Factors affecting patient safety culture in terms of compliance with preventing bloodborne pathogens among general hospital nurses

As the standard of living has improved and the provision of medical services and public interest in health have increased, patients and caregivers who use hospitals have increasingly demanded high-quality medical services in safe environments [1]. Access to appropriate medical services is regarded as a basic patient right [2]; however, the increasing severity of patient conditions and complexity of medical services still threaten patient safety. Improving patient safety and the quality of care has become a critical public health issue [3, 4].

Patient safety policies aim to minimize potential risks in medical services to prevent errors and to minimize risk factors, with the ultimate goal of decreasing the incidence of medical malpractice [5, 6]. Incidents of medical malpractice cause financial loss, distrust in healthcare professionals and hospitals, and longer hospital stays, directly influencing patient health and lives; therefore, medical malpractice is an important factor that decreases the quality of care [7, 8]. The American Institute of Medicine [9] emphasized the need to mitigate medical malpractice and suggested fostering a culture that prioritizes patient safety.

Patient safety culture is an organizational culture in which hospital staff recognize patient safety as a priority. This is guided not only by patient safety policies and improved organizational systems but also by the management of patient safety through active communication and teamwork between the members [10]. Nurses’ perceptions of patient safety culture have been seen to increase their compliance with safe nursing practices, thus creating a safe medical environment [11]. Nurses often encounter situations requiring them to make critical judgments and independent decisions and where factors such as teamwork, knowledge, techniques, attitude, leadership, and communication are necessary for efficient workflow and problem solving [12].

Among the various healthcare-associated infections (HAIs), bloodborne infections are caused by exposure to blood or bodily fluids of a patient. Although prevention is of the utmost importance, when such exposure occurs, team members often criticize one another instead of communicating effectively, which creates obstacles to patient safety [11, 13]. Nurses who provide direct care to patients are at high risk of exposure to bloodborne infections such as hepatitis B, hepatitis C, and HIV [14‐16].

According to previous studies, patient safety and patient safety culture have a positive influence on outcomes [17], and the application of various interventions could change the organizational safety culture and improve infection control [18]. Therefore, it is necessary to develop interventions for infection control by investigating the factors affecting patient safety culture for bloodborne pathogen prevention.

Table 1 shows the demographic and clinical characteristics of the participants. It was noted that 275 (96.8%) participants were female, and 202 (71.1%) were below 30. Of the total participants, 205 (72.1%) had a bachelor’s degree and 234 (82.4%) were staff nurses. In terms of total work experience, 199 (70.1%) had less than 5 years of experience, and 85 (29.9%) had more than 5 years. Further, 234 (82.4%) were noted to have been working in their current unit for less than 5 years, and 50 (17.8%) had been working in their current unit for more than 5 years. Of the total, 55 (19.4%) worked in non-surgical internal medicine units. In terms of experiencing needle stick and sharp injury (NSSI), 221 (77.8%) had experienced NSSI, in contrast with 63 (22.2%) who had not. Further, 37 (58.7%) experienced NSSI from disposable syringes, and 21 (33.3%) experienced NSSI while disassembling needles or sharp instruments. It was noted that 253 (89.1%) never experienced mucous membrane exposure to blood and bodily fluids, and 249 (87.7%) never experienced skin exposure to blood and bodily fluids. Of the total, 257 (90.5%) never completed a report on infection exposure, and 231 had received the hepatitis B vaccine (81.3%). The results showed that 142 completed 0 patient safety case reports (50%), and 135 (47.5%) completed 1–5 patient safety case reports. Further, 259 (91.2%) participants received education on prevention of bloodborne pathogens, and 119 (41.9%) and 123 (43.3%) received education at hospital and at both school and hospital, respectively.

According to the participants’ demographic characteristics, compliance with practices promoting prevention of bloodborne pathogens was higher in participants older than 30 (F = − 2.04, p = 0.042), head nurses and those in higher positions (F = 3.89, p = 0.021), and participants without NSSI experience (t = − 2.29, p = 0.024) (Table 2).

