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Introduction
China's national Health Industrial Standard (version number: WS 310.2-2016) which was released in December 2016 states that the user shall timely remove visible contaminants from medical instruments, implements and articles, and keep them moist as required after use. Guidelines of Association of PeriOprative Registered Nurses of the United States also expressly require keeping instruments moist before cleaning1. Failure in timely keeping instruments moist will lead to biofilm formation. Biofilm refers to a collective of bacteria attached to the surface of living or non-living objects and enclosed with bacterial extracellular macromolecules. Biofilm is very difficult to remove after formation2,3. According to the previous studies, bacteria may develop on dry contaminants in 4-20 min and biofilm will appear in 2 h. Therefore, contaminants shall be timely removed from surgical instruments after use, and subsequently the instruments shall be sent to the central sterile supply department (CSSD) for cleaning within 30 min. If it is not available, it will be necessary to keep instruments moist4,5. However, because of conflicts with work schedule of CSSD, surgical instruments may not be immediately cleaned or sterilized by CSSD staff members after use. If surgical instruments are not kept appropriately moist, tarnish or rusting may occur on the instruments, which will not only affect cleaning quality, but also shorten the normal service life of the instruments6,7. According to the initial investigation, only 57.59% of the surgical instruments were kept moist in our hospital, and the nurses did not have adequate perception toward their behaviors for keeping instruments moist. We aimed to use the health belief model to analyze the nurses' perception toward their behaviors for keeping surgical instruments moist. This study will contribute to improve implementation rate of keeping surgical instruments moist.
Materials and methods
Setting and participants
The survey was performed with 360 nurses from a grade a tertiary hospital in China during June 1 to August 31, 2019.
Study design
The health belief model (HBM), first proposed by Hochbaum, and revised by Rosenstock8, was the theoretical base of this study. HBM's 5 components, that is, perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and self-efficacy, were applied to define nurses' perceived susceptibility to instruments not kept moist, perceived severity of instruments not kept moist, perceived benefits of keeping instruments moist, perceived barriers for keeping instruments moist, and self-efficacy in keeping instrument moist9,10 in analyzing nurses' perception toward their behaviors for keeping surgical instruments moist.
The survey was performed based on an electronic questionnaire regarding respondent's demographic information and a self-designed nurses' perception-behavior scale for keeping surgical instruments moist. The electronic questionnaire was produced through a smartphone application called “WJX.” Quick response code of the questionnaire was only shared to the WeChat group for nurses of the hospital. Because WJX is a specialized online questionnaire survey tool and is commonly used in China, we did not test usability and technical functionality of the electronic questionnaire before sharing the quick response code to the WeChat group. Aims and importance of this study and time limit of the investigation were stated in the WeChat group chat. The nurses who were interested in participating in the research study accessed to the questionnaires by scanning the quick response code, and then they filled out the questionnaires voluntarily and anonymously without inputting username and password. Respondents were not provided with any form of incentives to participate in this study.
The questionnaire consisted of 41 questions, and all questions were shown on one page. There were no response options for “not applicable” or “rather not say.” Respondents could review and change their answers before submitting the questionnaires. Respondents could scan the quick response code to view the questionnaire again at any time after submitting the questionnaires, but no changes were allowed to their answers after submitting the questionnaire. If respondent did not answer all questions, the questionnaire would not be submitted successfully. We were able to obtain the information of IP addresses and WeChat nicknames of the respondents who successfully submitted the questionnaires. If questionnaires from the same IP address or same WeChat nicknames were submitted multiple times, the first submission would be considered as valid and information from the first submission was analyzed.
The demographic information section was used to gather information about departments where the nurses were working in, and their age, length of service, educational backgrounds, and job titles. The nurses' perception-behavior scale for keeping surgical instruments moist was designed based on the HBM, with Cronbach's alpha of 0.911 and the great overall consistency. Validity test was performed through the use of content experts. After two rounds of expert consultation, the content validity index of each item ranged from 0.833 to 1.000, and that of universal agreement was 0.852. The nurses' perception-behavior scale for keeping surgical instruments moist covered 5 components and 36 items, of which six items were for the component “perceived susceptibility to instruments not kept moist,” six items were for the component “perceived severity of instruments not kept moist,” eight items were for the component “perceived benefits of keeping instruments moist,” nine items were for the component “perceived barriers for keeping instruments moist,” and seven items were for the component “self-efficacy in keeping instrument moist.” The 5-point Likert scale was used for scoring, namely, 5 = strongly agree, 4 = agree, 3 = neither agree or disagree, 2 = disagree, and 1 = strongly disagree.
