|
 
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| ORIGINAL ARTICLE |
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| Year : 2014 | Volume
: 9
| Issue : 1 | Page : 6-14 |
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Assessment of compliance to standard precautions among surgeons in Zagazig University Hospitals, Egypt, using the Health Belief Model
Eman M Mortada1, Marwa M Zalat2
1 Department of Community Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt
2 Department of Occupational and Environmental Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| Date of Submission | 06-Nov-2013 |
| Date of Acceptance | 30-Dec-2013 |
| Date of Web Publication | 22-Jul-2014 |
Correspondence Address:
Eman M Mortada
Department of Community Medicine, Faculty of Medicine, Zagazig University, Zagazig
Egypt
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/1687-4293.137319
Background/aim
Although it is recommended that healthcare professionals should comply with the standard precautions to prevent acquiring blood-borne diseases (AIDS, hepatitis B and C), yet, they frequently do not comply with this recommendation. Understanding the reasons for compliance and noncompliance will help in designing educational programs for hospital staff and in determining a strategy for improving health behavior. The present study aimed to assess surgeons' compliance to standard precautions and determine surgeons' perceived beliefs affecting their compliance using the Health Belief Model.
Participants and methods
A cross-sectional study was carried out at surgical departments in Zagazig University Hospitals from December 2012 to May 2013. A questionnaire on various aspects of infection control and standard precautions practices was provided to 307 surgeons, with a response rate of 70%.
Results
Our findings indicated that 57.5% of the surgeons sampled in Zagazig University Hospitals were compliant with standard precautions. 59.8% of compliant surgeons had been exposed to at least one needle-stick injury in the previous 3 months, whereas slightly less than half of compliant surgeons (48.4%) had been exposed to splashes, with a highly significant difference compared with nonexposed surgeons. All Health Belief Model subscales were correlated directly with the surgeons' compliance, except perceived barriers.
Conclusion
There is adequate compliance with standard precautions among surgeons in Zagazig University Hospitals, especially female surgeons, with a high level of knowledge among compliant compared with noncompliant surgeons. All Health Belief Model subscales were correlated directly with the surgeons' compliance, except perceived barriers. Adequate training of surgeons, provision of infection prevention equipment, regular reporting, follow-up, and assessment of occupational exposures need to be introduced. Keywords: compliance and standard precautions, Health Belief Model, surgeons
How to cite this article:
Mortada EM, Zalat MM. Assessment of compliance to standard precautions among surgeons in Zagazig University Hospitals, Egypt, using the Health Belief Model. J Arab Soc Med Res 2014;9:6-14 |
How to cite this URL:
Mortada EM, Zalat MM. Assessment of compliance to standard precautions among surgeons in Zagazig University Hospitals, Egypt, using the Health Belief Model. J Arab Soc Med Res [serial online] 2014 [cited 2023 Mar 20];9:6-14. Available from: http://www.new.asmr.eg.net/text.asp?2014/9/1/6/137319 |
| Introduction | |  |
Healthcare workers (HCWs) are at an increased risk of occupationally acquired infections transmitted from both blood-borne pathogens (BBP), such as hepatitis B and C and HIV. Exposure to blood and body fluids is a major concern for HCWs; surgeons are especially at an increased risk of exposure to these pathogens during surgical procedures. Surgeons have been shown to have a four-fold to eight-fold higher incidence of exposure to patients' blood compared with internists [1]. Exposure can occur through a percutaneous injury and/or mucosa exposure (needle-stick or other sharps injury), a mucocutaneous occasion (splash of blood and body fluids into the eyes, nose, or mouth), or blood contact with damaged skin [2,3], and presents a major risk for the transmission of BBPs such as HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV). The highly significant predictors for compliance of surgeons were training on standard precautions, knowledge level, perceived severity, perceived barrier, and perceived cues to action [4].
