A Causal Model of Factors Influencing Adherence to Standard Precautions Practices Among Chinese Emergency Nurses: A Cross-sectional Study


  • Yanfang Huang PhD (Candidate), Faculty of Nursing, Chiang Mai University, Thailand.
  • Wanchai Lertwatthanawilat Faculty of Nursing, Chiang Mai University, Thailand.
  • Pimpaporn Klunklin Faculty of Nursing, Chiang Mai University, Thailand.
  • Akeau Unahalekhaka Faculty of Nursing, Chiang Mai University, Thailand.




Attitude, Causal model, Emergency nurses, Infection control, Infection prevention climate, Intention, Nursing, Standard precautions, Theory of Planned Behavior


Standard precautions are essential to prevent cross-infections among emergency nurses, particularly during a pandemic of infectious diseases. However, poor adherence to such standard precautions is an ongoing global health system problem. This may be due to nurses’ lack of adequate understanding regarding the influencing mechanisms of various factors that cause cross-infection in practice. In this cross-sectional study, we rigorously utilized the Theory of Planned Behaviors as a guiding framework to develop and test a causal model of factors influencing adherence to standard precautions practices among Chinese emergency nurses. From July 2022 to February 2023, purposive sampling was used to recruit 310 emergency nurses from eight tertiary hospitals in four cities in Sichuan Province, China, during the COVID-19 pandemic. Research instruments included a Demographic Data Form, the Standard Precautions Questionnaire, the Leading Culture of Quality in Infection Prevention Scale, and the Compliance with Standard Precautions Scale. Data were analyzed using descriptive statistics and the Analysis of Moment Structure program to test the influencing factors.

The final model of factors influencing adherence to standard precautions practices among Chinese emergency nurses explained 36% of the variance. This model provides a practical tool for understanding and improving adherence to standard precautions. Infection prevention climate and intention can affect adherence practices directly. In addition, nurses’ attitudes to standard precautions, social norms of standard precautions, perceived behavioral control of standard precautions, and infection prevention climate indirectly affected adherence practices through intention as the mediator. Among these factors, infection prevention climate had the most substantial effect on adherence practices. These findings underscore the pivotal role of nursing administrators in highlighting the remarkable benefits of standard precautions, shaping emergency nurses’ positive attitudes and confidence toward standard precautions, and creating a supportive climate for infection control. By implementing these strategies, nursing administrators can significantly improve adherence to standard precautions, ensuring a safer healthcare environment for workers, patients, and the public.


Lam SC. Validation and cross-cultural pilot testing of compliance with standard precautions scale: self-administered instrument for clinical nurses. Infect Control Hosp Epidemiol. 2014;35(5):547-55. doi: 10.1086/675835. DOI: https://doi.org/10.1086/675835

West KH, Cohen ML. Standard precautions--a new approach to reducing infection transmission in the hospital setting. J Intraven Nurs. 1997;20(6 Suppl):S7-10.

World Health Organization. Minimum requirements for infection prevention and control programs. 2019 Nov 18 [cited 2021 Mar 11]. Available from: https://apps.who.int/iris/handle/10665/330080

Editorial board of the Chinese Journal of Emergency Medicine. Expert consensus on prevention and control of hospital infections in emergency departments of county hospitals in China. Chin J Emerg Med. 2020;29(4):461-5. doi:10.3760/cma.j.issn.1671-0282.2020022.002 (in Chinese).

Hoyt KS, Evans DD, Wilbeck J, Ramirez E, Agan D, Tyler D, et al. Appraisal of the emergency nurse practitioner specialty role. J Am Assoc Nurse Pract. 2018;30(10):551-9. doi:10.1097/jxx.0000000000000134. DOI: https://doi.org/10.1097/JXX.0000000000000134

Liang SY, Riethman M, Fox J. Infection prevention for the emergency department: out of reach or standard of care? Emerg Med Clin North Am. 2018;36(4):873-87. doi: 10.1016/j.emc.2018.06.013. DOI: https://doi.org/10.1016/j.emc.2018.06.013

Pan Y, Wang L, Feng Z, Xu H, Li F, Shen Y, et al. Characterisation of SARS-CoV-2 variants in Beijing during 2022: an epidemiological and phylogenetic analysis. Lancet. 2023;401(10377):664-72. doi:10. 1016/S0140-6736(23)00129-0. DOI: https://doi.org/10.1016/S0140-6736(23)00129-0

Zhang B, Kang W, Xiong S, Huang X, Chen P, Huang J, et al. Changes in the epidemiological characteristics of prehospital emergency services before and during the COVID-19 pandemic, Chengdu, 2016–2021. Sci Rep. 2023;13(1):7796. doi: 10.1038/s41598-023-34852-y. DOI: https://doi.org/10.1038/s41598-023-34852-y

Mynaříková E, Jarosova D, Janíková E, Plevová I, Polanská A, Zelenikova R. Occurrence of hospital-acquired infections in relation to missed nursing care: a literature review. Cent Eur J Nurs Midwifery. 2020;11(1):43-9. doi:10.15452/cejnm.2020.11.0007. DOI: https://doi.org/10.15452/cejnm.2020.11.0007

