This paper will focus on needle sticks injury among nurses and issues pertaining underreporting and intervention strategies.
A needle stick injury is a percutaneous piercing wound typically set by a needle point, but possibly also by other sharp instruments or objects. Commonly encountered by people handling needles in the medical setting, such injuries are an occupational hazard in the medical community.
WHO reports in the World Health Report 2002, that of the 35 million health-care workers, 2 million experience percutaneous exposure to infectious diseases each year. An estimated 600,000 to 800,000 needle stick and other percutaneous injuries are reported annually among U.S. health care workers [NIOSH, Washington, DC]. It is estimated that 100,000 needle stick injuries occur annually in UK alone [O'Connor, M.B.] and 500,000 annually in Germany [Hofmann F, K.N., Beie M.].Despite their seriousness as a medical event, needles stick injuries have been neglected, most go unreported and ICD-10 coding is not available. On the other hand, as needle sticks have been recognized as occupational hazards, their prevention has become the subject of regulations in an effort to reduce and eliminate this preventable event.
According to cross sectional study was conducted in Serdang Hospital Malaysia, The overall prevalence of needle stick or sharps injuries was 23.5%. Staff nurses had the highest prevalence (27.9%).The causes of needle stick injury in 58% of cases were hypodermic needle and 27.2% cases were recapping. However, out of those health care workers (23.5%) who had needle stick injuries, only 30.9% had reported the incident of needle stick injuries indicating that there were gaps between knowledge and practice among the health care workers especially among nurses[European Journal of Social Sciences â€" Volume 13, Number 3 (2010)].
The highest prevalence of needle stick injuries among nurses also reported in several other studies [Singapore Medicine Journal, 2008 and Applied Occupational and Environmental Hygiene, 1999]. Researches also have shown that, between all health care workers, nurses are the ones who sustain a high needle stick injuries burden [Smith, D.R., et al., Journal of Professional Nursing, 2006]. This can be explained by the fact that nurses administer most of the injections and are responsible for venipunctures, intravenous fluid administration, vaccination and other procedures which require the use of needles. Gerberding in 1991 stated that one reason that may account for the increased vulnerability of injury among nurses is the greater amount of time nurses spent in direct patient contact [Journal of Infectious Diseases, 1994].
In Malaysia, for the period 2000 to 2006, the number of needle stick injuries reported by health care workers increased by 50% from 498 to 746 [Chua, S.L. (2007) Speech by YB Dato Seri Dr Chua Soi Lek Minister of Health Malaysia at the Opening Ceremony & Launch of Clinical Practice Guidelines, Liver Update 2007].The statistics can be arguable because, it is likely that these ï¬gures represent only the tip of the iceberg whilst a large number of cases are unreported.
Needle sticks injuries represent a significant hazard in professional nursing. Needle stick injuries are extensive source of infections with blood borne pathogens among nurses such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus. In addition, it can cause substantial health consequences and psychological stress for them and their loved ones. Likewise, the national economic burden of needle stick injuries is tremendous. Lee et al. (2005) estimated that the total mean annual cost of needle stick injuries for the 110 nurses (out of 400) who experienced at least one needle stick injury within 12 months of participating in the study was $28,492, or approximately $259 spent annually per injured nurse. 56% of this total was attributed to indirect costs, 15% to post-exposure tests, 20% to physician visits, and 9% to use of drugs.
Practice analysis and discussion of issues.
In order to evaluate if similar barriers are also force by nurses in my workpace, a focus group discussion was conducted to explore nurses views on reporting needle stick injury. The focus group involve 20 nurses, of whom 5 were from emergency unit, 5 from treatment room unit, 5 from paediatric unit and oters from medical ward. Discussion concerning professional issues regarding reporting. Among them included:
Total number of needlestick injuries
Reporting or occurrence
Knowledge about reporting process and universal precaution guidelines
Fear for positive result.
MOH policy regarding needle stick injury
The discussion also revealed 19 out of 20 nurses sustained needle stick injuries during recapping. Aiken, Klocinski and Sloane (1997) suggested that many of the needlestick injuries occur during needle recapping. Beside this it also shows nurses have insuffiecient knowledge about recapping because their unaware that recapping of needles has been prohibited under the Occupation Safety and health Administration (OSHA) blood-borne pathogen standard (OSHA 1991).
During this discussion all the participants were agreed that they had experienced needle stick injury more then once over their working lifetime. Out of them, the nurses who are working in emergency unit claimed they have more frequent needle stick encounters. This is because the staff in emergency unit are more busy and stressfull. Hence they perceive that their workload is increased by adhering to universal precautions . Most of procedure require speed and efficiency.The number of staff are not sufficient to enable the procedur to be safe. This situation also make the nurses do not have the time to reported all needle stick injury incident. Jagger and Perry (2005) reported that critical care areas have a high risk of having needlestick injuries, and suggested that this is related to the pressure involved in crisis situations and the fast response that is needed from staff. Another study focus on working condations, short staffing and the influence on increases in accidental injuries. Stone,Clerke, cimiotti & Correa (2004).
The nurses working at night shift unable to report the needle stick injury immediately because the location supervisor are not physically present and usually their forget to report in the next morning.
