American Journal of Infection Control 44 (2016) 183-8
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American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Qualitative content analysis of psychologic discomfort and coping process after needlestick injuries among health care workers Jae Sim Jeong RN, MPH, PhD, KAPN a, Haeng Mi Son RN, PhD a, Ihn Sook Jeong RN, PhD b, *, Jun Seok Son MD, PhD c, Kyong-sok Shin MD d, Sung Won Yoonchang RN, PhD e, Hye Young Jin RN, PhD f, Si Hyeon Han RN, MSN g, Su Ha Han RN, PhD h a
Department of Nursing, University of Ulsan, Ulsan, Republic of Korea College of Nursing, Pusan National University, Busan, Republic of Korea c Department of Occupational and Environmental Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea d Seegene Medical Foundation, Seoul, Republic of Korea e Department of Nursing, Chungwoon University, Chungnam, Republic of Korea f Department of Infection Control Office, Ajou University Hospital, Suwon, Republic of Korea g Infection Prevention and Control Team, Dankook University Hospital, Cheon-An, Republic of Korea h Infection Prevention and Control Team, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea b
Key Words: Needlestick injuries Health personnel Qualitative research Adaptation Psychologic
Background: This study was designed to survey psychologic discomfort and coping processes of health care workers that suffered needlestick injuries (NSIs). Methods: This qualitative analysis was performed with 15 health care workers who experienced NSIs. Data were collected using face-to-face interviews. The study subjects were asked the following: please describe the psychologic discomfort that you experienced after the NSI incidence. Data were evaluated by qualitative content analysis. Results: Types of psychologic discomfort after NSI among health care workers included anxiety, anger, and feelings of guilt. Some personnel adopted active coping strategies, such as seeking first aid or reporting the incident to a monitoring system, whereas others used passive coping methods, such as avoidance of reporting the incident, vague expectancy to have no problems, and reliance on religious beliefs. Recommended support strategies to improve the prevention of NSIs were augmenting employee education and increasing recognition of techniques for avoiding NSIs. Conclusion: Medical institutions need to provide employees with repeated education so that they are familiar with guidelines for preventing NSIs and to stimulate their alertness to the risk of injuries at any time, in any place, and to anybody. Copyright Ó 2016 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Health care workers risk viral infection when they handle sharp tools such as injection needles; in one report, 70.4% of nurses (n ¼ 3,079) working at 60 hospitals reported having experienced a needlestick injury (NSI).1 An NSI exposes health care workers to
* Address correspondence to Ihn Sook Jeong, RN, PhD, College of Nursing, Pusan National University, 49 BusanDaehak-ro Mulgeum-eup Yangsan-si, 626-870, Gyeongnam. E-mail address: [email protected] (I.S. Jeong). Funding/Support: Supported by the Korea Occupational Safety and Health Institution in 2012. Conflicts of interest: None to report.
patient blood or body fluids and increases the risk of infection with bloodborne viral pathogens, such as hepatitis B, hepatitis C, and HIV. In addition to physical risk by NSI, employees who have experienced NSI show significantly higher levels of depression2,3 and anxiety3-5 than those who have not had an NSI. The level of anxiety was even higher if the infection status of the patient involved in the NSI was unknown.4 If such psychologic discomfort is not managed properly during the early stages, it can worsen or develop into a chronic condition, such as post-traumatic stress disorder.6 It was found that 12% of medical doctors who had experienced NSI also experienced post-traumatic stress disorder, and this level was 4.28 times higher than the rate (3%) of the general population.7,8
0196-6553/$36.00 - Copyright Ó 2016 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2015.09.002
blood blood blood blood blood blood blood little little little little little little little skin, skin, skin, skin, skin, skin, skin, through through through through through through through Penetrate Penetrate Penetrate Penetrate Penetrate Penetrate Penetrate Blood Blood Blood Blood Blood Blood Blood 8 y, 4 mo 9 mo 1 y, 1 mo 17 y, 4 mo 1y
Anti-HCV Anti-HCV None HBsAg Unknown Unknown Unknown 11 mo
M F F M F M F 4 5 6 7 8 9 10
MD (intern) RN Technician Technician Housekeeper Technician RN
F 3
F, female; IV, intravenous; M, male; MD, medical doctor; RN, registered nurse; HBsAg, Hepatitis B surface antigen; ID/SC, intradermal/subcutaneous; HCV, hepatitis C virus.
