JSUR Journal

Introduction

Bloodborne occupational exposure, defined as accidental percutaneous or mucocutaneous contact with pathogen-contaminated blood, body fluids, or sharps during patient care [1], remains a critical global healthcare hazard. Prevention effectiveness directly impacts both healthcare worker safety and patient care quality. China's 2009 "Guidelines for the Prevention of Occupational Exposure to Bloodborne Pathogens" established prevention standards for HIV, HBV, and HCV [2]. Surgical personnel face heightened risks due to their work environment, characterized by frequent sharp instrument use and blood exposure [3]. While research often focuses on operating room nurses and surgeons, comparative studies involving surgeons, anesthesiologists, and nursing assistants are limited. High-risk moments include suture needle injuries, surgical incision injuries, and blood/body fluid splashes [4]. Anesthesiologists are also at risk during invasive procedures like lumbar punctures [5]. Beyond health risks and increased stress [6], bloodborne exposure reduces surgical team efficiency. Enhancing surgical staff's knowledge and awareness of bloodborne pathogens is therefore crucial. However, existing studies exhibit limitations in multi-position comparisons, analysis of knowledge-behavior gaps, and development of targeted interventions. This study aims to systematically compare exposure characteristics across surgical roles, analyze multidimensional influencing factors using the KAP model, and provide evidence for developing stratified, precise protective interventions.

Methods

Study Design and Participants

A cross-sectional study was conducted at the surgical anesthesia center of a tertiary hospital in Guangdong Province. Cluster sampling enrolled all eligible on-duty staff (N=73). Inclusion criteria: 1) Direct involvement in surgical operations; 2) Employment duration ≥3 months; 3) Provision of informed consent. Exclusion criteria: 1) Trainees or standardized training personnel; 2) Questionnaires with <90% completion rate after two reminders. Based on the Krejcie & Morgan formula (95% confidence level, 5% margin of error), the minimum sample size was 66; our sample size (73) met statistical requirements.

Survey Instrument and Data Collection

Data were collected anonymously via the "Questionnaire Star" electronic platform. The questionnaire comprised four sections:

• Demographics: 14 items (gender, age, position, work experience, title, education, prior exposure history, exposure details).
• Knowledge: 13 items on bloodborne pathogen transmission, standard precautions, post-exposure management (Cronbach's α = 0.81, CVI = 0.89).
• Attitude: 5 items on perceived importance of protection and preventive measures.
• Behavior: 4 items, including scenario-based questions (e.g., "Sort steps for intraoperative needlestick injury management") validated by two infection control experts.

Quality control measures included: IP restriction (one response per IP), embedded attention checks (e.g., reverse-scored items), time thresholds (<120 s or >900 s excluded), and dual independent data cleaning (multiple imputation for missing values). The response and valid questionnaire rates were both 100%.

Statistical Analysis

Data were analyzed using SPSS 25.0. Categorical data were presented as frequencies and percentages; continuous data as mean ± Standard Deviation (SD). Group comparisons used independent samples t-tests (two groups) or one-way ANOVA (multiple groups). Categorical variables were compared using χ² tests or Fisher's exact test. Statistical significance was set at p < 0.05 (two-tailed).

Results

Participant Characteristics

All 73 distributed questionnaires were completed (100% response rate). Participants' mean age was 28.85 ± 0.81 years. Demographic and occupational exposure characteristics are detailed in Table 1.

Table 1: Participant Demographics and Exposure History (n=73).

Knowledge of Bloodborne Pathogen Protection

The overall knowledge correct rate was 70.60%. Significant variation existed across items. While knowledge of basic risks (e.g., infection risk after positive patient sharps injury: 100% correct) was high, understanding of specific concepts like HIV exposure level grading (15.07% correct) and standard precaution components (27.40% correct) was poor. Details are presented in Table 2.

Table 2: Knowledge Assessment Results (n=73).

Attitudes Towards Protection

Attitudes towards protection were generally positive (Table 3). Most staff recognized the value of Hepatitis B vaccination (95.89%) and reported frequently performing key protective behaviors: checking for hand skin damage before patient contact (38.36% always, 57.53% sometimes), wearing gloves during blood/body fluid contact (78.08% always), and performing hand hygiene after patient contact (71.23% always).

Table 3: Attitudes Towards Protection (n=73).

Protective Behaviors

The overall correct rate for behavioral knowledge was low (52.06%). While 90.41% expressed willingness to participate in training, only 65.75% reported educating patients/families about bloodborne diseases. Error rates were high for procedural knowledge: 68.49% incorrectly identified sharps injury management steps, and 35.62% misunderstood post-exposure prophylaxis principles (Table 4).

