580035 research-article2015
WHSXXX10.1177/2165079915580035Workplace Health & SafetyWorkplace Health & Safety
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ARTICLE
Needlestick and Sharps Injuries Among Nurses at a Teaching Hospital in China Xujun Zhang, PhD1, Yue Gu, MD1, Mengjing Cui, MD1, Lorann Stallones, MPH, PhD2, and Huiyun Xiang, MD, MPH, PhD3
Abstract: Needlestick and sharps injuries (NSIs) are a major occupational injury to health care workers worldwide. This study aimed to report the prevalence and risk factors of NSIs among nurses working at a Chinese teaching hospital. From 463 nurses, 402 completed questionnaires were obtained. A total of 261 (64.9%) nurses reported needlestick or sharps injuries. NSIs were more common among females, young nurses, surgical nurses, and junior nurses. Logistic regression analysis suggests that age and work department were independent risk factors for NSIs. By type of devices, syringe needles accounted for the highest proportion of all NSIs (59%), followed by glass items (22%), and trocar core/ catheter wires (4%). NSIs remain an important occupational hazard issue or Chinese nurses. Programs must be developed to prevent injuries caused by needlesticks and sharps. Keywords: needlestick injuries, sharps injuries, risk factor, nurse, China
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eedlestick and sharps injuries (NSIs) are a major occupational hazard for health care workers worldwide (Pruss-Ustun, Rapiti, & Hutin, 2003). The World Health Organization (WHO) reported that the annual number of NSIs among health care workers is four injuries per person in Africa, western Mediterranean, and Asia (Mantel, 2002). NSIs are the second most common occupational injury identified by the National Health Service (NHS), accounting for 17% of all injuries among health care workers (National Audit Office, 2003). A Royal College of Nursing (RCN) survey of 4,407 nurses found that almost half of all nurses (48%) had been injured by a needle or sharp that had previously been used on a patient (RCN, 2009). Other studies found that nurses are at the highest risk for NSIs among health care workers (Tarantola et al., 2003; Wilburn & Eijkemans, 2005). Contaminated needles and sharps are the most common cause of transmitting blood- or body-fluid-borne infections
between patients and health care workers (Gershon et al., 2000; Pruss-Ustun et al., 2003). According to one study, more than 3 million health care workers were exposed to the hepatitis B virus (HBV), the hepatitis C virus (HCV), or the human immunodeficiency virus (HIV) due to NSIs every year worldwide (White, 2007). These work-related exposures may have resulted in about 66,000 HBV, 16,000 HCV, and 1,000 HIV infections worldwide among health care workers in 2000 (Pruss-Ustun, Rapiti, & Hutin, 2005). NSIs cause not only physical injury and emotional effects but also economic losses (Reis, Gir, & Canini, 2004; RCN, 2009). It is estimated that needlestick injuries that occur during insulin administration cost the NHS approximately £600,000 per year in the United Kingdom, including post-NSI prophylaxis, laboratory tests, counseling, treatment of transmitted diseases, and litigation (Trueman, Taylor, Twena, & Chubb, 2008). The economic cost of managing NSIs is substantial, ranging from US$51 to US$3,766 (USD) for every case of NSIs in the United States (Lee, Botteman, Xanthakos, & Nicklasson, 2005). However, this amount did not account for the cost of treating the long-term complications of needlestick injuries, such as HIV, HBV, and HCV infections, each of which can cost hundreds of thousands of dollars (Lee et al., 2005). The economic loss due to NSIs is enormous, but emotional problems caused by NSIs are immeasurable (Leigh et al., 2007). China has the world’s largest population and is the largest developing country with at least 1.2 million nurses. They are required to perform various types of health-related treatments and handle sharps, such as subcutaneous, intramuscular, and intravenous needles and various cutters. However, no law calls for the use of safety needles and devices in China. Safety needles and devices are less commonly used in China compared with other countries due to the high cost of safety devices. Results of previous studies in China showed that nurses working in hospitals were at high risk of NSIs (Wang et al., 2012; Xie, Nie, Pan, & Bai, 2003; Zheng, Di, & Guo, 2005). China has one of the highest rates of endemic HBV infection in
DOI: 10.1177/2165079915580035. From 1Southeast University, 2Colorado State University, and 3The Ohio State University College of Medicine. Address correspondence to: Xujun Zhang, PhD, Injury Prevention Research Institute, Key Laboratory of Environmental Medicine Engineering, Ministry of Education, School of Public Health, Southeast University, 87 Dingjiaqiao Rd., Nanjing, Jiangsu 210009, People’s Republic of China; email: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2015 The Author(s)
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Applying Research to Practice Needlestick and sharps injuries are an important occupational safety concern among health care workers worldwide. Nurses are at high risk for needlestick and sharps injuries among health care workers. Age and employment department were significant risk factors for needlestick and sharps injuries among nurses in China. Syringe needles were the most common causative device, and about half of needlestick and sharps injuries involved devices that had been contaminated with blood or body fluids from patients. Nurses in China face a significantly high risk of being infected with HBV, HCV, and HIV because of their high risk of needlestick and sharps injuries at work. Further studies are needed to develop and evaluate interventions for the prevention of needlestick and sharps injuries among registered nurses in China. the world, with an estimated 150 million hepatitis B surface antigen (HBsAg) carriers nationwide (Yao, 1996). Moreover, the prevalence of HCV and HIV is rising in China (Phipps et al., 2002). Therefore, exposure to blood or body fluid pathogens is a serious occupational hazard for Chinese nurses. Despite this, little data have been published about patterns of and risk factors for needlestick and sharps injuries among Chinese nurses. This study was conducted to determine the prevalence of NSIs among nurses working in a Chinese teaching hospital and to examine the contributing risk factors for these injuries.
