Understanding the factors associated with nonreporting of needlestick injuries in nurses at Imam Khomeini Hospital Complex, Tehran 2016: A case study

Introduction: Needle in the body creates one of the potential problems which put people working in the health-care environment at risk of exposure to infection. The number of contaminated needlestick injuries among health-care workers as a result of underreporting of these injuries is unknown. The aim of this study is to investigate factors related to nurses reporting of needlestick in Imam Khomeini in Tehran. Materials and Methods: The present research method is a descriptive–analytic survey. The statistical population included all nurses in Tehran Imam Khomeini Hospital Complex consisting of three centers (Imam Khomeini Hospital, Vali-Asr, and Cancer Institute) in 2016. According to the Statistics center of Tehran University of Medical Sciences and Human Resources, on-duty nurses are 1100. Two hundred and eighty-five nurses stratified randomly sampling table and using Morgan were selected. To collect the data, in this study, a standard questionnaire reporting Azadi and Anoushe (2007) was used. Research data analysis, descriptive and inferential statistics were performed using SPSS software. Results: The results of descriptive statistics showed that 61.5 percent of nurses had experienced a needlestick exposure, while fending off contaminated needles has been the most frequent (RF = 61.5). Inferential statistical findings showed that the average area of individual and organizational affecting the reporting of needlestick respectively was 2.14 and 2.26. Also, there was a significant difference between individual and organizational factors affecting the reporting of needlestick injury based on education and work experience. Conclusion: The results of this study showed that contaminated needlestick injuries and underreporting of injuries among nurses include a high rate and larger studies need to be done in this regard. Interventions such as a standard protocol as well as reporting, staff training, and postexposure prophylactic standard treatments can be effective in improving the reporting percentage of these injuries.

Keywords: Needlestick, nurses, reporting, Imam Khomeini Hospital Complex, Tehran

Today, health workers especially nurses who use needles are at high risk of needlestick injury. Several studies have shown that nurses compared to other health-care workers are at higher risk of needlestick.^[1],[2],[3] According to available statistics, over 35 million people worldwide are health professionals, the ratio of which is about 12% of the world population. These groups are exposed to a wide range of risks associated with the job and work environment. One of the most important worry among is the possibility of unwanted needle entrance into the body or injury caused by sharp objects. Along with the possibility of the transmission of infection to health-care workers, there is considerable stress for them and their loved ones.^[4] Needlestick injuries are common in health-care systems. While drugs are injected intravenously or intramuscularly or other operations are performed in which sharp tools and needles are involved, they can be mistakenly stumbled and cause wounds in the caregiver body. This will allow transmission of pathogens from one carrier to the recipient. This usually takes place when recapping the needle and finally put in sharp objects containers.^[5] The highest number of injuries from needles among health personnel has been reported among nurses.^[6] It may be due to more use of needles in this group compared to other health-care workers and due to multiple injections per work shift. Studies showed that in the USA only, 600–800 thousands injuries caused by unwanted needle or other sharp objects occur among health personnel. About “half of them do not report”, or in other words the real number is more than the number of injuries have been reported.^[7] Despite the high prevalence of needlestick exposure to blood and other body fluids among nurses, they do not report of injuries and initiate appropriate treatment often for fear of negative consequences, busy job, dissatisfaction of treatments regimen, and lack of awareness.^[8] On the other hand, training staff can lead to safe working environment and minimize injuries. It could also facilitate the reporting process as a friendly, nonthreatening, confidential, and effective prophylaxis treatment can increase the damage report.^[9] Contact with blood pathogens is a major issue in occupational safety although statistically, infectious disease transmission is low. It can have negative effects on physical and mental health of nurses those spend most of their work time in direct care of patients and exposed to needles that contain the greatest amount of serious risks in this area. Thus, the importance of preventing this damage is an important health problem.^[10] In addition, the universal precautions and safety during injection training is not enough. Regarding the serious effects these hazards, the health planner should pay more attention to the nurses more than before; on the other hand, most studies have been done on the frequency of needlestick to medical staff, while it is important to note that clarifying the factors influencing reporting and non reporting of needlestick injuries is vital for health care planner. In this study, researchers seek to identify the factors associated with the reporting of needlestick injuries from the perspective of nurses.