During the focus group discussion, some nurses regard reporting or occurrence incident needle stick injury are not necessarily. Nurses who are working in paediatric unit claimed peads client who are came for get imunisation almost healty client. They believe that the risk to get disease are rare compaired with adult client or patients. Inaccurate assessment of source-patient risk factors - Nash and Goon (2000) identified that only 5% of needlestick injuries were reported because the health-care worker's decision to report was influenced by judgements made about the source-patient's lifestyle
Knowledge about universal precaution and report process among them also expressed during the focus group with regards to report injury. A majority of nurses claimed that they don’t have enough knowledge about proper universal precaution and believed needle stick is a common thing with nurses who handeling needles in their daily works. Health-care workers perceived needlestick injuries as an inevitable part of handling sharp devices and therefore injuries were unreported and bad practice tolerated (Connington, 2002; Jeanes, 1999). The other thing is most of the participents claimed that they have no idea how to do the report because the reporting process is perceived as time consuming. Health-care workers' lack of knowledge of the reporting process. only 10% knew how to report a needlestick injury despite a comprehensive training and education programme. This deficient knowledge base may have been due to the lack of a standardised reporting policy across all UK hospitals, in addition to variations in reporting practice during day and night shifts (Trim et al, 2003).
Nurses also fear for reporting needle stick injury if may result is positive. The stigma associated with blood-borne pathogens, the fear of a positive result as well as health-care workers' denial of personal risk prevents the reporting of such incidents (May and Brewer, 2001; Osborn et al, 1999). From anecdotal evidence it seems that many nurses and doctors would rather not know their status following injury for fear of the result because of the potentially devastating impact a positive result could have on their career. Indeed, previous research studies identified that injuries were not reported due to health-care workers' inability to influence the outcome following injury (Rabaud et al, 2000; Burke and Madan, 1997). Health-care workers may thus perceive reporting a needlestick injury as futile. However, this may be influenced by their knowledge of post-exposure prophylaxis.
The othars cause for unreporting is fear of punitive measures. Most of the nurses are scared they will be scold by the incharge or superior because their not handeling needles properly or carefully. One of the nurse shared are past experience in her previous hospital where by her working collegue scolded by the incharge for reporting needla stick injury. Since then her collegue emotionally traumatized and phobia to report similar incident.
One of the nurse said she not report needle stick injury because she felt that the needle stick injury is punishment from god for her poor performance.The spirictual variable is what the nurse believes is the another reasons for unreporting.
Recommendation and implication for practice.
The following recommendation can be incorporated in my local practice to improve needle stick injury reporting.
Training and education â€" Progrms to educate nurses and improve clinical skill .Training and education have been identified as integral to developing awareness among nurses, as well as improving adherence to good clinical practice (Wang et al, 2003; Heinrich, 2000; Mercier, 1994). Training approach can include skill-base workshop. Indeed, the DoH recommended training and education to prevent needlestick injuries (DoH, 2002); with medical staff being the most recent focus for training initiatives (NAO, 2003). Numerous studies have found that training and education - for example, in universal precautions and sharps management - not only encouraged safer work practices but improved concordance with policy and procedures (Gerberding, 2003; Connington, 2002; Short Life Working Group, 2001).
Nurses must continue to demonstrate inadequate knowledge of universal precautions or fail to comply. Anecdotal reports suggest that health-care workers were frequently unaware that gloves may reduce the volume of blood transferred via a needlestick injury from the source to recipient (Mast et al, 1993); even though this information was highlighted by the DoH (1998) and the Infection Control Nurses' Association (2003), which both noted that blood may be 'wiped off' as the needle passes through the glove, reducing the volume of blood transferred. Reasons for health-care workers' deficient knowledge base may be due to a lack of investment in staff training or limited understanding of health-care workers' safe behaviour in the clinical setting or complacency (Twitchell, 2003; Henderson, 2001; Godin et al, 2000).
Knowledge and adherence to taught practice may still be deficient despite training and education due to insufficient information retention (Trim et al, 2003; Stein et al, 2003; Twitchell, 2003; Nobile et al, 2002; Doig, 2000). Induction programmes have been highlighted as a forum for initiating education, but owing to the large volume of information presented on such days, nurses do not retain all the information. For example, Doig (2000) found that the importance of sharps management literature provided during induction was not realised and therefore not retained by staff.
Methods of training and educating nurses with an aim to improve concordance, raise awareness of the risks associated with handling sharp devices and improve clinical practice are varied. Practical training sessions should be available for all nurses in their own local hospital environment - for example, training and update sessions on universal precautions, the process of reporting needlestick injuries and preventive measures to be undertaken in the clinical environment. However, nurses are also able to access educative conferences where expert practitioners share their experiences, research and expertise, giving attendees the opportunity to question, seek advice and potentially return to their own clinical areas with new ideas.
To improve the reporting of such incidents, it is essential to understand health-care workers' behaviour, including reasons for not reporting incidents, and to review current reporting processes. Indeed, as highlighted previously, a standardised protocol across all hospitals may reduce confusion among health-care workers who frequently move jobs and therefore have to familiarise themselves with a number of protocols and procedures.
The degree of information retention following training programmes is currently unclear. One study found only immediate improved concordance post-training (Moongtui et al, 2000).
Sister in-charge and sister on-call should treat the nurses kindly when they are notifying the needle stick injuries,especialy during night shift..By doing this,one make realize to them that notification is not the purpose for punitive but to help them indeed.So nurses are more willing and comfortable to notify the needle stick incidents in future.
Sister in-charge should continuouly educate the nurses so that their not be scared or worried about discrimination due to positive result. Furthermore prompt notification enables early treatment can be given to prevent from infecting to patients or family members. early treatment also can prevent to other complication.
Guidelines on occupational exposures and sharps injury surveilance manual (occupational health unit,ministry of Malaysia) must made available in all wards and unit.The supervisor or incharge of each unit ensure the nurses always read and practice those guidelines.
The Ministry of health and hospital admin must ensure enough nurses in each unit especially in emergency and critical care units.In case of inadequate nurses in those units,a staff deployment system from less critical unit must be in place.By doing this needle stick injuries can be minimized to certain level.
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