The ethical and pedagogical effects of modeling “not-so-universal” precautions

Abstract

Aim: We sought to understand current medical students’ levels of training and knowledge, and their attitudes regarding universal precautions practices and underlying professional and ethical issues.

Method: A total of 54 US medical students at two schools were interviewed to determine the level of understanding and training students receive about universal precautions, their feelings about the effectiveness (or ineffectiveness) of universal precautions, the frequency and kinds of universal precautions used by healthcare professionals as observed by medical students, and students’ perspectives about the lack of or inconsistent use of universal precautions.

Results: Pre-clinical students focused on safe-sex practices among students and professionals, as well as simple, important acts to protect oneself against infection and disease, such as hand-washing. Clinical students, on the other hand, had more exposure to observing and practicing universal precautions, thus presented us with more, in-depth responses pertaining to inconsistent and ineffective use of universal precautions among peers and role models. Several themes were noted from students’ responses.

Conclusion: This study confirms previously acquired data that universal precautions are not consistently or appropriately used by healthcare professionals, it is a significant and novel study in that it reveals a hidden, ethical, and clinical problem in medical education.

Introduction

The Occupational Safety and Health Administration (OSHA), the American Medical Association (AMA), the World Health Organization (WHO), and other governing bodies have detailed codes of ethics, as well as policies and laws regulating the use of universal, or standard, precaution procedures among healthcare professionals and students. According to OSHA (2008), universal precautions should be followed by ALL personnel at ALL times on ALL patients. Under these precautions, “blood and certain body fluids of all patients are considered potentially infectious for AIDS [Acquired Immunodeficiency Syndrome], HBV [Hepatitis B Virus], and other blood pathogens” (Centers for Disease Control and Prevention 1996). According to WHO (2003), “among the 35 million health workers worldwide, about 3 million experience percutaneous exposures to bloodborne pathogens each year; two million of those to HBV, 0.9 million to HCV and 170 000 to HIV. These injuries may result in 15 000 HCV, 70 000 HBV and 1000 HIV infections. More than 90% of these infections occur in developing countries.” The WHO has implemented a universal precautions checklist, and has advised healthcare workers to use the checklist. However, these procedures, such as the use of blunt suture needles to prevent percutaneous injuries, are not being widely used (Tuboku-Metzger et al. 2005), and if they are being used by healthcare professionals, it is often after a patient has been identified as having a contractible disease such as AIDS. When universal precautions are not used for every patient, regardless of their seropositive status, healthcare professionals perpetuate the stigmas associated with HIV, HBV, and other contractible diseases, while acting as poor role models to healthcare students, who imitate what they observe rather than acknowledge learned policies and guidelines. In the United States, the AMA recommends all medical students be instructed in universal precautions and OSHA's Bloodborne Pathogens Rule requires annual instruction of universal precautions procedures for healthcare professionals who may be at risk (Diekema et al. 1995). These guidelines provide additional benefits beyond infection control, such as respecting the perceived need of some patients for anonymity, and making irrelevant the HIV status of caregivers practicing universal precautions (Osterman 1995).

Recent studies reveal that students’ knowledge of universal precautions prior to entering residency may be inadequate. Koenig and Chu (1993), for example, revealed that only one half of the students surveyed correctly identified the proper protective equipment needed for procedures that required the use of masks, gloves, and protective eyewear. Ganguly et al. (1999) showed 43% of medical students in three Florida medical schools were noncompliant in practicing universal precautions. And, even though the potential risk of acquiring infection during routine clinical care is on the increase globally, medical students in Germany, for example, overestimated the risk of occupational HIV infection in several clinical settings, such as changing dirty linen or wound dressings (Klewer et al. 2001).