The research method is descriptive analytic. The population of the study was all nurses working in Imam Khomeini Hospital Complex consisting of three central Tehran (Imam Khomeini Hospital, Vali-Asr, and Cancer Institute) in 2016. The number of whom according to the Department of Statistics and staffing Tehran University of Medical Sciences were 1100 people. In this study, to determine the sample size, The researchers used Morgan formula [Table 1]. According to the general population, 285 nurses were selected randomly based on gender. Of the 285 questionnaires distributed among nurses, 283 (99%) were returned. In this study, researchers used a demographic questionnaire and two standardized questionnaire was used to collect data. Demographic questionnaire includes 21 questions of characteristics and job profile. The second part of the questionnaire was related to the individual and organizational domains. To assess the validity of the research tools and scientific texts referring to the preliminary version of the questionnaire, they were sent to 8 academic experts. They were asked about the questions form and content. About 87% of experts agreed about the validity the questionnaire. The reliability coefficient for individual domain of questionnaire was 0.89 and in organizational domain was 0.92 and for all was 0.90. This indicates that both instruments used in this study had acceptable reliability. Research to analyze the data, descriptive-statistical methods such as mean, standard deviation, frequency, and percentage distributions were used and in inferential statistics to test hypotheses Kolmogorov–Smirnov test was used to ensure normal distribution of the sample Levine’s test was used to ensure the homogeneity of variances and one-sample t test used to compare the mean samples with the hypothetical mean population as well as independent t-test and F was used to compare means. Statistical analyses were conducted using SPSS software version 22 (SPSS Inc. Chicago, Ill) and the error level was 0.05.

Nearly 94.3% of nurses had received hepatitis B vaccine and 5.7% had not received. 92.2% of nurses had received three doses of hepatitis B vaccine and 7.8% had received it. 72.4% of nurses often and 19.1% sometimes and 8.5% rarely use gloves at work. 61.5% of the nurses in the study had a needlestick exposure and 38.5% so far had not been exposed. 43.1% of nurses in the past year only once, 9.9% twice, 7.1% three times, and 1.4% have had experienced four times. 6.4% of the nurses in the study had a needlestick exposure in patients with HIV, hepatitis B surface (HBS), hepatitis C virus, and 33.6% had not encountered so far. 6.8% of the nurses in the study after a needlestick washed the injured sign with plain water, 25.3% wetted with water and soap and 68.9% water and soap and antiseptics. The highest frequency of operation led to the needlestick in the subjects related to needlestick during disposal of contaminated needles and lowest frequencies of operations intravenous and intramuscular injections at 0.7%. 22.6% of nurses facing the needlestick report to the supervisor, 4.2% report to hospital’s infection control committee, 1.4% report to doctors, and 33.2% do not report to any of these cases. 54.4% of the nurses had specific protocol for reporting exposure to blood and body fluids of patients in their hospital. However, 3.5% of nurses said that they do not have any particular protocol for reporting exposure to blood and body fluids and 3.5% of nurses also were unaware of any protocols. 9.2% of nurses expressed that sterile or clean, 54.6% busy job, 6% dissatisfied with the track, and 19.7% lower risk of HIV infection and hepatitis B and C in patients who were the damage source as the reasons for nonreporting of needlestick. 21.2% of nurses participated in special training for the prevention of blood-borne infections and 41% of companies have not participated in these courses so far.

[Table 1] showed that obtained values for individual domain is: P ≥ 0.01, Z = 0.902, in organizational domain is: P ≥ 0.01, Z = 0.811, and for both variables P value is more than 0.01 error. Therefore we can conclude that 99% confidence probability distribution of scores and data are normal, so the normality of data was approved and we used parametric tests for statistical analysis.

As shown in [Table 2], it is observed that t values calculated for the individual and all statements of the scope of the critical value of 1.96 are smaller than α = 0.01, so it can be concluded that the individual scope and all the factors with probably 99% is higher than average and it can be extended to the entire community. This means that individual domains can be effective on the reporting of needlestick. On the other hand, among the factors, on average, the first judgment of nurse about the patient’s condition in terms of HIV, HBS. According to tests, the second high workload and third fatigue have the most important role individual scope.