Method Study Design and Sampling This cross-sectional study engaged nurses working at a teaching hospital in Nanjing, the capital city of Jiangsu Province, China. Based on an anticipated prevalence of NSIs among Chinese nurses of 20%, a total of 384 participants were needed to achieve a study power of 0.80 and an alpha of .05. The total number of nurses in the university teaching hospital was 938. Anticipating a 15% nonresponse rate, a total of 463 nurses were needed for the study. Nurses were excluded if they held administration positions without direct patient care responsibilities. The Institutional Review Board of Southeast University School of Public Health approved the study procedures. Informed consent was secured from participants in accordance with ethical guidelines.
Measurements The questionnaire was developed by a research team at the Southeast University Injury Prevention Research Institute and pilot tested the survey questionnaire in a small group of the target population in the study area in February 2012. Specifically, 10 nurses were interviewed and provided feedback about the questionnaire. Minor changes were made before the survey questionnaire was finalized.
Data Collection The study was launched, and data were collected in April 2012. A list of all potential participants and the departments where they worked were obtained from the nursing department of the hospital. Participants were contacted by the researchers at the hospital, and they were provided a copy of the questionnaire. Questionnaires were collected several hours after distribution. The data collection was completed in 1 week. The first part of the questionnaire gathered sociodemographic characteristics and was followed by questions about whether the participants had experienced a work-related needlestick or sharps injury during the past year. Characteristics of NSIs included causative devices, causative activities, work department, and part of body injured.
Statistical Analysis Data were entered into EpiData 3.0 and analyzed using SAS 9.1. First, demographics, parts of body injured, and causative devices of NSIs were described. Second, chi-square analyses assessed the association of NSIs to select demographic factors. Third, to control for confounding, multivariate logistic regression analyses were conducted. In the logistic regression analyses, the outcome variable was NSIs (yes/no), and the independent variables were gender, age, work department, and years in nursing. Statistical significance was set at p < .05.
Results Of the 463 nurses who received the questionnaire, 402 completed the questionnaire, yielding an overall response rate of 86.8%. Of the 61 nurses who did not respond, they were either absent from the hospital when the survey was conducted or they failed to complete the questionnaire. Most of the participants were female (96%) and less than 36 years of age (76.6%), representing different departments of the hospital: 36% from internal medicine, 26% from surgery, 6% from obstetricsgynecology, and 32% from other departments. Table 1 presents the prevalence of NSIs by select demographic factors. A total of 261 cases of NSIs (64.9%) were reported. The prevalence of NSIs was significantly higher in females than in males (66.3% vs. 31.3%, p < .05). NSIs disproportionately affected young workers, with more than 80% of injuries among those workers less than 36 years of age. The prevalence of NSIs also varied by department. Comparing the prevalence of NSIs in internal medicine (60%), surgery (84.6%), obstetrics/gynecology (66.7%), and other departments (54.3%) suggested that the prevalence of NSIs in surgery was significantly higher than that in internal medicine, obstetrics/gynecology, and other departments (p < .001). The prevalence of NSIs was higher for nurses who worked in the surgery department, with their risk being 4.4 times higher than for those working in other departments (OR = 4.43, 95% CI [2.30, 8.50]). The proportion of nurses who suffered NSIs was higher among those nurses who had practiced less years: less than 5
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Table 1. Comparison of Needlestick and Sharps Injuries by Selected Demographics
Total
Total N of nurses
Persons with injury n (%)
p valuea
402
261 (64.9)
Gender
.004
Men
16
5 (31.3)
Women
386
256 (66.3)
Age (years)
.001
≤25
171
118 (69.0)
26-35
137
98 (71.5)
36-45
58
30 (51.7)
>45
36
15 (41.7)
Work department
45
Reference
Work department Internal medicine
.000 −0.056
0.261
0.95 [0.57, 1.58]
.829
Surgery
1.488
0.333
4.43 [2.30, 8.50]
.000
Obstetrics or gynecology
0.440
0.484
1.55 [0.60, 4.01]
.363
Other department
Reference
Figure 1. Parts of hand injured.
