NURSES’ UNDERSTANDI NG OF STANDARD PRECAUTI ONS
AT A PUBLI C HOSPI TAL I N GOI ANI A - GO, BRAZI L
Dulcelene de Sousa Melo1 Adenícia Cust ódia Silv a e Souza2 Anaclar a Fer r eir a Veiga Tipple2 Zilah Cândida Per eir a das Nev es3 Milca Sev er ino Per eir a4 Melo DS, Silva e Souza AC, Tipple AFV, Neves ZCP, Pereira MS. Nurses’ underst anding of st andard precaut ions at a public hospit al in Goiania - GO, Br azil. Rev Lat ino- am Enfer m agem 2006 set em br o- out ubr o; 14( 5) : 720- 7.
St andar d Pr ecaut ions ( SP) ar e effect iv e st r at egies t o pr ev ent and cont r ol nosocom ial infect ions. This st udy aim ed t o verify nurses’ underst anding about st andard precaut ion m easures. Dat a w ere collect ed t hrough int er v iew s, follow ed by cont ent analy sis in accor dance w it h Bar din. Eight y - t w o nur ses t ook par t in t his st udy , 75.6% of w hom under st and SP as pr ot ect iv e m easur es: for pr ofessionals ( 11.0% ) ; for bot h pr ofessionals and pat ient s ( 52.4% ) ; for pat ient care independent ly of t he diagnosis ( 7.3% ) ; for pat ient s wit h diagnosed infect ion ( 9. 8% ) . Ot her nur ses indicat ed SP as hum an car e ( 4. 9% ) and only as I ndiv idual Pr ot ect ion Equipm ent ( I PE) ( 11.0% ) . Most par t icipant s’ under st anding point s t o favor able cognit ive adapt at ion t o t he daily im plem ent at ion of SP. How ever , r educt ionist and even m ist aken per cept ions about t heir r ange per sist , w hich m akes t he social funct ion of t hese m easur es v ulner able.
DESCRI PTORS: nur sing; k now ledge; univ er sal pr ecaut ions; cr oss infect ion
COMPRENSI ÓN SOBRE PRECAUCI ONES MODELO POR LOS
ENFERMEROS DE UN HOSPI TAL PÚBLI CO DE GOI ANI A - GO, BRASI L
Las pr ecau cion es m odelo con st it u y en est r at egias ef ect iv as par a la pr eser v ación y el con t r ol de las infecciones en los servicios de at ención a la salud. La finalidad de est a invest igación fue const at ar la com prensión d e los en f er m er os r esp ect o a las m ed id as d e p r ecau ción m od elo. Los d at os f u er on ob t en id os a t r av és d e ent revist a, seguida de un análisis de cont enido de acuerdo con Bardin. Part iciparon de est e est udio 82 enferm eros y el 7 5 , 6 % de est os com pr en de las pr ecau cion es m odelo com o m edidas de pr ot ección : par a el pr of esion al ( 11,0% ) , para el profesional y para el pacient e ( 52,4% ) ; en la at ención al pacient e independient e del diagnóst ico ( 7,3% ) ; en la at ención a pacient es que se sabe que est án infect ados ( 9,8% ) . Ot ros enferm os se refirieron a las pr ecauciones m odelo com o cuidado hum ano ( 4, 9% ) y apenas com o la ut ilización de un equipo de pr ot ección in d iv id u al ( EPI ) ( 1 1 , 0 % ) . La com p r en sión em it id a p or la m ay or ía d e los su j et os p r esen t a ad ecu ación d e conocim ient o fav or able a la im plem ent ación de las pr ecauciones m odelo diar iam ent e. Mient r as t ant o, fuer on com pr obadas per cepciones de r educción y hast a dist or sionadas del alcance de est as, lo que dej a vulner able la función social de est as m edidas.
DESCRI PTORES: en fer m er ía; con ocim ien t o; pr ecau cion es u n iv er sales; in fección h ospit alar ia
COMPREENSÃO SOBRE PRECAUÇÕES PADRÃO PELOS
ENFERMEI ROS DE UM HOSPI TAL PÚBLI CO DE GOI ÂNI A - GO
As pr ecauções padr ão ( PP) const it uem est r at égias efet ivas par a a pr evenção e cont r ole das infecções, em Serviços de Assist ência à Saúde. O obj et ivo dest a invest igação foi verificar a com preensão dos enferm eiros sobr e as m edidas de PP. Os dados for am obt idos por m eio de ent r ev ist as com post er ior Análise de Cont eúdo con for m e Bar din . Par t icipar am do est u do 8 2 en fer m eir os e 7 5 , 6 % com pr een der am as PP com o m edidas de pr ot eção: par a o pr ofissional ( 11,0% ) ; par a o pr ofissional e o pacient e ( 52,4% ) ; no at endim ent o ao pacient e in d ep en d en t e d o d iag n óst ico ( 7 , 3 % ) ; e a p acien t es sab id am en t e in f ect ad os ( 9 , 8 % ) . Ou t r os en f er m eir os relat aram as PP com o cuidado hum ano ( 4,9% ) e apenas com o o uso de EPI ( 11,0% ) . A com preensão em it ida pela m aioria dos suj eit os apont a adequação cognit iva favorável à im plem ent ação das PP no cot idiano. Ent ret ant o, for am v er ificadas per cepções r edu cion ist as e at é dist or cidas da su a abr an gên cia, o qu e coloca v u ln er áv el a função social de t ais m edidas.