'Standard precautions' aim to prevent the transmission of BBPs. The objective is to assume that patients are infected with BBPs, and ensuring that health staff minimizes the risk of exposure to infected body fluids [5]. The proper and consistent use of personal protective equipment (PPE) during operative/invasive procedures by members of surgical teams reduces the risk of acquiring blood-borne disease. Studies worldwide have shown that despite training on universal precautions, availability of PPE, and effective organizational safety climate, some surgical team members choose not to comply with regulations and recommendations related to exposure to pathogens. Compliance is the extent to which certain behavior (e.g. following a physician's orders or implementing healthier lifestyles) is in accordance with the physicians' instructions or healthcare advice. To explain and understand the factors that influence an individual's compliance, which may consequently contribute toward the adoption of certain behavior, the most commonly used model is the Health Belief Model (HBM) [6,7]. HBM was originally developed by a group of psychologists in the 1950s; the model offers the ability to understand the different behaviors or attitudes that individuals may develop. It has been used widely and is considered one of the most useful models in healthcare prevention and promotion [8]. Finding the reasons for compliance and noncompliance with reporting needle-stick injuries (NSIs) will help in designing educational programs for hospital staff and in determining a strategy for improving health behavior [9].
According to the HBM, individuals are ready to take action if they believe that they are susceptible to a disease (perceived susceptibility), believe that a condition has serious consequences (perceived severity), believe that taking action will reduce their susceptibility to the condition (perceived benefits), understand that the costs of taking action (perceived barriers) are outweighed by the benefits, are exposed to factors that prompt action (cue to action), and are confident in their ability to perform that action successfully (self-efficacy). The model is based on the understanding that an individual will engage in a health-related action if the individual:
(a) Believes that he or she can avoid a negative health condition (i.e. exposure to BBPs),
(b) Has a positive expectation that he or she will avoid a negative health condition by taking a recommended action (i.e. wearing PPE to avoid exposure), and
(c) Believes that he or she can successfully take a recommended health action [10].
The aim of this study was to provide the foundation for planning a program for prevention of BBPs among surgeons.
| Objectives | | |
The objectives of the study were as follows:
(1) Assess the surgeons' compliance with standard precautions.
(2) Determine the surgeons' perceived beliefs affecting their compliance using the HBM.
| Participants and methods | | |
Study design and setting
To fulfill our objectives, a cross-sectional study was carried out at surgical departments in Zagazig University Hospitals during the period from December 2012 to May 2013.
Target population and sampling
Surgeons in different surgical departments and surgical subspecialties were selected because they have the highest rates of exposure and are at an increased risk of exposure to HBV, HCV, and HIV while performing operative or invasive procedures. There are eight surgical departments; from these, only four departments were chosen randomly (general surgery, orthopedic, urology, and obstetrical and gynecologic departments). The target population for the study included all surgeons in the randomly chosen departments (n = 410). In total, 307 questionnaires were completed by consenting clinicians who agreed to participate in the study. After excluding incompletely filled questionnaires from the final analysis, only 287 were included in final analysis, yielding a 70.0% response rate (287/410).
Instrument used for data collection
A questionnaire [11,12] on various aspects of infection control and standard precaution practices was devised and modified after being tested on a sample of 25 surgeons to determine the acceptability and clarity of the questionnaire and to confirm its face validity. The internal consistency of each subscale was measured by Cronbach's α and it ranged from acceptable to desire. The final version included the following three parts:
Personal and job-related variables
Personal and job-related variables included sex, age, surgical specialty, recent qualification, years of experience in practice, and whether they had received training related to infection control and standard precautions. Also, questions addressed the history of HBV vaccination, including number of doses, and postvaccine serologic testing. In addition, the questionnaire specifically asked participants about exposures to sharps injuries, and splash of blood and body fluids during the previous 3 months. This 3-month time period was used to minimize recall bias.
Questions to assess compliance with standard precautions (desired behavior)
Compliance with standard precautions was determined using the modified standard precautions questionnaires. The items measured how often these surgeons followed specific recommended work practices, such as use of protective barriers as (gloves, gowns, masks, and goggles), disposal of sharps, and needles. Response options included 'never', 'rarely', 'sometimes', 'often', and 'always' on a five-point Likert scale ranging from 1 to 5. In addition, three other questions assessed vaccination status. We also asked questions related to the reasons for noncompliance with standard precautions. Then, we classified the results of the scoring and the respondents were divided into two groups for the purpose of analysis using median as a cutoff point (less than median as noncompliant and more than median as compliant).
Health belief questionnaire
A health belief questionnaire included questions to assess:
(a) Knowledge of disease transmission and standard precautions (12 items): A correct answer was assigned a score of 1, whereas an incorrect answer was assigned a score of 0. The mean knowledge score was computed by adding the number of correct answers.
