Personal Protective Equipment: Getting Compliance or Resistance

August 1, 2001

Personal Protective Equipment: Getting Compliance or Resistance

By Karen A. Huggins, MN, RN, CNOR

the past decade, the healthcare industry has provided many technical
innovations, safety device equipment and supplies, and research related to
healthcare risks and personnel protective equipment (PPE). The question now is
"Are we achieving compliance or encountering resistance in the use of PPE?."
Collectively, there may not be a right or wrong answer in the determination of
which particular piece of PPE should be used; however, there are factors in the
work environment that influence compliance.

The purpose of this article is to describe some attributes of PPE and to
discuss some of the root causes that must be considered when an accident occurs.
Do these become a pattern of non-compliance or is it resistance? If a task has
been completed for many years without an incident, will it alter the result if

The more appropriate issues of concern need to be that we are given access to
supplies and equipment that meet the needs of healthcare workers and patients in
providing safety. Training of healthcare employees must include information on
blood-borne pathogens and standard precautions. Staff must gain an understanding
of the risks involved in exposure, to not only themselves, but to the patient.
Accidents and exposures continue to occur and need to be reported and

Among healthcare workers, one of the most universal perceptions regarding
exposures is that the risk of injury is part of the nature of the business.
Knowing the root cause of an exposure may help to verify whether the incident
occurred due to a lack of knowledge or from non-compliance. Resistance implies a
holding back as in resisting change. The individual knew PPE was available but
under the circumstances held back and chose an excuse, avoiding protection. This
is as if to say that "just this time, it will not happen to me, or I will
be careful." Vaccines for hepatitis are available and there are some
individuals who have refused to be vaccinated. Resistance is also shown by
failing to report an injury and or to refuse treatment following the injury.
"The failure of nurses to report needlestick injuries has been estimated in
studies to range from 30% to 60%. Marcus and coworkers report that needlestick
exposure to HBV carries a 6% to 30% risk of infection whereas HIV needlestick
contact carries less than a 1% chance of seroconversion."1

Regrettably, knowing the incidence of blood exposure and injury does not
allow us to know the exact risk of contracting a blood-borne infection. By
implication, however, any maneuver that reduces exposure to blood and injury
will also reduce the risk of contracting a blood-borne infection2

Risks for exposure in the healthcare setting are unlimited as to where one
may occur. The literature reviewed was centered on the surgical arena and
infection control research. The content may be applicable to any patient care
setting. The risk of acquiring bloodborne pathogens in the surgical setting is
not limited to OR personnel. There are several reports in the literature
documenting health care worker-to-patient transmission of HIV, HBV, and HCV
during invasive procedures.3


In the surgical setting, the occurrence of an exposure is noted as being
higher among surgeons and first assistants initially, followed by OR personnel.

Several factors were found to significantly alter the risk of blood
contamination or injury in surgery.

  • surgical specialty,
  • role of each person,
  • duration of procedure,
  • amount of blood loss,
  • number of needles used, and
  • volume of irrigation fluid used.4

Surgical specialties such as orthopedics, cardiovascular, and plastic
reconstruction are noted to be among the higher risks for injury. Injuries
caused by vascular access needles fall into the Centers for Disease Control and
Prevention's (CDC) high risk category for bloodborne pathogen transmission. The
higher risk is linked to a larger blood inoculum associated with injuries from
blood filled hollow-bore needles. Anesthesia personnel sustain most of these
potentially high-risk injuries.5

In the last three areas, a logical relationship exists between blood loss,
needles, and irrigation fluid. The higher the quantity of the substance, the
greater the risk of exposure. Gowns, are an example of PPE that clearly reflect
this correlation. Liquid penetration through a gown is dependent upon several
things: duration of the exposure, the pressure that is applied to the liquid,
the surface tension of the liquid, the fabric contact angle, and fabric stresses
(such as stretching or abrasions).6

Root Causes

Examples of root causes associated with the exposures to blood-borne
pathogens can be categorized by the event of occurrences without providing
specific details. Root causes may be identified by events that occur in a
particular setting or as identified by national benchmarks such as those done by
CDC. The events become the stories that many healthcare workers experienced as
an exposure or injury.

No PPE being worn or used when an incident occurred or not having the most
effective protection available for the task at hand. This could impact the event
over a period of time and make the safety device being used inadequate. For
instance not wearing eye protection during any number of procedures where there
is exposure to bodily fluids; examples include activities like obtaining
specimens or suctioning. In surgery, a scrub person not wearing eye protection
during a laparoscopic procedure because there is not an open wound. The
potential for risk is still there with the port holes where the amount of
irrigation used may create the potential experience of a splash injury.

The need for more consistent use of protective eyewear also has been
stressed. One study concluded: "Twice the number of blood contacts to the
face were recorded than to the hands, which ranked second in frequency in a
study of six hospitals during a 15 month period. Consistent with the body
location was the finding that blood contact with the mucosa of the eyes was the
most common type of exposure, accounting for 45.3% of incidents.7

There are several root causes associated with sharps' incidents reported by
healthcare workers. The type of sharp is not the key issue in relating an
injury; use and disposal relationships are the root causes. Do the sharps used
have a safety device or not? If it does, is the sharp device being used

Has the user received training on the handling of the safety device? These
questions should be answered when investigating the root cause.

