Prevalence of needle stick and sharp injuries among nursing and midwifery students

Zohreh Khoshnood¹, Esmat Nouhi^2*, Seyed Adel Mahdi³

¹Candidate in Nursing Ph.D. Faculty of Nursing, Medical Science University, Kerman, Iran

²Assistance Professor of Faculty of Nursing, Medical Science University, Kerman, Iran

³Internal Resident, Medical Science University, Kerman, Iran

*Corresponding Author Email: smnouhi@yahoo.com

ABSTRACT:

Introduction: Needle stick injuries (NSIs) caused by sharp objects are the most important issue in exposure of healthcare workers especially nurses to blood borne pathogens. Nursing and midwifery students are highly exposed to the risks as well when they perform clinical trainings. The present study aimed to determine frequency of those injuries and associated factors among nursing and midwifery students affiliated to Kerman University of medical Sciences.

Material and Methods: A cross sectional study method was conducted to recruit 190 nursing and midwifery students who were training in clinical settings. The data was collected using Shiao questionnaire including demographic factors and 25 specific questions regarding history of needle stick and sharp object injuries and associated factors as well as vaccinating against hepatitis B. All statistics were computed by the SPSS software using Chi-square and regression tests.

Results: The study demonstrated that 30.1% of the students experienced the injuries during the previous year and 42.2% were exposed to minimum one injury during their university education. Needle stick injuries were the most common sort of injuries (71.6%). 33.9% of them reported the accident. The most frequent reason of not reporting was their confident of absence of any serious infection in their patients.

Most of student were vaccinated against hepatitis B (93.6%). Students in their second educational year had experienced the most injuries. There was no significant difference between nursing and midwifery students also between students in their internship or earlier clinical trainings considering the frequency of injuries.

Conclusion: The study indicated a relatively high rate of needle stick and sharp objects injuries among nursing and midwifery students in Studies University. Although hepatitis B vaccinations was extensively predicted, but it is recommended to instruct the students to prevent the injuries and intervene appropriately after injuries.

KEYWORDS: Needle stick injuries, sharp injuries, relative factors, and trainee nursing and midwifery students

INTRODUCTION

Needle stick injuries (NSI) are wounds caused by sharps such as hypodermic needles, blood collection needles, iv cannulas or needles used to connect parts of iv delivery systems. A needle stick injury (NSIs) is a percutaneous piercing wound typically set by a needle point, but possibly also by other sharp instruments or objects (Muralidhar, Singh, Jain, Malhotra, and Bala, 2010). Needle stick and sharps injuries (NSIs) are the most efficient method of transmitting blood-borne infections between patients and healthcare staff, and hepatitis B, hepatitis C and human immunodeficiency virus (HIV) are the most common results(Smith, Mihashi, Adachi, Nakashima, and Ishitake, 2006; Smith et al., 2009).

Despite recommendations aimed at reducing NSIs in recent years, these injuries are the most common cause of accidental exposure to and transmission of blood borne pathogens (BBPs) in health care workers (HCWs) (Judith S-C Shiao, McLaws, Huang, Ko, and Guo, 1999). Although the nursing workers are at risk of this events, nursing and midwifery students may be at similar or even greater risk due to their limited clinical experience (Judith Shu-Chu Shiao, Mclaws, Huang, and Guo, 2002).some causative factors are important for NSIs such as the event that cause NSIs, the instrument cause NSIs, the year of entrance to university and location of hospital at which injury occurred.

In the study of Askareian and Malekmakan 27.8% medical, dental, nursing and midwifery students in Shiraz have experienced NSIs once(Askarian and Malekmakan, 2006; Askarian, Malekmakan, Memish, and Assadian, 2012). Ya-Hui Yang found that 50.1% nursing students in Taiwan sustained 1 or more NSIs during survey period(Yang et al., 2004). J.Shiao reported that 87.3% of health care workers had NSIs in Taiwan during a 12-month period(Judith S-C Shiao et al., 1999).

The epidemiology as well as the incidence of NSIs among nursing and midwifery students in Iran has not been clearly reported. The aim of our study was therefore to investigate the prevalence and nature of NSIs among Kerman nursing and midwifery students.

MATERIAL AND METHODS:

Aims

The aim of our study was therefore to investigate the prevalence, nature and relative items of NSIs among Kerman nursing and midwifery students.