To educate and better prepare medical students, Diekema et al. (1995) developed and implemented a universal precautions training program. The authors assessed the effect of practical training sessions, which used skilled instructors to teach safe performance of bedside invasive procedures, in concert with routine use of universal precautions. After assessing 170 second-year medical and pre-clinical physician assistant students, authors report that following universal precautions training, knowledge scores increased significantly, personal assessments of the risk of developing HIV due to patient care significantly decreased, and willingness to provide patient care for HIV patients increased (Diekema et al. 1995).

However, recent data identifying the impact of universal precautions training programs on pre-clinical and clinical students is scarce, especially data acknowledging how students feel about the effectiveness of universal precautions and the impact of inconsistent use of universal precautions among clinical educators and role models on students’ education, attitudes about communicable diseases, personal and patient care, and subsequent ethical concerns. Training programs may be effective in teaching students about universal precautions and their effectiveness, but without understanding students’ attitudes and feelings about universal precautions, we fail to see why universal precautions may not be taken as seriously or inconsistently used when students advance through residency training and beyond. We also fail to understand why students do not view universal precautions as a morally relevant practice when caring for patients and themselves in the clinical setting. Furthermore, without positive clinical role models who consistently use universal precautions in appropriate ways, proper training will not be enforced and students may develop inappropriate behaviors, for example taking risks, only using precautions when treating infectious patients, and so forth.

From an ethical perspective, justice is called into question when healthcare professionals and students consciously treat patients with communicable diseases different from other patients in their use of universal precautions. For example, if a student were to double-glove before merely touching an AIDS-infected patient, but wears no gloves when touching noninfected patients, such inconsistent and unwarranted behavior singles out the patient diagnosed with AIDS and calls into question the students’ possible lack of knowledge about AIDS and universal precautions practices.

In addition to concerns about fair treatment of patients, students may become fearless, ignoring institutional, state, federal, and global guidelines and rules (e.g., OSHA, WHO) as they take risks even when the level of transmission of an infectious disease is high. Their fearless attitudes and behaviors may result in ethical violations of core principles such nonmaleficence (i.e., we ought to act in ways that do not cause needless harm to others), as well as professional rules and regulations that are designed to keep both patient and practitioner safe regardless of low probabilities of transmission (e.g., HIV).

Furthermore, along with a lack of compliance in using universal precautions, many healthcare professionals, especially operating physicians, fail to report any injuries to themselves or to their patients (Tuboku-Metzger et al. 2005, p. 317). By failing to report occupational injuries resulting in a healthcare worker's or patient's exposure to blood and other body fluids, the healthcare professional is placing the patient and herself/himself at some risk for harmful, transmittable infections. Although many healthcare professionals worldwide would argue that most occupational injuries, especially a patients’ exposure to a healthcare worker's blood or body fluids, is irrelevant due to the incredibly low probability of transmission and harm, we must acknowledge that not all healthcare facilities, medical and surgical practices, patient populations, and health worker populations are equal around the world, and that probabilities of transmission will vary accordingly. The failure to report any occupational injuries regardless of where one lives and practices medicine violates ethical principles of beneficence and nonmaleficence, and may infringe upon an individual's autonomous right to take action (e.g., obtain prophylaxis and follow-up care, become more knowledgeable about diseases and disease transmission, etc.). This concern has been examined in medical education as medical students and young interns are encountering occupational exposures to blood and body fluids (Goetz et al. 1992; Osborn et al. 1999). Therefore all healthcare institutions should enforce the use of universal precautions, adopting technologies that prevent injuries and protect healthcare workers and patients from communicable diseases. Furthermore, through stricter, institutional enforcement of universal precautions, healthcare professionals become better role models for healthcare professional students in two ways: by modeling personal and patient safety and by modeling good patient care without discrimination and without perpetuating the associated stigma.

