Journal of Hospital Infection (2007) 66, 346e351

www.elsevierhealth.com/journals/jhin

Surgical nurses and compliance with personal

protective equipment
M. Ganczak*, Z. Szych

Department of Hygiene, Epidemiology and Public Health, Pomeranian Medical University,

Szczecin, Poland

Received 7 July 2006; accepted 4 May 2007

Available online 27 July 2007

KEYWORDS Summary The study objectives were to evaluate self-reported compli-

Nurses; Personal
protective equipment
ance with personal protective equipment (PPE) use among surgical nurses
and factors associated with both compliance and non-compliance. A total
of 601 surgical nurses, from 18 randomly selected hospitals (seven urban
and 11 rural) in the Pomeranian region of Poland, were surveyed using a
confidential questionnaire. The survey indicated that compliance with
PPE varied considerably. Compliance was high for glove use (83%), but much
lower for protective eyewear (9%). Only 5% of respondents routinely used
gloves, masks, protective eyewear and gowns when in contact with
potentially infective material. Adherence to PPE use was highest in the
municipal hospitals and in the operating rooms. Nurses who had a high or
moderate level of fear of acquiring human immunodeficiency virus (HIV)
at work were more likely (P < 0.005 and P < 0.04, respectively) than staff
with no fear to be compliant. Significantly higher compliance was found
among nurses with previous training in infection control or experience of
caring for an HIV patient; the combined effect of training and experience
exceeded that for either alone. The most commonly stated reasons for
non-compliance were non-availability of PPE (37%), the conviction that the
source patient was not infected (33%) and staff concern that following locally
recommended practices actually interfered with providing good patient care
(32%). We recommend wider implementation, evaluation and improvement
of training in infection control, preferably combined with practical experi-
ence with HIV patients and easier access and improved comfort of PPE.
ª 2007 The Hospital Infection Society. Published by Elsevier Ltd. All rights
reserved.

* Corresponding author. Address: Department of Hygiene, Epidemiology and Public Health, Pomeranian Medical University,
_
Zo1nierska 48, 70-250 Szczecin, Poland. Tel.: þ48 91 4871392; fax: þ48 91 4800952.
E-mail address: mganczak@sci.pam.szczecin.pl