Table 4: Protective Behaviors and Behavioral Knowledge (n=73).

Factors Influencing Knowledge Scores

Position and education level significantly influenced knowledge scores (p < 0.01). Surgeons scored highest (55.00 ± 6.83), followed by nurses (52.35 ± 6.88), anesthesiologists (50.83 ± 5.57), and nursing assistants (42.27 ± 2.61). Doctoral degree holders scored highest (61.67 ± 12.58), while those with high school education or below scored lowest (42.50 ± 2.67). Age and title also showed significant associations (p < 0.05). Gender, work experience, vaccination status, teaching activity, training frequency, and prior exposure history did not significantly affect scores (Table 5).

Significant values: Bolded; p < 0.05, p < 0.01 (two-tailed). Assoc. = Associate; HS = High School.

Table 5: Factors Associated with Knowledge Scores.

Discussion

This KAP-model study identified a significant gap between knowledge acquisition and protective behaviors among surgical staff concerning bloodborne pathogen exposure. While the overall knowledge correct rate (70.60%) reflected adequate theoretical understanding, critical deficiencies emerged in applied knowledge (e.g., HIV exposure grading: 15.07% correct, standard precaution components: 27.40% correct) and procedural knowledge (sharps injury management: 68.49% incorrect, PEP principles: 35.62% incorrect) [7-12]. This disconnect is consistent with findings by Lee et al. [13], highlighting that theoretical knowledge alone does not guarantee safe practices, particularly in high-pressure surgical scenarios. The predominance of passive lecture-based training likely contributes to this gap, failing to adequately prepare staff for translating knowledge into action during emergencies [14]. Simulation training, drills, and scenario-based learning are demonstrably more effective for building high-risk response capabilities [14]. Position and education level were key determinants of knowledge scores (p < 0.01). Surgeons scored highest (55.00 ± 6.83), reflecting the direct impact of high-risk tasks on systematic learning. However, scores among anesthesiologists (50.83 ± 5.57) and nurses (52.35 ± 6.88) indicated persistent challenges in complex scenario management, suggesting current training may overlook position-specific needs (e.g., needle handling post-anesthesia puncture). Nursing assistants constituted the most vulnerable group (42.27 ± 2.61), linked to lower education levels (11.00% high school or below) and lack of targeted training. Crucially, 31.30% of reported exposures occurred during waste handling – a primary responsibility for assistants. Their higher rates of delayed exposure reporting likely stem from inadequate emergency knowledge and complex reporting procedures, aligning with WHO concerns regarding non-medical technical staff protection [15-17].

To address these findings, we propose a tiered intervention strategy based on position-specific risk profiles and competency needs:

• High-Risk Positions (Surgeons, Anesthesiologists): Implement advanced complex scenario simulation training (e.g., intraoperative hemorrhage control, non-contact sharps transfer techniques). Integrate "standardization of intraoperative sharps handling" into performance evaluations to reinforce behavioral compliance.
• Medium/Low-Risk Positions (Nurses, Nursing Assistants): Develop standardized operational modules (e.g., waste segregation protocols, PPE donning/doffing). Utilize a hybrid "micro-lessons + situational drills" teaching model. For nursing assistants, augment training with visual operation guides (e.g., pictograms in waste areas) and regular skills competitions to enhance engagement and compliance.
• System-Level Safeguards: Integrate key metrics ("sharps injury management compliance rate," "post-exposure reporting timeliness") into medical quality sensitive indicator monitoring. Establish a dual-track competency assessment based on position and education level, mandating protection knowledge certification for non-clinical personnel before duty commencement. Studies support that stratified training improves protection awareness and reduces exposure risk [18].

Limitations

This study has limitations. The sample was drawn from a single tertiary hospital in Guangzhou, limiting regional generalizability. Trainees and standardized training personnel were excluded, creating a gap in understanding this subgroup. While efficient, the self-reported survey design carries inherent risk of social desirability and recall bias. Future multi-center studies encompassing diverse hospital levels and incorporating mixed methods (e.g., surveys, interviews, direct observation) are recommended to deepen understanding of the knowledge-behavior gap causes and intervention effectiveness.