underreporting in the United States, the high rate of injury reported by these Chinese nurses is striking (Phipps et al., 2002). This study also found that the risk of NSIs due to invasive treatment and nursing procedures was significantly associated with factors such as gender, age, department, and years in the profession, but results from multivariate modeling suggested that age and department were more important than other demographics. The results from logistic regression analysis indicated that age and department were statistically significant risk factors for NSIs.
In this study, more than 80% of NSIs occurred among nurses age 25 years or younger. A previous study estimated that the risk of NSIs among nurses younger than average (27 years) was 3.1 to 4.5 times higher than for nurses who were older than average (Smith, Choe, et al., 2006). It is possible that younger nurses have less seniority, and therefore might be required to complete more routine daily tasks involving patient care with NSI devices (e.g., giving injections) or older nurses might be more likely to hold administrative roles and other tasks where NSIs exposure is low (Smith, Choe, et al., 2006). The prevalence of NSIs was highest among nurses with less than 5 years of
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Figure 2. Causative devices of needlestick and sharps injuries.
service at the hospital (71.1%), suggesting that nurses have more NSIs during the early years of their professional lives (Ilhan, Durukan, Aras, Türkçüog˘lu, & Aygün, 2006). NSIs disproportionately affected nurses working in specific hospital departments. This study reported that NSIs occurred most frequently in the surgical department (84.6%). Other studies have reported similar results (Ilhan et al., 2006; Nsubuga & Jaakkola, 2005; Smith, Choe, et al., 2006). This finding may reflect higher exposure to invasive interventions in surgical departments such as injections, intravenous infusions, and drug preparation (Ilhan et al., 2006). In contrast, a study from Saudi Arabia showed no difference in NSI risk between medical and surgical departments (Abu-Gad & Al-Turki, 2001). These results suggested that prevalence rates of NSIs across departments are not consistent in different countries. The syringe needle is believed to be the most common injury-causing device because most NSIs result from intramuscular, subcutaneous, intradermal, and intravenous needles. The results showed syringe needles and glass accounted for 59% and 22% of all NSIs, respectively. The findings of this study are consistent with previous studies from China (92.5%; Phipps et al., 2002), Australia (65.3%; Whitby & McLaws, 2002), Turkey (65.1%; Irmak, 2012), and the United States (35%; Jagger, Hunt, Brand-Elnaggar, & Pearson, 1988). In addition, a longitudinal study has also shown that syringe needles may be responsible for the highest rate of NSIs among nurses (Perry, Jagger, & Parker, 2003). This study reported that 42.5% of injury-causing devices had been contaminated with blood or body fluid, 37.9% occurred in the drug preparation and administration process, and for 19.6% patient status was unknown. This finding is also consistent with previous studies (Shiao, Mclaws, Huang, & Guo, 2002; Smith, Wei, & Wang, 2004). More than 40
million individuals are currently infected with HCV; HCV is the fourth most commonly reported infectious disease in China (Lu et al., 2013; Qin et al., 2015). The use of contaminated injection equipment causes a significant number of unrecognized transmissions every day and is the major risk factor for HCV infection (Prati, 2006). This study result suggested that Chinese nurses are at high risk of blood or body fluid pathogen transmission from contaminated devices. A previous study found that at least 60 blood or body fluid pathogens, including the most common HBV, HCV, and HIV, can be transmitted to health care workers by contaminated devices (Tarantola, Abitebout, & Rachline, 2006). It is reported that about 500,000 NSIs affect health care workers, with 1 in every 100 involving an HIV-positive patient in the United States each year (Gershon et al., 2000). Studies have shown that only 1 part per 10,000 ml of HBV-infected blood is required for HBV transmission (Costigliola, Frid, Letondeur, & Strauss, 2012), and the average risk of HCV and HIV transmission after NSIs exposure to HCV-infected and HIV-infected blood is approximately 1.8% and 0.3%, respectively (Beltrami, Williams, Shapiro, & Chamberland, 2000). The risk for blood or body fluid infection transmission among health care workers was 2 to 19 times that of the general population (Zafar et al., 2009). Limitations must be considered when interpreting findings from this study. The sample in this study was solicited from only one teaching hospital in China. The results of this study cannot be extrapolated to all nurses in China. Recall bias may have led to inaccurate estimation of the prevalence of NSIs and accompanying risk factors. The data were collected in a retrospective cross-sectional study; NSI incidence rates could not be calculated.
