http://doi.org/10.33698/NRF0075 – Rajinder K, Indarjit Walia, Baljit Kaurb
Abstract : Universal precautions are safety norms for the health personnel against the infections that are being carried by the patients they handle. All the health workers must follow these in order to keep themselves uninfected from various infectious diseases. Taking this into concern whether the presently employed health staff is aware of the universal precautions or not, the present study was conducted in the Government Multi-Specialty Hospital Sector 16 Chandigarh in the months of December 2006 and January, 2007. Total number of subjects who responded was 150. The mean age of respondents was calculated to be 37.7 years. Out of the total, 89% were staff nurses. The needle prick injury during last six months was reported by 16(10.66%) respondents. Those who got 60-80% marks in knowledge score were 40.67% of the total and only 4.66% of them scored 80-100% marks. In the practice score 38.7% of subjects reported the universal precautions to be time consuming whereas 26% of them did not take it as time consuming while at the same time 21.3% of the total subjects did not attempt the question.
Key words :
Universal Precautions, Knowledge, Practice.
Correspondence at :
Rajinder K
School of Nursing General Hosptial (Multispeciality) Sector 16, Chandigarh.
Introduction
The practice represents an effort to make human’s laws approximate the laws of nature and when nature’s laws are not well understood, human’s rule are likely to be more or less irrational and their observance vacillating and ritualistic.1 The role of rituals in the isolation practices used to prevent transmission of infectious organism since the contagious nature of some diseases was organized. Well designed studies to evaluate specific element of infection prevention practices have been performed only recently. Some infection prevention practices are valuable but inadequately used. For example, when patient leaves the hospital with open wounds, dressing or indwelling drains or devices, the staff may not instruct family members to use aseptic technique. Thus the patient is at risk for acquiring new organism at the site. Universal precautions are intended to modify the physical environment and affect the social and microbiological environment for the benefit of potential hosts and care giver.2
Health care workers are at risk of acquiring nosocomial infections, most commonly due to staphylococci, streptococci, mycobacterium, herpes simplex and rubella. In addition since 1980s with the emergence of human immunodeficiency virus (HIV) and hepatitis B virus (HBV), the occupational transmission of these diseases concerns health care providers through out the world.3 The risk of health care worker of acquiring HIV infection during the course of health care delivery is possible, though unlikely. The most common way in which health care workers are exposed to HIV is through accidental exposure to sharp objects. The risk is primarily related to percutaneous (sharp injury) exposure like needle stick injury which has been reported to be less than 0.5%. The HIV can not enter the body through intact skin but can do so through intact mucous membrane.4
Universal precautions mean taking routine safe working practices to protect staff and patients from infections by blood and body fluids. These involve the use of protective barriers such as gown, gloves, aprons, masks or protective eye wear which can reduce the risk of exposal of the health care workers’ skin or mucus membrane to potentially infective materials. In addition it is recommended that all health care workers take precautions to prevent injuries caused by needles, scalpels and other sharp instruments or devices. Used needles should not be recapped by hand and puncture resistant containers are to be used for disposal of sharp objects.5
One infection control researcher described gloves as the most wonderful invention! You can choose a sterile or clean layer of skin that can be peeled off and reapplied.2
Table 1: Occupational Health and Safety Administration (OSHA) requirements for personal protective apparel to minimize exposure to blood borne pathogens.