DESCRI TORES: en fer m agem ; con h ecim en t o; pr ecau ções u n iv er sais; in fecção h ospit alar
Disponível em língua port uguesa na SciELO Brasil w w w .scielo.br/ rlae
1
I NTRODUCTI ON
I
n f e ct i o n s i n h e a l t h ca r e se r v i ce s ( HCS) represent a global problem and const it ut e one of t hem ain causes of m or bidit y and deat h associat ed w it h
clin ical, d iag n ost ic an d t h er ap eu t ic p r oced u r es( 1 - 2 ).
Besides t heir range for pat ient s, t he problem is equally
im por t an t f or h ealt h car e w or k er s ( HCW) , w h o ar e
cont inuously subj ect t o occupat ional risks. As exposure
is a con st an t p r em ise f or p r of ession als as w ell as
pat ient s, int er v ent ion m easur es hav e been pr oposed
t o m inim ize t his sit uat ion, wit h t he im plem ent at ion of
st an dar d pr ecau t ion s ( SP) as on e of t h e st r at egies.
These are a set of planned act ions aim ed at prot ect ing
pat ient s and pr ofessionals.
Th e u se o f SP i s r e co m m e n d e d f o r ca r e
d e l i v e r y t o a l l p a t i e n t s , i n d e p e n d e n t l y o f t h e i r
pr esum ed infect ion st at e, w hen handling equipm ent
an d dev ices t h at ar e con t am in at ed or su spect ed of
cont am inat ion, in sit uat ions of cont act risk wit h: blood,
b od y f l u i d s, secr et i on s an d ex cr et i on s, ex cep t f or
sw eat , w it hout consider ing t he pr esence or absence
of v isible blood an d sk in w it h solu t ion of con t in u it y
and m ucous t issues( 3).
St an d ar d p r ecau t ion s in clu d e t h e f ollow in g
m easu r es: h an d w ash in g , u se of b ar r ier s ( g lov es,
gow n, cap, m ask) , car e w it h devices, equipm ent and
cl o t h i n g u sed d u r i n g ca r e, en v i r o n m en t a l co n t r o l
( su r f ace pr ocessin g pr ot ocols, h ealt h ser v ice w ast e
handling) , adequat e discar ding of shar p inst r um ent s
and needles and pat ient ’s accom m odat ion in line wit h
r e q u i r e m e n t l e v e l s a s a n i n f e ct i o n t r a n sm i ssi o n
sour ce( 3). Anot her im por t ant m easur e is pr ofessional
i m m u n i z a t i o n , a s t h i s g u a r a n t e e s a n t i c i p a t e d
pr ot ect ion again st im m u n o- pr ev en t able diseases.
We know t hat t he Cent ers for Disease Cont rol
and Pr ev ent ion ( CDC) est ablished t hese m easur es in
1996( 3), and t hat t hey should be consolidat ed in care
pract ice. However, t his has not been observed. Alt hough
easily u n d er st an d ab le, im p lem en t in g SP r em ain s a
challenge. One of t he reasons is low adherence am ong
professionals, condit ioned by different fact ors, including
t heir subj ect ive aspect s( 4- 9).
Ack n o w l e d g i n g t h i s r e a l i t y i n cr e a se s o u r
an x iet y an d d iscom f or t , w h en w e ob ser v e t h at t h e
dist ancing of infect ion prevent ion and cont rol pract ices
in HCS obj ect iv ely t ur ns int o dam age t o indiv iduals,
w h ose r an g e is d if f icu lt t o m easu r e. Th er ef or e, w e
inquire how professionals, in t heir professional pract ice
t hat is aim ed at care for life, exalt t he great er good,
i.e. t heir own life and t hat of ot hers, but neglect such
im por t ant pr act ices? What can ex plain t his behavior ?
Un d er st an d i n g t h i s p ar ad o x i cal r el at i o n i s
challenging. Thus, w e proposed t his st udy t o t ry and
cl a r i f y a sp e ct s o f p r o f e ssi o n a l s’ a d h e r e n ce t o SP
m easur es, w it h a view t o appr ehending t he subj ect s’
underst anding of SP on t he basis of t heir subj ect ivit y.
I n a d d r e ssi n g t h e su b j e ct s’ p e r sp e ct i v e , w e w i l l
in dicat e issu es t h at can act u ally gu ide in t er v en t ion
st r at egies t o change infect ion pr ev ent ion and cont r ol
pr act ices in HCS.
OBJECTI VE
To v er ify nur ses’ under st anding of st andar d
p r ecau t ion m easu r es.
METHODOLOGY
Th is d escr ip t iv e an d q u alit at iv e st u d y w as
carried out at a large public hospit al in Goiania - GO,
Brazil. Ninet y nurses were chosen for t he st udy, 82 of
w h o m p a r t i c i p a t e d . A l l p a r t i c i p a n t s h a d b e e n
pr of ession ally act iv e f or on e ( 0 1 ) y ear or m or e, in
dir ect pat ient car e, hospit al hy giene and pr ocessing
o f cl o t h i n g a n d d e n t a l - m e d i ca l - h o sp i t a l m a t e r i a l
processing. Eight ( 9.9% ) professionals w ere excluded
b e ca u se t h e y w e r e o n l e av e , h o l i d a y, r e f u se d t o
par t icipat e or did not have t im e for t he int er view s.