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Conclusion Needlestick injures are a significant occupational hazard for nurses, and NSIs occur among Chinese nurses at a high rate compared internationally. This study showed that the risk of NSIs was significantly associated with factors such as gender, age, department, and years in the profession; age and department were the most important risk factors. Syringe needles were the most common injury-causing device, and about half of NSIs involved devices that had been contaminated with patient blood or body fluids. Continuing education on safe injection techniques is needed. Further studies are needed to generate interventions for the prevention of NSIs among nurses.
Conflict of Interest The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Smith, D. R., Wei, N., & Wang, R. S. (2004). Needlestick and sharps injuries among Chinese hospital nurses. Advances in Exposure Prevention, 7(1), 11-12.
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Author Biographies
Tarantola, A., Golliot, F., Astagneau, P., Fleury, L., Brucker, G., & Bouvet, E. (2003). Occupational blood and body fluids exposures in health care workers: Four-year surveillance from the northern France network. American Journal of Infection Control, 31, 357-363. doi:10.1067/ mic.2003.75 Trueman, P., Taylor, M., Twena, N., & Chubb, B. (2008). The cost of needlestick injuries associated with insulin administration. British Journal of Community Nursing, 13, 413-417. doi: http://dx.doi. org/10.12968/bjcn.2008.13.9.30911 Wang, S. H., Yao, L., Li, S. X., Liu, Y., Wang, H. Y., & Sun, Y. (2012). Sharps injuries and job burnout: A cross-sectional study among nurses in China. Nursing & Health Science, 14, 332-338. doi: 10.1111/j.14422018.2012.00697.x Whitby, R. M., & McLaws, M. L. (2002). Hollow-bore needlestick injuries in a tertiary teaching hospital: Epidemiology, education and engineering. Medical Journal of Australia, 177, 418-422. White, S. M. (2007). Needlestuck. Anaesthesia, 62, 1199-1201. doi:10.1111/ j.1365-2044.2007.05375.x. Wilburn, S. Q., & Eijkemans, G. (2005, Winter). Preventing needle stick injuries and occupational exposure to bloodborne pathogens (The Global Occupational Health Network, Gohnet Newsletter, Issue 8). Retrieved from http://www.who.int/occupational_health/publications/ newsletter/gohnet8eng.pdf Xie, H. Z., Nie, J., Pan, S. S., & Bai, Y. (2003). An epidemiological investigation on injection related risk factors. Zhonghua Liu Xing Bing Xue Za Zhi, 24(3), 172-175. Yao, G. B. (1996). Importance of perinatal versus horizontal transmission of hepatitis B virus infection in China. Gut, 38(Suppl. 2), S39-S42. doi:10.1136/gut.38 Zafar, A., Habib, F., Hadwani, R., Ejaz, M., Khowaja, K., Khowaja, R., & Irfan, S. (2009). Impact of infection control activities on the rate of needle stick injuries at a tertiary care hospital of Pakistan over a period of six years: An observational study. BMC Infectious Diseases, 9, Article 78. doi:10.1186/1471-2334-9-78
Xujun Zhang is an associate professor in the Epidemiology Division, School of Public Health, Southeast University. He is the president of the Injury Prevention Research Institute at the Southeast University. His research interests include multidisciplinary injury research in road safety, agricultural injuries, childhood injuries, and occupational injuries. Yue Gu is a physician specializing in public health. She is studying for a public health graduate degree at the Southeast University School of Public Health. Mengjing Cui is a physician specializing in public health. She is studying for a public health graduate degree at the Southeast University School of Public Health. Lorann Stallones is a professor in the Department of Psychology, Colorado State University and in the Department of Epidemiology, Colorado School of Public Health. She is the director of the Colorado Injury Control Research Center. Her research interests are occupational injuries, agricultural safety and health, and community based injury prevention. Huiyun Xiang is professor of pediatrics, College of Medicine and a professor of Epidemiology, School of Public Health, The Ohio State University. He is the director of Center for Pediatric Trauma Research and the director of research core and international programs of the Center for Injury Research and Policy at the Nationwide Children’s Hospital. His primary research interests include injury epidemiology among individuals with disabilities, trauma outcome research, and injury research and prevention in the developing world.