| Equipment | Indications for use | Must be: |
| ¨ When contact with infectious material is likely Sterile Surgical Procedures | ¨ Suitable for task: General Patient Care, | |
| ¨ During all vascular procedures | ¨ Individualized: Various sizes,Hypoallergenic, powder less | |
| Gloves | ¨ Before contact with |
mucous membranes and non intact skins Clothing (Gowns, When splattering of Suitable for task: Prevent , Aprons, Shoe covers, clothing with body blood, infectious materials Hats, Hoods) substances is likely from penetrating treaching employee’s skin or clothes Facial protection When splattering, splashing ¨ Effective: in preventing (Masks, Face shields, or spraying of eyes, nose infectious material from Eyewear including or mouth with blood or other penetrating around barriers glasses with side potentially infectious body or under
Source: – Occupational Safety and Health Administration: Federal Register 56:64003-64182, 1992 shields, goggles) substances is likely
In April 1993 a study on the knowledge, compliance and attitudes of doctors and nurses on “universal precautions” was done in Thailand. Questionnaires were sent to doctors and nurses working in government hospitals; 468 doctors and 4539 nurses responded. 94.9% of physicians and 85.5% of nurses were knowledgeable of universal precautions, but only 47.1% of the doctors and 27.9% of nurses reported that they would take precautions with all patients.
The rest would apply universal precautions with patients known to be infected with HIV. 71.9% of doctors and 81.6% of nurses knew that ‘sharp injuries’ is the main cause of HIV transmission to health care personnel. Only 75% of doctors and 47% of nurses washed their hands after caring for patients, and 16% of doctors and 50% of nurses rubbed their hands with alcohol after washing them with an antiseptic.8
A study was conducted on universal precautions’ practice among staff nurses in 2002 in Nehru Hospital PGIMER Chandigarh. Mean compliance with hand washing was 7.42%, which was poor. Compliance with wearing gloves was also poor (14.97%). Mean compliance with wearing gloves was 80.95%. Compliance with safe disposal of sharps was poor i.e. 7%. Seventy eight percent subjects had attained excellent knowledge score and 22% attained good knowledge score.9
A study aimed at assessing the observance of universal precautions by HCWs in Abeokuta, Ogun State, Nigeria was conducted in May 2006. There were 433 respondents, 211 (48.7%) of which were trained nurses. About a third of all respondents always recapped used needles. Compliance with no recapping of used needles was highest among trained nurses and worst with doctors. Less than two-thirds of respondents (63.8%) always used personal protective equipment, and more than half of all respondents (56.5%) had never worn goggles during deliveries and at surgeries. The provision of sharps containers and screening of transfused blood by the institutions studied was uniformly high. A high percentage (94.6%) of HCWs observed hand washing after handling patients. The use of barrier equipment was variable in the institutions studied.10 A study was undertaken, involving 266 HCWs (response rate, 87%) from 7 rural north Indian health care settings. Information was gathered regarding compliance with UPs and a range of other relevant variables that potentially influence compliance (e.g., demographic information, perception of risk, knowledge of blood borne pathogen transmission, perception of safety climate, and barriers to safe practice). The study revealed that knowledge and understanding of UPs were par tial, and UPs compliance was suboptimal, e.g., only 32% wore eye protection when indicated, and 40% recapped needles at least sometimes. After controlling for confounding, compliance with UPs was associated with being in the job for a longer period, knowledge of blood borne pathogen transmission, perceiving fewer barriers to safe practice and a strong commitment to workplace safety climate.11
Objectives
Main objective of the study was to assess the knowledge and practice of nursing personnel regarding universal precautions in Government Multi-Specialty Hospital Sector 16 Chandigarh.
Materials and Methods
The study was conducted in the Government Multi-Specialty Hospital, Sector 16, Chandigarh. This hospital has a strength of 500 beds. It has an emergency unit which is combined with Critical Care Unit, AIDS Cell, 20 indoor wards/ departments and 10 out- patient departments. The hospital has one dialysis unit and four major operation theaters i.e. eye OT, general OT, trauma OT and Gynae
- Also, there are three minor operation theaters. This hospital has a school of nursing also. A total of 197 nursing personnel work in the hospital, out of which 160 are staff nurses, 25 are nursing sisters, 5 nursing tutors, 2 ANMs, 3 MPHWs, one assistant matron and one nursing superintendent. Permission to conduct a study was taken from Director of Health Services, UT Chandigarh. The tools to collect data were validated by the experts. The purposive sampling technique was followed and all the Nursing Personnel were taken for the purpose. The tools used for data collection were Interview schedule for data identification which included 9 questions, Structured Questionnaire for assessing the knowledge regarding universal precautions which included 15 questions and structured questionnaire for assessing the practice and attitude regarding universal precautions that contained 25 questions. Data was collected during the months of December and January. The data collection tools were distributed amongst all the 197 nursing personnel but only 150 responded.