Th e r esear ch pr oj ect w as su bm it t ed t o t h e
Resear ch Et hics Com m it t ee at t he Hospit al Dr. Anuar
Auad and appr ov ed on 1 1 / 1 6 / 0 3 ( Pr ot ocol 0 1 5 / 0 3 ) .
Pr ofessionals par t icipat ed aft er individual cont act and
clar ificat ion s abou t t h e st u dy obj ect iv e. All su bj ect s
signed t he free and inform ed consent t erm . Dat a were
collect ed in t h e f ir st sem est er of 2 0 0 4 . I n t er v iew s
w er e held at t he w or k place and dur ing w or k hour s,
using a sem ist ruct ured script wit h dat a t o charact erize
t he subj ect s and a guiding quest ion: t alk about what
you t hink are st andard precaut ions. All int erviews were
w r i t t e n d o w n a n d , a t t h e e n d , r e a d t o t h e
int erviewees, in order t o confirm or change t he report s
accor ding t o t heir r eliabilit y and conv enience.
We u se d Co n t e n t An a l y si s p r o p o se d b y
Bar d in( 1 0 ). Af t er ex h au st iv e r ead in g , t h r ee an aly t ic
cat egor ies w er e ext r act ed, one of w hich gave r ise t o
four subcategories. The subj ects’ discourse was identified
RESULTS AND DI SCUSSI ON
Eigh t y - t w o ( 9 0 . 1 % ) n u r ses par t icipat ed, 6 6
( 8 0 . 5 % ) o f w h o m w e r e sh i f t su p e r v i so r s a n d 1 6
( 19.5% ) nursing service m anagers. The subj ect s’ ages
ranged from 27 t o 65 years, wit h a m ean age of 39.6
y e a r s . Mo s t p a r t i c i p a n t s w e r e w o m e n ( 9 1 . 5 % ) .
Service t im e at t he inst it ut ion varied bet ween 6 m ont hs
and 29 years. Fift y- nine ( 72.0% ) part icipant s had been
p r of ession ally act iv e f or b et w een 0 1 an d 1 4 y ear s
( M e a n : 8 y e a r s ) . Th e s e d a t a c o n f i r m t h e
predom inance of fem ale professionals in Nursing, and
a m ean service t im e of eight years suggest s t hat t hese
p r o f e s s i o n a l s p r o b a b l y d i d n o t h a v e a c c e s s t o
k n o w l e d g e a b o u t SP d u r i n g t h e i r u n d e r g r a d u a t e
course, as t hese w ere issued in 1996( 3).
Th e an aly t ic cat eg or ies w er e: 1 ) St an d ar d
precaut ions as prot ect ion m easures, wit h t he following
subcat egories: prot ect ion m easures - for pat ient care
independent ly of t he diagnosis; for pr ofessionals; for
p a t i e n t s w i t h d i a g n o s e d i n f e c t i o n ; 2 ) s t a n d a r d
pr ecaut ions as car e; 3) st andar d pr ecaut ions as t he
use of per sonal pr ot ect iv e equipm ent .
One st udy subj ect ( 1.2% ) did not m anage t o
clearly express her underst anding of SP, despit e being
a daily pract ice: SP are precaut ions we have t o t ake according
t o t he case we are dealing wit h, we need t o t ake precaut ions... SP
is m ore general ( E34). Two ( 2.4% ) professionals present ed
SP as hospit al infect ion ( HI ) pr ev ent ion and cont r ol
m easures: That would be precaut ions t o avoid HI , t o cont rol
HI ( E43) .
St andar d pr ecaut ion s as pr ot ect ion m easur es
Sixt y- t wo subj ect s ( 75.6% ) considered SP as
a prot ect ion st rat egy in daily healt h care act ivit ies. We
agree, as we believe t hat prot ect ion is t he basic prem ise
of SP, which im plies risk prevent ion and cont rol.
Prot ect ion, t ranslat ed in pract ice as safet y in
t h e r ecipr ocal pr ocess est ablish ed in h ealt h car e, is
t he t arget of infect ion prevent ion and cont rol m easures
i n HCS. Th ese m ea su r es ar e f u n d a m en t a l , a s w e
cannot im agine qualit y care wit hout t hem , in t erm s of
t h e p r o b l e m s ca u se d b y H CS- r e l a t e d i n f e ct i o n s,
w het her t o ser v ice pr ov ider s or r eceiv er s.
Th e r e p o r t s e v i d e n c e d t h e p a r t i c i p a n t s ’
subj ect iv it y w it h r espect t o t he pr ot ect ion offer ed by
SP, ex pr essed in t he follow ing subcat egor ies.
Pr o t e c t i o n m e a s u r e s f o r p a t i e n t c a r e
independent ly of t he diagnosis
Si x ( 7 . 3 % ) n u r se s e x p r e ss t h i s p o si t i o n ,
d eclar in g t h at SP m u st b e ad op t ed in car e f or all
p at ien t s, in d ep en d en t ly of t h eir p r esu m ed st at e of
infect ion or not : They are basic t o deliver care t o any pat ient ,
independent ly of t he exist ence of an infect ious- cont agious disease
diagnosis ( E15) .