Data collection
Data were collected through cluster sampling. If respondent did not answer all questions in the questionnaire and did not submit the questionnaire successfully, we would not obtain any information about the unsubmitted questionnaire. A total of 360 questionnaires were distributed, and 360 questionnaires were returned, among which 351 questionnaires were valid. The valid response rate was 97.5%.
Statistical methods
Data were analyzed in SPSS Version 20.0. The enumeration data were described with frequency (relative frequency), and the measurement data were expressed with mean (±) and standard deviation (SD). A statistically significant difference (p < 0.05) was found through t-test, variance analysis, and multivariable linear regression analysis.
Results
Demographic information of the nurses
The 351 nurses' average length of service was 7.60 ± 8.204 years, their average age was 30.14 ± 7.327 years. 275 (78.35%) of them had bachelor's degree qualifications, and 169 (48.15%) of them were nurse practitioners (Table 1).
Table 1 Demographic information of nurses (n = 351)
| Item | n | Assignment | Percentage |
|---|---|---|---|
| Age (years) | |||
| < 25 | 68 | 1 | 19.37 |
| 25-30 | 160 | 2 | 45.58 |
| 31-35 | 54 | 3 | 15.39 |
| 36-40 | 36 | 4 | 10.26 |
| 41-45 | 12 | 5 | 3.42 |
| 46-50 | 12 | 6 | 3.42 |
| > 50 | 9 | 7 | 2.56 |
| Length of service (years) | |||
| < 1 | 15 | 1 | 4.27 |
| 1-5 | 185 | 2 | 52.71 |
| 6-10 | 57 | 3 | 16.24 |
| 11-15 | 39 | 4 | 11.11 |
| 16-20 | 25 | 5 | 7.12 |
| > 20 | 30 | 6 | 8.55 |
| Educational background | |||
| Junior college diploma or below | 60 | 1 | 17.09 |
| Bachelor | 275 | 2 | 78.35 |
| Master or above | 16 | 3 | 4.56 |
| Job title | |||
| Nurse | 94 | 1 | 26.78 |
| Nurse practitioner | 169 | 2 | 48.15 |
| Supervising nurse | 86 | 3 | 24.50 |
| Associate senior nurse | 2 | 4 | 0.57 |
Score of nurses' perception-behavior scale for keeping surgical instruments moist
For the 351 nurses, total score of nurses' perception-behavior scale for keeping surgical instruments moist was 139.93 ± 15.145, and the mean scale score was 4.21 ± 0.423. The HBM-based components placed in ascending order of their mean scores were perceived barriers for keeping instruments moist (3.47 ± 0.945), self-efficacy in keeping instruments moist (4.16 ± 0.666), perceived severity of instruments not kept moist (4.50 ± 0.574), perceived benefits of keeping instruments moist (4.57 ± 0.523), and perceived susceptibility to instruments not kept moist (4.62 ± 0.484).
Impact of age
Single factor analysis showed that age had an impact on nurses' perceived barriers for keeping instruments moist, with a statistically significant difference (p = 0.001 < 0.05) (Table 2).
Table 2 Impact of age on nurses' perception toward their behaviors for keeping surgical instruments moist
| Item | Perceived severity of instruments not kept moist | Perceived susceptibility to instruments not kept moist | Perceived benefit of keeping instruments moist | Perceived barriers for keeping instruments moist | Self-efficacy in keeping instruments moist |
|---|---|---|---|---|---|
| Age (years) | |||||
| < 25 | 27.2 ± 3.012 | 24.38 ± 2.144 | 36.90 ± 4.023 | 22.57 ± 7.522 | 28.96 ± 4.180 |
| 25–30 | 27.04 ± 3.633 | 24.66 ± 1.958 | 36.81 ± 4.132 | 20.97 ± 8.645 | 29.21 ± 4.893 |
| 31–35 | 27.13 ± 3.108 | 24.46 ± 1.910 | 36.09 ± 4.319 | 25.13 ± 8.239 | 29.22 ± 4.521 |
| 36–40 | 27.03 ± 3.211 | 24.61 ± 1.793 | 36.53 ± 4.074 | 23.47 ± 8.365 | 29.47 ± 4.313 |
| 41–45 | 26.08 ± 4.033 | 24.17 ± 2.250 | 35.42 ± 4.122 | 26.50 ± 8.274 | 27.50 ± 4.719 |
| 46–50 | 25.92 ± 4.231 | 23.67 ± 2.015 | 35.33 ± 4.997 | 25.83 ± 8.032 | 27.92 ± 5.435 |
| > 50 | 25.67 ± 4.387 | 23.89 ± 2.619 | 34.89 ± 5.183 | 30.56 ± 7.828 | 30.44 ± 5.615 |
| t | 0.652 | 0.454 | 0.834 | 4.033 | 0.553 |
| p | 0.689 | 0.842 | 0.544 | 0.001 | 0.767 |
Impact of length of service
Single factor analysis showed that length of service had an impact on nurses' perceived benefits of keeping instruments moist and perceived barriers for keeping instruments moist, with a statistically significant difference (p < 0.05) (Table 3).