The study Design

Our study was a questionnaire-based, cross-sectional study. Our anonymous three-page questionnaire was adapted from questions and items shown to be appropriate during other international investigations conducted among nursing students (Puro, De Carli, Petrosillo, and Ippolito, 2001; Judith Shu-Chu Shiao et al., 2002; Yassi and McGill, 1991). It used sections for demographic items (such as age, sex and year of study), type of device that caused the injury, the event that cause the NSI, and whether the event was reported. We also asked the location where the NSI occurred (nursing laboratory, teaching hospital, labor, operating room), the total number of NSI events and the percent of reporting NSIs. We also asked about HBV vaccination and the way of warding off needles and sharp injuries. The survey instrument was distributed and collected during January 2010 at the end of an exam sessions for each of the 3 years of the program following a verbal briefing by one of the investigators.

Participants

The participants of our study were from Raazi nursing and midwifery school of Kerman medical science university. There were a total of 250 students in all 3 years as follows that 190 of these students answer questionnaires. These 190 students that answer the questionnaires include: second year (n= 81), third year (n=62) and fourth year (n=47).

Validity and reliability

Reliability of the questionnaire was ensured through answering the questionnaires by 20 students in 10 days and the level (r =0.74) of test-retest reliability was identified. Validity of questionnaires was ensured through assessment of some experts of Kerman medical science university.

Ethical considerations

The study was approved by a university ethics committee. The questionnaires were anonymous and there were no penalties or rewards for participation, and students were told that participation was voluntary. The person who entered data had no relation with nursing and midwifery school.

Statistical analysis

Questionnaires were coded and entered into a standard program before being analyzed by statistical software. Methods of inferential statistics Included Chi-square test and logistic regression for categorical variables and student t-test for continuous variables were performed using SPSS version 16. Results were expressed as odds ratios (OR), with 95% confidence intervals (95% CI) and probability (P) values. P values below 0.05 were considered statistically significant throughout.

RESULTS:

Participants

From a group of 250 students, 190 successfully completed questionnaires were obtained. There were 81 students from the second year (42.9% of the total), 62 from the third (32.8%) and 46 from the forth (24.3%). 155 of these students were female (81.6%) and 34 of them were male (18.4%). Their mean age was 24 years (SD: 2.60).133 of participants were nursing (70%) and 57of them were midwifery students (30%). Of them, 172 were right handed (91%) and 17 were left handed (9%). A total of 75% of students had received the full three-dose hepatitis B vaccination schedule and only 6.3 % of them knew their antibody titer of HBV. 61 (32.3%) reported that they use gloves always and only 7(3.7%) said that they use double gloves always. 80 (42.3%) stated that they never used double gloves. 173 said that they never use glasses when they do clinical cares (Table 1).

Table 1- Demographic characteristics of participants (N=190)

	n (%)
Demographics
Female	155(82)
Male	35(18)
Year of study
Second year	81(42.9)
Third year	62(32.8)
Forth year	43(22.8)
Major
Nursing	133(69.8)
Midwifery	57(30.2)
Clinical status
Trainee students	153(81)
Internship students	37(19)

Epidemiology of NSIs

A total of 80 students (42.3%) reported NSI once during their clinical education. 57 of students (30.2) reported NSIs in the last 12-month. 43 (58.9%) had one injury in education period, 14(7.4%) had twice and 16(21.6%) had more than twice. By causative item, 55 of students (73.3%) had been injured by a normal hollow-bore syringe needle, 20had been injured (26.8%) by other instruments. Around 26 of all NSIs occurred in the wards of teaching hospitals (33.3%), 16 of them occurred in operating room (20.5%).

Opening the needle cap and drawing drugs were the most common causative event of NSI among participants. 15(23.8 %) of those reported one NSI while opening the cap, and 15(23.8%) of all cases occurred whilst the students were drawing drugs from ampoules or vials. Recapping the needle was another important cause of NSI, with the prevalence of 15.9%. 58 of these injuries occurred in the morning shift (81.7%) and the rest (18.3%) were reported in evening and night shift.

A total of 64.5% of NSIs were not reported. The main reason for non-reporting was that the patient didn’t have any worrying disease (30%). 20 of the reporters (74.1%) reported injuries to their couch. They were asked some questions about prophylaxis education, 51.9% of students stated that they had been educated about the topic. They were also asked about warding off the hollow bore needles. 117 of students (61.9%) said that they recapped the needle and put them in a safety box. 46 of them (24.3%) stated that they put the needle in a safety box without recapping. Others said that they used another way for warding off the needles.