Results
Table 2 shows the socio demographic characteristics of the respondents. These characteristics include the data regarding age, sex and educational qualification of the respondents. The range of the age of respondents varies between 21 to 58 years, which is due to the fact that the eligibility for joining the service is 21 years and the retirement age i.e. 58 years. The mean age for the subjects was 37.07 years with a standard deviation of ±11.275. Almost 36.67% of the subjects were found to be of the age group of 20-30 years. The age groups of 30-40 and 40 to 50 accounted for 23.33 and 26% respectively. And those who were above 50 years of age made 14% of the total.
There is no need to explain that the number of female subjects outnumbered the male ones as the profession of nursing ‘by conventions’ is mainly thought to be for females. Out of the total, 98% subjects were females and only 2% were males. But the scenario is fast changing now with the advent of male students in various nursing colleges because Nursing Care is widely seen as a lucrative job and business now.
The third characteristic taken was educational qualification of the subjects. A whopping number of subjects i.e. 78.67% had the matriculation and senior secondary certificates. Graduates accounted for 17.34% of the total while only 4% of them had done a post graduate degree in academics.
Table 2 : Socio Demographic Characteristics of the Respondent N = 150 Characteristics f (%)
Sex
Age of Respondent (in Years)
Females 147 (98.00)
Males 3 ( 2.00)
Academic Education
| Matriculation & Senior Secondary | 118 (78.67) |
| Graduation | 26 (17.34) |
| Post Graduation | 6 ( 4.00) |
Different Nursing Personnel Working in the Hospital
Table 3 describes the professional qualification and present designations of the subjects. Almost 89% of the subjects had done GNM. Five of them were MPHW and 8% of them were B. Sc. Nursing but none was a post graduate. Later part of the table shows more or less the hierarchy of nursing staff with the exception of nursing tutors who come under the principal of school of nursing. There were two administrators. Nursing sisters accounted for 12% of the total subjects. Staff nurses constituted nearly 82% of subjects. Not to mention that staff nurses are subordinates of nursing sisters. Also there were 5 MPHWs.
Table – 3 : Distribution of the Respondents According to Professional Qualification
N = 150
| Professional Qualification | f (%) |
| MPHW | 5 ( 3.33) |
| GNM | 133 ( 88.67) |
| B. Sc. Nursing | 12 ( 8.00) |
| Present Designation | |
| Administrators | 2 ( 1.33) |
| Nursing Tutor | 3 ( 2.00) |
| Nursing Sister | 18 (12.00) |
| Staff Nurse | 122 (81.34) |
| MPHW | 5 ( 3.33) |
Professional Experience of Different Nursing Personnel
Table 4 describes the professional experience of the subjects and it also shows the areas where the respondents had worked. About 32% of subjects had an experience of about 5 years. Those with an experience of 6-14 years accounted for 18.67%. While, the senior staff with the professional experience of more than 15 years accounted for nearly 50%.
When classified in terms of the areas where worked, the subjects were found to have worked mostly in medicine, surgery, emergency, pediatrics and obstetrics. These were the areas where most of the subjects had worked. Those, who had an experience of working in the Operation Theater, accounted for 27.33% of the total subjects.