I n a st udy about biological risk and biosafet y
in n u r ses’ an d n u r sin g au x iliar ies’ daily w or k , m ost
p a r t i ci p a n t s r e v e a l e d t h i s u n d e r st a n d i n g , w h i ch
d e m o n st r a t e s t h e i r co m p r e h e n si o n a b o u t t h e
u n iv er salit y of SP( 8 ). Facilit at or s of HCS- associat ed
infect ion prevent ion and cont rol have been working on
t his underst anding t oget her wit h healt h professionals,
w i t h a v i ew t o cr eat i n g aw ar en ess ab o u t ex i st i n g
exposure, as well as t o est ablish a safet y cult ure.
We observed in report E48 t hat care pract ice
covers specific behaviors t hat m ust be associat ed wit h
SP, in punct ual sit uat ions: I t is t he habit ual pract ice t hat
m ust be used t o w or k in t he hospit al ar ea, w it h all t ypes of
pat ient s, independent ly of t he diagnoses, w hich giv e r ise t o
specific m easu r es ( E4 8 ). Kn ow ledge abou t pr ecau t ion s
b a se d o n t h e t r a n sm i ssi o n o f m i cr o o r g a n i sm s i s
necessary for care delivery t o pat ient s who have been
infect ed or are suspect ed of infect ion w it h pat hogens
w h ose t r an sm ission is ep id em iolog ically im p or t an t ,
m ax im izing t heir pr ev ent ion and cont r ol.
The st at em ent : Look, for m e, t he arrival of AI DS
ent ailed HI , SP em erged, which are universal precaut ions for
prot ect ion against blood, feces, secret ions and aerosols in care
for any pat ient , because it is not writ t en on any pat ient t hat he
h as HI V ( E6 ) r ev eals t h at , alt h ou gh t h is pr ofession al
con sider s t h at SP do n ot depen d on t h e diagn osis,
t he focus of concern is HI V infect ion, m ent ioning t he
l a n d m a r k i n g l o b a l p u b l i c h e a l t h t h a t co m p l e t e l y
changed concept s, v alues, beliefs about t he healt
h-disease pr ocess, at differ ent social lev els, and w hich
b e c o m e s e v i d e n t a s t h e s o u r c e o f c o n c e r n i s
pr of ession al pr act ice.
Blood b or n e in f ect ion an d ot h er b od y f lu id s
alr eady exist ed befor e st udies t hat dem onst r at ed t he
et iopat hogeny of HI V. However, it was on t his occasion
t hat epidem iology and t he prevent ion of occupat ional
ex p osu r e t o b lood b or n e p at h og en s an d ot h er b od y
fluids st ar t ed t o r eceiv e em phasis( 11).
Desp it e ack n ow led g in g t h e ep id em iolog ical
i m p o r t a n c e o f H I V i n f e c t i o n , m a i n l y d u e t o i t s
c o m m u n i t y p r e v a l e n c e , b e y o n d t h i s a s p e c t ,
professionals’ concern oft en is also guided by t he social
represent at ions t his syndrom e is loaded wit h. I t is an
sit uat ion t hat poses r isks, consider ing t hat , w hen w e
select possibilit ies, w e ex clude act ual possibilit ies.
Pr ot ect ion m easu r es f or pr of ession als
N i n e ( 1 1 . 0 % ) s u b j e c t s r e v e a l e d t h e
u n d e r st a n d i n g t h a t SP a r e a i m e d a t p r o f e ssi o n a l
prot ect ion: SP are m et hods we use t o prot ect ourselves against
secret ions. To be prot ect ed against t hese m icroorganism s ( E16) ;
I t is t h e m in im al car e pr of ession als h av e t o t ak e t o av oid
cont am inat ion for t hem selves ( E38) .
Pr ofessionals’ pr ot ect ion is pr esent ed as t he
b asic aim of SP, w h ich clear ly ex p r esses con cer n s
w i t h b i o l o g i c a l r i s k . Pr o f e s s i o n a l s ’ e x p o s u r e t o
b i o l o g i ca l m a t e r i a l h a s b e e n a sso ci a t e d w i t h t h e
t r a n s m i s s i o n o f H CV, H B V a n d H I V( 1 2 - 1 3 ), w i t h
p r e v a l e n c e r a t e s e x c e e d i n g t h o s e f o u n d i n t h e
com m unit y. However, in care, at t ent ion needs t o t urn
t o a collect iv it y ( p at ien t s, p r of ession als, r elat iv es,
com m u n it y ) . Con sid er in g on ly on e of t h e su b j ect s’
n e e d s m e a n s l o si n g t h e o p p o r t u n i t y t o cr i t i ca l l y
est ablish effect ive prot ect ion and safet y m easures for
t hem selv es and ot her per sons.
Pr o t e c t i o n m e a s u r e s i n c a r e f o r p a t i e n t s w i t h
diagn osed in fect ion
Fo u r s u b j e c t s ( 4 . 9 % ) r e v e a l e d t h e
underst anding t hat SP are aim ed at care for pat ient s
w it h d ef in ed d iag n oses, m ain ly w it h in f ect iou s an d
t r ansm issible diseases: SP ar e univ er sal pr ocedur es t hat
have t o be used for car e deliver y t o pat ient s w it h infect ious
diseases [ ...] ( E11) ; SP exist for all t ransm issible diseases ( E20) ;
I t are precaut ions t hat have t o be used wit h all pat ient s according
t o t he diagnosis, t o perform procedures in t hem ( E76) .
Adopt ing SP under t hese cr it er ia only t ur ns
t h e sa f e t y o f ca r e p r o f e ssi o n a l s v u l n e r a b l e : t h e
professionals’ own safet y in t he first place and t hat of
p at ien t s an d p eer s in t h e secon d . Th is p er cep t ion
en t ails aspect s r elat ed t o t h e su bj ect s’ belief s t h at
r isk s ex ist , but in concr et e sit uat ions.