(b) Perceived susceptibility of infection and acquiring BBPs (one item) and perceived severity of consequences of exposure to blood and body fluids (one item). The response to perceived susceptibility and severity was on a scale of 1 (being none) to 5 (being very high).
(c) Perceived benefits of standard precautions (one item): 'to what extent do you believe that standard precautions practices protect against blood borne infections?'(very low = 1 to very high = 4).
(d) Perceived barriers to practice of standard precautions (seven items) (yes = 1, no = 0). (e) Cue to action (five items) that motivates action to be taken (yes = 1, no = 0).
(e) Perceived self-efficiency (one item) 'are you confident in your ability to successfully practice safe standard precautions at your workplace?' (not confident = 0, completely confident = 2).
Ethical consideration
Ethical permission to carry out the study was obtained from the hospital director before data collection. Participation in the study was voluntary and informed verbal consent was obtained before data collection. The questionnaires were strictly confidential and anonymous and each questionnaire was numerically coded.
Statistical analysis
Data were analyzed using the statistical package for the social sciences (SPSS, version 19.0; SPSS Inc., Chicago, Illinois, USA) for Windows. Descriptive statistics such as frequency, percent, mean, and SD were determined. Analytical statistical tests such as χ2 , analysis of variance, independent t-test, Mann-Whitney, and Kruskal-Wallis tests were used to compare continuous variables. Pearson's correlation coefficient was calculated to determine the associations between surgeons' compliance and HBM subscales. Logistic regression was used to assess predictors of compliance; the threshold of statistical significance was set at P value less than 0.05 (two-tailed).
| Results | | |
Of the 410 surgeons selected, 287 (70%) were included in the final analysis. [Figure 1] shows the distribution of sampled surgeons according to their specialties; 37.9% were general surgeons, 31.4% were gynecologists and obstetricians, 18.1% were urologists, and 12.6% were working in the orthopedic department. Analysis of data showed that 57.5% of the sampled surgeons in Zagazig University Hospitals were compliant with standard precautions [Figure 2]. The mean score of compliance among surgeons was 72.9 ± 7.3. The mean score of overall knowledge level was 14.3 ± 3.5. The Cronbach's α for internal consistency of knowledge items was 0.79 [Table 1]. | Figure 1: Distribution of the studied sample according to surgical special ty.
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 | Table 1 Mean, SD, and Cronbach's ¦Á for the Health Belief Model subscale
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[Table 2] shows the relationship between the demographic characteristics of the surgeons at risk of blood-borne occupational exposures and their compliance with the standard precautions. It was found that 54.9% of female surgeons were highly compliant with standard precautions. Of the compliant surgeons, 46.7% were 35-44 years old and 42.6% worked in the general surgery department; 39.3% of highly compliant surgeons were lecturers in Zagazig University Hospitals and 55.7% had spent 10 or more years in their current occupation. Forty-nine (40.2%) surgeons who had received infection control training were highly significantly compliant with standard precautions (P = 0.000). More than half of the compliant surgeons (59.8%) had been exposed to at least one NSI in the previous 3 months, whereas around half of the compliant surgeons (48.4%) had been exposed to splashes with a highly significant difference compared with nonexposed surgeons. | Table 2 Personal and occupational characteristics of the studied sample according to their compliance with the standard
precautions (n = 287)
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On analyzing the reasons for noncompliance with the standard precautions among surgeons, it was found that improper training had the most cumulative percentage, as shown in the Pareto chart in [Figure 3]. On comparing the knowledge and beliefs scores of compliant and noncompliant surgeons, there were highly significant mean scores of awareness, perceived severity, and perceived barriers among compliant than among noncompliant surgeons [Table 3].
In terms of the relationship between subscales of HBM and personal characteristics of the sampled surgeons, it was found that there were significantly perceived benefits among male than female surgeons. Moreover, perceived self-efficacy and cues to action were also significant among surgeons younger than 35 years old. Perceived barriers and perceived self-efficacy were highly significant among gynecologists and urologists than other surgeons. Highly significant cues to action were found among residents than those with other job titles. Significantly perceived susceptibility was found among surgeons with less than 10 years' work experience. Significantly higher perceived susceptibility, perceived self-efficacy, and cues to action were found among surgeons who had received infection control training than those who had not. Perceived susceptibility, perceived severity, perceived barriers, and cues to action were significantly higher among surgeons exposed to NSI compared with nonexposed surgeons, whereas only perceived barriers, perceived self-efficacy were significantly higher among surgeons exposed to splashes [Table 4]. | Figure 3: Pareto chart showing the reasons for noncompliance. PPE, personal
protective equipme nt.