Patient movement Transfer device During sampling blood Transfer to needle box Needle in an inappropriate place During use of item Disassembling device or equipment Needle attached to syringe Suture needle Phlebotomy needle Phlebotomy needle ID/SC needle Needle attached to syringe Needle attached to syringe
During arrangement after IV injection Needle attached to syringe Penetrate through skin, little blood Blood HBsAg 2 mo
M M 1 2
RN
Situation
Arterial venepuncture Venous puncture
Sex Participant
This study was approved by the Asan Medical Center Institutional Review Board, Seoul, South Korea (approval no. 2011-0683). Data were collected between September and October 2011 by an expert (H.M.S.) in qualitative research. Each participant was interviewed one-on-one using the open-ended question: How would you describe your NSI experience? If necessary, additional and more detailed questions were asked, such as (1) In what situation did the NSI occur?; (2) How did you feel and what did you think just
Table 1 Characteristics of participants
Data collection
Occupation
Job experience
Source blood
Type of fluid
Depth of injury
The participants in this study included 15 health care workers who sustained an NSI. These individuals were selected based on occupation, exposure to bloodborne pathogens (eg, hepatitis B, hepatitis C, HIV), medium of exposure (eg, blood, body fluids), and instruments involved (eg, needles, mess). The participants were selected through purposive sampling from employees who were monitored for follow-up because of an NSI up to 6 months before the start of data collection. The study participants were health care workers who reported an NSI to data collectors working at 1 of 53 medical institutions participating in the national NSI surveillance system organized by the Korea Occupational Safety and Health Research Institute. The 15 participants included 10 women and 5 men. Three of the participants were doctors, 8 were nurses, 2 were clinical pathologists, 1 was a sanitation worker, and 1 was a medical engineer. The periods of employment varied from 2 months to 17 years and 4 months. Most of the NSI cases involved blood as the medium of exposure, and the injuries sustained were described as needle penetration of the skin with a small amount of bleeding. The results of antibody screening for hepatitis B were positive at the time of exposure in most cases (14/15). Many cases involved needles attached to syringes, among other appliances. The situations during which the NSIs occurred were variable, and a great number of cases took place during or after use of the involved appliances (Table 1).
HBsAg (þ) HBsAg () HBsAb (þ) HBsAg () HBsAb (þ) HBsAb (þ) HBsAb (þ) HBsAb (þ) HBsAb (þ) HBsAb (þ) HBsAb (þ) HBsAb (þ)
Device
Study participants
Penetrate through skin, little blood Penetrate through skin, little blood
In this study, a qualitative analysis was performed to understand and describe the experiences of health care workers after an NSI.
Blood Blood
Study design
Anti-HCV HBsAg
Health care personnel
METHODS
4 y, 7 mo 4 y, 8 mo
Most previous studies on psychologic discomfort experienced by health care workers after an NSI have been quantitative. These investigations have focused on the level or severity of a specific type of psychologic discomfort but have failed to identify patterns of psychologic discomfort. Moreover, it is unclear how medical professionals who have suffered NSIs cope with the accompanying psychologic distress. There is therefore a need to examine the experiences of health care workers who have sustained NSI through in-depth interviews and surveys on the methods used to cope with the accompanying psychologic discomfort and to prepare strategies to support this ability to cope effectively. In recognition of these needs, this study was conducted to identify the patterns of psychologic discomfort experienced by nurses after an NSI by administering an in-depth survey to understand how they cope with the stress from this event. Strategies for effectively preventing and managing NSI were formulated based on the survey results. The key research question in this study was as follows: What were the experiences, characteristics of psychologic discomfort, and coping strategies of health care workers who experienced an NSI?