As shown in [Table 3], it is observed that t values calculated for organizational scope and all its subdivisions are higher than the critical value (1.96) and smaller than α = 0.01, so it can be concluded that the organizational scopes and all the factors with probability of 99% are higher than average and it can be extended to the entire community. This means that the organizational scope can be effective in reporting of needlestick. On the other hand, among the factors, on average, first the lack of emphasis of nursing managers on the importance of reporting the needlestick injuries, second absence of a known center for diagnostic and therapeutic procedures after needlestick injuries, third time-consuming process of needlestick reporting, and forth lack of informing about how to report and to follow-up needlestick injuries by hospital have the most important role of organizational areas.

The aim of this study was to identify the parameters associated with lack of nurses reporting of needlestick in Imam Khomeini Hospital complex in Tehran. In many of internal investigations carried out about needlestick, researchers are more likely to evaluate the frequency (description) of needlestick injuries among nurses.^{[11],[12],[13],[14],[15]} On the other hand, in some reports, they studied about the number of needlestick and the reasons for the increased incidence,^[15] or in one study, researchers only studied operations and the time that nurses are mostly exposed to needlestick.^[16] The researchers in this study not only studied the frequency of needlestick injuries among nurses perfectly but also evaluated factors affecting nurses’ lack of reporting when facing the needlestick. The results of descriptive study of Saye Miri et al.^[16] on the operation that led to the nurses’ needlestick injury are consistent with this study. In above-mentioned study, researchers introduce needle as the first factor of needlestick in nurses (58%); however, in this study, this operation with needle is the most important factor (by 62%). Also, the actions after the needlestick significantly correlated with this study. The result of this study inconsistent compared with the study of Adarvishi et al., entitled that determination of the frequency and causes of injuries from sharp instruments in the operating room personnel in teaching hospitals of Ahvaz. In Adarvishi et al., study’s the main leading cause of needle stick in nurses was suture needles with 51.4 percent as a first factor. The study results showed that the most important device to needlestick in nurses was suture needles with 51.4% ( first factor). The results of this study are consistent with research by Khatooni et al.^[14] in hepatitis B vaccine. In this study, researchers reported that 82.7% of nurses had received vaccination against hepatitis B. On the other hand, compared with studies of abroad, the results are not consistent with the study Manzoor et al.^[17] as needlestick injuries in nurses at a tertiary health care facility. The researchers reported that more than 64.9 percent of the nurses do not use gloves when doing these operations while the figure for nurses in this study is only 8.5 percent. The results match with the study of Yoshikawa et al.,^[18] as determined by the incidence of needlestick in Japan. In these two studies, researchers have noted that the most common means of injuries were disposal syringes. As a result, disposal of contaminated syringes requires serious management and health-care system should pay special attention to this issue. Periodic training for nurses about disposal of needles without recapping is needed and more control should be imposed in this case.