Logistic regression analysis revealed that being a third year’s student was the only statistically significant risk factor for NSI. Students in the second and third year were 3.4 times more likely to have had one NSI than their counterparts in other years (OR= 14.8, CI=95%, .5.2–50.3, P < 0.05). No more demographic variables were shown to be significant risk factors in regression analysis (Table 2).

Table 2- The relation between injury and Background variables such as gender, major, year of study and status of students

Experience of injury

Background variables

Yes n (%)

No n (%)

X²test results

Gender

Male

female

10 (17.2)

48 (82.8)

25 (20)

107 (81.1)

P=0.659

Major

Nursing

Midwifery

40 (69)

18 (31)

93 (70.5)

39 (29.5)

P=0.837

Year of study

Second year

Third year

Forth year

18 (31)

23 (39.7)

17 (29.3)

63 (47.7)

39 (29.5)

30 (22.7)

P=0.022

Clinical status

Trainee students

Internship students

15 (25.9)

43 (74.1)

22 (16.7)

110 (83.3)

P=0.140

DISCUSSION:

According to the results 42.3% nursing and midwifery students in Kerman medical university experience NSIs once. The prevalence of NSI reported in the other studies conducted in Iranvaried between 20.6 % and 73.7 %(Askarian and Malekmakan, 2006; Askarian et al., 2012). The prevalence of NSIs among nursing students in the other countries varied between Australia(Smith et al., 2006), 61.9 %in Taiwan (Yang et al., 2004)and 26.2% in china(Yao et al., 2010). NSI among medical students has been reported internationally at the following rates: 24% in France(Rosenthal et al., 1999), 30–33% in the United States of America (USA) (Patterson, Novak, Mackinnon, and Ellis, 2003).Compared to the international level, the prevalence of NSIs among Kerman medical university seems to be in the average range.

The results indicated that the most common causative device for NSI among participants was syringe needle (73.3%). The similar findings were reported in Taiwan (Judith Shu-Chu Shiao et al., 2002), Australia (Elseviers, Arias‐Guillén, Gorke, and Arens, 2014) and china (Wang et al. 2003). Opening and recapping the needle cap (23.8%) and drawing out the drugs from ampoule or vial (23.8%) was the most common causative event among participants. Similarly, in Taiwan (Judith Shu-Chu Shiao et al., 2002). Reported opening and recapping the needle cap as the most common cause of NSIs among health care workers. Clinical inexperience and insufficient training are probably responsible for the high proportion of NSI among nursing students.

The most common places for NSIs to be happened were: the wards within clinical training occurred, the operating room, and labor. It is consistent with the findings in study of Shiraz (Askarian and Malekmakan, 2006; Askarian et al., 2012)where they reported operating room as the most common place for injuries to be occurred.

Regarding to the first injury; more than 34.7% of students said that it was a little scratching and 31.9% said that it was like a wound with bleeding. This type of injury is very important because of transforming blood borne infections.

Almost 64.3% of NSIs were not reported by nursing students. Non- reporting NSI is a contentious issue within the nursing profession. In the Australia, Derek smith reported that 40% of NSIs were not reported. Shiao et al. (Judith S-C Shiao et al., 1999) conducted a detailed epidemiological study and found that 81.8% of NSIs were not reported by Taiwanese healthcare workers. The main reason for non reporting NSIS was that the patient didn’t have any worrying disease (30%). Shiraz students stated that they didn’t know how and to whom they should report the injuries (Askarian et al., 2012). Educating students about NSIs and the necessity of its reporting therefore is an important issue to prevent such injuries.

