysis	Descriptive cross- -sectional study	Insufficient attitudes regarding adherence to SP. Adherence was more significant in the group with greater knowledge.	Lack of knowledge is reported as one factor of low adherence to SP.	Implications for the control of hospital infections and exposure to accidents and diseases. Investment in training and changes of attitudes and practices related to SP are recommended.
Gammon et al, 2008 / Cochrane / Reino Unido	A review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control precautions	Study of literature review – 1994 to 2006	Adherence to SP is lower than the what is internationally recommended as ideal. Compliance with aspects of the standards varies among professionals.	There is no evidence regarding interventions and durations that impact adherence to SP and whether non-adherence is.	Implications for the safety of personnel, patients and the care environment. It is recommended the identification of the reasons for non-adherence to the standards and the implementation of measures to improve adherence to SP.
Aguiar et al, 2008 / Cochrane / Brasil	Use of standard precautions in nursing care: a retrospective study	Study of literature review – 1999 a 2005	Low adherence to SP, which makes control of infections difficult.	Not included in the article.	Lack of control of hospital infections exposing patients and health professionals. The implementation of educational programs to improve knowledge on the issue is suggested.

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