Statistical analysis showed that individual scopes and all statements of the scope are above average and it can be extended to the entire community. This means that individual domains can be effective on the reporting of needlestick. On the other hand, among the factors, based on the mean scores, firstly “the nurse’s own judgment about the patient’s condition in terms of HIV, HBS according to patient laboratory test”, secondly “high workload”, and thirdly “fatigue” have the most important role in individual areas respectively. In comparing the results of this study with other studies in this area, research results by Cho et al.^[19] can be mentioned. In this study, researchers introduce fatigue as one of the most important factors affecting the reporting of needlestick which is consistent with our results. As a result, it can be said that managers should identify the reasons for fatigue of nurses including long work shifts without a break, and working in the busy wards and caring of high-risk patients and try to fix them and take care of avoiding excessive workload. Costigliola et al. studies ^[8] along with the results of this study showed that imaginary guess source of injury is the most important reason due to lack of reporting of needlestick injuries. The results obtained by Kebede et al.^[2] that needlestick prevalence among employees of health care and related factors and Mill et al.^[20] in the area of individual factors are inconsistent. In this study, the researchers believe that one of the most important factors of nonreporting needlestick is insufficient education and lack of a suitable protocol for needlestick exposure, However, in this study, unawareness of nurses of following up after needlestick injuries (by average 2.08) is the least important factors in reporting the needlestick. Or in other words, nurses are familiar with follow-up process after needlestick injuries. As a result, it is recommended that nursing managers develop retraining courses for nurses to familiarize them with reporting the needlestick injuries, follow-up process, and periodic evaluation of cases. As previously mentioned, most of the studies in Iran described the frequency of needlestick injuries in nurses so the reasons have not been investigated sufficiently; single and the first study that has been clarified the reasons that led needlestick injuris in nurses was the Azadi and Anoushe study’s ^[5] as needlestick injuries and the amount of reporting the damage in clinical nurses. The results of the before-mentioned studies are in some cases consistent. For example, low risk of infection in damage source and high workload were main factors in the lack of nurses reporting. However, lack of familiarity with the process of reporting is also an important factor in nonreporting of needlestick of nurses in their study. This is inconsistent with this study. In general, lack of consistency can be attributed to differences in the study population.

Statistical analysis showed that all items of personal, organizational scope is above average and it can be extended to the entire community. This means that the organizational scope can be effective in reporting needlestick injuries. On the other hand, among the factors, on average, the lack of nursing manager’s emphasis on the importance of reported needlestick injuries, absence of centers to provide diagnostic and therapeutic procedures after needlestick injuries, time-consuming reporting process, lack of informing about how to report, and follow-up of needlestick injuries by hospital play the most important role in organizational scope. Compared to the results of other studies in this area, it can be pointed out the results of the study of Mill et al.^[20] that explains the function of nurses about precautions in dealing with patients with HIV and Clarke et al.^[9] study’s that mentioned the human and organization factor those affected the rang of the needle stick in nurses. In this study, the researchers were partially coordinated and consistent with the results of this study the absence of widely available written policies and written hospital policies or as the lack of emphasis officials about this topic were recognized as the most important factors in the lack of reporting of needlestick by nurses and clinical staff. The results of the study and the results of Ghanei Gheshlagh ^[21] as needlestick injuries and related factors in nurses are consistent. In this study, researchers have recognized time-consuming reporting process and lack of informing about the reporting the most important factors influencing nurses nonreporting of needlestick. However, the result of the study of Azadi and Anoushe ^[5] does not fit within organizational factors. The researchers believe that the lack of satisfactory follow-up acts as the most important factor affecting the nonreporting of needlesticks. However, nurses in this study dissatisfied with nursing managers and officials of follow-up process (mean 2.05) have reported this as the least important factor in underreporting agency. In general, noncompliance can be attributed to the differences in methodology and sample size.

Limitations of the study included personal opinions could be subject to affect the results. According to the research tools, the attitude questionnaire, some of the personal and administrative considerations may affect the responses of the subjects. Daytime fatigue and psychological states of participants is out of discretion the researcher.

Suggestions

Training classes and increase protection equipment such as gloves and glasses for health workers, especially nurses, are recommended. Conferences and seminars for nurses to better orientation and empowerment is need, also vaccination and antibody measurement, manage the recording and reporting system in the offices of nursing is recommended for better management of the needle stick problems and control of infection. Recapping would be prevented.

Suggestions for future research

It is recommended that a study should be done to compare the frequency and amount of reporting among nurses and physicians design and implementation of needlestick. It also recommended that a comparative study should be carried out with several hospitals in developing countries and its reporting on the design and implementation of needlestick.

According to the results mentioned and in accordance with lack of education about the prevention and reporting of needlestick and the wrong behaviors observed in everyday life of nurses at work, it is essential to take care of nursing managers injury prevention techniques and process of dealing with this problem, including safe work environment for nurses, interventions such as a complete standard protocol for reporting and immunization and also standardization of the treatment of postexposure prophylactic should be considered.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ATMPH.ATMPH_199_17

[Table 1], [Table 2], [Table 3]