Table 3 Impact of length of service on nurses' perception toward their behaviors for keeping surgical instruments moist
| Item | Perceived severity of instruments not kept moist | Perceived susceptibility to instruments not kept moist | Perceived benefit of keeping instruments moist | Perceived barriers for keeping instruments moist | Self-efficacy in keeping instruments moist |
|---|---|---|---|---|---|
| Length of service (years) | |||||
| < 1 | 28.00 ± 3.464 | 25.33 ± 1.633 | 39.13 ± 2.134 | 19.87 ± 5.986 | 29.60 ± 3.795 |
| 1–5 | 27.30 ± 3.320 | 24.56 ± 2.018 | 36.88 ± 4.130 | 21.74 ± 8.636 | 29.37 ± 4.614 |
| 6–10 | 26.35 ± 3.533 | 24.47 ± 1.919 | 35.95 ± 3.988 | 22.89 ± 8.010 | 28.70 ± 4.953 |
| 11–15 | 27.05 ± 3.464 | 24.62 ± 2.021 | 36.13 ± 4.714 | 24.62 ± 8.359 | 29.13 ± 4.691 |
| 16–20 | 26.72 ± 3.234 | 24.24 ± 1.877 | 36.04 ± 3.889 | 23.00 ± 8.495 | 28.76 ± 3.919 |
| > 20 | 26.00 ± 4.009 | 23.87 ± 2.193 | 35.23 ± 4.651 | 27.87 ± 8.080 | 28.40 ± 5.462 |
| t | 1.483 | 0.833 | 2.396 | 3.547 | 0.397 |
| p | 0.195 | 0.527 | 0.037 | 0.004 | 0.851 |
Impact of educational background
Single factor analysis showed that educational background had no impact on nurses' perception toward their behaviors for keeping surgical instruments moist (Table 4).
Table 4 Impact of educational background on nurses' perception toward their behaviors for keeping surgical instruments moist
| Item | Perceived severity of instruments not kept moist | Perceived susceptibility to instruments not kept moist | Perceived benefit of keeping instruments moist | Perceived barriers for keeping instruments moist | Self-efficacy in keeping instruments moist |
|---|---|---|---|---|---|
| Educational background | |||||
| Junior college diploma or below | 27.13 ± 3.332 | 24.32 ± 2.103 | 36.35 ± 4.173 | 22.67 ± 8.136 | 29.28 ± 5.256 |
| Bachelor | 26.89 ± 3.466 | 24.49 ± 1.992 | 36.49 ± 4.211 | 22.87 ± 8.651 | 29.04 ± 4.519 |
| Master or above | 28.29 ± 3.405 | 25.47 ± 1.463 | 38.24 ± 3.597 | 20.88 ± 8.108 | 29.41 ± 5.075 |
| t | 1.124 | 2.011 | 1.232 | 0.167 | 0.253 |
| p | 0.326 | 0.135 | 0.293 | 0.846 | 0.777 |
Impact of job title
Single factor analysis showed that job title had an impact on nurses' perceived susceptibility to instruments not kept moist, perceived benefits of keeping instruments moist, and self-efficacy in keeping instruments moist, with a statistically significant difference (p < 0.05) (Table 5).