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WHSXXX10.1177/2165079915580035Workplace Health & SafetyWorkplace Health & Safety
Workplace Health & Safety
vol. XX ■ no. X
ARTICLE
Needlestick and Sharps Injuries Among Nurses at a Teaching Hospital in China Xujun Zhang, PhD1, Yue Gu, MD1, Mengjing Cui, MD1, Lorann Stallones, MPH, PhD2, and Huiyun Xiang, MD, MPH, PhD3
Abstract: Needlestick and sharps injuries (NSIs) are a major occupational injury to health care workers worldwide. This study aimed to report the prevalence and risk factors of NSIs among nurses working at a Chinese teaching hospital. From 463 nurses, 402 completed questionnaires were obtained. A total of 261 (64.9%) nurses reported needlestick or sharps injuries. NSIs were more common among females, young nurses, surgical nurses, and junior nurses. Logistic regression analysis suggests that age and work department were independent risk factors for NSIs. By type of devices, syringe needles accounted for the highest proportion of all NSIs (59%), followed by glass items (22%), and trocar core/ catheter wires (4%). NSIs remain an important occupational hazard issue or Chinese nurses. Programs must be developed to prevent injuries caused by needlesticks and sharps. Keywords: needlestick injuries, sharps injuries, risk factor, nurse, China
N
eedlestick and sharps injuries (NSIs) are a major occupational hazard for health care workers worldwide (Pruss-Ustun, Rapiti, & Hutin, 2003). The World Health Organization (WHO) reported that the annual number of NSIs among health care workers is four injuries per person in Africa, western Mediterranean, and Asia (Mantel, 2002). NSIs are the second most common occupational injury identified by the National Health Service (NHS), accounting for 17% of all injuries among health care workers (National Audit Office, 2003). A Royal College of Nursing (RCN) survey of 4,407 nurses found that almost half of all nurses (48%) had been injured by a needle or sharp that had previously been used on a patient (RCN, 2009). Other studies found that nurses are at the highest risk for NSIs among health care workers (Tarantola et al., 2003; Wilburn & Eijkemans, 2005). Contaminated needles and sharps are the most common cause of transmitting blood- or body-fluid-borne infections
between patients and health care workers (Gershon et al., 2000; Pruss-Ustun et al., 2003). According to one study, more than 3 million health care workers were exposed to the hepatitis B virus (HBV), the hepatitis C virus (HCV), or the human immunodeficiency virus (HIV) due to NSIs every year worldwide (White, 2007). These work-related exposures may have resulted in about 66,000 HBV, 16,000 HCV, and 1,000 HIV infections worldwide among health care workers in 2000 (Pruss-Ustun, Rapiti, & Hutin, 2005). NSIs cause not only physical injury and emotional effects but also economic losses (Reis, Gir, & Canini, 2004; RCN, 2009). It is estimated that needlestick injuries that occur during insulin administration cost the NHS approximately £600,000 per year in the United Kingdom, including post-NSI prophylaxis, laboratory tests, counseling, treatment of transmitted diseases, and litigation (Trueman, Taylor, Twena, & Chubb, 2008). The economic cost of managing NSIs is substantial, ranging from US$51 to US$3,766 (USD) for every case of NSIs in the United States (Lee, Botteman, Xanthakos, & Nicklasson, 2005). However, this amount did not account for the cost of treating the long-term complications of needlestick injuries, such as HIV, HBV, and HCV infections, each of which can cost hundreds of thousands of dollars (Lee et al., 2005). The economic loss due to NSIs is enormous, but emotional problems caused by NSIs are immeasurable (Leigh et al., 2007). China has the world’s largest population and is the largest developing country with at least 1.2 million nurses. They are required to perform various types of health-related treatments and handle sharps, such as subcutaneous, intramuscular, and intravenous needles and various cutters. However, no law calls for the use of safety needles and devices in China. Safety needles and devices are less commonly used in China compared with other countries due to the high cost of safety devices. Results of previous studies in China showed that nurses working in hospitals were at high risk of NSIs (Wang et al., 2012; Xie, Nie, Pan, & Bai, 2003; Zheng, Di, & Guo, 2005). China has one of the highest rates of endemic HBV infection in
DOI: 10.1177/2165079915580035. From 1Southeast University, 2Colorado State University, and 3The Ohio State University College of Medicine. Address correspondence to: Xujun Zhang, PhD, Injury Prevention Research Institute, Key Laboratory of Environmental Medicine Engineering, Ministry of Education, School of Public Health, Southeast University, 87 Dingjiaqiao Rd., Nanjing, Jiangsu 210009, People’s Republic of China; email: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2015 The Author(s)
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Applying Research to Practice Needlestick and sharps injuries are an important occupational safety concern among health care workers worldwide. Nurses are at high risk for needlestick and sharps injuries among health care workers. Age and employment department were significant risk factors for needlestick and sharps injuries among nurses in China. Syringe needles were the most common causative device, and about half of needlestick and sharps injuries involved devices that had been contaminated with blood or body fluids from patients. Nurses in China face a significantly high risk of being infected with HBV, HCV, and HIV because of their high risk of needlestick and sharps injuries at work. Further studies are needed to develop and evaluate interventions for the prevention of needlestick and sharps injuries among registered nurses in China. the world, with an estimated 150 million hepatitis B surface antigen (HBsAg) carriers nationwide (Yao, 1996). Moreover, the prevalence of HCV and HIV is rising in China (Phipps et al., 2002). Therefore, exposure to blood or body fluid pathogens is a serious occupational hazard for Chinese nurses. Despite this, little data have been published about patterns of and risk factors for needlestick and sharps injuries among Chinese nurses. This study was conducted to determine the prevalence of NSIs among nurses working in a Chinese teaching hospital and to examine the contributing risk factors for these injuries.