Conclusion

This study confirms a significant knowledge-practice gap in bloodborne pathogen protection among surgical staff, driven primarily by position type and education level. Passive knowledge acquisition is insufficient for ensuring safe practices in high-risk surgical environments. Our findings underscore the urgent need for stratified, competency-based training interventions that move beyond theory to emphasize simulation, procedural drills, and position-specific scenarios. Integrating compliance monitoring into quality systems and ensuring competency certification, especially for support staff, are critical system-level enhancements. Implementing the proposed tiered strategy holds promise for reducing occupational exposure risk and optimizing protection for the entire surgical team.

Conflicts of Interest: The authors declare no conflict of interest.

Funding: None

Ethical Approval: This study was exempted from ethical review by the Institutional Review Board of The First Affiliated Hospital of Sun Yat-sen University . As it met the exemption criteria, informed consent requirements were waived in accordance with relevant regulations.

References

1. Huang Q (2023) Analysis of Knowledge and Influencing Factors of Blood-Borne Infectious Disease Protection Among Operating Room Medical Staff in Wuzhou Area. South China Journal of Preventive Medicine 49: 1060-1063.
2. Zhou XX (2022) Survey on Awareness Rate of Blood-Borne Occupational Exposure and Protection Cognition Among Medical Interns. Popular Science & Technology 24: 79-83.
3. Zhu TT (2023) Investigation on Blood-Borne Occupational Exposure and Prevention and Control Among Medical Staff. Chinese Journal of Disinfection 40: 949-951.
4. Li J Y (2022) Investigation on Blood-Borne Occupational Exposure Among Operating Room Physicians in a Class III Grade A Hospital in Henan Province. Henan Journal of Preventive Medicine 33: 230-232.
5. Li RL, Wang L (2022) Research Progress on the Status of Sharp Injuries and Protection Measures Among Operating Room Physicians. Today's Nurse (Mid-Monthly Edition) 29: 5-8.
6. Zhang M, Li Y, Li ZL (2024) Investigation and Analysis of Blood-Borne Occupational Exposure in Operating Rooms. Zhejiang Journal of Traumatic Surgery 29: 398-400.
7. Zhou Y (2021) Survey on the Current Status of Knowledge, Attitude and Behavior of Blood-Borne Infectious Disease Exposure Protection Among Operating Room Nurses. Journal of Medical Pest Control. 37: 578-582+586.
8. Xu YL, Wan X, Li XJ (2021) Survey on the Current Status of Knowledge, Attitude and Practice of Occupational Exposure to Blood-Borne Pathogens Among Operating Room Nurses. Henan Medical Research 30: 4390-4393.
9. Zhang QP (2021) Monitoring and Analysis of Blood-Borne Occupational Exposure Among Medical Staff in a Class III Grade A General Hospital and Protection Countermeasures. Chinese Journal of Disinfection 38: 185-188.
10. Yang WQ, Han L, Zhang Q (2024) Monitoring of Blood-Borne Occupational Exposure and Research on Protection Strategies in a Class III Grade A Traditional Chinese Medicine Hospital from 2014 to 2023. Chinese Journal of Infection Control 23: 1544-1551.
11. van Heuvel Y (2022) Infectious RNA: Human Immunodeficiency Virus (HIV) Biology, Therapeutic Intervention, and the Quest for a Vaccine. Toxins 14: 138.
12. Xie ML, Zhang ZY (2020) Survey on Cognition and Self-Protection Ability of Blood-Borne Occupational Exposure Among Hospital Workers. Journal of Hospital Administration of Chinese People's Liberation Army 27: 342-345+349.
13. Lee JB, Choi JS (2023) Epidemiology of Occupational Exposure to Blood-Borne Viruses, Postexposure Prophylaxis and Seroconversion over 10 Years among Healthcare Workers. J Hosp Infect 135: 18-27.
14. Kang M (2022) The role of simulation-based training in healthcare-associated infection (HAI) prevention. Antimicrob Steward Healthc Epidemiol 2: e20.
15. Guo XY (2024) Construction and Validation of a Nomogram Prediction Model for Blood-Borne Occupational Exposure Among Medical Staff. Modern Preventive Medicine 47: 2901-2902.
16. Sakr CJ (2021) Occupational Exposure to Blood-Borne Pathogens among Healthcare Workers in a Tertiary Care Center in Lebanon. Annals of Work Exposures and Health 65: 475-484.
17. Wilburn SQ, Eijkemans G (2004) Preventing Needlestick Injuries among Healthcare Workers: a WHO-ICN Collaboration. Int J Occup Environ Health 10: 451-456.
18. Zhang S (2021) Survey on the Current Status of Blood-Borne Occupational Exposure and Protection Cognition Among Operating Room Staff in a Large Class III Grade A Hospital. Occupational Health and Emergency Rescue 39: 192-196.