Using the Integrative Behavioural Model to explore the factors influencing nurse adherence towards personal protective equipment (PPE)

Abstract

BACKGROUND: Infectious disease has become an increasing field of interest due to the recent COVID-19 pandemic on a long-standing background of nosocomial infections, which have contributed to excess and largely avoidable morbidity and mortality, worldwide. In the hospital setting, the appropriate use of personal protective equipment is the mainstay of preventing the transmission or acquisition of nosocomial pathogens and yet, adherence among health professionals has been less than desirable. Suboptimal adherence to personal protective equipment remains a key issue within Saudi Arabia but there has been little understanding of the factors contributing to this problem. Therefore, this research addressed this gap through conducting a mixed-methods study that evaluated factors associated with nurses PPE use.

METHODS: A mixed-methods study design was used to develop and field a closed-ended survey is strongly influenced by the Integrated Behavioural Model (IBM). The (IBM) was used to elicit the psychological, behavioural, and contextual factors (e.g., attitudes, subjective norms, and perceived control) influencing nurses’ adherence to PPE guidelines. In keeping with the IBM, research was conducted in a phased approach: a convenience sample of nurses was obtained from two hospitals in the North of Saudi Arabia: 14 completed open-ended interviews (phase 1, qualitative elicitation phase) and in phase 2 (quantitative behavioural prediction phase), 279 nurses completed a self-report survey informed by the phase 1 data, using random sampling: the response rate was 96.5%. Data were gathered from August 2020 to April 2021.

RESULTS: Based on the themes identified through the qualitative content analysis, survey items were constructed for each construct (e.g., attitudes) using a 7-point bipolar scale. The final instrument demonstrated high internal consistency (Cronbach alpha of 0.92) and desirable test-retest reliability (intraclass coefficients mostly exceeding 0.80). For the direct measures of the independent variables, the mean scores for attitudes, subjective norms and perceived behavioural control were 5.7, 5.5 and 3.5, respectively, on the 7-point scale, indicating that nurses tended to hold positive attitudes, receive positive influence from others and perceptions of others’ judgements upon their intentions to adhere to PPE precautions. For the indirect measures, the mean scores for behavioural beliefs and outcome evaluation, control beliefs and power and normative beliefs were 6.0, 5.1 and 4.4, respectively. These findings also indicate that most nurses held favourable intentions to comply with PPE due to understanding of its importance in protecting patient safety but encounter numerous obstacles in adhering to PPE guidelines all the time. Multiple regression analyses showed that the overall model accounted for 62% of the variance in nurses’ intentions to comply with guidelines (R2= 0.62, p=0.000). Notably, the attitudes construct was the strongest predictor of nurses’ intentions to comply with guidelines(R2=0.58, p(R2=0.32, pduring the COVID-19 pandemic received influence from a broad range of factors; some acting as barriers to PPE adherence, whilst others encouraged said adherence. Nurses’ attitudes imparted the strongest influence over PPE adherence, taking precedence over the more practical and hierarchical influences of PPE access and usage.

IMPLICATIONS: This study provided the first insight into the varied factors influencing adherence to PPE among Saudi Arabian nurses. Key recommendations for ongoing practice include a need for ongoing and regular education and training to maintain nurses’ positive attitudes towards PPE adherence, recruiting and deploying infectious disease nurses to act as role models in infection prevention and control, introducing measures to mitigate nursing anxiety and fear of using equipment and establishing a means to evaluating infection rates. Overall, it is intended that this work will lead to meaningful improvements in nursing adherence to personal protective equipment and in turn, reduce adverse patient outcomes related to nosocomial infections.