We k now t hat est ablished diagnoses do not
define HCW’ and pat ient s’ exposure, but m erely advise
on cer t ain specific conduct s. Thus, pr ofessionals put
t hem selv es and ot her subj ect s inv olv ed in t he hands
of luck it self. Pat hogen t ransm ission r isk s should not
be ignored as, besides exposure t o know n, em erging
an d r eem er g in g p at h og en s, w e m ay b e liv in g w it h
ot h er m icr oor g an ism s, of u n k n ow n ep id em iolog ical
im por t ance, w hose pr oblem s w e cannot dim ension.
Pr ot ect ion m easur es for pat ient s and pr ofessionals
Th i s g r o u p o f 4 3 ( 5 2 . 4 % ) i n t e r v i e w e e s
declar ed t h at SP aim t o pr ot ect pat ien t s as w ell as
professionals: They are prot ect ion m easures for professionals
as well as pat ient s ( E42) ; I believe t hese are precaut ions you
have t o follow t o prevent infect ion for professionals and pat ient s
( E71) .
The subj ect s’ r efer ences ar e in line w it h t he
CD C’ s p r e c a u t i o n a n d i s o l a t i o n g u i d e( 3 ). Th e y
const it ut e an adequat e v iew fr om t he per spect iv e of
n ot u n der est im at in g r isk s, n eit h er for HCW’ n or for
p a t i e n t s, a n d m a k e p r o f e ssi o n a l s r e sp o n si b l e f o r
im plem ent ing and applying t he pract ices: SP are t hose
pr ecaut ions t hr ough w hich you pr event your self and pr event
infect ion risk for t he pat ient ... ( E69) ; SP are t hose, all t hose
m easur es y ou use t o pr ot ect y our self and ot her colleagues,
besides pat ient s ( E46). Wit hout t his precious aw areness
of pr of ession als’ in div idu al an d social r espon sibilit y,
infect ion pr ev ent ion and cont r ol m easur es cannot be
est ablished in HCS.
Som e int erview ees refer t o t he personal and
p r o f essi o n a l d i m en si o n s o f u si n g SP: SP a r e t h o se
p r ecau t ion s y ou h av e t o ad op t as a p er son , p r of ession al,
pr ot ect ing y our self and t he pat ient , neit her t o cont am inat e
yourself nor t o cont am inat e t he pat ient ( E74). They present
t hat t hese m easures em erge from t he individual as a
hum an being and pr ofessional, in a r elat ion bet w een
persons. We believe t hat one of t he point s of success
f o r t h e i m p l e m e n t a t i o n o f SP i n d a i l y ca r e i s t o
u n d er st an d t h ese in t er p er son al r elat ion s’ sen se of
st r en g t h , as t h ey r ecov er t h e b asic an d n ecessar y
v aluat ion t hat is capable of m ot iv at ing indiv iduals t o
est ablish et hical pract ices for infect ion prevent ion and
cont r ol pr act ices in HCS.
Th e y a l s o c o n s i d e r t h a t S P p r e v e n t
p r o f e ssi o n a l a cci d e n t s a n d t h a t t h e i r r a n g e g o e s
b e y o n d p a t i e n t a n d p r o f e ssi o n a l p r o t e ct i o n , a n d
su g g est t h at in f ect ion su r v eillan ce, p r ev en t ion an d
cont r ol am ong pat ient s should be est ablished by t he
t eam : I t would be a way for you t o prevent a kind of occupat ional
accident . Bot h for ourselves and for pat ient s, not t aking infect ions
from one pat ient t o anot her ( E37) ; I t are t hose basic procedures
t h e en t ir e t eam u ses f or in d iv id u al, collect iv e an d p at ien t
prot ect ion in disease prevent ion ( E56) .
Cr oss in f ect ion is a lar g e p r ob lem in HCS
nowadays. We highlight t hat , wit hout t he t eam ’s effort s
an d w or k , im plem en t in g m easu r es lik e SP becom es
i m p o s s i b l e . Th i s c o n t r i b u t e s t o m a i n t a i n t h e
p r ocess. Join t act ion is cap ab le of m ak in g a lar g e
d if f er en ce, m ot iv at in g , su p p or t in g an d m ain t ain in g
cohesion w it h posit iv e feedback .
On e r e l e v a n t a s p e c t t h a t e m e r g e d f r o m
discour se r efer s t o t he collect iv e r ange of pr ot ect ion
an d t o t h e con sid er at ion of ch an g es est ab lish ed in
t he healt h car e env ir onm ent : They ar e safet y m easur es
aim ed at not t ransport ing infect ions, whet her from pat ient t o
pat ient or t o t he t eam , from pat ient t o t eam and from t eam t o
pat ient ( E66) ; I see SP as all t hese precaut ions t o avoid infect ion,
for m y own and t he pat ient ’s prot ect ion... and t hen not t aking
t his infect ion t o ot her persons, nor from ot hers t o ot hers, nor t o
t he ent ire t eam ... ( E60) .
Art iculat ed act ions t o respect and prot ect any
of t h e su bj ect s in v olv ed in car e r esu lt in collect iv e
pr ot ect ion. Gr eat adv ances w ill be possible w hen all
pr of ession als becom e t r u ly aw ar e of t h e dim en sion
a n d i n d i v i d u a l a n d co l l ect i v e ex t en t s o f i n f ect i o n
pr ev ent ion and cont r ol pr act ices in HCS.