Table – 4 : Distribution of the Respondents According to Professional Experience
N = 150
| Professional Experience (in Years) | f (%) |
| < 5 | 48 ( 32.00) |
| 6 – 14 | 28 ( 18.67) |
| 15 – 25 | 74 ( 49.33) |
| Areas Where Worked * | |
| Medicine | 71 ( 47.33) |
| Surgery | 71 ( 47.33) |
| Emergency | 66 ( 44.00) |
| Pediatrics & Immunization | 68 ( 45.33) |
| Obstetrics & Family Planning | 69 ( 46.00) |
| OT | 41 ( 27.33) |
* Respondents had worked in more than one area.
In-Service Educational Programmes Attended
Figure 1 shows whether the subjects had attended any in-service educational programmes related to universal precautions to brush up their knowledge and their skills. Out of the total 150 subjects, 48 had reported to have never attended any educational programme during their service. Yet about 68% or a total 102 subjects had attended in- service educational programmes. These are further classified according to the number of times they attended any educational programme. Those who had attended such programmes only once accounted for 31 of the total of 102 subjects, while 29 of them (including Nursing Superintendent) attended these twice. Thirteen subjects reported to have attended them three times. The subjects who had attended the 4 times were 12 in number which comprised 11 staff nurses and the assistant matron. Also 15 subjects had attended the educational programmes 5 times during their service which included 8 staff nurses, 6 nursing sisters and 1 MPHW. Even there were 2 subjects, one staff nurse and one nursing sister, who had attended these programmes six times.
In-Service Educational Programmes Attended
Distribution of the Respondents According to Frequency of Needle Prick Injury
Figure 2 shows the frequency of injury among the subjects during last six months. When surveyed, the subjects were asked about any needle prick injury caused to them during last six months during service hours. Though this frequency is generally high, it was surprising to know that only 16(10.66%) subjects out of the total of 150 reported injury due to needle prick. The number of subjects who got injured twice was 5 and those who got injured once were 9 in number.
Figure – 2 : Distribution of the Respondents According to Frequency of Needle Prick Injury during last six months. N= 150
Knowledge Score of the Respondents
Table 5 and Figure 3 describe the knowledge score of the subjects. All the subjects were given a questionnaire that contained 15 questions regarding the knowledge of universal precautions which included one subject who got less than 20% marks. While, 7 had in the range of 80 to 100% marks. The range of the marks obtained by subjects was 6.67% – 93.33% with a standard deviation of ±15.162 and mean 60.97%.
| Table 5: Classification according to Knowledge Score. | N = 150 |
| Marks Obtained | f (%) |
| < 20 | 1 ( 0.67) |
| 20 – 40 | 22 (14.67) |
| 40 – 60 | 59 (39.33) |
| 60 – 80 | 61 (40.67) |
| 80 – 100 | 7 ( 4.66) |
Figure – 3 : Classification according to Knowledge Score. N=150
Practice and Attitude Score of the Respondents
Table 6 shows the classification of subjects according to their practice and attitude score. The questionnaire that was used to assess the practice contained 25 questions regarding the practice of Universal Precautions. Less than 50% marks were obtained by only two subjects while 18% of the total subjects more than 90% marks. In this case mean marks were calculated to be 81.80, while the standard deviation was found to be ±10.681.
Table 6 : Classification according to Practice and Attitude Score
N = 150
Marks Obtained f (%)
<50 2 ( 1.33)
50 – 60 4 ( 2.67)
60 – 70 17 (11.33)
70 – 80 30 (20.00)
80 – 90 70 (46.67)
90 – 100 27 (18.00)
Components of Universal Precautions
Table 7 shows the components of universal precautions being practiced by the subjects. These include wearing gown, gloves, mask and eye glasses during assisting surgery or delivery. While more than 90% subjects reported to have always used the gown, gloves and mask during assisting a surgery or delivery, it was in the case of wearing eye glasses that only 28.7% subjects reported to have practiced this during the operation theater’s work. In the case of eye glasses being worn in the OT, there are very many variations in subjects’ responses as 18.7% of them repor ted to use them sometimes, 19.3% of them reported to have never used them and interestingly 33.30% of them did not even attempt the question. It’s important to note here that subjects had attempted the question theoretically as in practice there is a very meager number of subjects who actually practice wearing eye glasses in OT.
