Central Journal of Family Medicine & Community Health

Cite this article: Mollaoglu M, Mollaoğlu M, Şanal L (2015) Compliance with Standard Precautıons of Students in Clinical Practice. J Family Med Community Health 2(8): 1064.

Abstract

Nursing students are often exposed to blood- borne infections during clinical practicum. The aim of this study is to evaluate the compliance of nursing students with standard precautions in clinical procedures.

A cross-sectional survey was undertaken, involving 413 nursing students from a University hospital. Three forms were used for data collection in the research. The research data were were assessed using the Statistical Package for Social Sciences (SPSS) version 11.0

The students showed high level of compliance with standard precautions such as wearing gloves, hand washing, and protection against penetrating injuries. However, the levels of compliance with wearing mask, using goggles, and wearing protective gowns were low. Students at advanced ages and those in their senior years displayed higher compliance with the standard precautions.

Particularly when they start clinical practicum, the students should be informed and educated about how they can protect themselves from blood-borne infections.

*Corresponding authorMukadder Mollaoglu, Cumhuriyet University Faculty of Health Sciences, 58140 Sivas, No: 13, Turkey, Tel: 0-346-225-23-21; Fax: 00-90-346-225-12-31; E-mail:

Submitted: 05 November 2015

Accepted: 09 December 2015

Published: 11 December 2015

ISSN: 2379-0547

Copyright© 2015 Mollaoglu et al.

OPEN ACCESS

Keywords•Standard precautions•The compliance of nursing students•Blood-borne infections

Research Article

Compliance with Standard Precautıons of Students in Clinical PracticeMukadder Mollaoglu1*, Muratcan Mollaoğlu2 and Laser Şanal3

1Cumhuriyet University Faculty of Health Sciences, Turkey 2Department General Surgery, Cumhuriyet University, Turkey3Türkiye Yüksek İhtisas Eğitim ve Araştırma Hospital, Turkey

INTRODUCTION Hospitals pose significant risks with regard to worker health

and safety. Any blood-borne microorganism can infect an injured person [1,2]. However, owing to their current prevalence and potential to cause systemic infections, the most important pathogens are hepatitis B virus (HBV), hepatitis V virus (HCV), hepatitis D virus (HDV) and human immunodeficiency virus (HIV) [3,4].

Healthcare professionals are at risk of these occupational infection with blood borne pathogens. World Health Organisations (WHO) forecast that, among the 35 million health care workers worldwide, almost 3 million experience percutaneous subject of blood borne pathogens each year [1]. These injuries are estimated to result in 16,000 hepatitis C, 66,000 hepatitis B, and 200 to 5000 HIV infections. More than 90% of these infections are occurring in least developed countries and most are preventable [3].

When an increasing number of health professionals became infected with HBV and was upward raised in the 1980s with the beginning of the HIV outbreak, insight that health professionals are at threat of infection with blood borne viruses incremented during the 1970s [4,5]. Stabmedical instruments (needles and

sharps) were developed by considering this case, practice guidelines to improve health professionals reliability by minimizing the chance of exposure to blood, the ingredient of the guidelines have varied over time. Before these measures were known asuniversal precautions, but is now known as standard [6,7].

Standard precautions are applied to reduce the risk of transmission of blood born epathogens. Standard precautions are a set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin (including rashes), and mucous membranes [8,9]. Standard precautions includes the use of: hand washing, appropriate personal protective equipment such as gloves, gowns, masks, whenever touching or exposure to patients’ body fluids is anticipated. These measures are to be used when providing care to all individuals, whether or not they appear infectious or symptomatic [10,11].

Nursing students are in close contact to patients with blood-borne infections during their clinical practices and afterwards. They are exposed to blood borne pathogens in health care areas such as health care workers [12,13]. Under graduate nursing students are exposed to contamination by blood borne pathogens during their academic activities, as well as by others

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found in body fluids, such as HBV, HCV and HIV [13,14]. Proper compliance toward these infections of nursing students are corner stones of preventing the spread of blood-borne infections.