0195-6701/$ - see front matter ª 2007 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jhin.2007.05.007
Use of protective barriers by nurses
Introduction
Healthcare workers (HCWs) still fail to adhere to
standard precaution guidelines despite evidence
that such a failure increases the risk of mucocuta-
neous blood and body fluid exposure resulting in
blood-borne infection (BBI).1e7 The major infec-
tious occupational hazards in the healthcare indus-
try are hepatitis B and C viruses (HBV, HCV), and
human immunodeficiency virus (HIV).8 Data pro-
vided by the Central Register of Occupational Dis-
eases in Poland indicates that among 314 new
cases of occupational diseases in HCWs in 2005,
HBV and HCV represented 42.6% of all cases.9 De-
spite the substantial reduction in HBV infection
since vaccination was introduced in 1989, the inci-
dence of HCV hepatitis in Poland is still on the
increase in this occupational group.9,10
Exposures to specific health hazards are likely to
affect certain high-risk groups of HCWs. For exam-
ple, the care of surgical patients with the in-
creased chance of contact with blood means that
surgical staff are more at risk of occupationally
acquired infections.11 For this reason a better un-
derstanding of surgical nurses’ adherence with
PPE usage is important as it provides an assess-
ment of the efficacy of existing preventative strat-
egies. This could then help to identify preventive
factors which are likely to improve the compliance
and reduce the risk of BBI. Finally, it is then poss-
ible to incorporate these preventative approaches
into institutional health strategies.
There are many published studies which have
focused on the use of PPE among HCWs as part of
existing health preventive measures.3e6 However,
there have been no similar studies on the use of
protective equipment by surgical nurses. This spe-
cific study therefore intends to evaluate compli-
ance with PPE use among surgical nurses in
selected Polish hospitals and to identify factors
associated with both compliance and non-
compliance. The results of this study are likely to
be of value in modifying existing barrier pro-
grammes in order to enhance the safety of staff
working on surgical wards.
Methods
The study was conducted from January to March
2003 in 18 Polish hospitals: seven of these were
urban hospitals located in the city of Szczecin of
which two were academic and five municipal. The
remaining 11 hospitals were located in rural areas.
All hospitals were selected randomly from a list
obtained from the West Pomeranian County Health
347
Department. At each selected hospital, all wards
representing surgical subspecialities participated
in the study. The head nurses at each hospital
were contacted to discuss the importance of the
study and the study protocol.
An anonymous 32-item questionnaire was pre-
pared by the authors using the guidelines from
a previous American study.12 With a few excep-
tions, all questions had fixed answer categories.
The questionnaire was pilot-tested and dealt
with the following topics: demographic data; hep-
atitis B vaccination status; fear of acquiring HIV in-
fection at work; exposures to patients’ blood or
body fluids during the previous year; compliance
with the use of PPE, i.e. gloves, masks, protective
eyewear (spectacles included), and gowns when in
contact with potentially infective material; poss-
ible answers were ‘always’, ‘sometimes’, ‘never’;
reasons for not complying with the barrier
precautions.
Data collected from this questionnaire on the
incidence and risk factors of blood exposures have
been described previously.13 This study examines
the data relating to the compliance with PPE
use. All categoric data were analysed using the
Chi-squared test with or without Yates’ correction,
whilst the KruskaleWallis test or U-ManneWhitney
test was used for numeric variables. Statistical
significance for all analyses was presumed for
P  0.05.
For the purposes of comparing nurses with and
without training in infection control and occupa-
tional experience with HIV-infected patients, we
grouped all nurses who had had one or more
courses together as having experienced the ‘in-
tervention’, and all nurses with experience of one
or more known HIV patients as positive for that
‘intervention’. Since occupational experiences had
not been organized in a systematic manner for
educational purposes, we placed the term inter-
vention in parentheses.
Results
None of the nurses present in the ward on the day
when the questionnaire was administered refused
to participate.
The sample population surveyed consisted of
601 nurses who were mostly young (aged 20e58
years, median 38), female (99.3%), and working
full-time (565, 94%). Almost half of the respon-
dents (257, 42.8%) practised in municipal hospi-
tals, and more than one-third (229, 38.1%) in rural
hospitals. More than one-quarter of the respon-