Method Study Design and Sampling This cross-sectional study engaged nurses working at a teaching hospital in Nanjing, the capital city of Jiangsu Province, China. Based on an anticipated prevalence of NSIs among Chinese nurses of 20%, a total of 384 participants were needed to achieve a study power of 0.80 and an alpha of .05. The total number of nurses in the university teaching hospital was 938. Anticipating a 15% nonresponse rate, a total of 463 nurses were needed for the study. Nurses were excluded if they held administration positions without direct patient care responsibilities. The Institutional Review Board of Southeast University School of Public Health approved the study procedures. Informed consent was secured from participants in accordance with ethical guidelines.
Measurements The questionnaire was developed by a research team at the Southeast University Injury Prevention Research Institute and pilot tested the survey questionnaire in a small group of the target population in the study area in February 2012. Specifically, 10 nurses were interviewed and provided feedback about the questionnaire. Minor changes were made before the survey questionnaire was finalized.
Data Collection The study was launched, and data were collected in April 2012. A list of all potential participants and the departments where they worked were obtained from the nursing department of the hospital. Participants were contacted by the researchers at the hospital, and they were provided a copy of the questionnaire. Questionnaires were collected several hours after distribution. The data collection was completed in 1 week. The first part of the questionnaire gathered sociodemographic characteristics and was followed by questions about whether the participants had experienced a work-related needlestick or sharps injury during the past year. Characteristics of NSIs included causative devices, causative activities, work department, and part of body injured.
Statistical Analysis Data were entered into EpiData 3.0 and analyzed using SAS 9.1. First, demographics, parts of body injured, and causative devices of NSIs were described. Second, chi-square analyses assessed the association of NSIs to select demographic factors. Third, to control for confounding, multivariate logistic regression analyses were conducted. In the logistic regression analyses, the outcome variable was NSIs (yes/no), and the independent variables were gender, age, work department, and years in nursing. Statistical significance was set at p < .05.
Results Of the 463 nurses who received the questionnaire, 402 completed the questionnaire, yielding an overall response rate of 86.8%. Of the 61 nurses who did not respond, they were either absent from the hospital when the survey was conducted or they failed to complete the questionnaire. Most of the participants were female (96%) and less than 36 years of age (76.6%), representing different departments of the hospital: 36% from internal medicine, 26% from surgery, 6% from obstetricsgynecology, and 32% from other departments. Table 1 presents the prevalence of NSIs by select demographic factors. A total of 261 cases of NSIs (64.9%) were reported. The prevalence of NSIs was significantly higher in females than in males (66.3% vs. 31.3%, p < .05). NSIs disproportionately affected young workers, with more than 80% of injuries among those workers less than 36 years of age. The prevalence of NSIs also varied by department. Comparing the prevalence of NSIs in internal medicine (60%), surgery (84.6%), obstetrics/gynecology (66.7%), and other departments (54.3%) suggested that the prevalence of NSIs in surgery was significantly higher than that in internal medicine, obstetrics/gynecology, and other departments (p < .001). The prevalence of NSIs was higher for nurses who worked in the surgery department, with their risk being 4.4 times higher than for those working in other departments (OR = 4.43, 95% CI [2.30, 8.50]). The proportion of nurses who suffered NSIs was higher among those nurses who had practiced less years: less than 5
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Table 1. Comparison of Needlestick and Sharps Injuries by Selected Demographics
Total
Total N of nurses
Persons with injury n (%)
p valuea
402
261 (64.9)
Gender
.004
Men
16
5 (31.3)
Women
386
256 (66.3)
Age (years)
.001
≤25
171
118 (69.0)
26-35
137
98 (71.5)
36-45
58
30 (51.7)
>45
36
15 (41.7)
Work department
45
Reference
Work department Internal medicine
.000 −0.056
0.261
0.95 [0.57, 1.58]
.829
Surgery
1.488
0.333
4.43 [2.30, 8.50]
.000
Obstetrics or gynecology
0.440
0.484
1.55 [0.60, 4.01]
.363
Other department
Reference
Figure 1. Parts of hand injured.