Needle attached to syringe Needle attached to syringe
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MD (resident) MD (intern)
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after the NSI; (3) How severe was the psychologic discomfort you experienced after the NSI?; (4) What did the NSI mean to you?; (5) How did you cope with the NSI?; and (6) What do you think should be done to prevent NSIs? Each interview was conducted until data saturation, that is, until the same information was repeated by the participant. The contents of the interviews were recorded and transcribed exactly as spoken by the participant. Each interview took about 1 hour, and each participant completed 1-2 interviews. Data analysis Qualitative content analysis is a method used to interpret the meanings of extensive and complicated textual data.9 Data of this study were evaluated through qualitative content analysis. After reading the transcribed texts to identify meaningful words, phrases, and sentences, open coding was performed. Subcategories were established according to the relationships among codes in terms of the continuous comparative analysis of differences and similarities in open coding. Finally, relationships among the subcategories were further elaborated, and more abstract categories were established. Study rigor This investigation was designed to adhere to criteria for credibility, fittingness, auditability, and confirmability.10 For credibility, the researchers participated in an educational qualitative research course, directed by an expert in qualitative studies, and all researchers actively engaged in discussions throughout the course of the research to obtain convergence. Findings of this study were based on vivid experiences of health care workers who had sustained an NSI, and the data analysis followed the coding scheme suggested by the qualitative content analysis technique. The categories established during the course of data analysis were elaborated in continuous comparative analysis. For auditability, which indicates whether readers can evaluate the researcher’s analytical processes and research outcomes, the data collection process was described in detail. For fittingness, which indicates the diversity of situations, various types of health care workers who had experienced an NSI were invited to be interviewed, and data were collected until the participants’ statements reached the state of saturation. For confirmability (which indicates the adequacy of categories derived from data analysis by experts in qualitative research, experts in infection control, and interviewees), the categories were refined through continuous comparative analysis. A bilingual translator translated the article into English under the guidance of the research team, and the translated contents were confirmed by the research team. RESULTS NSI circumstances Excessive workload Environments in which NSIs frequently occurred included operating rooms, departments of clinical pathology, and hospital wards, where things are routinely busy. As a result, many NSIs were attributed to carelessness and mistakes associated with excessive workload. The participants frequently felt that they were exposed to an environment of risk of NSIs. Additionally, the participants felt they needed to be careful with each other to prevent accidents. In addition, they often thought that it would be difficult for them to continue their jobs in such a dangerous environment. One participant stated the following:
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“First of all, the problem is an excessive work load. It can be an insurmountable problem. Two of the three stabbing instances occurred within a short time when I had a lot of work.I needed to do some sampling work in the intensive care unit (ICU), but the workload was enormous.thus, I was stabbed while being hasty. I also thought that I might not have been stabbed if I had not been hasty, if I had had enough time to complete my tasks more carefully.” Another example is as follows: “We are excessively busy in our operating rooms. We should really deal with all patients while wearing gloves, but since we are excessively busy, we frequently touch and move patients or arrange appliances with bare hands.although we make a great effort to remember to put gloves on.” Lack of attention among health care workers The participants generally thought that NSIs were trivial. Doing their jobs repetitively out of habit, they helped cause the NSIs because of overlooked precautions and insufficient performance of preventive measures. Despite their knowledge and training, health care workers had a low level of recognition of the seriousness of frequent NSIs. After the NSIs, the participants belatedly realized their carelessness and lack of adherence to the guidelines provided by their hospitals. One participant stated, “When I was first stabbed, I was afraid that something serious would happen, but everyone around said it was alright. As for hepatitis B infection, we have medications for it, and therefore hepatitis B infection is considered trivial.” As a second example, “I would not have had such an incident if I had followed the manual for preventing injuries. Even though I knew that I should not recap needles, I still made the mistake because I thought I would be fine and overlooked the possibility of a mistake. I believe that this kind of mistake would not have happened if I had done my job as I had been taught.”