The purpose of this study was to gain an understanding of our current medical students’ perspective on and use of universal precautions. We specifically sought to determine the level of understanding and training students receive about universal precautions, their feelings about the effectiveness (or ineffectiveness) of universal precautions, the frequency and kinds of universal precautions used (or not used) by healthcare professionals as observed by medical students, and students’ perspectives about the lack of or inconsistent use of universal precautions. While understanding healthcare workers’ levels of training and knowledge about universal precautions is important for studies such as this one, especially when identifying individuals who work directly with our students, the purpose of this particular study is to specifically understand our students’ levels of training and knowledge, as well as their attitudes regarding universal precautions practices and underlying professional and ethical issues.

Table

Practice points

Recent studies reveal that students’ knowledge of universal precautions prior to entering residency may be inadequate. When universal precautions are not used for every patient, regardless of their seropositive status, healthcare professionals perpetuate the stigmas associated with HIV, HBV, and other contractible diseases, while acting as poor role models to healthcare students, who imitate what they observe rather than acknowledge learned policies and guidelines. Although universal precautions training, along with occupational bloodborne pathogen exposure management and prevention measures, have greatly improved patient care, increased reportability of needle sticks and other occupational exposures, and increased the level of accurate and consistent use of universal precautions in the clinical setting, such training should also include better role modeling practices and clinical faculty development. Clinical role models and educators should be aware of their own inaccurate or inconsistent uses of universal precautions and how their own safety and patient care may be affected (e.g., discriminating AIDS patients).

Methods

During 2006–2007, a total of nine focus groups, containing 54 volunteer student-participants (34 females and 20 males), ranging in ages 18–26, from two, four-year medical schools in the United States were interviewed by the investigators of this study. Although both schools have an equal ratio of males and females enrolled (50 : 50), there was a disproportionate of female students who volunteered to participate in the study. All students at both medical schools were invited to participate via email invitations and in-person, classroom announcements, both of which included a detailed description of the study (i.e., informational sheet). A total of six focus groups, containing 30 first- and second-year students (19 females and 11 males) were interviewed during their nonclinical training at their respective medical schools. Three focus groups, containing 24 third- and fourth-year medical students (15 females and 9 males), were interviewed during their clinical training at their respective medical schools, with the exception of one group (3 male third-year medical students) who were interviewed during a psychiatry clinical rotation at one of the local hospitals. All IRB guidelines and ethical procedures were followed (i.e., informed consent). All student-participants were asked a pre-established set of open-ended questions designed to provide students with the opportunity to express their beliefs and feelings, as well as disclose their knowledge, level of training, and personal experiences surrounding universal precautions. These open-ended questions were carefully crafted to prompt discussion, giving students the opportunity to think and talk about the concepts of “protection,” “communicable disease,” “universal precautions,” etc. Through these open-ended questions, students were also prompted to use their moral imagination to think about consequences, professional and ethical duties, and individual and collective rights surrounding the use, misuse, or abuse of universal precautions. The pre-established questions used in the recorded interviews are as follows:

1. What can medical students do to protect themselves from communicable diseases such as HIV/AIDS?

2. Do you believe (universal) protections are effective? Why/why not?

3. Do you know of anyone who does not consistently or effectively protect themselves from infection (i.e., universal precautions)?

4. How do you feel about persons who do not consistently or effectively protect themselves (i.e., universal precautions)?

The pre-established questions and responses reported in this article are representative of the second part of our study which focused on universal precautions: the first part involved questions surrounding HIV testing and disclosure for medical students and healthcare professionals and findings are reported in a separate paper titled “The Ethics of HIV Testing and Disclosure for Healthcare Professionals: What do our future doctors think?”. Focus group interviews for the entire study were conducted for 60–75 minutes and recorded using held-hand audio recorders; interviews for this portion of the study took 30–45 minutes depending on the number of participants and individuals in the group (i.e., some students were more vocal than others). All recorded interviews are transcribed and qualitatively evaluated by the project investigators. Both project investigators used thematic data analysis to determine repetitive themes emerging from students’ responses; meaning units were recorded and coded. The project investigators included the authors of this article, both of whom also conducted the focus groups at their respective institutions. The first author analyzed the data, and the second author verified the analysis; both authors are qualitative researchers.