|
|||||||||||||||||||||||||||||||||||||||||||||||||
Table 7: Components of Universal Precautions. N = 150 Responses f (%)
Attitude towards Universal Precautions
Table 8 describes the attitude of subjects towards universal precautions. When asked if they found hand washing as time consuming; 56.7% of them reported that they did find it as time consuming. Only 13.3% of subjects reported to have never found this practice as time consuming. At the same time there were 18% subjects who did not attempt the question. Giving answer to another question of whether the subjects found following universal precautions as time consuming or not, 38.7% of them said that it was time consuming. At the same time 21.3% of the subjects did not attempt the questions.
Only 16% subjects admitted to never differentiate between HIV positive and normal patients. Those who did not attempt the questions accounted for 10% of the total subjects.
|
Table – 8 : Attitude towards Universal Precautions N = 150 Responses f (%)
Practice of Universal Precautions
Table 9 describes the practice of universal precautions amongst the subjects. When asked whether the disinfectant solutions should be used in diluted strength than recommended strength due to the cost factor, almost 70% subjects said these should be used in diluted form than the recommended strength. Only 18% subjects said they would never compromise on recommended strength. While giving answer to the questions, whether they use aseptic technique during handling open wounds, 93.3% of the subjects said that they always do use aseptic technique
able – 9 : Practice of Universal Precautions N = 150
| Responses | f (%) | ||
| Disinfectant solutions should be used in diluted strength than recommended strength | Using aseptic technique during handling open wounds | ||
| Always | 98 (65.30) | 140 (93.30) | |
| Mostly | 7 ( 4.70) | 4 ( | 2.70) |
| Sometimes | 8 ( 5.30) | 0 ( | 0.00) |
| Never | 27 (18.00) | 3 ( | 2.00) |
| No Response | 10 ( 6.70) | 3 ( | 2.00) |
Discussion
Universal precautions are the infection control techniques that were recommended following the AIDS outbreak in the 1980s. Because universal implies perfect protection, which universal precautions do not provide, however, this term is no longer recommended. Current recommendations call for a two-tiered system, using the terms standard and additional precautions. Standard precautions apply to all patients no matter what their infectious status is known or suspected to be. This applies to blood (wet and dry) and all bodily fluids except sweat, as well as non- intact skin and mucous membranes. Essentially, both standard and universal precautions are good hygiene habits, such as hand washing and the use of gloves and other barriers, correct sharps handling, and aseptic techniques. Additional precautions are used in addition to standard precautions for patients who are known or suspected to have an infectious condition, and vary depending on the infection control needs of that patient. Additional precautions are not needed for blood-borne infections, unless there are complicating factors. The present study was conducted taking into consideration knowledge and practice of different components of universal precaution.
The mean age for all the subjects was calculated to be 37.07 years. The standard deviation of the data regarding age of the subjects is ±11.275. Out of the total, 98% subjects were females and only 2% were males. A whopping number of subjects i.e. 63.33% had the senior secondary certificate. About 15% were matriculates. Graduates accounted for 17.34% of the total while only 4% of them had done a post graduate degree in academics. Almost 89% of the subjects had done GNM. Five of them were MPHW and 85% of them were B. Sc. Nursing. Nursing sisters accounted for 12% of the total subjects. Staff nurses constituted nearly 82% of subjects. Also there are 5 MPHWs. The senior staff with the professional experience of more than 15 years accounted for nearly 50%. The subjects were found to have worked mostly in medicine, surgery, emergency, pediatrics and obstetrics. The subjects, who had an experience of working in the Operation Theater, accounted for 27.33% of the total.