BACKGROUNDBlood-borne infections may be transmitted by accidental

self-injection; injury with penetrating objects stained with blood; disruption of the skin integrity due to laceration, cut, or wounding; and mucosal transmission of infected blood or other fluids [15,16]. Since injuries inflicted by penetrating instruments (eg. syringes, surgical blades) increase the risk for parenteral transmission of infections, it is considered as an important route of transmission. Preventing contact with blood is the best approach to eliminate transmission of blood-borne infections [7]. Centers for Disease Control and Prevention (CDC)has developed a guideline under the title of “Standard Precautions” aiming to prevent transmission of infectious diseases to healthcare providers via blood or body fluids. This guideline recognizes blood and body fluids of all people as potential infection focirequiring certain safety measures [10]. These measures are hand washing before and after all procedures, as well as following the removal of the gloves; using protective barriers preventing transmission through skin and mucous membranes (eg. gloves, gown, mask, goggle); and continuously arranging in-house training programs to update current levels of knowledge and awareness [7,10,].

Moreover, in case of contact with patient blood or body fluid, people are advised to wash the injury area with ample water, clean with antiseptic solutions and visit the hospital infection committee to monitor and control any infectious transmission [17,18]. Again, in the same guideline, it is recommended that used needles, syringes, blades, and other sharps should be collected in sharps containers. Moreover, during the recent decade, safe health devices targeting to reduce percutaneous injuries such as waste containers with trash level monitoring systems and safe medical instruments such as retractable needles have been showing increased employment rates [19,20]. In addition to healthcare workers, medical and nursing students are also under risk for injuries with penetrating objects during clinical practices due to their low level of clinical experience [12,13,21]. Studies show that 11-50% of medical students and 50-80% of nursing students experience penetrating injuries during their education [14,22,23,24,25].

As known by many, patient care, being the basis of nursing education is first theoretically taught at school before starting to practice on patients in hospitals. Throughout the nursing education, students are informed about the preventive measures against blood-borne diseases in various courses. Similar to other healthcare staff, under graduate students working in hospitals may be exposed to blood-borne diseases, as well. Since they do not have adequate practical experience and theoretical knowledge, their level of exposure can be even higher than other responsible healthcare staff [14,26,27]. Recently, although there is an increase in the bulk of studies focusing on protection from blood-borne infections, it is believed that nursing students should receive more information on potential clinical hazards and preventive measures [9,28,29]. In this study we aim to evaluate the compliance of nursing students with standard safety precautions in hospitals.

MATERIALS AND METHODSSample and setting

This study was a cross-sectional survey which was performed from March-June 2013 to assess the knowledge and compliance regarding standard precautions of 413 nursing students in Nursing Department of Cumhuriyet University Health Sciences Faculty (NDCUHSF).

The study enrolled the entire 4-year students in the school including first, second, third and fourth year students. In this nursing school, students learn about the blood-borne pathogens in theoretical courses before starting to work in clinical settings. The theoretical information on this subject is delivered during the first year in the courses of Microbiology, Pathology, and Principles of Nursing. Subsequent to employing the standard safety precautions in laboratory settings (wearing gloves, hand washing, proper disposal of contaminated materials), the students start to work in clinical settings in the second semester of year 1. In other words, after gaining theoretical and practical knowledge on blood-borne pathogens, as a part of the principles of nursing course, they complete an internship program of 16-hours in the surgery and internal medicine clinics during the second semester.

These subjects are also taught more comprehensively, both theoretically and practically, during the course of internal medicine in the second semester, as well as during the courses of surgery, infectious diseases, and gynecology in the third semester. In the second and third years, students receive 24 hours of clinical practice in each semester. In the fourth year, the duration of clinical practice is even longer (28 hours/week).

The Questionnaires

Three forms were used for data collection in this research: a Personal Information Form (PIF), Knowledge on Universal Precautions (KUP) and Compliance with Universal Precautions (CUP)

Personal Information Form (PIF): Demographic data containing participants’ age, sex, marital state, year of training were registered for each participant. Questionnaires were filled by direct interviews which were performed by a trained general practitioner from the research team after taking informed consent from the subjects in the university or hospitals.

Compliance with Universal Precautions: Participating nursing students were asked to indicate using a 5-point Likert scale (never, rarely, sometimes, often always,) whether or not they engaged in 1 of 12 behaviors related to the practice of universal precautions. An overall compliance score was calculated by assigning a value ranging from 1 to 5 (according to the Likert responses) to each of the 12 items and summing these values (the highest score possible was 60 and the higher the score the more compliant the nursing students). This questionnaire has been used previously in surveys with health care workers by [30] and has been tested for internal consistency and reliability. The questionnaires’ validity and reliability were also confirmed by Cronbach’s alpha coefficient (alpha = 0.88) in this study.