Results

Data revealed that there were no identifiable differences in responses between our male and female students or among students between the two medical schools. There were slight variations in responses between pre-clinical students (first- and second-year medical students) and our clinical students (third- and fourth-year medical students). This was based on our collected data, but informed and supported by the level of experience, types of courses taken (e.g., OSHA training course at the start of the clinical years), and exposure to clinical settings. Pre-clinical students focused on safe-sex practices among students and professionals, as well as simple, important acts to protect oneself against infection and disease, such as hand-washing. Clinical students, on the other hand, had more exposure to observing and practicing universal precautions, thus presented us with more, in-depth responses pertaining to inconsistent and ineffective use of universal precautions among peers and role models. The sub-headings refer to identifiable themes within the data, but are in no way discrete topics.

Protection from communicable diseases

In answering the broad question, “What can medical students do to protect themselves from communicable diseases such as HIV?,” first-year students from both medical schools looked to general ways to protect themselves from communicable diseases, especially STDs, indicating that they and their peers generally do not use IV drugs or engage in unprotected sex as ways to protect themselves. One first-year student explained, “I would say, even in the clinics, always use gloves … put things in the Sharpies container. At least be cautious of that.” Exactly 29 out of the 30 (96.7%) pre-clinical students interviewed focused on safe-sex practices when protecting themselves from HIV, HBV, and other stigmatized diseases. One first-year student explained that unprotected sex happens even with “well-educated” medical students who are not aware of their partners’ sexual history, a fact that her peers did not want to accept. A third student indicated that “we do not do a good enough job with STD education; it can happen to anyone,” and emphasized the need to teach even medical students about safe sex, since many only received an education about abstinence and are “obviously not abstinent.” Although clinical students focused more on universal precautions, three were particularly concerned about the sexual promiscuity among their peers, and felt that medical students and professionals should look at themselves before placing blame on their patients for “risky” behaviors that could harm themselves and others.

Besides discussions surrounding safe sex practices, students at each level of medical training revealed that when given the opportunity to work in clinical settings, they fail to follow universal precautions and the general rules of the medical school, hospitals, and clinics regarding patient and personal safety. Reasons for their noncompliance ranged from “not being exposed to communicable diseases” to “following what their mentors did.” A first-year student at another medical school felt that students “are not responsible keeping after their colleagues and mentors,” believing that peer education about safe sex and the use of universal precautions is important. After getting a general sense of what students thought about protective measures against diseases such as HIV, questions were directed more specifically to the topic of universal precautions.

Universal precautions

The majority (70%) of first- and second-year students we interviewed were unclear as to when universal precautions should be implemented and which protective gear should be used at specific times (e.g., gloves, double gloves, protective eyewear, etc); these pre-clinical students believed precautions only included hand-washing, gloving, and using a biohazard container for sharp needles and instruments. A first-year student from one medical school even admitted to not paying attention during a lecture on universal precautions. Another first-year explained, “When we go to hospitals I think that they give you an orientation of their own, for legal reasons. And it's really boring to go over all the … I mean, it's just over basics. Use gloves, do this thing, call these people if this happens.” Though, another male first-year student, who was particular interested in his formal universal precautions training and AIDS education, stated that education is important for protecting oneself and others and for improving patient care. He explained,

And we even had an AIDS discussion in one of our electives, and the questions that were asked truly blew me away. I honestly did not know there was that much ignorance regarding AIDS in our own medical school class. And so I think in order to avoid discriminating against our patient and in order to protect us … we don’t want to see someone doing a procedure they think isn’t risky because they think they won’t get hurt, and at the same time not discriminating against a patient because they think it's too risky.