A significant correlation was found between awareness of patient safety culture and compliance with bloodborne pathogen prevention (r = 0.36, p < 0.010). In terms of sub-categories, leadership had the highest correlation (r = 0.85, p < 0.010), followed by teamwork (r = 0.82, p < 0.010), patient safety policy/procedures (r = 0.77, p < 0.010), knowledge and attitude toward patient safety (r = 0.76, p < 0.010), system to improve patient safety (r = 0.61, p < 0.010), and non-punitive environment (r = 0.17, p < 0.050). Priority of patient safety, which was also a sub-category of patient safety culture awareness did not show a significant correlation (r = 0.07, p = 0.223) (Table 3).

A hierarchical multiple regression analysis was conducted to identify factors that influence compliance with bloodborne pathogen prevention. In the analysis, job position (demographic characteristic) and experience of NSSI (clinical characteristic) were used as the dummy variables, and patient safety culture and its sub-categories were used as independent variables. Model 1, which included job position, explained 1% (F = 4.26, p = 0.040) of compliance with practices promoting prevention of bloodborne pathogens, and the explanatory power increased by 2% in Model 2, which included NSSI experiences (F = 4.79, p = 0.009). In Model 3, the following sub-categories of patient safety culture awareness were found to have significant effects on compliance with bloodborne pathogen prevention: leadership (β = 0.15), teamwork (β = 0.41), knowledge and attitude toward patient safety (β = 0.34), and priority of patient safety (β = 0.14). The model had an explanatory power of 53% (F = 32.26, p =< 0.001) (Table 4).

The present study analyzed the relationship between patient safety culture and nurses’ compliance with bloodborne pathogen prevention. When the participants’ compliance with the prevention of bloodborne pathogens was analyzed according to their demographic and clinical characteristics, compliance was found to be higher among head nurses, those in higher positions, and participants who had not experienced a needlestick and sharps injury (NSSI) in the preceding year. This finding was in contrast with those of previous studies that found no difference in compliance with prevention of bloodborne pathogens based on job position. However, the finding can be compared to those of previous research that reported that compliance was higher among those who had not experienced an NSSI than among those who had experienced an NSSI [16, 21, 22]. At the hospital where this study was conducted, head nurses and nurses in higher positions are responsible for the overall management of the unit, including monitoring of infection control, instead of providing direct care to patients; this might explain the results indicating higher awareness of infection prevention practices among higher-ranking nurses than among staff nurses. Thus, to improve compliance with the prevention of bloodborne pathogens, education on NSSIs should be improved, and continuous monitoring of prevention compliance should be implemented.

A significant correlation was seen between the participants’ patient safety culture and compliance with the prevention of bloodborne pathogens. In terms of patient safety culture, the subcategories of leadership, teamwork, patient safety policy, procedures, knowledge or attitude toward patient safety, patient safety improvement system, and priority of patient safety were significantly correlated, whereas nonpunitive responses did not correlate with compliance with prevention of bloodborne pathogens. Although direct comparisons are difficult to make due to the limited number of similar studies, one study reported that perception of patient safety culture in hospital nurses was significantly related to compliance with standard precautions [23]. Thus, as shown in the present study, since patient safety culture, including standard precautions, can influence the prevention of bloodborne pathogens, it is necessary to understand and pay attention to patient safety culture and relevant factors to prevent bloodborne infections [24].

According to a hierarchical regression analysis of factors that influence compliance with bloodborne pathogen prevention, experience with NSSIs and patient safety culture were found to be significant factors. Among the subcategories of patient safety culture, the significant factors were found to be teamwork, knowledge and attitude toward patient safety, leadership, and priority of patient safety.