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Ethical considerations

School directors approved the study protocol. All the participants were fully informed about the purpose of the study. Students were assured that participation was voluntary and their refusal to participate would not affect their clinical performance assessment or future opportunities for employment. In addition, the researcher assured them of the protection of their anonymity and confidentiality.

Statistical analysis

Data were entered into SPSS 18 software and analyzed by descriptive statistics (i.e., mean, SD, frequency) and comparison means (i.e., one way ANOVA, t Test). A P value less than 0.05 was considered statistically significant.

RESULTSTotally 413 nursing students entered the survey, 120 of

whom where male and 293 were female with the mean (SD) age of 21.10±1.63 years old. Among the students, 135 (32.7%) were in the first 2 semesters (1 st year) of their studies, 120 (39.1%) in semesters 3-4 (2nd year), 104 (25.2%) in semesters (3rd) and only 54 (13.0%) of them were fourth year students. The mean compliance with universal precautions score of the studentswas 37.7 (SD:8.90) with the minimum score of 10 and maximum of 57 (Table 1).

Self-reported compliance with some practices such as wearing gloves ((91.5 %), protection against penetrating instruments; take extra care when using scalpels, needles, razors or other sharp objects (84.3 %), put used needles and other sharp objects into the designated sharps container (85.2 %), dispose of all blood-contaminated items into the bag or bucket designated for disposal (72.6%) and hand washing after removing disposable gloves (81.4 %) was good but compliance with several other practices such as wearing a water proof apron (20.8 %) whenever there is a possibility of blood or other body fluids splashing on clothes (14.5 %) and promptly wiping up all spills of blood and other body fluids was poor (Table 2).

Table 3 shows there was a positive significant correlation between participants’ age and their compliance with universal

precautions. In addition,thosein the upper year of training compliance with universal precautionswas high. No statistically significant difference was found between the gender status and compliance with standard precautions among the students.

DISCUSSIONThe incidence of blood-borne infections has been increasing

along with studies highlighting the importance of standard safety precautions [9,19]. Nonetheless, the number of studies concerning the compliance of healthcare providers, particularly students practicing their internship, with safety measures is limited. Therefore, we aim to investigate the adherence of nursing students to standard safety precautions while completing their internship in clinical settings.

Our study revealed a moderate level of compliance with standard safety precautions in nursing students completing

Table 1: Some characteristics of students.

CharacteristicsGenderFemale 293 (70.9)

Male 120 (29.1)Age

<22 years 320 (77.5)<22 years 93 (22.5)

Age; mean (SD)years 21.10 (1.63)Year of training

First year 135 (32.7)Second year 120 (39.1)Third Year 104(25.2)

Fourth year 54 (13.0)Compliance on Universal Precautions

Mean (SD): min-max 37.7 (8.90); 10-57

Table 2: Compliance with components of Universal Precautions.

Item n (%Compliant)*Regardless of their diagnosis I protect myself against the blood and body fluids of all patients, 119(28.8)

I put used needles and other sharp objects into the designated sharps container. 325(85.2)

I wear gloves whenever there is a possibility of exposure to blood or other body fluids. 378(91.5)

I wash my hands after removing disposable gloves. 336(81.4)I wear a waterproof apron whenever there is a possibility of blood or other body fluids splashing on my clothes.

86(20.8)

I wear eye protection (goggles/glasses) whenever there is a possibility of blood or other body fluids splashing in my face.

60(14.5)

I wear a mask whenever there is a possibility of blood or other body fluids splashing in my face. 169(40.9)

I do not recap needles that have been contaminated with blood. 169(40.9)

I dispose of all blood-contaminated items into the bag or bucket designated for disposal. 300(72.6)

I take extra care when using scalpels, needles, razors or other sharp objects. 348(84.3)

I promptly wipe up all spills of blood and other body fluids. 110(26.6)

I cover my broken skin before coming to work. 184(44.6)

*Expressions are more than one.

Table 3: Compliance with Universal Precautions of nursing students in relation to the some demographic characteristics (n: 413).