Ineffectiveness and inconsistency of universal precautions

Second-year students at one medical school reported that universal precautions are not widely used among their peers because they “don’t look good wearing the recommended goggles” or “the protective gear is uncomfortable.” One second-year student explained that she was not properly taught to wash her hands during a physical exam session; however, her peers interviewed in the focus group argued they were taught the proper procedures, and blamed their friend for not paying attention. Another student in the same focus group argued that even if proper hand-washing procedures are overtly taught, they should be properly modeled by healthcare professionals on a regular basis so as to enforce students’ learning. This was a common perception among all of our focus group participants.

Third- and fourth-year students believed the use of universal precautions was an appropriate way to protect themselves and others, but there were varying responses as to what these precautions included and when they should be used in the clinical setting. Third-year students from both medical schools agreed that precautions are not used as much as recommended due to several factors including: “rushing, or the “urgent need to meet deadlines,” “poor role models,” “forgetting why universal precautions are needed,” and “disagreement on level of universal precautions.” Fourth-year students at one medical school, who have completed rotations and electives in a variety of hospitals and clinics, noted that universal precautions are used more frequently and consistently in bigger cities, but that every doctor and healthcare facility seems to have different rules and regulations. A male fourth-year student shared his experience working with a surgeon who only double gloved for AIDS patients. “In the OR [operating room] when we, like, talk about double gloving, I’ve seen it where somebody says this is an HIV positive patient, “double glove!” And so this is where I go back to where we don’t know who is HIV positive …”

When asking students about the effectiveness of universal precautions, some students (37%) reported that even though the transmission of infectious diseases such as AIDS was low, they felt it was not due to the use of universal precautions, but due to appropriately “picking out which patients were infectious and which were not.” A male first-year student expressed, “I think people might just assume that, just make assumptions that, based on statistics that the person they are looking at is not likely to have a disease, and that the person might be well-educated and look clean cut …” One third-year student explained that, in one urban hospital, universal precautions were only used for those patients who had a communicable disease such as AIDS. Another third-year student confirmed that when there is a patient with AIDS, universal precautions are not consciously used as a method of protecting the healthcare professional and the patient, but used to alleviate irrational fear. A female fourth-year student at the same medical school expressed her feelings of paranoia when working with HIV positive patients: “When I have a patient who is HIV positive on the chart, or Hep C, honestly I get a little more paranoid even if I am just examining their skin. I am just being honest- like it's just something about it and I’m like, why am I paranoid? I am not even drawing their blood because there is no change that anything will happen.”

The ineffectiveness of universal precautions was determined by students as the failure to protect oneself from exposure to blood and other bodily fluids, typically from needle-sticks, either because the procedures or equipment (gloves, goggles, shields, and the recommended care and use of needles) did not work properly or a human error was made. Interestingly, the discussion led to some of the fears and difficulties imagined by medical students when disclosing a needle stick to medical personnel. Students at each level of their training recognized the need to disclose when a needle stick occurs so as to acquire necessary prophylaxis. However, they also recognized how difficult it would be to admit a mistake and to be treated for a possible infectious disease such as AIDS. One first-year student, taking a general position about needle sticks, stated, “Physicians should use universal precautions and just follow the rules when getting needle sticks, etc.” Another first-year student from a different medical school explained that “People may be too afraid to disclose even if they got stuck by a needle.” Three first-year students explained that if they were to acquire an occupational injury they would not want to fill out the paperwork or “go through the red tape,” and thus not disclose their injury. One student in particular complained about the amount of “unnecessary” paperwork after witnessing her clinical advisor complaining and looking for shortcuts.

Discussions about the ineffective or inconsistent use of universal precautions were not separate from discussions about students’ clinical role models, who they felt were important to their universal precautions training and education in communicable diseases and patient care. However, none of the students interviewed talked about positive role models; they only discussed their negative role models who contradicted their formal training, and at times, left the students questioning the meaning of “universal” in universal precautions.