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 | Table 3 Comparison of knowledge and beliefs scores among compliant and noncompliant surgeons
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 | Table 4 Relationship between subscales of Health Belief Model and personal characteristics of the sampled surgeons
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[Table 5] shows the correlation between surgeons' compliance and HBM subscales. It is well evident that all HBM subscales were correlated directly with the surgeons' compliance, except perceived barriers. Knowledge of standard precautions, perceived susceptibility, and perceived severity was significantly correlated with compliance. | Table 5 Correlation between surgeons' compliance and Health Belief Model subscales
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| Discussion | | |
To our knowledge, this is the first research study carried out in Zagazig University Hospitals among a group of surgeons investigating the issue of compliance with standard precautions to avoid occupational exposure to BBPs. The HBM has been used previously as a theoretical framework in many studies, and has been successful in explaining a variety of human behaviors and attitudes, including compliance with universal precautions, the previous version of standard precautions. Therefore, the use of the HBM as a sound and useful theory improves the internal validity of this study and enables comparisons among similar studies. This study examined surgeons' compliance with standard precautions and determined surgeons' perceived beliefs affecting their compliance to avoid occupational exposure to BBPs. Using the HBM as a theoretical framework, this study focused on the factors that affect compliance either negatively (barriers), leading to noncompliance, or positively, leading to compliance.
'Standard precautions' is a system of barrier precautions to be used by all personnel for contact with blood, all body fluids, secretions, excretions, nonintact skin, and mucous membranes. It applies to all patients receiving care in hospitals, irrespective of their diagnosis or presumed infection status [13]. Although this study supports previous studies in reporting a less than 100% compliance rate with standard precautions, a trend toward improved compliance is evident. The level of compliance in this study is similar to a finding from Alexandria Teaching Hospitals (57.5, 46.3%, respectively) [11] and higher than the report from the UAE (19%) [14], but lower than the finding in Ethiopia (80.8%) [15]. The rate of use of standard precautions in teaching hospitals in developed countries is considerably higher than that in our hospitals [16,17]. In addition, a previous study among medical doctors working in a tertiary care hospital in Pakistan reported that compliance with hand washing was 86%, that for wearing gloves was 79% and masks 46%, and 45% for the use of gowns/plastic aprons. Partial compliance and suboptimal practices were also reported in other countries such as Nigeria [18], India [2], and the UK [19], where HCWs make unjustified assessments of risks from and infection status of clients rather than properly and consistently applying standard precautions. However, there are sometimes high rates of noncompliance among HCWs and this may be because of a lack of understanding among HCWs of proper use of protective barriers. Furthermore, noncompliance among medical doctors and nurses is associated with insufficient knowledge, work place safety, forgetfulness, and workload [20,21].
Among the demographic characteristics, only sex show a significant difference, where women were highly compliant with standard precautions. Of compliant surgeons, 46.7% were 35-44 years old, 42.6% worked in the general surgery department, and 55.7% had spent 10 or more years in their current occupation, which differed from a previous finding that reported a higher level of noncompliance among older HCWs; this can be attributed to the fact that years of experience and tradition may result in resistance to changing their behavior. We found that 47% of the surgeons questioned had sustained at least one NSI in the past 3 months preceding the study. A higher prevalence of NSI was reported among HCWs of University of Alexandria Hospitals and Malaysian Teaching Hospitals (67.9 and 52.9%, respectively) [11,22]. However, in Vietnam, 38% of physicians reported sustaining a sharp stick injury in the previous 9 months [23]. Much lower finding of 1-year prevalence of NSI was obtained in a report from the UAE by Jacob et al. [14], in which 19% of HCWs faced injury, but lower than a finding in northern Ethiopia [15], in which a 3-month prevalence of 17.2% was reported.
The variation in this prevalence may be related to the different categories of HCWs involved in these studies. Physicians mostly do not administer injections and hence their risk of injury exposure is lower than that of nurses. Housekeepers clean and collect waste without protective equipment and hence are at a high risk of exposure to injury. Accurate information on the risk of blood-borne transmission from occupational exposure to needle sticks is necessary and should include information on the most effective measures to control exposure and infection.