Psychologic discomfort after an NSI Anxiety about disease onset Having experienced an NSI, most of the participants suffered from overwhelming stress because of worries and concerns about the negative impact to their health, job, and influence on their lives overall. Most NSI cases involved stabs from syringes contaminated with blood from patients with hepatitis. The participants tried to determine the seriousness of their injuries by reviewing the relevant patients’ medical records. The injured employees reported that they felt great fear of disease onset because as health care workers they were well aware of the clinical development of hepatitis and its possible threat to their lives. One participant stated, “Regardless of others’ thoughts, I considered my injury to be an extreme situation. Beginning with what should I do if I had been infected with hepatitis C, I was also concerned with questions such as how I could quit my job, tell other people, or get married.” A second participant stated, “What was the patient’s history? I first of all wondered this, and I also feared whether there was any chance that the patient had an infection.” The participants also had difficulty facing their current situations and had serious concerns about their future because they were aware of other cases of infection because of NSI. For example, “It was said that an intern was infected last year. We witnessed the incident and are anxious. The ideal romantic partner does not have hepatitis. In addition, we now are experiencing enormous stress due to this incident. We have suffered more serious stress because we have observed such cases directly.”
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In particular, the participants grew increasingly worried and concerned about their NSIs if they experienced any sort of illness after the occurrence. Most of the participants had difficulty controlling their feelings when imagining their bad physical condition to be related to their injury. Because they strongly wished that the situations were not real, they considered the correct test results to be wrong or they hoped the test results were not accurate. For example, “I felt very bad because I was tired and in bad physical condition, even though I have antibodies. I also worried about getting cancer since the mess was used for cancer patients. I suffered such serious stress that I doubted the results of the test.” The participants were anxious and distressed as a result of the recurrence of memories of the injury. Their anxiety was caused by fear of the possibility that they could experience repeated NSIs because of their carelessness. Therefore, the participants were nervous when they performed tasks that they would usually complete with confidence. One participant stated, When stabbed, I suffered short-term rather than long-term stress .with the highest stress on that day or for a few days thereafter. However, I felt better when I thought it would be alright. Nevertheless, the memory of the moment continued . always when I flushed something. Then I thought, this is my fault, isn’t it? This also is a kind of stress. The stress, it seems to overwhelm me. The worst thing seems to be the short-term stress.” Another participant stated the following: “I couldn’t even sleep.I couldn’t perform my tasks properly, fearing that it would happen again.if I did things wrong.again.fearing that such a thing would happen again.I just hesitated about things that I had usually performed without any problem.” Respondents reported some relief after receiving negative test results, but they still experienced anxiety about disease onset, along with the fact that they had sustained an NSI. For example, “Then came the results. I read them and saw that I was alright. I was at ease, but then had a follow-up phone call. They said I was alright and should repeat the test one month later. I heard from the department of infection management, and then the painful feelings disappeared.” Anger The participants were also angry about their NSIs. In particular, they showed more serious emotional reactions in cases of infection by agents with high infectivity rates. They also experienced negative feelings projected toward their patients. Some felt resentment toward patients with infected blood and complained that the NSIs hindered their busy everyday work routines. For example, “Why me? In this case, I questioned why it happened to me. Why me? Anybody could be stabbed, but why me? Why did this particular patient have to have a high HBV titer and be rapid plasma regainpositive? It’s such a misfortune. Why am I so unfortunate?” As a second example, “I wondered why I had to be stabbed by the needle during a busy moment when I needed to work.” One of the participants expressed regret, saying that the injury might not have occurred if a safe environment had been created for the avoidance of NSIs. They stated, “Although it was primarily due to my carelessness, the probability of being stabbed due to carelessness would have decreased if there had been things like safety needles, which would have made it easier to properly cope with such situations.” Such resentful thoughts gradually disappeared over time, and the participants found relief based on their medical knowledge and data. For instance, “Based on figures, objective data on the occurrence of the bloodborne diseases by stabbing, then.nonetheless, I took solace in the thought that I would be unlikely to be included. And, well, time will handle the rest.ha ha (laugh).”