Table 5 Impact of job title on nurses' perception toward their behaviors for keeping surgical instruments moist
| Item | Perceived severity of instruments not kept moist | Perceived susceptibility to instruments not kept moist | Perceived benefits of keeping instruments moist | Perceived barriers for keeping instruments moist | Self-efficacy in keeping instruments moist |
|---|---|---|---|---|---|
| Job title | |||||
| Nurse | 27.90 ± 2.915 | 24.89 ± 1.769 | 37.86 ± 3.304 | 21.61 ± 8.751 | 30.01 ± 4.287 |
| Nurse practitioner | 26.67 ± 3.587 | 24.31 ± 2.150 | 36.09 ± 4.440 | 22.05 ± 8.266 | 28.72 ± 4.783 |
| Supervising nurse | 26.67 ± 3.582 | 24.45 ± 1.883 | 36.00 ± 4.279 | 25.48 ± 8.304 | 29.02 ± 4.733 |
| Associate senior nurse | 25.00 ± 1.414 | 24.00 ± 2.828 | 35.50 ± 4.950 | 23.00 ± 5.657 | 24.50 ± 2.121 |
| t | 3.199 | 1.992 | 4.422 | 3.987 | 2.245 |
| p | 0.083 | 0.008 | 0.005 | 0.115 | 0.024 |
Multivariable linear regression analysis
Total score of nurses' perception-behavior scale for keeping surgical instruments moist was considered as the dependent variable. Age, length of service, and job title were considered as the independent variable. Stepwise regression (Alpha-to-Enter = 0.05, Alpha-to-Remove = 0.10) of multivariable linear regression analysis was carried out on the data. The analysis showed that one variable was entered into the regression equation, that is, length of service. A statistically significant difference existed, as shown in table 6.
Table 6 Multivariable linear regression analysis on factors influencing nurses' perception toward their behaviors for keeping surgical instruments moist
| Variable | B | Standard error | β | t | p | 95% CI |
|---|---|---|---|---|---|---|
| Age | 1.597 | 1.326 | 0.147 | 1.204 | 0.229 | −1.011-4.206 |
| Length of service | −2.923 | 1.466 | −0.261 | −1.993 | 0.047 | −5.807-−0.039 |
| Job title | −2.380 | 1.711 | −0.114 | −1.391 | 0.165 | −5.745-0.985 |
R2=0.055; adjusted R2=0.047; F=6.721; p=0.001. CI: Confidential interval
Discussion
As revealed in the results of this study, the mean score of nurses' perception-behavior scale for keeping surgical instruments moist was 4.21 ± 0.423. According to score assignments in the survey, the score above 4 meant “agree”8. This indicated that the nurses had positive health belief in keeping surgical instruments moist, possibly because 78.35% of them had bachelor's degree qualifications. The nurses with high levels of education had greater ability to learn and master many new skills and had higher-level perception. Their score for perceived barriers for keeping instruments moist was low, possibly because the hospital where the participants worked in was for women and children and most surgeries here were obstetric and gynecologic ones. The time for preparing each operation was short, the turnover time of operating rooms was short, the operating room nurses were unable to timely moisten surgical instruments, and CSSD staff members were unable to timely receive the surgical instruments. All of these led to low score for perceived barriers for keeping instruments moist7.
The single factor analysis showed that age, length of service, and job title affected nurses' perception toward their behaviors for keeping surgical instruments moist. With an increase of experience and knowledge, nurses' perception, and behaviors also changed. The nurses with shorter length of service perceived more benefits of keeping surgical instruments moist than those with longer length of service, but had significantly less perceived barriers for keeping instruments moist than those with longer length of service, possibly because the nurses with shorter length of service had less clinical experience and insufficient basic knowledge on keeping surgical instruments moist, and were not familiar with the relevant procedures. However, the nurses with longer length of service experienced occupational fatigue due to long period of working, and had decreasing perception to benefits of keeping surgical instruments moist, which affected their handling of keeping instruments moist.
Multivariable regression analysis showed that length of service had an impact on nurses' perception toward their behaviors for keeping surgical instruments moist. The shorter the length of service was, the greater perception of nurses to keeping instruments moist. The nurses with longer length of service had poorer attitude for keeping instruments moist than the newly employed nurses, possibly because such new nurses were full of enthusiasm in work but had less experience, and they handled surgical instrument moistening strictly according to requirements. In contrast, the nurses with longer length of service were insensitive to perception of the severity and benefits of keeping surgical instruments moist due to their long period of working, which led to poor health belief in keeping surgical instruments moist.
Conclusions
In summary, training on basic knowledge for keeping surgical instruments moist should be enhanced for nurses with shorter length of service, including regularly attending seminars, reading brochures, watching relevant videos, and weekly post-training follow-up should be strengthened. For nurses with longer length of service, their awareness to benefits of keeping surgical instruments moist and their confidence in overcoming barriers should be enhanced, and eventually they could fulfill their task for keeping surgical instruments moist.