Sharma R, Gupta P, Jelly P. Pattern and serological profile of healthcare workers with needle-stick and sharp injuries: a retrospective analysis. J Family Med Prim Care. 2020; 9(3):1391-6. doi:10.4103/jfmpc.jfmpc_1078_19. DOI: https://doi.org/10.4103/jfmpc.jfmpc_1078_19

Jiang J, Liu Y, Han P, Zhang P, Shao H, Dai Z, et al. Post-traumatic growth among emergency nurses after COVID-19 in Shanghai, China: a qualitative study. BMJ Open. 2024; 14(2):e081212. doi:10.1136/bmjopen-2023-081212. DOI: https://doi.org/10.1136/bmjopen-2023-081212

Holtz HK, Weissinger GM, Swavely D, Lynn L, Yoder A, Cotton B, et al. The long tail of COVID-19: implications for the future of emergency nursing. J Emerg Nurs. 2023; 49(2):198-209. doi:10.1016/j.jen.2023.05.00. DOI: https://doi.org/10.1016/j.jen.2022.10.006

Simic MR, Porter JE, Peck B, Mesagno C. “I don’t really wanna go back. I know what I’ve got in front of me.” lived experiences of emergency nurses 2 years into the global COVID-19 pandemic. J Emerg Nurs. 2024;50(2):273-84. doi:10.1016/j.jen.2023.11.011. DOI: https://doi.org/10.1016/j.jen.2023.11.011

Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50(2):179-211. doi:10.1016/0749-5978(91)90020-T. DOI: https://doi.org/10.1016/0749-5978(91)90020-T

Sin CS, Rochelle TL. Using the theory of planned behavior to explain hand hygiene among nurses in Hong Kong during COVID-19. J Hosp Infect. 2022;123:119-25. doi:10.1016/j.jhin.2022.01.018. DOI: https://doi.org/10.1016/j.jhin.2022.01.018

Young SD, Goldstein NJ. Applying social norms interventions to increase adherence to COVID-19 prevention and control guidelines. Prev Med. 2021;145:106424. doi: 10.1016/j.ypmed.2021.106424. DOI: https://doi.org/10.1016/j.ypmed.2021.106424

Smith SR, Hagger MS, Keech JJ, Moyers SA, Hamilton K. Improving hand hygiene behavior using a novel theory-based intervention during the COVID-19 pandemic. Ann Behav Med. 2022;56(11):1157-73. doi: 10.1093/abm/kaac041. DOI: https://doi.org/10.1093/abm/kaac041

Erasmus V, Otto S, De Roos E, van Eijsden R, Vos MC, Burdorf A, et al. Assessment of correlates of hand hygiene compliance among final year medical students: a cross-sectional study in the Netherlands. BMJ Open. 2020;10(2):e029484. doi: 10.1136/bmjopen-2019-029484. DOI: https://doi.org/10.1136/bmjopen-2019-029484

Smiddy MP, R OC, Creedon SA. Systematic qualitative literature review of health care workers’ compliance with hand hygiene guidelines. Am J Infect Control. 2015;43(3):269-74. doi: 10.1016/j.ajic.2014.11.007. DOI: https://doi.org/10.1016/j.ajic.2014.11.007

Cruz JP. Infection prevention climate and its influence on nursing students’ compliance with standard precautions. J Adv Nurs. 2019;75(5):1042-52. doi: 10.1111/jan.13904. DOI: https://doi.org/10.1111/jan.13904

Ajzen I. The theory of planned behaviour: reactions and reflections. Psychol Health. 2011;26(9):1113-27. doi: 10.1080/08870446.2011.613995. DOI: https://doi.org/10.1080/08870446.2011.613995

Ajzen I. The theory of planned behavior: frequently asked questions. Hum Behav Emerg Techol. 2020;2(4):314- 24. doi:10.1002/hbe2.195. DOI: https://doi.org/10.1002/hbe2.195

Moon JE, Jang KS. The performance of healthcare-associated infection control guideline among hospital nurses: a structural equation model. Iran J Public Health. 2018;47(5):648-57. PMID: 29922606.

Godin G, Kok G. The theory of planned behavior: a review of its applications to health-related behaviors. Am J Health Promot. 1996;11(2):87-98. doi:10.4278/0890-1171-11.2.87. DOI: https://doi.org/10.4278/0890-1171-11.2.87

Kim NS, Choi SE. Factors affecting the performance of infection control of multi-drug resistant organisms in intensive care unit nurses of general hospitals based on the theory of planned behavior: the mediating effect of intention. Res Community Public Health Nurs. 2023;34(3):183-95. doi:10.12799/rcphn.2023.00150. DOI: https://doi.org/10.12799/rcphn.2023.00150

Seong M, Bae K. A study of pandemic prevention health behavior in adults. Int J Environ Res Public Health. 2022;19(13): 8181. doi:10.3390/ijerph1913818. DOI: https://doi.org/10.3390/ijerph19138181