First, participants who had never experienced an NSSI were found to be more compliant with bloodborne pathogen prevention than those who had experienced an NSSI. This finding is in line with that of a previous study that reported higher compliance with practices promoting bloodborne infection control among those who had never experienced blood exposure [16]. Moreover, our finding also agrees with that of another study reporting higher compliance with standard precautions among those who had never experienced needle stick injuries [25]. This seems to be the case because nurses’ compliance with practices that protect them from infection would have prevented NSSIs, and the finding further indicates the importance of preventing exposure to blood. Therefore, cases of bloodborne pathogen infections should be introduced in infection prevention training to emphasize the seriousness of the situation, and efforts should be made to help nurses habitually perform practices promoting the prevention of infections. Moreover, nurse awareness should be improved to encourage them to prioritize their own protection when providing care in situations where bloodborne infections are possible [21].

NSSI is a major cause of bloodborne infections, and considering that more than half of nurses who experience an NSSI encounter repeated injuries [26, 27], it is important to prevent NSSIs in the first place. Furthermore, to improve compliance with the prevention of bloodborne pathogens, continued safety training on the safe use of syringes and NSSIs is necessary. In particular, in the present study, NSSIs were seen to occur most often in the process of disassembling needles or sharp instruments, mostly while disposing and washing used instruments and while recapping used needles.

Therefore, these specific cases should be included in periodic infection education for nurses, and further training should be provided on precautions while using sharp instruments. In addition, appropriate administration or legislation should be implemented to prevent the recapping of used needles and to promote the wider use of safe injection devices [16, 28]. Furthermore, we found that nurses received more infection education at hospitals than during their regular nursing curriculum at school. Infection education programs should be a part of nursing curricula. It is also crucial to provide access to continuing education in clinical settings [29, 30].

Second, within patient safety culture, the subcategories of knowledge and attitude toward patient safety, leadership, and priority of patient safety were found to have positive effects on bloodborne pathogen prevention. This result is comparable to previous research findings that suggest that those with higher perceptions of patient safety culture have higher compliance with standard precautions [11] and compliance with practices promoting infection control [20]. These findings indicate that it is important to cultivate a positive patient safety culture through leadership and that patient safety culture is an important factor in the prevention of bloodborne pathogens. In terms of leadership in patient safety culture, a significant factor in the present study, it was found that leadership WalkRound programs aiming to change patient safety culture awareness inside and outside of South Korea have led to improvement and are a meaningful way to improve patient safety culture [31, 32].

The present study is significant because it confirms how patient safety culture influences compliance with practices promoting the prevention of bloodborne pathogens as a variable. In other words, the findings of the present study should be considered in developing programs for HAI prevention and training on infections. Moreover, this study used tools of Korean patient safety culture that were developed based on the consideration of Korean culture. A notable difference from the globally used Hospital Survey on Patient Safety Culture (HSOPSC) and Safety Attitudes Questionnaire (SAQ) [33‐35] is the exclusion of questions from patient safety culture tools on the openness of communication, staff distribution, and handover. Instead, the Korean tools used in the present study added questions on policy or procedures, knowledge and attitude toward safety, and priority of patient safety [19]. The tools have different questions, probably because medical systems differ and the awareness of patient safety culture in Korea differs from that in other countries.

There are several limitations to this study: the data were collected through convenience sampling at a general hospital in one city, and it is difficult to generalize the findings due to regional bias. Moreover, the number of reports on patient safety incidents over the past year exceeded that of NSSI incidents because the hospital’s reporting system includes NSSIs as well as exposure to pressure ulcers, falls, and near misses.

The present study analyzed the effects of hospital nurses’ patient safety culture on compliance with bloodborne pathogen prevention and found that an NSSI experience, leadership, and priority of patient safety were significantly related. Therefore, to increase the compliance of hospital nurses with practices promoting the prevention of bloodborne pathogens, it is necessary to carefully prevent NSSIs and to implement various programs that emphasize factors of patient safety culture, such as leadership, teamwork, and priority of patient safety.