How ev er, t alk in g abou t t h e im plem en t at ion
of SP im plies t he availabilit y of an organizat ional and
work st ruct ure t o perm it t hese act ions( 4, 6). One of t he
su b j ect s ex p r esses t h i s p er cep t i o n : SP i s a w ay o f
prot ect ing ourselves and prot ect ing pat ient s and t heir com panions
in t he exchange of m icrobes, of realizing t he procedure calm ly, it
is no use if you have t he knowledge but you neit her have t he
condit ions t o w ork, nor aw areness of t he im port ance ( E50) .
Th is pr of ession al h igh ligh t s t h at k n ow ledge
of SP is not sufficient and t hat condit ions t o put t hese
a c t i v i t i e s i n t o p r a c t i c e a r e f u n d a m e n t a l . Th e
p r ecar iou sn ess of w or k in HCS h as b een a r ealit y,
cr eat i n g st r ess an d ex h au st i o n , b esi d es ex p o si n g
p e r s o n s d i r e c t l y r e l a t e d t o c a r e , l e a d i n g t o
unsat isfact or y car e qualit y.
I n t w o r epor t s, w e found t hat nur ses r ev eal
concern about t hem selves and pat ient s. However, wit h
r esp ect t o p at ien t s, at t en t ion is lim it ed t o sp ecif ic
sit uat ions: SP ar e appr opr iat e m easur es w e use t o pr ot ect
ourselves and, depending on t he sit uat ion, t o prot ect pat ient s.
E.g.: leukem ia ( E10) ; t he m easures used so as not t o cat ch
infect ions. Not t o cont am inat e m yself in general, but t o prot ect
t he pat ient at t im es ( asept ic t echniques) ...( E68). They ignore
t hat , no m at t er pat ient s’ condit ions or t he procedures
t hey will be subj ect t o, t he risk of infect ion is int rinsic,
and pr ofessionals ar e r esponsible for int er vening and
m inim izing t hese possibilit ies.
Alt hough t hese are pert inent punct ual aspect s,
w e need t o cont inuously est ablish t he pat ient safet y
cult ure, and t his includes: equit y and equalit y in care.
Ho w e v e r, t h i s i m p l i e s t h a t p r o f e ssi o n a l s a r e n o t
con sid er ed an y less im p or t an t t h an p at ien t s. Bot h
should be t aken int o account equally. I f not , we m ay
fall int o pract ices wit h irrem ediable consequences. We
believe t hat all sides will benefit if we incorporat e t his
under st anding in pr act ice.
W i t h i n t h e u n d e r st a n d i n g o f SP, r e p o r t s
d e m o n s t r a t e t h a t p r o t e c t i o n a l s o i n c l u d e s t h e
environm ent : SP is a set of at t it udes, professional post ure,
t echnique in which you perform care safely, prot ect ing pat ient s,
our selves, pr ofessionals and t he envir onm ent , because ot her
elem ent s are involved in care pract ice ( E47) .
En v i r o n m e n t a l c o n t r o l i s p a r t o f S P
m easur es( 3) and is associat ed w it h infect ions in HCS,
giv in g r ise t o f oci of con t act an d t r an sm ission at a
secondar y but not less im por t ant lev el( 14). Pr ot ocols
need t o be est ablished w hich pr ior it ize t his quest ion,
so as t o guar ant ee high- qualit y and safe pr ocesses.
B e s i d e s i n t e r f e r i n g , e v e n i f s e c o n d a r i l y, i n t h e
occurrence of HCS- relat ed infect ions, SP also prom ot e
all indiv iduals’ com for t and w ell- being.
St andar d pr ecaut ions as hum an car e
Ei g h t n u r se s ( 9 . 8 % ) co n si d e r SP a s ca r e
aim ed at pr ot ect ing pr ofessionals and pat ient s, in a
com p r eh en siv e h u m an car e p er sp ect iv e. Th is v iew
r ev eals t hat t hey look at t he int er per sonal r elat ions
experienced in healt h care: That whole process, t he care
y ou t ak e t o pr eser v e t h e ph y sical, m en t al in t egr it y of t h e
com panion, of t he professional colleagues, our own and m ainly
t he pat ient ’s. I t is a device you have t o work safely, wit h less
risk ( E27) . SP are care we have t o t ake when we are handling
pat ient s, t o prot ect ourselves and t he pat ient , not t o cont am inat e
neit her ourselves nor t he pat ient ( E55) .
Th ese st at em en t s r ef er t o t h e u n iq u e an d
essent ial charact erist ic of Nursing. This care is int rinsic
in v alues t hat pr ior it ize peace, fr eedom , r espect and
lov e, am ong ot her aspect s( 15).
Th ese p r of ession als d em on st r at e a h olist ic
v i ew , ev i d en ced i n t h ei r co n cer n w i t h sa f et y a n d
m ain t ain in g t h e ph y sical an d psy ch ological in t egr it y
of t h e per son s in v olv ed in t h e h ealt h car e pr ocess,
m ainly of pat ient s, and t hat care is perm anent : SP are
t he car e w e have t o t ake in daily car e act ivit ies, dir ect ed at
ourselves... bot h I and he. I believe t hat , when t here’s no m at erial
for w ound dressing, you can´ t do it j ust any w ay ( E73) .