Variables Mean (SD) compliance score Statistical tests

Gender FemaleMale

34.68(8.90)34.40 ( 8.83)

t: 0.898P:0.128

Age <22 years>22 years

35.7 (10.12)37.8 (8.42)

t:11.34P:0.01

Year of training

First yearSecond yearThird YearFourth year

32,7 (10,3)36,2 (9,4)36,4 (9.5)39.5 (9.0)

F: 4.6490.0001

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their internship in clinical settings. The most commonly used precautions against blood-born infections are wearing gloves, hand washing, and protection against penetrating instruments. In the study of [31] the rate of wearing gloves among nurses was 41.4%. In his study, [32] found the same rate as less than 50%. Failure to use gloves may be associated with lack of gloves, forgetting to use gloves, disbelief in the benefit of using gloves, and feeling more comfortable without gloves. In the present study, the inclination to wear gloves was higher in the students than in the nurses working in clinical settings. It is important to encourage using gloves among students.

In the present study, our students were found to pay attention to the importance of hand washing. In previous studies conducted in Saudi Arabia [33] and Italy [34], the students showed low levels of compliance with hand hygiene. [35] reported higher sensitivity for hand hygiene in nursing students than in medical students, and explained this difference by the fact that nursing students received adequate training on this subject right from the beginning of their education while medical students received inadequate information in later courses. In order to make the students immediately take the required safety precautions upon entering the clinical environment, standard precautions should be adequately taught starting from the first year. As part of their educational course requirements, nursing students are in contact with patients during clinical practicum and internship programs. Nursing students is important to increase the knowledge and skills which are necessary in prevention of infections transmitted through their blood.

In this study, the compliance rate with protection using goggles, masks, or gowns against blood or fluid splatter was low. Compliance with the need to use personal protective equipment, was poor overall to compliance levels reported in similar studies of health care workers [5,9,11]. The reason behind this low rate may be the absence of such equipment in the clinical environments. In order to improve compliance with universal precautions should be provided continuous in service training against blood-borne infections, supplied of personal protective devices in hospitals, vaccinated against HBV to healthcare workers and students and development of appropriate infection control and injury surveillance programmes in curriculum programme. Interventions to improve universal precautions’ compliance among nursing students are urgently needed.

Majority of the students reported that they were compliant with safe disposal of used needles, sharps and other blood-contaminated items, washing hands after removing gloves and taking extra care when handling used needles and sharps. Recapping, a common behaviour among health care workers is one of the most frequent causes of infection with blood borne pathogens. However, it is of concern that only 40.9 % said “I do not recap needles that have been contaminated with blood” given the strong association between needle recapping and percutaneous injury [19,29]. This relationship should be sought with further studies in this population. On the other hand, there is a scope for improvement in safety protocols. Issues to be considered include use of safety equipments, notification and registration ofinjury, training of all nursing/medical students in handling and elimination of sharps, establishing a staff student

health service and indoctrinating anaccountable attitude among health care workers.

The mean scores of universal precautions was significantly associated with some variables. The compliance with universal precautions was lower in the students who in the first year of their training. Compliance was better among students continuing their education in the upper-class, knew more about nosocomial blood borne pathogen transmission, perceived fewer barriers to compliance and had a positive perception of the safety climate in their workplace. Consistent withthis result in the study, inthe upper-class students whoareolder students age naturally. Therefore, the compliance ofthe older student’s was high. For students continuing their professional training in the upper class was made more practical applications to the health care setting, the more likely that his or her level of compliance of universal precautions increased. In this study, nursing students trained in the health sector for longer peri ods were more aware of universal precau tions compared with those who served for shorter periods. Training and education have been found to be of paramount im portance to developing awareness among health care workers, as well as improving adherence to good clinical practice [27,36]. Education plays a role in exposure to infection. The findings of this study suggest that nurse educators reconsider current curriculum design, course content and teaching strategies concerning nursing student compliance with standard and transmission-based precautions for the prevention of transmission of infectious diseases.

In conclusion, the mean scores of compliance with universal precautions was moderate level in this study. The mean scores of universal precautions was significantly associated with some variables such as age andyear of training. The compliance in the upper-class students who are older students age was high. Continuous education is necessary for nursing students to increase and maintain the knowledge ofpreventive strategies for blood borne infectious agents and to develop appropriate attitude. Nursing education curricula is important to be updated in terms of student needs.

Study limitations

There are two limitations of this study. One of the limitations of the study, since this survey was only conducted in a nursing school of Turkey, its generalisability is limited. The second limitation of the study is that the design of the study is not longitudinal but cross-sectional. Because of this reason it was not possible to observe and evaluate all the changes coming into existence among the students beginning their education in the first grade throughout their education.

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Mollaoglu M, Mollaoğlu M, Şanal L (2015) Compliance with Standard Precautıons of Students in Clinical Practice. J Family Med Community Health 2(8): 1064.

Cite this article

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