Guilty feeling Some participants experienced regret and blamed themselves for their careless behavior. They also felt uncomfortable and ashamed as people around them tended to devalue their performance rather than seeing the incidents as simple mistakes. One participant stated the following: “My case was more serious. I naturally tend to think bad things are due to me.since I have emphasized that everyone should always be careful and attentive.I thought such a thing would not happen if I were careful.Then, I believed that it would be my fault if such a thing happened.” A second participant stated, “I was careless when it happened. The needle should have been oriented more inwardly, but I was stabbed by it because I oriented it upwardly instead. Why did I do that despite the fact that I typically never did so? This idea came to my mind, and I blame myself somewhat.” Coping with NSIs Active coping Most of the participants coped with the NSIs according to the guidelines for first aid treatment and care provided by their hospitals’ infection management department. They reported that the department of infection management normally communicated the guidelines for NSIs to employees and that their hospitals had established appropriate policies. However, some participants were embarrassed because of their ignorance of first aid treatment and measures. For example, “After first squeezing blood sufficiently by pressing on the stab site, I hurried to the faucet for running water, squeezed more and disinfected, and then immediately went down to the ER to take precautionary measures.” A second participant stated, “I provided primary treatment. I immediately took off my gloves and poured alcohol, betadine, and then more alcohol on the wound.” Most participants were satisfied with the follow-up care provided through the monitoring system of hospitals after sustaining an NSI. During follow-up care, they underwent blood tests conducted by infectious disease physicians and nurses and were provided with sufficient information about test results and treatment plans. One participant stated, “I made a phone call, and then they took blood samples, provided guidance, and informed me of test results. I felt they provided good care. Thus, I was satisfied.” A second participant stated, “I felt rather relieved as I was in a hospital. They performed blood tests and took care of me, and even if I were to be infected, I felt I would be taken care of because I was in a hospital.” A third participant stated, “I received a text message that I needed to give blood for tests due to the incident. Our hospital took good care of such things.” Passive coping The participants coped passively for various reasons. First was fear of their superiors’ rebukes. They experienced mental conflict when reporting their NSIs to the supervising office of their hospital. They were concerned about reporting their NSIs to their hospital, which they felt would indicate poor work performance. Fear and concern about reporting incidents to a supervising department or a supervisor was a phenomenon predominantly observed in cases with novices or less experienced nurses. Some participants tried to conceal their NSIs, fearing that their supervisors would blame them for their injury. These participants did not file a report because they thought they would be fine or they did not consider their condition to be serious after obtaining patient information. For example, “Momentarily, I was conflicted, wondering whether I should report the incident or if it would be okay. I happened to think that the best thing I could do for myself would be to make a report for the sake of my safety and to receive an examination and systematic follow-up care.” A second example, “I was stabbed again a short time after I
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reported my NSI. I was afraid I would be blamed if I made another report. I didn’t say anything about it but quietly dealt with things by myself since I felt that I was a careless nurse who always caused trouble, and things seemed to go well.” Another reason for not filing a report was the vague expectation that everything would be fine. Respondents recognized the importance of reporting because it was necessary for follow-up management of NSIs and their own health care. However, they sometimes did not report trivial or repetitive incidents to the monitoring section of their hospitals. For example, “The reason why I made a report was that I was concerned with my health because I was stabbed.” As a second example, “First of all, I look at the patient’s information. If there is nothing special in the information, I just overlook the incident; however, when there is something of