Th ey r ecov er t h e u n d er st an d in g of h u m an
dignit y and r espect , and t hat it is not et hical “ t o do
it j u st an y w ay ”, w hich is a daily exer cise. At cer t ain
i t i s h ar d t o ch o o se b et w een w h at i s et h i cal an d
w h a t i s n e c e s s a r y, i n v i e w o f i n a d e q u a t e w o r k
con d it ion s. Pr of ession als sh ou ld p u r su e r ecog n it ion
and cr it ique in or der t o achiev e et hical car e, as w e
can n ot br eak codes t h at st ain h u m an in t egr it y, an d
adopt an an t i- et h ical at t it u de u n der t h e def en se of
b ein g et h ical.
On e o f t h e s u b j e c t s b r o a d e n s t h e
u n d er st an d i n g of SP as car e b ey on d si t u at i on s of
con t act w it h blood an d body flu ids t o pr ev en t r isk s
and problem s: SP are t he care you t ake when you are going t o
deliver care and have cont act wit h blood, secret ions, t he pat ient
him self, t o prevent furt her com plicat ions not only for t he pat ient ...
but when I prepare serum , m edicat ion... ( E21) .This st at em ent
ev iden ces t h at t h er e ar e ot h er im por t an t act ion s in
care, and t hat t he failure t o m aint ain asept ic principles
can ent ail unw ant ed consequences for pat ient s.
St andard precaut ions as t he use of personal prot ect ive
equ ipm en t ( PPE)
Nine subj ect s ( 11.0% ) r efer r ed t o SP as t he
use of physical barriers: I t hink of PPE, t hat is what it boils
dow n t o ( E45) ; St andard Precaut ions, t hat ’s w hat I am going t o
use t o prot ect t he pat ient from an infect ion and m yself t oo. I use
a m ask, safet y glasses...( E2) ; I believe it ’s what applies t o all
pat ient s, independent ly of t he disease. We use it because it
prot ect s us, it prot ect s t he m ucosa, airways and cont act wit h t he
pat ient ’s body fluids, and in t he opposit e direct ion ( E3) .
Sin ce t h e st ar t of t h e aids epidem ic, w h ich
c u l m i n a t e d i n t h e e s t a b l i s h m e n t o f u n i v e r s a l
p r ecau t ion s( 1 6 ), t h e f ollow in g m easu r es h av e b een
em phasized: use of PPE, hand washing and adequat e
h a n d l i n g o f s h a r p i n s t r u m e n t s a n d n e e d l e s , a s
evidenced in t he following st at em ent s: For m e, it ’s relat ed
t o yourself and t he use of PPE: m ask, safet y glasses, gloves... I
believe ot her it em s would be t he use of t he lead apron, rubber
gloves for HI V pat ient s or double lat ex gloves, hand washing,
discar ding of pier cing and cut t ing m at er ial ( E7) ; SP is hand
w ashing, using a cap, m ask, gow n... discar ding pier cing and
cut t ing m at erial adequat ely, using gloves ( E36) .
Th is is alr eady par t of h ealt h pr ofession als’
collect iv e const r uct ion, alt hough t his does not m ean
f u ll adh er en ce. We in f er t h at low adh er en ce lev els,
m ain ly t o som e PPE, is du e, am on g ot h er r eason s,
t o: u n d er est im at ion or r isk s, u n av ailab ilit y of PPE,
per cept ion t h at t h ey cr eat e ph y sical d iscom f or t f or
p r o f e s s i o n a l s a n d p s y c h o l o g i c a l d i s c o m f o r t f o r
pat ient s, as w ell as lack of clarit y about sit uat ions in
which t he use of PPE is j ust ified( 4- 9).
Th e se st a t e m e n t s r e v e a l e d t h e a sp e ct o f
h e a l t h p r o f e ssi o n a l s a s a so u r ce o f i n f e ct i o n f o r
pat ient s: if I had an infect ed inj ury, I would have a focus and
I could be t r ansm it t ing it ( E3). This lev el of r eflect ion is
ex alt ed in daily pr ofessional act iv it ies, not only as a
sou r ce of in f ect ion , b u t also as a sou r ce of ot h er
inj uries, result ing from t he lack of a syst em t hat bot h
or ganizes safet y and aim s for safet y.
Alt hough physicians, nur ses and phar m acist s
a r e ca r e f u l a n d t r a i n e d f o r e x ce l l e n t ca r e , t h e i r
p r o f e s s i o n a l p r a c t i c e s r e v e a l h i g h e r r o r r a t e s .
How ever, t hese ar e ignor ed and hav e not st im ulat ed
reflect ions and init iat ives t o prevent t hem , for different
r easons: difficult y t o deal w it h er r or s, r esult ing fr om
t h eir acad em ic t r ain in g , w h ich im p oses a p r act ice
where errors are not allowable and professionals need
t o be infallible( 17).
Ot h er com p on en t s t h at h av e r en d er ed t h is
per cept ion difficult r efer t o under st anding t he et hics
of car e. I t is ev ident t hat t he good r eigns ov er ev il.
However, when we believe in our subj ect ivit y t hat our
act ions ar e t he good, ev en if t he ending is not , t he
feeling of dut y accom plished and t he sat isfact ion of
an im m ediat e response t o t he pat ient ’s needs, wit h a
p o si t i v e / n e g a t i v e o u t co m e , r e p l a ce t h e f e e l i n g s
der iv ed fr om er r or s dur ing t he pr ocess, in w hich t he
assessm ent of t his fact is not consider ed necessar y.