dents (162; 27%) had occupational contacts with
348
HIV patients during their professional carrier;
almost three-quarters (450; 74.9%) had partici-
pated in a training course on infection control. As
to hepatitis B vaccination status, 85.2% had been
immunized, 5.3% had been previously infected
with HBV, and 9.5% had never been either infected
or immunized.
A high degree of fear of acquiring HIV at work
was reported by 63.9% of respondents (N ¼ 378/
592; 95% CI: 60e68%), moderate fear by 31.8%
(N ¼ 188; 95% CI: 28e36%), no fear by 4.4%
(N ¼ 26; 95% CI: 2e6%).
Almost half of the respondents (276/601, 45.9%;
95% CI: 42e49%) reported having an occupational
puncture injury during the past year and 134 (22.3%;
95% CI: 19.2e25.8) had sustained contact via their
mucous membranes. Over half the nurses (N ¼ 323,
53.7%; 95% CI: 49.7e57.7) had worked at least once
with a recent abrasion or cut on their hands.
In general, compliance with PPE varied consid-
erably, and was highest for glove use (83%), and
lowest for protective eyewear use (9%) (Table I).
Compliance with all items (i.e. gloves, gowns,
masks and protective eyewear) was 29/601 (4.8%;
95% CI: 3.4e6.8). Comparison of age between
non-compliant and compliant nurses did not show
significant differences for PPE use (P > 0.63).
To examine nurses’ overall compliance to PPE
precautions, we calculated the overall score for
each respondent, giving 5 points for using each
single PPE ‘always’, 3 points for using it ‘some-
times’, and 0 for ‘never’. Thus, the maximum
score for PPE compliance was 20, and the mini-
mum was 0. Using this scoring scheme the mean for
the whole group of respondents was 11.6  4.8.
There was no significant effect of age on the
PPE compliance score (P > 0.32). However, a com-
parison of surgical subspecialities showed signifi-
cant differences for PPE compliance, with the
highest compliance in the operating room (mean:
15.4  3.5), and the lowest in the admitting area
(mean: 8.4  4.1) (P < 0.0001).
Table I Adherence to personal protective equip-
ment use among surgical nurses (N ¼ 601)
Personal No. of respondents (%)
protective
Always Often Never
equipment
Gloves 501 (83.4) 64 (10.6) 36 (6.0)
Gowns 242 (40.3) 222 (36.9) 137 (22.8)
Protective 53 (8.8) 137 (22.8) 411 (68.4)
eyewear
Masks 202 (33.6) 245 (40.8) 154 (25.6)
M. Ganczak, Z. Szych
Compliance was significantly influenced by
hospital location. It was lowest for nurses working
in academic hospitals (mean: 10.0  4.4), and
highest for nurses from municipal hospitals (mean:
12.1  4.7) (P < 0.0001).
The survey showed that there was a significant
association between the fear of acquiring HIV at
work and PPE compliance. Nurses who had high
or moderate levels of fear were more likely
(P < 0.005 and P < 0.04, respectively) than staff
with no fear to be compliant (mean scores for
the groups: 12.0  4.9; 11.1  4.3; 9.3  4.8, re-
spectively). Compliance was also related to the
past experience with HIV patients. It was signifi-
cantly higher (P < 0.0001) among experienced
nurses (mean: 12.9  4.5) than non-experienced
(mean: 11.1  4.8). Compliance was also signifi-
cantly higher among the trained nurses (mean:
12.0  4.6) than non-trained (mean: 10.4  5.1)
(P < 0.009). Compliance was found to be even
higher among nurses with both training and
experience using the KruskaleWallis test in
comparison with nurses who had neither, either
or both training and experience (P < 0.0001).
The mean results included: no intervention
10.3  5.1; experience only, 11.0  5.1; training
only 11.4  4.6; both training and experience
13.4  4.3 (Figure 1).
Infection control training and experience
with HIV patients had no impact on the degree
of fear among nurses (P > 0.86 and P > 0.26,
respectively).
Among nurses with perfect compliance for glove
use, 217/501 (43.3%) experienced a sharps injury
during the past year which was significantly
(P < 0.0007) less than the group with poor compli-
ance (62/100, 62%). Among the nurses who had
used masks or protective eyewear regularly, the per-
centage of those who sustained splash contact via
their mucous membranes was 50% (20/40), which
was not significantly (P > 0.7) higher than for the
group with poor compliance (179/386, 46.4%).
Only 396 of the respondents (65.9%) answered
the question on the reasons for non-compliance.
More than one reason per respondent was allowed
and the most commonly stated reasons were non-
availability of PPE (37%), the conviction that the
source patient was not infected (33%), lack of time
(19.2%), staff concern that following locally rec-
ommended practices actually interfered with pro-
viding good patient care (32%) and a perception
that the equipment provided was ineffective, e.g
poor-fitting gloves (9.8%). More nurses from the
academic and municipal hospitals believed that
the source patient did not pose a risk compared to
the nurses from the rural hospitals (30.8% of 91,
Use of protective barriers by nurses 349

