The present study analyzed the relationship between patient safety culture and nurses' compliance of bloodborne pathogen prevention. When the participants' compliance of prevention of bloodborne pathogens was analyzed according to their demographic and clinical characteristics, compliance was found to be higher among head nurses, those in higher positions, and participants who had not experienced NSSI in the preceding year. This finding was in contrast with previous studies that found no difference in compliance with prevention of bloodborne pathogens based on job position. However, the finding can be compared to previous research that reported compliance was higher among those who had not experienced NSSI than among those who had experienced NSSI [21, 22, 16]. At the hospital where this study was conducted, head nurses and nurses in higher positions are responsible for the overall management of the unit, including monitoring of infection control, instead of providing direct care to patients; this might explain the results indicating higher awareness of infection prevention practices among higher-ranking nurses compared to staff nurses. Thus, to improve compliance with prevention of bloodborne pathogens, education on NSSI should be improved and continuous monitoring of prevention compliance should be implemented.
A significant correlation was seen between the participants' patient safety culture and compliance with prevention of bloodborne pathogens. In terms of patient safety culture, the subcategories of leadership, teamwork, patient safety policy, procedures, knowledge or attitude toward patient safety, patient safety improvement system, and priority of patient safety were significantly correlated, whereas non-punitive responses did not correlate with compliance with prevention of bloodborne pathogens. Although direct comparisons are difficult to make due to the limited number of similar studies, one study reported that perception of patient safety culture in nursing hospital nurses was significantly related to compliance with standard precautions . Thus, as shown in the present study, since patient safety culture, including standard precautions, can influence the prevention of bloodborne pathogens, it is necessary to understand and pay attention to patient safety culture and relevant factors to prevent bloodborne infections .
According to a hierarchical regression analysis analyzing factors that influence compliance with bloodborne pathogen prevention, experience of NSSI and patient safety culture were found to be significant factors. Among the sub-categories of patient safety culture, the significant factors were found to be teamwork, knowledge and attitude toward patient safety, leadership, and priority of patient safety.
First, participants who had never experienced NSSI were found to be more compliant with bloodborne pathogen prevention than those who had experienced NSSI. This finding is in line with that of a previous study that reported higher compliance with practices promoting bloodborne infection control among those who had never experienced blood exposure . Moreover, our finding also agrees with another study reporting higher compliance with standard precautions among those who had never experienced needle stick injuries . This seems to be the case because nurses' compliance with practices that protect them from infection would have prevented NSSI, and the finding further indicates the importance of preventing exposure to blood. Therefore, cases of bloodborne pathogen infections should be introduced in infection prevention training to emphasize the seriousness of the situation, and efforts should be made to help nurses habitually perform practices promoting the prevention of infections. Moreover, nurses' awareness should be improved to encourage them to prioritize their own protection when providing care in situations where bloodborne infections are possible .
NSSI is a major cause of bloodborne infections and, considering that more than half of nurses who experience NSSI encounter repeated injuries [26, 27], it is important to prevent NSSI in the first place. Furthermore, to improve compliance of prevention of bloodborne pathogens, continued safety training on the safe use of syringes and NSSI is necessary. In particular, in the present study, NSSI was seen to occur most often in the process of disassembling needles or sharp instruments, mostly while disposing and washing used instruments and while recapping used needles.
Therefore, these specific cases should be included in periodic infection education for nurses, and further training should be provided on precautions while using sharp instruments. In addition, appropriate administration or legislation should be implemented to prevent the recapping of used needles and to promote the wider use of safe injection devices [16, 28]. Furthermore, we found that nurses received more infection education at hospitals than during their regular nursing curriculum at school. Infection education programs should rather be a part of nursing curricula. It is also crucial to provide access to continuing education in clinical settings [29, 30].
Second, within patient safety culture, the sub-categories of knowledge and attitude toward patient safety, leadership, and priority of patient safety were found to have positive effects on bloodborne pathogen prevention. This result is comparable to previous research findings which suggest that those with higher perception of patient safety culture have higher compliance with standard precautions  and compliance with practices promoting infection control . These findings indicate that it is important to cultivate positive patient safety culture through leadership and that patient safety culture is an important factor in the prevention of bloodborne pathogens. In terms of leadership in patient safety culture, a significant factor in the present study, it was found that leadership WalkRound programs aiming to change patient safety culture awareness inside and outside of South Korea have led to improved and are a meaningful way to improve patient safety culture [31, 32].
The present study is significant because it confirmed how patient safety culture influenced compliance with practices promoting the prevention of bloodborne pathogens as a variable. In other words, the findings of the present study should be considered in developing programs for HAI prevention and training on infections. Moreover, this study used tools of Korean patient safety culture which were developed based on the consideration of Korean culture. A notable difference from the globally used Hospital Survey on Patient Safety Culture (HSOPSC) and Safety Attitudes Questionnaire (SAQ) [33, 34, 35] is the exclusion of questions from patient safety culture tools on the openness of communication, staff distribution, and handover. Instead, the Korean tools used in the present study added questions on policy or procedures, knowledge and attitude toward safety, and priority of patient safety . The tools have different questions probably because the medical system is different and the awareness of patient safety culture in Korea differs from that in other countries.
There are a several limitations to this study that the data were collected through convenience sampling at a general hospital in one city, it is difficult to generalize the findings due to regional bias. Moreover, the number of reports on patient safety incident over the past year exceeded that of NSSI, because the hospital's reporting system includes NSSI as well as pressure ulcers, falls, and near misses.