underreporting in the United States, the high rate of injury reported by these Chinese nurses is striking (Phipps et al., 2002). This study also found that the risk of NSIs due to invasive treatment and nursing procedures was significantly associated with factors such as gender, age, department, and years in the profession, but results from multivariate modeling suggested that age and department were more important than other demographics. The results from logistic regression analysis indicated that age and department were statistically significant risk factors for NSIs.
In this study, more than 80% of NSIs occurred among nurses age 25 years or younger. A previous study estimated that the risk of NSIs among nurses younger than average (27 years) was 3.1 to 4.5 times higher than for nurses who were older than average (Smith, Choe, et al., 2006). It is possible that younger nurses have less seniority, and therefore might be required to complete more routine daily tasks involving patient care with NSI devices (e.g., giving injections) or older nurses might be more likely to hold administrative roles and other tasks where NSIs exposure is low (Smith, Choe, et al., 2006). The prevalence of NSIs was highest among nurses with less than 5 years of
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Figure 2. Causative devices of needlestick and sharps injuries.
service at the hospital (71.1%), suggesting that nurses have more NSIs during the early years of their professional lives (Ilhan, Durukan, Aras, Türkçüog˘lu, & Aygün, 2006). NSIs disproportionately affected nurses working in specific hospital departments. This study reported that NSIs occurred most frequently in the surgical department (84.6%). Other studies have reported similar results (Ilhan et al., 2006; Nsubuga & Jaakkola, 2005; Smith, Choe, et al., 2006). This finding may reflect higher exposure to invasive interventions in surgical departments such as injections, intravenous infusions, and drug preparation (Ilhan et al., 2006). In contrast, a study from Saudi Arabia showed no difference in NSI risk between medical and surgical departments (Abu-Gad & Al-Turki, 2001). These results suggested that prevalence rates of NSIs across departments are not consistent in different countries. The syringe needle is believed to be the most common injury-causing device because most NSIs result from intramuscular, subcutaneous, intradermal, and intravenous needles. The results showed syringe needles and glass accounted for 59% and 22% of all NSIs, respectively. The findings of this study are consistent with previous studies from China (92.5%; Phipps et al., 2002), Australia (65.3%; Whitby & McLaws, 2002), Turkey (65.1%; Irmak, 2012), and the United States (35%; Jagger, Hunt, Brand-Elnaggar, & Pearson, 1988). In addition, a longitudinal study has also shown that syringe needles may be responsible for the highest rate of NSIs among nurses (Perry, Jagger, & Parker, 2003). This study reported that 42.5% of injury-causing devices had been contaminated with blood or body fluid, 37.9% occurred in the drug preparation and administration process, and for 19.6% patient status was unknown. This finding is also consistent with previous studies (Shiao, Mclaws, Huang, & Guo, 2002; Smith, Wei, & Wang, 2004). More than 40
million individuals are currently infected with HCV; HCV is the fourth most commonly reported infectious disease in China (Lu et al., 2013; Qin et al., 2015). The use of contaminated injection equipment causes a significant number of unrecognized transmissions every day and is the major risk factor for HCV infection (Prati, 2006). This study result suggested that Chinese nurses are at high risk of blood or body fluid pathogen transmission from contaminated devices. A previous study found that at least 60 blood or body fluid pathogens, including the most common HBV, HCV, and HIV, can be transmitted to health care workers by contaminated devices (Tarantola, Abitebout, & Rachline, 2006). It is reported that about 500,000 NSIs affect health care workers, with 1 in every 100 involving an HIV-positive patient in the United States each year (Gershon et al., 2000). Studies have shown that only 1 part per 10,000 ml of HBV-infected blood is required for HBV transmission (Costigliola, Frid, Letondeur, & Strauss, 2012), and the average risk of HCV and HIV transmission after NSIs exposure to HCV-infected and HIV-infected blood is approximately 1.8% and 0.3%, respectively (Beltrami, Williams, Shapiro, & Chamberland, 2000). The risk for blood or body fluid infection transmission among health care workers was 2 to 19 times that of the general population (Zafar et al., 2009). Limitations must be considered when interpreting findings from this study. The sample in this study was solicited from only one teaching hospital in China. The results of this study cannot be extrapolated to all nurses in China. Recall bias may have led to inaccurate estimation of the prevalence of NSIs and accompanying risk factors. The data were collected in a retrospective cross-sectional study; NSI incidence rates could not be calculated.