note in the patient information, I see someone about it. That is, I first look at the patient’s information before I enter the reporting system.if there is nothing special, I don’t report it.” The third reason for not reporting an NSI was excessive workload. There were cases in which individuals were not able to take proper measures for NSIs because of the characteristics of their job. Nurses who experienced NSIs in the operating room reported that they could not receive immediate first aid because they were in the middle of performing a surgical procedure. As health care workers they placed priority on patient safety and treatment. One participant stated, We say that we should go immediately to the infection control unit, but I was involved in an operation with betadine disinfection administration and had to put on gloves because we were in the middle of an operation, even though the NSI might result in an infection. I cannot stop everything to go down to the department of infection management after I have just been stabbed in a situation where a patient’s life is in greater danger. The final reported reason for not informing superiors of an NSI was strong religious belief. A few participants assumed a calm air about the NSIs or put priority on their jobs rather than their injuries because of their work-oriented mindset. A participant who was ardently engaged in religious activities had faith that they would not suffer negative effects as a result of their injury. One participant stated, “I don’t believe that my health will go bad just because I was stabbed by this one needle, ha ha. I don’t think I will need an operation like those patients who receive a liver transplant.after their livers have gone bad.” A second participant stated, “Because I believe in Jesus, I just pray, saying that I believe in him. I just believe. Trust!”
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provide more education about previous cases and about what to do in various types of cases.” A second example is as follows: “I now will shout ‘needle cap, cap, cap!’ Now, when new employees arrive, I will tell them what I have experienced and to be careful. I feel it is important to gather substantial and vivid data from various cases and then to advise others about being careful.” Additionally, participants mentioned the importance of announcement for the prevention of NSIs. They suggested that announcement should involve the use of some spaces in the hospital (eg, examination rooms) and be available for all health care workers. In addition, study participants emphasized the need to dispose of dangerous medical waste in appropriate receptacles. Some participants suggested that continuous development of appliances used for blood sampling would be helpful for preventing NSIs. One participant suggested, “It would be good to inform every medical office about precautions.” A second suggested, “We have medical waste boxes, which are frequently used by patients and healthcare workers to get rid of garbage.It’s good to dispose of garbage properly. That is, it’s good to throw garbage into these boxes.” Enhanced recognition about the prevention of NSIs Most of the study participants reported being more careful and paying more attention to the prevention of NSIs after their experiences. They were aware that the most important factor for avoiding NSIs is proper care and attentiveness at work. The participants practiced careful arrangement of syringes and needles after blood sampling and use of separate garbage receptacles for disposable sharps and reported that they started to pay attention to the actions of their coworkers when evaluating their own safety. One participant stated, “First of all, it is individuals themselves who are most responsible. It is us after all who have to use syringes, and there are many cases where interns are required to take blood samples. It is important to have proper awareness when performing a procedure. We should be careful.” A second stated, “I never forget the feeling at the moment, and I’m just really careful when dealing with syringes. Even more important, I remove what I used in order to prevent others from being stabbed. In addition, I am careful myself. When culturing, I insist that I throw syringes into garbage boxes. Previously, I used to hand them over without care.” These participants recognized that such injuries cannot always be avoided even if they are very careful, simply because of the dangerous working environment. For example, “Even though I was careless in that moment, we are continuously exposed to NSI risks at work. As such, I’ve come to believe that I should be more careful. It was a chance to place more consideration on safety issues.”