About 68% subjects had attended in-service educational programmes while 32% of the subjects did not attend any in-service programme. A study was conducted in PGIMER Chandigarh in the year 2002. It revealed that 94% subjects had attended in-service programme there and only 6% were such who had never attended any such programmes. The reason for this disparity among the two institutions is that PGIMER is a post graduate institution where such programmes are organized very frequently. 9
Though the frequency of needle prick injury is generally high, it was surprising to know that only 16 subjects out of the total of 150 reported injury due to needle prick. According to a study published in American Journal of Infection Control which included 2287 nurses in 22 hospitals, 20 of which were magnet institutions, almost half reported having had a needle stick injury at least once during their careers, with 9% having reported one within the last year. Of these injuries, 85% were reported to hospital officials. The most frequent reasons cited for the injury were needle disposal and venipuncture. Fewer years of experience, frequent performance of venipuncture, and recent adding of phlebotomy or intravenous responsibilities because of changing staffing patterns increased the risk of injury, as did a high repor ted workload and a low level of administrative support for nursing. Use of needle less systems or other protective devices decreased the risk of injury. Staffing patterns and organizational characteristics, along with the adoption of improved technology, can impact nurse on-the-job safety.
Regarding the knowledge of universal precautions, one subject got less than 20% marks. Those who got marks between 20 – 40% were 14.67% of the total subjects. Marks between 40 – 60% were scored by 39.33% of the subjects. In the next category of marks i.e. 60 – 80%, come 40.67% of the subjects. From 80 to 100% marks were obtained by 4.66% of the subjects. The mean value for the score of the subjects was calculated to be 60.97. There was found to be a standard deviation of ±15.162 while, the range of the marks obtained by subjects was 6.67 – 93.33. In April 1993 a study on the knowledge, compliance and attitudes of doctors and nurses on “universal precautions” was done in Thailand. Questionnaires were sent to doctors and nurses working in government hospitals; 468 doctors and 4539 nurses responded. 94.9% of physicians and 85.5% of nurses were knowledgeable of universal precautions. 8
In the practice score test, less than 50% marks were obtained by two subjects; one MPHW and one staff nurse. The category, which included the 70-80% marks, had 30 subjects in it. In the next two categories; 46.67% subjects scored 80-90% and 90- 100% marks were scored by 18% of the total subjects. In this case mean marks were calculated to be 81.80, while the standard deviation was found to be ±10.681. In the present study more than 90% subjects reported to have always used the gown, gloves and mask during assisting a surgery or delivery. In the case of wearing eye glasses, only 28.7% subjects reported to have practiced this during the operation theater’s work. Interestingly 33.30% of them did not even attempt the question. A study aimed at assessing the observance of universal precautions by HCWs in Abeokuta, Ogun State, Nigeria was conducted in May 2006 revealed that less than two-thirds of respondents (63.8%) always used personal protective equipment, and more than half of all respondents (56.5%) had never worn goggles during deliveries and at surgeries. 10
In the present study 56.7% of the subjects reported that they did find hand washing as time consuming. Only 13.3% of subjects reported to have never found this practice as time consuming. At the same time there were 18% subjects who did not attempt the question. A study aimed at assessing the observance of universal precautions by HCWs in Abeokuta, Ogun State, Nigeria conducted in May 2006 revealed that a high percentage (94.6%) of HCWs observed hand washing after handling patients. 10 In April 1993 a study on the knowledge, compliance and attitudes of doctors and nurses on “universal precautions” done in Thailand stated that 75% of doctors and 47% of nurses washed their hands after caring for patients, and 16% of doctors and 50% of nurses rubbed their hands with alcohol after washing them with an antiseptic.8
Giving answer to another question of whether the subjects found following universal precautions as time consuming or not, 38.7% of them said that it was time consuming, whereas 26% of them reported that it was not time consuming. At the same time 21.3% of the subjects did not attempt the questions.