In surgery, suture needles account for numerous types of injuries that occur
during a procedure, such as:

  • during activity of suturing
  • passing suture material
  • loading suture onto a needle holder
  • unloading a needle
  • suture needles disposal.

Inappropriate disposal of sharps is also a root cause category to be assessed
and evaluated. Not paying attention to where needles are placed following use
accounts for a variety of stories. How often has someone heard of needles
remaining in a bed or stretcher following use leading to an inadvertent

In surgery, flat needle magnets are often used and pose a greater risk for
injury when being disposed. The magnet can fold in on itself and the sharps
penetrate the pad.

Sharps' container buckets have designated fill lines and overfilling
frequently is an observable practice. Sharps' containers should be closed and
replaced when they are full as determined by the manufacturer's marker.

Recapping needles has been identified as a continual source of worker
exposure, and many of these injuries are considered preventable through use of
safer devices, procedures, and work practices.8

Gaining Compliance or Incurring Resistance

The comfort of PPE greatly affects staff willingness to be compliant.
"If a product is not comfortable, it is more difficult to get staff
compliance in using it. Convenience and ease of use also affect compliance and
need to be considered in evaluating PPE9."

Accessibility to PPE and safety devices to many nurses may mastermind
resistance. Unless the equipment and/or supplies are readily available to use,
the delay may cause poor decision making and will not facilitate best practice.
If additional steps or time is required to obtain a safety device, the mindset
easily becomes "this time, I will be careful."

Cost considerations of PPE should be weighed against patient safety,
personnel safety, user preferences, and the cost of OSHA fines if employees fail
to adhere to PPE use. In looking at the cost of PPE, it is important to remember
that the CDC recommends a performance-oriented standard.10 The task
and degree of exposure should determine characteristics for PPE.

In choosing protective eyewear, comfort, clear vision, accessibility,
individual preference, protection, and use with prescription glasses are all
critical to compliance with universal precautions. In addition to personal
eyewear, there can be standard face shields, side shields and safety glasses or
goggles accessible for general use.11

Seeking Better Outcomes

In healthcare , prevention and reduction of injury incidents are the keys to
successful outcomes. Manufacturer's are being forced to invent and produce
products that are not only used safely, but are safe for workers and patients.
Healthcare provider's, are investigating the processes and quality available to
improve outcomes. Changing practices does not always come easily.

The practice of double gloving has been promoted actively as a method for
reducing blood exposures to hands, especially among surgeons; the use of
puncture resistant gloves has been proposed as a method for reducing
percutaneous injuries to hands. The potential benefits of using puncture or
laceration resistant gloves or finger guards to prevent percutaneous injuries to
the hands should be assessed. The acceptance of this approach in the surgical
setting remains low because of the loss of tactile sensation and less than total
puncture resistance of most available barrier materials12.

Blunt suture needles have been designed to provide protection when suturing
specific tissue types like muscle and fascia13 This does not indicate
that a blunt needle is appropriate for all muscle or fascia or that it will be
used by all surgeons. Although this may be a good practice, there is resistance
to use by surgeons. If they have been in practice for an extended time and the
risk for injury has been small, the reluctance to switch will occur.

Masks need to be assessed for the fit on the face, comfort, filtration, the
type of procedure to be done, and the risk of exposure. There are many on the
market and from experience, the one most often worn is based on habit.
Exceptions to this may be when caring for patients with TB exposures or on laser
cases; these require modifications. Unconventional wearing of a face shield
upside down will not always a prevent splash exposure from penetrating to the

Gowns need to be evaluated and used according to which offers the best
strike-through protection. A variety of different gowns geared toward the
anticipated exposure possibility would be the ideal. The cost and inventory
stock is not practical. Hospitals must decide the types of gowns they will
provide the best practice for everyone. The use of shoe covers has changed to be
a protective device, used when the risk for exposure is potential. Higher boot
protective shoe cover wear is available for healthcare workers that are exposed
to bodily fluids and irrigation such as orthopedic and urological procedures.

Better outcomes for healthcare workers includes investigating the supplies
being used within a facility and identifying the safety devices available. The
issues of PPE are interdependent between infection control, employee health,
education and the unit level. Involvement in providing for the best practices in
PPE, should include participation of multidisciplinary team members to identify
the various root causes and the options for preventing or reducing incidents.
Consensus of an action plan would be the next step, followed by measuring the

Seeking better outcomes is done also by encouraging staff to develop a sense
of curiosity about the issues surrounding PPE. Begin by investigating online the
information available on PPE, needlestick injuries, exposures and other related
topics. Manufacturing companies provide information on line. OSHA's revision of
the Bloodborne Pathogen Compliance Directive is available on line as well as the
NIOSH manual for evaluating sharps disposal containers.


Concerns for safety of the patient and employees should remain a priority in
any situation. Human nature dictates that accidents happen. The lessons learned
in retrospective analysis usually determine whether the event could have been
prevented. Maintaining awareness during any procedure is essential. Identifying
personnel protective equipment will promote a best practice in any work area.
Determining root causes for injuries and using a continuous improvement model to
reduce incidents will continue to be researched.

Karen A. Huggins, MN, RN, CNOR, is a clinical specialist in the operating
room of Presbyterian Hospital of Dallas, Texas.

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