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Conclusion Needlestick injures are a significant occupational hazard for nurses, and NSIs occur among Chinese nurses at a high rate compared internationally. This study showed that the risk of NSIs was significantly associated with factors such as gender, age, department, and years in the profession; age and department were the most important risk factors. Syringe needles were the most common injury-causing device, and about half of NSIs involved devices that had been contaminated with patient blood or body fluids. Continuing education on safe injection techniques is needed. Further studies are needed to generate interventions for the prevention of NSIs among nurses.
Conflict of Interest The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Author Biographies
Tarantola, A., Golliot, F., Astagneau, P., Fleury, L., Brucker, G., & Bouvet, E. (2003). Occupational blood and body fluids exposures in health care workers: Four-year surveillance from the northern France network. American Journal of Infection Control, 31, 357-363. doi:10.1067/ mic.2003.75 Trueman, P., Taylor, M., Twena, N., & Chubb, B. (2008). The cost of needlestick injuries associated with insulin administration. British Journal of Community Nursing, 13, 413-417. doi: http://dx.doi. org/10.12968/bjcn.2008.13.9.30911 Wang, S. H., Yao, L., Li, S. X., Liu, Y., Wang, H. Y., & Sun, Y. (2012). Sharps injuries and job burnout: A cross-sectional study among nurses in China. Nursing & Health Science, 14, 332-338. doi: 10.1111/j.14422018.2012.00697.x Whitby, R. M., & McLaws, M. L. (2002). Hollow-bore needlestick injuries in a tertiary teaching hospital: Epidemiology, education and engineering. Medical Journal of Australia, 177, 418-422. White, S. M. (2007). Needlestuck. Anaesthesia, 62, 1199-1201. doi:10.1111/ j.1365-2044.2007.05375.x. Wilburn, S. Q., & Eijkemans, G. (2005, Winter). Preventing needle stick injuries and occupational exposure to bloodborne pathogens (The Global Occupational Health Network, Gohnet Newsletter, Issue 8). Retrieved from http://www.who.int/occupational_health/publications/ newsletter/gohnet8eng.pdf Xie, H. Z., Nie, J., Pan, S. S., & Bai, Y. (2003). An epidemiological investigation on injection related risk factors. Zhonghua Liu Xing Bing Xue Za Zhi, 24(3), 172-175. Yao, G. B. (1996). Importance of perinatal versus horizontal transmission of hepatitis B virus infection in China. Gut, 38(Suppl. 2), S39-S42. doi:10.1136/gut.38 Zafar, A., Habib, F., Hadwani, R., Ejaz, M., Khowaja, K., Khowaja, R., & Irfan, S. (2009). Impact of infection control activities on the rate of needle stick injuries at a tertiary care hospital of Pakistan over a period of six years: An observational study. BMC Infectious Diseases, 9, Article 78. doi:10.1186/1471-2334-9-78
Xujun Zhang is an associate professor in the Epidemiology Division, School of Public Health, Southeast University. He is the president of the Injury Prevention Research Institute at the Southeast University. His research interests include multidisciplinary injury research in road safety, agricultural injuries, childhood injuries, and occupational injuries. Yue Gu is a physician specializing in public health. She is studying for a public health graduate degree at the Southeast University School of Public Health. Mengjing Cui is a physician specializing in public health. She is studying for a public health graduate degree at the Southeast University School of Public Health. Lorann Stallones is a professor in the Department of Psychology, Colorado State University and in the Department of Epidemiology, Colorado School of Public Health. She is the director of the Colorado Injury Control Research Center. Her research interests are occupational injuries, agricultural safety and health, and community based injury prevention. Huiyun Xiang is professor of pediatrics, College of Medicine and a professor of Epidemiology, School of Public Health, The Ohio State University. He is the director of Center for Pediatric Trauma Research and the director of research core and international programs of the Center for Injury Research and Policy at the Nationwide Children’s Hospital. His primary research interests include injury epidemiology among individuals with disabilities, trauma outcome research, and injury research and prevention in the developing world.
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