Pan C, Pang JJ, Cheng K, Xu F, Chen YG. Trends and challenges of emergency and acute care in Chinese mainland: 2005-2017. World J Emerg Med. 2021;12(1):5-11. doi:10.5847/wjem.j.1920-8642.2021.01.001. DOI: https://doi.org/10.5847/wjem.j.1920-8642.2021.01.001

Bentler PM, Chou CP. Practical issues in structural modeling. Sociol Methods Res.1987;16(1):78-117. doi: 10.1177/0049124187016001004. DOI: https://doi.org/10.1177/0049124187016001004

Michinov E, Buffet-Bataillon S, Chudy C, Constant A, Merle V, Astagneau P. Sociocognitive determinants of self-reported compliance with standard precautions: development and preliminary testing of a questionnaire with French health care workers. Am J Infect Control. 2016;44(1):14-9. doi: 10.1016/j.ajic.2015.07.041. DOI: https://doi.org/10.1016/j.ajic.2015.07.041

World Health Organization. Process of translation and adaptation of instruments. 2018 [cited 2021 July 25]. Available from: https://www.who.int/substance_abuse/research_tools/translation/en/

Pogorzelska-Maziarz M, Nembhard IM, Schnall R, Nelson S, Stone PW. Psychometric evaluation of an instrument for measuring organizational climate for quality: evidence from a national sample of infection preventionists. Am J Med Qual. 2016;31(5):441-7. doi: 10.1177/1062860615587322. DOI: https://doi.org/10.1177/1062860615587322

Xiong P, Zhang J, Wang XH, Wu TL, Hall BJ. Effects of a mixed media education intervention program on increasing knowledge, attitude, and compliance with standard precautions among nursing students: a randomized controlled trial. Am J Infect Control. 2017;45(4):389-95. doi:10.1016/j. ajic.2016.11.006. DOI: https://doi.org/10.1016/j.ajic.2016.11.006

Pereira VH, Torres LN, Rodrigues NM, Monteiro DAT, Moraes JT, Pereira-Ávila FMV, et al. Compliance with standard precautions by nursing professionals and related factors. Esc Anna Nery. 2021;25(3):e20200193. doi:10.1590/2177-9465-EAN-2020-0193. DOI: https://doi.org/10.1590/2177-9465-ean-2020-0193

Mukhtar K, Javed K, Arooj M, Sethi A. Advantages, limitations and recommendations for online learning during COVID-19 pandemic era. Pak J Med Sci. 2020;36(COVID19-s4): S27-31. doi: 10.12669/pjms.36.COVID19-S4.2785. DOI: https://doi.org/10.12669/pjms.36.COVID19-S4.2785

Liddelow C, Ferrier A, Mullan B. Understanding the predictors of hand hygiene using aspects of the theory of planned behavior and temporal self-regulation theory. Psychol Health. 2023;38(5):555-72. doi:10.1080/0887044 6.2021.1974862. DOI: https://doi.org/10.1080/08870446.2021.1974862

Kim SJ, Lee EJ. Factors influencing emergency department nurses’ compliance with standard precautions using multilevel analysis. Int J Environ Res Public Health. 2021;18(11): 6149. doi:10.3390/ijerph18116149. DOI: https://doi.org/10.3390/ijerph18116149

Curtis SJ, Trewin A, McCormack LM, Were K, McDermott K, Walsh N. Building a safety culture for infection prevention and control adherence at Howard Springs: a workplace survey. Infect Dis Health. 2023;28(1):47-53. doi:10.1016/j.idh.2022.07.004. DOI: https://doi.org/10.1016/j.idh.2022.07.004

Quan M, Wang X, Wu H, Yuan X, Lei D, Jiang Z, et al. Influencing factors on the use of standard precautions against occupational exposures to blood and body fluids among nurses in China. Int J Clin Exp Med. 2015;8(12): 22450-9. PMID: 26885227.

Fishbein M, Ajzen I. Belief, attitude, intention and behavior: an introduction to theory and research: Reading, MA: Addison-Wesley; 1975.

Sheeran P, Trafimow D, Armitage CJ. Predicting behaviour from perceived behavioural control: tests of the accuracy assumption of the theory of planned behaviour. Br J Soc Psychol. 2003;42(Pt 3):393-410. doi: 10.1348/014466603322438224. DOI: https://doi.org/10.1348/014466603322438224

Wang C, Jiang W, Yang K, Yu D, Newn J, Sarsenbayeva Z, et al. Electronic monitoring systems for hand hygiene: systematic review of technology. J Med Internet Res. 2021;23(11):e27880. doi: 10.2196/27880. DOI: https://doi.org/10.2196/27880




How to Cite

Huang Y, Lertwatthanawilat W, Klunklin P, Unahalekhaka A. A Causal Model of Factors Influencing Adherence to Standard Precautions Practices Among Chinese Emergency Nurses: A Cross-sectional Study. PRIJNR [Internet]. 2024 Jun. 1 [cited 2024 Jul. 12];28(3):525-36. Available from: https://he02.tci-thaijo.org/index.php/PRIJNR/article/view/267631