In agreement with another study among HCW in Ethiopia [24], our study detected a high level of self-reported exposure to blood and body fluids (61.3%) that was significantly different among noncompliant compared with compliant surgeons.
Training and education have been found to be of paramount importance in developing awareness among HCWs as well as improving adherence to good clinical practice [25,26]. The level of training in terms of standard precautions of the current participants (57.8%) is higher than a finding obtained in a study carried out in India [2], in which 36% HCWs had received training. Unfortunately, receiving training was not found to be protective from occupational exposures such as NSI and exposure to splashes of blood and body fluid. This will be a major challenge to infection prevention efforts. This is similar to previous reports [27-29] in which training to HCWs does not necessarily seem to lead to protection from exposures. The reason for this may be that the knowledge acquired may not necessarily translate into practice of preventive measures or that the training provided may be more theoretical than practical, and the limited sources of continuous information on standard precautions. The lack of an enabling environment to comply with standard precautions may have also contributed toward poor compliance in these studies.
Ideally, HCWs are expected to have a good understanding of the risk of BBPs at the work place and of the preventive measures for reducing risk. Also, this study found that their knowledge was adequate as the mean score of the overall knowledge level of the surgeons was high (14.3 ± 3.5) compared with that (3.8 ± 2.3) in a previous study at first care facilities in Pakistan [10], and slightly high among compliant than noncompliant surgeons, which indicated that the consistent use of universal precautions can prevent major exposure to BBPs. Similarly, previous studies in the university hospital of the West Indies and in Thailand reported high knowledge of universal precautions among medical doctors [30]. The lower level of knowledge can be attributed to the incorporation of occupational safety, lack of investment in staff training, or limited understanding of HCWs' safe behavior in the clinical setting [31,32]. The differences in the knowledge of universal precautions among HCWs may be influenced by their different types of training. Also, there could be methodological differences in the assessment of knowledge levels in different studies. In addition, HCWs commonly overestimate their knowledge and practices of infection prevention [2,33], the magnitude of which is methodologically difficult to estimate. Providing a regular and systematic educational program may improve knowledge among HCWs.
This study partially supports the findings of an earlier study that showed that constructs of the HBM are appropriate to identify attitudes of HCWs in terms of standard precautions [34]. Barriers to compliance have been reported extensively in previous studies. Some of these include lack of time (71-74%), perceived 'low risk' of patient (50-57%), PPE interfering with care (55%), and PPE not available (19.3-41%) [35]. This study shows that all HBM subscales were correlated directly with the surgeons' compliance, except perceived barriers. However, previous studies [35] have concluded that a correlation exists between barriers and compliance. In addition, perceptions of risk, severity, and benefits also exert an influence on compliance as reported by a previous study among operating room nurses in Australia [36]. It is clear from the data analysis and discussion that measures must be implemented to increase surgeons' compliance with standard precautions. Standard precautions are guidelines developed to protect the HCW from occupational exposure.
The commonly recommended preventive strategies for increasing conformity with standard precautions include education, awareness campaigns, use of risk-reducing devises such as single-use needles, reduction of unnecessary injections, legislative action, provision of PPE, introduction of safety guidelines and reporting mechanisms, and creating a compliance-enabling environment [37,38]. The involvement of HCWs in infection control decisions is considered important [39]. The best way to enable the staff to comply with written policies is to allow the staff to develop the policy. The more the input that staff members provide into policies on the unit, the more likely they are to comply with standard precautions [40].
Noncompliance is determined by a range of factors including lack of knowledge [17], interference with work skills [33], risk perception, conflict of interest [17,33], not wanting to offend patients [39], lack of equipment and time, uncomfortable PPE [33], inconvenience, work stress [20], and perceiving a weak organizational commitment to safety climate [20,21]. In our study, analysis of findings from the Pareto chart guided us on how to solve the 80% noncompliance problem by providing PPE to the surgeons, training courses for the surgeons, and increasing their information about MOHP guidelines. Similarly, another study carried out at first-level care facilities in Pakistan [10] reported that lack of knowledge, poor qualifications, absence of a system for prevention of BBPs and lack of training, equipment, and postexposure prophylaxis are major determinants for noncompliance. The differences in compliance between studies may be attributed to the differences in infection control polices mandated by each hospital or facility. The BBP prevention system is present in few tertiary care hospitals and none of the first-level care facilities. First-level care facilities in the private sector are completely different from hospitals because of their size, organization, manpower qualifications and training, and available finances. All these factors influence the BBP prevention program at these facilities and raise important pragmatic and ethical questions.