While attempting the questions whether they would like to work with HIV positive patient optionally, a huge 57% of subjects said they would never want to work with HIV positive patients. If taken collectively with subjects who mostly would not want to work with HIV positive patients, the number would increase to a surprising 70%. Only 16% subjects admitted to never differentiate between HIV positive and normal patients. Those who did not attempt the questions accounted for 10% of the total subjects. Interestingly and amazingly shocking that 70% of the subjects did not want to work with HIV positive patients, especially in a hospital where even a specialized AIDS Cell is also present.
When asked whether the disinfectant solutions should be used in diluted strength than recommended strength due to the cost factor, almost 70% subjects said these should be used in diluted form than the recommended strength. Only 18% subjects said they would never compromise on recommended strength.
Recommendations
- Educational programmes regarding universal precautions should be organized
- There is a need to change the attitude of nursing personnel about HIV positive
- A overhauling regarding the practice of universal precautions is needed among the nursing
- The staff that is employed on contract basis needs to be educated about universal precautions at the time of orientation
- Instructions regarding universal precautions should be displayed in print in every department of the
- A comprehensive research needs to be done which includes all the doctors, nursing personnel and also all the Implications
Making use of the data given in the present study regarding the knowledge and practice of universal precautions amongst the nursing personnel, the hospital administration can take steps to make the present condition better.
Refeneces
- Roth Ritual and magic in the control of contagion. American Sociological Review. 1957; 22(3): 310-314.
- Barbara M, Elaine L, Garry Infections and nursing practices: Prevention and control. Mosby 1995; pp 106-126.
- Handerson DK, Fahey BJ, Willy M, Schmitt JM, Carey K, Kozial Risk of occupational transmission of human immunodeficiency virus Type 1 (HIV1) associated with clinical exposure. Annals of Internal Medicine 1990; 113: 742- 746.
- Training Module on HIV Infection and AIDS for Medical National AIDS Control Organisation; Ministry of Health and Family Welfare, Government of India. New Delhi.
- Black JM, Jacobs Medical Surgical Nursing – Clinical Management for Continuity of Care. Philadelphia: Saunders, 1997.
- Post Exposure Prophylaxis Guidelines for Occupational Available from URL: http:/
/www.nacoonline.org/guidelines/guideline_7.pdf
- Gachigo JN, Naidoo HIV/AIDS -The knowledge, attitudes and behaviour of dentists in Nairobi, Kenya. Journal of the South African Dental Association. 2001 Dec; 56(12):587-91. Available from URL: http:/www.ncbi.nlm.nih.gov/ entrez/query.fcgi?CMD=search&DB=pubmed
- Danchaivijitr S, Tantiwatanapaiboon Y, Chokloikaew S, Tangtrakool T, Suttisanon L, Chitreechuer Universal precautions: knowledge, compliance and attitudes of doctors and nurses. Journal of the Medical Association of Thailand. 1995 Jul; 78 Suppl 2:S112-7. Available from: http://www.ncbi.nlm.nih.gov/entrez/ query.fcgi?CMD=search&DB=pubmed
- Devinder Staff Nurses’ compliance with universal precautions in relation to selected factors at Nehru Hospital PGIMER Chandigarh. Master’s Thesis 2002.
- Sadoh WE, Fawole AO, Sadoh AE, Oladimeji AO, Sotiloye Practice of universal precautions among healthcare workers. Journal of the National Medical Association. 2006 May; 98(5):722-6. Available from URL: http:// www.ncbi.nlm.nih.gov/entrez/query.fcgi? db=pubmed&cmd=Retrieve&dopt=Abstract Plus&list_uids=16749647&query hl=7&itool=pubmed_docsum
- M, Jolley D, Langkham B, Thomas MS, Holmes W, Gifford Compliance with Universal/Standard Precautions among health care workers in rural north India. American Journal of Infection Control. 2005 Feb; 33(1):27-
- Available from URL: http:// www .ncbi.nlm.nih.gov/entrez/ query.fcgi?CMD=search&DB=pubmed