Role models

First-year students at both medical schools suggested that people do not consistently or effectively protect themselves because universal precautions are not enforced. For example, first-year students from one medical school reported that some physicians “don’t always use gloves or wash their hands.” A second- and a third-year student both reported that “people don’t like to wear goggles and stuff,” and “if the attending isn’t wearing them, students don’t wear them.” A fourth-year student at the same medical school admitted having forgotten about the proper procedures (i.e., universal precautions), since he was “trained in the first year and such procedures were not enforced.” Other fourth-year students (77%) explained that inconsistent or ineffective measures of protection generally rested on the lack of good role models in the clinical setting; “role models do not follow universal precautions and students are confused and frustrated about what to do.” Four of these students also pointed out that their mentoring physicians would only use universal precautions for those patients who had AIDS or some other communicable disease. Nevertheless, eight first-year students recognized the unfair treatment of patients when universal precautions are only used for those with hepatitis, HIV, or some other disease that is highly stigmatized. A male first-year student stated, “If, if you would treat a patient differently because they had HIV, then I would argue you’re not practicing universal precautions. Because you should have been treating every patient that way.”

Most of the third- and fourth-year students (91.7%) we interviewed had witnessed during their clinical rotations that physicians and nurses did not always change their gloves after handling blood and other bodily fluids, attributing their failure to change or use gloves to “being overworked,” “forgetful,” or “lazy.” Two students reminded the group that sometimes the lack of universal precautions (e.g., glove use) is due to an inefficient healthcare system or simply a lack of resources. One student, who had been working at a free clinic, explained that only one box of gloves per day was allocated to the free clinic, so healthcare workers had to re-use gloves or not wear any at all. Although students at each stage of their training recognized the obstacles healthcare workers faced in fulfilling the guidelines and rules regarding universal precautions, there were students who told stories about inexcusable, unethical acts, and poor attitudes regarding the safety of patients. For example, one female first-year student expressed her frustration after being yelled at for having told her attending to change his gloves when moving from one patient to the next. She stated, “Until we really have the power to say something, there is not much we can do.”

Discussion

Several unexpected themes and issues arose during our qualitative study, including some of the attitudes and fears students have regarding communicable diseases, patient care, the reporting of mistakes (i.e., needle sticks), and reasons why students and healthcare workers fail to consistently use universal precautions. However, we do recognize the limitations of this study, which include a small sampling group from both clinical and nonclinical participants. Nevertheless, we believe this study is the first step toward future studies that involve not only more participants, but more institutions other than the two we have selected for this study.

Students at both medical schools get a formal education about infectious diseases, including lectures on communicable diseases from clinical, scientific, moral, and psychosocial perspectives, and receive yearly lectures on OSHA standards and their interpretations, however the stigmas and false assumptions about communicable diseases often cloud students’ judgments about their patients and even their own health. Some students interviewed for this study acknowledged their fears in caring for patients with specific diseases such as AIDS, with one student who was questioning her paranoia about touching the skin of an infected patient. Though these students have been taught what HIV and AIDS are, how HIV is transmitted, and how individuals can protect themselves from acquiring HIV/AIDS, it is evident that such irrational fears are present and have the potential to affect patient care. Exacerbating these fears are the clinicians who identify patients as infectious and teach students to use universal precautions with these patients, but fail to use such precautions when exposed to other patients’ blood and other bodily fluids, who are not suspected of having an infectious disease. Simply by entering an infected patient's room and yelling “double glove!” the clinician is confusing the medical student, possibly encouraging an irrational fear, dehumanizing an already vulnerable patient by treating him or her as a threat, and perpetuating the stigmas associated with communicable diseases. Although the purpose of universal precautions is to protect both physician and patient from transmission, regardless if a patient is suspected of having an infectious disease or not, the consistent and universal use of these precautions does not discriminate and does not treat those who are infectious less than human because of their disease.