As this is a cross-sectional study, the limitations that come with this type of design need to be taken into consideration when interpreting the findings. There was fewer than expected participation by surgeons as most of the time, they were busy at the clinics or operating rooms, which introduces a possibility of selections bias. Reporting of practices has been known to be affected by social desirability toward better practices.
In conclusion, this study showed that there is adequate compliance with standard precautions among surgeons in Zagazig University Hospitals, especially female surgeons. Knowledge of the mode of transmission of BBPs and precautions was high among compliant than noncompliant surgeons. All HBM subscales were correlated directly with the surgeons' compliance, except perceived barriers. Therefore, it is necessary to determine more factors that influence compliance (positively and negatively) and develop plans to eliminate those that do not allow the implementation of standard precautions and promote those that do. Our findings suggest that training of surgeons to increase their knowledge of BBPs and universal precautions could improve their use of universal precautions. Health authorities in the study area need to improve the training of HCWs and provision of infection prevention equipment. In addition, regular reporting, follow-up, and assessment of occupational exposures need to be introduced.
[TAG:2]Acknowledgements[/TAG:2]
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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Assessment of perceived risk and precautionary behavior toward COVID-19 pandemic using the health belief model, Saudi Arabia |
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| Eman M. Mortada, Ghada Moh Samir Elhessewi | | Journal of the Egyptian Public Health Association. 2022; 97(1) | | [Pubmed] | [DOI] | | | 2 |
Compliance of healthcare workers to the proper use of personal protective equipment during the first wave of COVID-19 pandemic |
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| Rehab H. El-Sokkary,Walaa S. Khater,Amani El-Kholy,Sally Mohy Eldin,Doaa M. Gad,Shereen Bahgat,Essam E.M. Negm,Jehan A. El Kholy,Sherif Mowafy,Eman Mahmoud,Eman M. Mortada | | Journal of Infection and Public Health. 2021; | | [Pubmed] | [DOI] | | | 3 |
Knowledge, Attitudes and Practices related to standard precautions among nurses: A comparative study |
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| Siyue Zhu,Kibrom Mehari Kahsay,Li Gui | | Journal of Clinical Nursing. 2019; | | [Pubmed] | [DOI] | | | 4 |
Standard precaution practice and associated factors among health professionals working in Addis Ababa government hospitals, Ethiopia: a cross-sectional study using multilevel analysis |
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| Dessie Abebaw Angaw,Lemma Derseh Gezie,Berihun Assefa Dachew | | BMJ Open. 2019; 9(10): e030784 | | [Pubmed] | [DOI] | | | 5 |
Training Needs of Extension Agents’ Regarding Organic Agriculture in Saudi Arabia |
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| Bader M. Alotaibi,Edgar P. Yoder,Mark A. Brennan,Hazem S. Kassem | | Evaluation and Program Planning. 2019; : 101711 | | [Pubmed] | [DOI] | | | 6 |
Prediction of Preventive Behaviors of the Needlestick Injuries during Surgery among Operating Room Personnel: Application of the Health Belief Model |
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| Yadollah Fathi,Majid Barati,Mitra Zandiyeh,Saeed Bashirian | | The International Journal of Occupational and Environmental Medicine. 2017; 8(4): 232 | | [Pubmed] | [DOI] | | | 7 |
FACTORS AFFECTING THE COMPLIANCE OF MYANMAR NURSES IN PERFORMING STANDARD PRECAUTION |
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| Sa Sa Aung,Nursalam Nursalam,Yulis Setiya Dewi | | Jurnal Ners. 2017; 12(1): 1 | | [Pubmed] | [DOI] | | | 8 |
Factors influencing nurse compliance with Standard Precautions |
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| Donna Powers,Donna Armellino,Mary Dolansky,Joyce Fitzpatrick | | American Journal of Infection Control. 2016; 44(1): 4 | | [Pubmed] | [DOI] | |
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