Mor eo v er, assessin g er r or sit u at ion s p laces
t he indiv idual in t he condit ion of v iolat ing st andar ds,
p r o t o co l s, v a l u es, et c., a n d t h i s t y p e o f p er so n a l
ex p osu r e h as n ot b een con st r u ct ed in ou r cu lt u r e.
Delaying or not per for m ing evaluat ions of success or
e r r o r si t u a t i o n s m e a n s l o si n g t h e o p p o r t u n i t y t o
est ablish safe car e pr ocesses. I f w e w ant t o m odify
o u r c a r e r e a l i t y, w e n e e d t o a d d p l a n n i n g a n d
perm anent assessm ent int o our care pract ice, in order
t o pr ev ent sit uat ions t hat t hr eat en t he m aint enance
and preservat ion of life in it s full sense.
FI NAL CONSI DERATI ONS
S t a n d a r d Pr e c a u t i o n s c o n t a i n t h e b a s i c
p r i n ci p l e s o f a l l i n f e ct i o n p r e v e n t i o n a n d co n t r o l
m easu r es. Par ad ox i cal l y, car e- r el at ed ex p osu r e t o
in f ect ion s in HCS is a p er m an en t in t h e sear ch t o
m a i n t a i n a n d / o r r e c o v e r l i f e , w h e t h e r t h r o u g h
pr ofession al act iv it ies or by t h e n eed t o r eest ablish
a n d m a i n t a i n h e a l t h . I t s r a n g e g o e s b e y o n d t h e
ot her m anual of st andar ds and pr ot ocols. SP inv olv e
p e r m a n e n t su r v e i l l a n ce a n d a sse ssm e n t o f ca r e
act ions. Guides and prot ocols are im port ant in infect ion
prevent ion and cont rol m easures in HCS, but are not
su fficien t . Th ey cer t ain ly per m it t h e or gan izat ion of
w ork t o t he benefit of t he safet y syst em .
The underst anding revealed by m ost subj ect s’
d i sco u r se sh o w s SP a s p r o t e ct i o n m e a su r e s f o r :
p a t i e n t c a r e i n d e p e n d e n t l y o f t h e d i a g n o s i s ;
p r o f e s s i o n a l s ; p r o f e s s i o n a l s a n d p a t i e n t s ; c a r e
deliv er y t o pat ien t s w it h diagn osed in f ect ion . Ot h er
n u r ses in dicat ed SP as: car e t o pr ot ect su bj ect s of
t h e h e a l t h ca r e p r o ce ss a n d t h e u se o f Pe r so n a l
Prot ect ive Equipm ent ( PPE) . The disclosed know ledge
lev els seem t o be adequ at e for t h e im plem en t at ion
of SP in daily pract ice. How ev er, w e did not obser ve
t heir solid const ruct ion, in t he whole group, in view of
r ed u ct ion ist an d ev en m ist ak en p er cep t ion s ab ou t
t heir range, which m akes t he social funct ion of t hese
m easu r es v u ln er ab le.
We believe t hat t he underst anding of SP, which
refers t o individuals’ cognit ive, affect ive and behavioral
aspect s, int er fer es in t he for m at ion and m aint enance
of at t it udes t hat are coherent wit h infect ion prevent ion
and cont rol in HCS. Our findings, which m ay apply t o
o t h er r eal i t i es, i n d i cat e t h e n eed f o r i n st i t u t i o n al
inv est m ent s in nur sing com pet ency t r aining for t his
p u r p o s e , u s i n g d i f f e r e n t s t r a t e g i e s , p a r t i c u l a r l y
p er m an en t an d con t in u in g ed u cat ion . Com p et en cy
developm ent skills for HCS- relat ed infect ion prevent ion
a n d c o n t r o l n e e d t o b e e x p l o r e d( 1 8 ), m a i n l y i n
professionals who are key elem ent s in t he nursing and
m ult idisciplinary t eam s. We believe t hey can facilit at e
t he pract ical im plem ent at ion of infect ion prevent ion and
cont rol m easures in t he work process of HCS.
I t should be em phasized t hat m aking possible
per m anent and cont inuing educat ion act iv it ies is not
sufficient . Ther e is a need t o r ev iew how t hese ar e
r e a l i z e d , a s t h e a t t i t u d e o f m e r e i n f o r m a t i o n
t r ansm ission, in line w it h t radit ional pedagogy, does
not at t end t o t he needs of t he post - m oder n societ y.
K n o w l e d g e c o n s t r u c t i o n s h o u l d b e g u i d e d b y
significant exper iences, in a dialogic appr oach. I f t he
healt h t eam is aw ar e of SP m easur es, accom panied
b y t h e su st en t ion of w or k or g an izat ion in a b r oad
sense, in our opinion, we will be m oving t owards et hical
a n d e s t h e t i c r e s p o n s e s t o p r e v e n t a n d c o n t r o l
infect ions associat ed w it h HCS.
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17. Leape LL. Error in m edicine. JAMA 1994; 272( 23) : 1851- 7. 18. Tipple AFV, Per eira MS, Hayashida M, Mor iya TM, Souza ACS. O ensino do cont r ole de infecção: um ensaio t eór ico-pr át ico. Rev Lat in o- am En fer m agem 2 0 0 3 ; 1 1 ( 2 ) : 2 4 5 - 5 0 .
