BEHIND THE MASK: Determinants of Nurses’ Adherence to Recommended Use of Facial Protective Equipment to Prevent Occupational Transmission of Communicable Respiratory Illness in Acute Care Hospitals by Kathryn Anne Nichol A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Institute of Medical Science University of Toronto © Copyright by Kathryn Anne Nichol (2010) BEHIND THE MASK: Determinants of Nurses’ Adherence to Recommended Use of Facial Protective Equipment to Prevent Occupational Transmission of Communicable Respiratory Illness in Acute Care Hospitals Kathryn Anne Nichol Doctor of Philosophy Institute of Medical Science University of Toronto 2010 Abstract (max 350w) Background - Communicable respiratory illness is a serious occupational threat to healthcare workers. A key reason for occupational transmission is failure to implement appropriate barrier precautions. Facial protective equipment, including surgical masks, respirators and eye/face protection, is the least adhered to type of personal protective equipment used by healthcare workers, yet it is an important barrier precaution against communicable respiratory illness. Objectives - To describe nurses‘ adherence to recommended use of facial protective equipment and to identify the factors that influence adherence. Methods - A two-phased study was conducted. Phase 1 was a cross-sectional survey of nurses in selected units of six acute care hospitals in Toronto, Canada. Phase 2 was a direct observational study of critical care nurses. ii Results – Of the 1074 nurses who completed surveys (82% response rate), 44% reported adherence to recommended use of facial protective equipment. Multivariable analysis revealed four organizational predictors of adherence: ready availability of equipment, regular training and fit testing, organizational support for health and safety, and good communication. Following the survey, 112 observations in 14 intensive care units were conducted that showed a 44% competence rate with proper use of N95 respirators. Common gaps included failure to verify the seal and touching the face piece. Multivariable analysis revealed knowledge of recommended use of facial protective equipment as a significant predictor of competence. Discussion – Despite the SARS experience and the resulting investment in our public health system, nurses‘ adherence to recommended use of facial protective equipment and competence in effective use of N95 respirators remains suboptimal. To improve adherence, organizational leaders should focus on equipment availability, training and fit testing, organizational support for health and safety, and positive communication. To improve competence in effective use of N95 respirators, strategies to increase knowledge should be implemented. These efforts should assist to reduce occupational transmission of communicable respiratory illness and foster a healthier and safer working environment for nurses. (314 w) iii Acknowledgments I would like to acknowledge my supervisor – Dr. D. Linn Holness – for supporting and guiding me through this degree; my thesis committee – Dr. Allison McGeer, Dr. Phil Bigelow, Dr. Linda O‘Brien-Pallas and Dr. James Scott – for their time and expertise; my former employer - Ms. Joseline Sikorski at OSACH - for encouraging me to further my education and providing a flexible work schedule; my research assistant - Ms. Sarah Hayday - for her hard work and dedication to the project; the Centre for Research Expertise in Occupational Disease at St. Michael‘s Hospital and the University of Toronto and the Research Advisory Council of the Workplace Safety and Insurance Board for generous funding; and, of course, my family – Ian, Austin and Kristianne – for keeping life fun and well balanced along the way. ―People underestimate the importance of diligence as a virtue. No doubt this has something to do with how supremely mundane it seems. It is defined as ‗the constant and earnest effort to accomplish what is undertaken‘. There is a flavor of simplistic relentlessness to it, yet it is the only true prerequisite of great accomplishment.‖ Dr. Atul Gawande, from his book Better: A Surgeon’s Notes on Performance ―All diseases have two causes – one pathological, and one political.‖ Dr. Rudolph Virchow (1821 – 1902) ―Between the extremes of panic and complacency lies the solid ground of vigilance.‖ Dr. Margaret Chan, Director-General of the World Health Organization, July 2, 2009 iv Table of Contents Acknowledgments .......................................................................................................................... iv Table of Contents ............................................................................................................................ v List of Abbreviations ..................................................................................................................... ix List of Tables ................................................................................................................................. xi List of Figures .............................................................................................................................. xiii List of Appendices ....................................................................................................................... xiv 1 CHAPTER 1: Introduction ......................................................................................................... 1 1.1 Background to the Problem ................................................................................................ 1 1.2 Problem Statement .............................................................................................................. 2 1.3 Purpose ................................................................................................................................ 2 1.4 Hypothesis ........................................................................................................................... 2 1.5 Study Objectives ................................................................................................................. 3 1.5.1 Phase 1 – Cross-Sectional Survey ........................................................................... 3 1.5.2 Phase 2 – Direct Observational Study of Critical Care Nurses .............................. 4 2 CHAPTER 2: Literature Review .............................................................................................. 5 2.1 History of Standards for the Protection of Healthcare Workers from Occupational Transmission of Communicable Respiratory Illness .......................................................... 6 2.2 Healthcare Workers‘ Adherence to Infection Control Practices ....................................... 13 2.2.1 Critical Appraisal Methods ................................................................................... 13 2.2.2 Hand Hygiene ....................................................................................................... 14 2.2.3 Medical Gloves and Universal Precautions .......................................................... 14 2.2.4 Vaccination/Immunization .................................................................................... 15 2.2.5 Facial Protective Equipment ................................................................................. 16 v 2.3 Theoretical Models and Self-Protective Behaviours ........................................................ 19 2.3.1 Value-Expectancy Models .................................................................................... 19 2.3.2 Behaviour Change Models .................................................................................... 22 2.3.3 Environmental/Contextual Model: The PRECEDE Model .................................. 24 2.4 Safety Climate and Adherence .......................................................................................... 29 2.5 The Relationship between Worker Safety and Patient Safety .......................................... 30 2.5.1 History of Patient Safety in Canada ...................................................................... 31 2.5.2 Link between Patient and Worker Safety ............................................................. 32 2.5.3 Measuring Patient Safety Climate ........................................................................ 34 2.6 Synthesis of the Literature ................................................................................................ 35 2.7 Critical Review of Methods Chosen ................................................................................. 36 2.7.1 Studies Comparing Observed and Self-Reported Adherence ............................... 36 2.7.2 Intervention Studies .............................................................................................. 37 2.7.3 Observational Studies of Adherence ..................................................................... 38 2.7.4 Measuring Competence ........................................................................................ 38 2.8 Pilot Study ......................................................................................................................... 40 3 CHAPTER 3: Methods ........................................................................................................... 41 3.1 Study Design ..................................................................................................................... 41 3.2