Vaccination rates among participants was similar to those reported in the other studies: such Shiraz (86.2%) (Askarian et al., 2012), Asautrali (72.3%) (Smith et al., 2006), China (69%) (Yang et al., 2004), Taiwan (Judith Shu-Chu Shiao et al., 2002) (75.4%) Nepal (86.5%) (Bhattarai, Smriti, Pradhan, Lama, and Rijal, 2014). We suggest that it may be theoretically possible to achieve 100% immunization coverage with aggressive promotion. Such a result would particularly desirable, as hepatitis B is one of the major infectious disease threats for healthcare workers. Unvaccinated individuals may have a 6–30% risk of becoming infected with the virus following NSI (Hanrahan and Reutter, 1997). This study indicated that 32.3% of students use single gloves always and only 3.7% of them use double glove when they do clinical cares. A number of studies have evaluated perforation rates after surgery in single and double gloves and have found fewer perforations in the inner glove compared with the outer glove or to single gloves alone(Askarian et al., 2012; Judith Shu-Chu Shiao et al., 2002). These studies concluded that double gloving decline the risk of blood borne pathogen exposure(Patterson et al., 2003). Logistic regression analysis revealed that being a second and third year student was a statistically significant risk factor for NSI more than forth year students. No other demographic variables were shown to be significant risk factors.

Questionnaire-base studies have some limitation. Since the sample was selected from one college of nursing and midwifery the findings may not be generalize to all nursing and midwifery students. Although hepatitis B vaccination coverage among the students of Kerman medical science university was excellent, the principles of infection-control training and reporting of all needle sticks needs to be more emphasized in undergraduate nursing education. In the event of exposure, students must be advised to report all needle stick injuries so that appropriate therapy can be instituted. With appropriate training early in their careers regarding blood borne pathogen protection strategies, students can develop behaviors that they will continue throughout their years of practice. This will help to develop a strong reporting culture among young nurses when they enter the workforce. As opening the needle cap and opening ampoules were shown to be particularly high-risk events, education for nursing students should focus on these procedures. Although many events seem to involve clean sharps, it is important that NSI reporting continuously be emphasized in undergraduate nursing education. An education program before going to clinical care may positively influence on NSIs prevention. Finally, further studied needs to be conducted to determine the student’s knowledge about NSIs and how it can be improved.

REFERENCES:

Askarian, M., and Malekmakan, L. (2006). The prevalence of needle stick injuries in medical, dental, nursing and midwifery students at the university teaching hospitals of Shiraz, Iran. Indian Journal of Medical Sciences, 60(6), 227.

Askarian, M., Malekmakan, L., Memish, Z. A., and Assadian, O. (2012). Prevalence of needle stick injuries among dental, nursing and midwifery students in Shiraz, Iran. GMS Krankenhaushygiene interdisziplinär, 7(1).

Bhattarai, S., Smriti, K., Pradhan, P. M., Lama, S., and Rijal, S. (2014). Hepatitis B vaccination status and Needle-stick and Sharps-related Injuries among medical school students in Nepal: a cross-sectional study. BMC research notes, 7(1), 774.

Elseviers, M. M., Arias Guillén, M., Gorke, A., and Arens, H. J. (2014). Sharps injuries amongst healthcare workers: Review Of incidence, transmissions and costs. Journal of renal care, 40(3), 150-156.

Hanrahan, A., and Reutter, L. (1997). A critical review of the literature on sharps injuries: epidemiology, management of exposures and prevention. Journal of Advanced Nursing, 25(1), 144-154.

Muralidhar, S., Singh, P. K., Jain, R., Malhotra, M., and Bala, M. (2010). Needle stick injuries among health care workers in a tertiary care hospital of India.

Patterson, J. M. M., Novak, C. B., Mackinnon, S. E., and Ellis, R. A. (2003). Needlestick injuries among medical students. American journal of infection control, 31(4), 226-230.

Puro, V., De Carli, G., Petrosillo, N., and Ippolito, G. (2001). Risk of exposure to bloodborne infection for Italian healthcare workers, by job category and work area. Infection Control, 22(04), 206-210.

Rosenthal, E., Pradier, C., Keita-Perse, O., Altare, J., Dellamonica, P., and Cassuto, J.-P. (1999). Needlestick injuries among French medical students. JAMA, 281(17), 1660-1660.

Shiao, J. S.-C., Mclaws, M.-L., Huang, K.-Y., and Guo, Y. L. (2002). Student nurses in Taiwan at high risk for needlestick injuries. Annals of Epidemiology, 12(3), 197-201.

Shiao, J. S.-C., McLaws, M.-L., Huang, K.-Y., Ko, W.-C., and Guo, Y. L. (1999). Prevalence of nonreporting behavior of sharps injuries in Taiwanese health care workers. American journal of infection control, 27(3), 254-257.