Besides targeting patients who are infectious for implementing universal precautions, students in this study also identified institutions who followed a different set of guidelines or rules about universal precautions, and negative role models who simply were lazy and failed to wear goggles or change gloves after every patient. Students provided several reasons for why universal precautions may not be consistently used among both student and healthcare worker populations ranging from the ridiculous (e.g., “I don’t look good wearing the goggles”) to the understandable (e.g., not enough time due to “rushing” or “having to meet deadlines”). However, when we found that when one of our students confronted a physician who wore the same gloves from patient to patient and was reprimanded instead of commended for her concern for the safety of her attending and his patients, this role model's behavior was inexcusable. It is this type of situation that not only improperly teaches our students about universal precautions and patient care, but indirectly guides our students to be powerless. This one incident sends the wrong message that even when one is able to find her moral courage to stand up to an authoritative figure and confront a potential problem, she has no power to fix the problem and will be punished or ridiculed for thinking she can. Even though many medical students are knowledgeable in universal precautions, they may be more likely to learn from the hidden curriculum (Hafferty 1998), that is follow the lead of their clinical role models rather than practice what they were formally, or overtly, taught, simply because they are disempowered and believe they should learn from those who are more clinically experienced and supposedly more knowledgeable. Because of these concerns, it is important for clinical mentors to understand what students are thinking and feeling about the uses and abuses of universal precautions, and to educate students regularly about communicable diseases without bias or prejudice, so as to confront rather than perpetuate associated stigmas and to protect students from taking potentially harmful risks.

Although our student-participants identified critical issues hidden beneath the medical curriculum and universal precautions training, such as the perpetuation of stigmas surrounding communicable diseases, and students’ lack of knowledge about the meaning and usefulness of universal precautions, there are limitations to this particular study. For one, we had a small sample size of student-participants (54 total) between the two medical schools and among the different levels of training. Although the size of focus groups was ideal for interviews (no more than six students), a larger sample size would have added to the number and diversity of student narratives we acquired. Nevertheless, the data we acquired were similar between the two medical schools and only differed among the pre-clinical versus clinical students (i.e., clinical students had more to say about their clinical role models, while the pre-clinical students had more to say about their knowledge of communicable diseases such as AIDS and safe-sex practices). Another limitation rests on the format of this study (i.e., open-ended question interviews) where student-participants often veered off from the questions being asked and attempted to focus on emerging topics (e.g., duty to report needle-sticks). At the same time, because of this qualitative study format, students felt more comfortable in telling their stories, challenging their peers, bringing up issues that were on their minds, and held genuine conversations about how they interpreted the questions being asked. While universal precautions training was a focus, a critical, consistent topic that arose among students was their irrational fears about diseases such as AIDS due to the inconsistency or “not-so-universal” precautions that are taught in the hidden curriculum.

Conclusion

Although universal precautions training, along with occupational bloodborne pathogen exposure management and prevention measures, have greatly improved patient care, increased reportability of needle-sticks and other occupational exposures, and increased the level of accurate and consistent use of universal precautions in the clinical setting, such training should also include better role modeling practices and clinical faculty development. Clinical role models and educators should be aware of their own inaccurate or inconsistent uses of universal precautions and how their own safety and patient care may be affected (e.g., discriminating AIDS patients). They should also be more amenable to students’ questions and concerns about possible misuses or abuses of universal precautions. By placing too much emphasis on status or hierarchy in the medical setting, clinical role-models and educators are placing harmful barriers between student and teacher, disempowering students to confront such misuses and abuses of universal precautions, and deterring them from disclosing possibly life-threatening mistakes (e.g., needle-stick accidents), which violates ethical principles, such as nonmaleficence and beneficence and professional standards of practice. While this study confirms previously acquired data that universal precautions are not consistently or appropriately used by healthcare professionals, it is a significant and novel study in that it reveals a hidden, ethical, and clinical problem in medical education: Within the “hidden” curriculum (Hafferty 1998), medical students are inconsistently trained in universal precautions by their clinical role models, which may lead to patient discrimination and the perpetuation of stigma.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.