15 linked to a lower probability of having a sharps in-

14 13.4 jury, which could lead to HBV, HCV or HIV serocon-
13
Compliance (the overall score)

version. Finally, apart from protecting the staff

12 11 11.4
11 10.3 from contagious diseases, gloves also protect
10 patients from micro-organisms during surgical pro-
9 cedures and the insertion of invasive devices as
8 well as from caregivers who may be carriers of
7
6 blood-borne viruses.
5 Gowns should be worn during procedures which
4 are likely to expose HCWs to spraying or splashing
3 with blood, body fluids, secretions and excre-
2
1
tions.15 However, only about one-third of our re-
0 spondents reported using them regularly. It is
Type of intervention also known that nurses can sustain blood contacts
(P < 0.0001)*
via mucous membranes, and one in five of our re-
‘Intervention’ spondents reported such contacts in the previous
Neither Training year. It has been reported in the literature that
Experience Training and experience some cases of exposure to HBV, HCV or HIV via mu-
cous membranes, leading to HCW seroconversion,
Figure 1 Compliance with personal protective equip- have occurred in this way.1,16e18 The regular use
ment among surgical nurses by training in infection con- of protective eyewear was reported by 9% of
trol and experience with HIV-infected patients, West nurses, and this probably reflected the use of cor-
Pomerania, Poland, 2003 (N ¼ 601). ) Kruskal-Wallis rective eyewear by older nurses rather than a de-
test for 4 groups.
liberate attempt to prevent exposure to blood.
As the facial protection used by nurses surveyed
and 25.8% of 236 vs 17.2% of 174; P < 0.02 and by us was not significantly linked to minimizing
P < 0.04, respectively). blood splashes, misunderstandings such as the be-
lief that spectacles can replace protective eye-
wear demonstrates a need for better education.
Discussion It would appear that the main reasons for non-
compliance with PPE use were similar to those
The response rate to the survey was excellent, reported by others2e7 and those identified in an
suggesting that this was an area of importance for earlier survey with surgeons.19 It is interesting to
surgical nurses. note that the main reason respondents in this study
It is recommended that HCWs should wear PPE gave for not using PPE was lack of availability. This
for any contact with blood or body fluids.1e2 How- problem would be relatively easy to address with
ever, this survey has identified that, despite the better institutional support. In Poland, recently
risk associated with blood contact, surgical nurses’ enacted regulation on occupational safety, up-
compliance with PPE was poor and placed them at dated in 2001, obliges employers to provide ade-
risk of contracting occupationally acquired BBI. quate protection for employees against harmful
In several published studies, including ours, substances including micro-organisms.20 Unfortu-
gloves have been shown to be the most frequently nately, a review of randomly selected state hospi-
used protective equipment, possibly reflecting the tals carried out by the Polish Ministry of Health and
long tradition of wearing them. Moreover, glove Occupational Safety Organization revealed that
use has been shown to be the largest contributor hospital directors were often failing to provide
to the efficacy of standard precautions.14 How- proper protective barriers to the staff, usually
ever, despite the fact that more than half of the due to financial constraints.21 Such a situation is
study respondents admitted that they had worked unacceptable. Whilst better protection would in-
while having a recent abrasion or cut on their volve increased costs for an adequate equipment
hands, and although almost half reported puncture supply, it is likely that this would be much less
injury in the last 12 months, regular glove use had than all the costs associated with treating HCWs
been neglected by 17% of them. This is even riskier who acquire BBI at the workplace.22
because glove wearing not only prevents the non- As reported by others, the respondents often
parenteral exposure to blood, but also can reduce blamed their non-compliance on a lack of percep-
the amount of virus inoculated.7,15 This study tion by the patient representing a health risk,
showed that glove wearing was also significantly despite the fact that patients with BBI can be
350
asymptomatic or unaware that they are in-
fected.4,5 Therefore, HCWs should regard the
blood of all patients as potentially infectious and
protect themselves routinely when exposure to
blood is expected.1,23
Another reason respondents gave for not
wearing PPE related to poor dexterity, which is
an issue that has often been raised in other
surveys.2,6 This suggests that protective equip-
ment used in Polish healthcare facilities needs
to be better designed and more comfortable.
Further studies to identify improvements to PPE
would be valuable, followed by an evaluation
of changes in compliance.
In this study, compliance with PPE use was
significantly related to the fear of acquiring HIV
(and probably other BBIs) at work, with a dosee
response effect evident. This is similar to previous
studies among surgical staff in which acquiring HIV
from patients was ranked as a strong influence on
compliance with PPE use.4 A fear of BBI tends also
to be the prime motivator for hospital personnel to
change their behaviour.22,23
As both training programmes and practical
experience in working with HIV-positive patients
positively influenced nurses’ compliance to PPE
use, and the combined effect was greater than
either alone, we recommend that all surgical
nurses should receive effective training in infec-
tion control methods, preferably with known HIV
patients.
The study has a number of limitations. First,
‘compliance’ is difficult to quantify reliably. Com-
parisons of observed and self-reported adherence
to barrier precautions among HCWs found signifi-
cant differences in the respective rates for more
protective barriers.8 Second, because the study
sampled only surgical nurses, the results may not
be generalizable to all hospital-based nurses. Third,
recall bias is possible. Finally, a cross-sectional
study design can be used only to show associations
and cannot confirm a cause-and-effect relation-
ship.5 The 100% response rate to the questionnaire
and the variety of hospitals selected randomly
means that the results of this study are likely to
reflect accurately the situation regarding the use
of PPEs in the surgical wards in Polish hospitals.
Our findings indicate that despite common
contacts with blood, compliance with PPE use
among Polish surgical nurses is unacceptably low,
which shows that the existing strategies to
control infections to HCWs have not been ade-
quate. There is a need to consider factors that
enable people to change their behaviour, and
also the availability, cost and convenience of the
preventive barriers.24 Thus, a combination of
M. Ganczak, Z. Szych
strategies is required, including continuous edu-
cation in infection control, easy accessibility to
PPE, and improvement in the comfort and con-
venience of barrier precautions.
Acknowledgements
Thanks to M. Milona, RN MSc, for help in perform-
ing the survey.
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