Efforts to improve the prevention of NSI DISCUSSION Necessity for employee education Although the participants had received education on NSI prevention from their hospitals, they were embarrassed that they did not perform proper preventive measures. Most participants wanted their hospitals to provide enhanced education at regular intervals. As one participant stated, I believe that hospitals should provide education about such things. I just had no idea what to do when I was stabbed. I just felt lost at sea, and I had no idea where to go. Even though I had previously learned what to do, nothing came to mind because I was embarrassed. Thus, it would have been better if my hospital had paid more attention and provided more education on how to respond to such things. Some participants emphasized the importance of preventing new employees from repeating their predecessors’ mistakes by providing more complete education about prevention of NSIs. For instance, “I believe that, with a focus on new employees, we should
Psychologic discomforts experienced after an NSI included anxiety, anger, and feelings of guilt about not preventing the injury. Anxiety was associated with the thought that the NSI might cause a disease that could prevent the individual from working and have a negative impact on life in general. In a previous study, the anxiety level was even higher if the infection status of the patient involved in the NSI was unknown.9 In this study, the participants’ anxiety increased when they perceived a deterioration in health status before receiving the results of their examination after the NSI. Their anxiety decreased on receiving the notification that the test results were negative. However, the participants were still anxious about the accuracy of the test results, showing that anxiety might persist for a relatively long period after an NSI incident. A few studies have shown that anxiety is a representative psychologic response to NSI,3-5 and it was reported that anxiety can continue for approximately 9 months after sustaining an NSI.2 When not managed adequately, anxiety can become chronic and cause serious mental problems such as post-
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traumatic stress disorder.6 Therefore, it is necessary to accurately measure the anxiety levels of individuals who have sustained an NSI and to monitor anxiety levels over a long period of time even after test results have been released. Anger and guilt are negative psychologic effects that have not been considered in previous studies on psychologic stress after an NSI.2-5,7 Anger is a representative response of individuals faced with an unwanted situation.11 Therefore, this emotion is also a type of psychologic discomfort that should be monitored in those who have experienced an NSI. The participants in this study reduced their anger and accepted the reality of their injuries by considering the low probability of getting a bloodborne infection after an NSI. This response suggests that health care workers with expert knowledge are able to calm themselves very quickly. Therefore, education is necessary to provide better knowledge not only for preventing NSIs, but also for adequately coping with these injuries. Participants who had sustained an NSI as a result of carelessness and mistakes tended to have feelings of guilt. This was mixed with self-criticism for not observing guidelines for preventing NSIs and shame about others being aware of their poor job performance. To our knowledge, no reports about the appearance of feelings of guilt after an NSI have been previously published; however, a previous study reported that individuals who have experienced sexual abuse or domestic violence suffer more severe post-traumatic stress symptoms when they have a guilty conscience.12,13 Furthermore, feelings of guilt were previously found to be associated with posttraumatic stress symptoms.10,14,15 Patterns of coping after an NSI are largely divided into active and passive methods. Active coping is responding promptly to an NSI with emergency care or control guidelines provided by an infection control department and reporting to the infection control department for follow-up. Passive coping includes avoiding follow-up because of fear of a superior’s rebuke for poor job performance, a vague expectation that it will be alright, difficulty with coping, and relying on religious beliefs. Participants in this study replied that they coped actively, but the rate of reporting NSIs to an infection control department has been shown to be as low as 14.3%16 to 29.8%17 in South Korea. This suggests a high possibility of passive coping, and generalization of our results requires further studies with a larger sample size. Because some of the participants who were coping actively expressed dissatisfaction with the follow-up care they received and individuals dissatisfied with follow-up are likely to adopt a passive coping strategy in the future, efforts should be made to reduce dissatisfaction by assessing followup care. Moreover, although some individuals were coping actively, not many were aware of the existence of emergency care and coping methods and were initially unsure of what to do before remembering the guidelines and responding properly. This suggests the need for continuous education. Finally, the participants mentioned greatly intensified education programs and repeated awareness as strategies for preventing further injuries after experiencing an NSI. Most participants had completed a course on the prevention of NSIs provided by their hospitals. However, when they were involved in such an incident, they were too overwhelmed to cope with it appropriately. This indicates a need for repeated education. In particular, many of the participants said that it would be helpful to describe possible situations leading to NSIs by introducing actual cases in the education courses and promoting the observance of guidelines related to NSIs in various places. Reduced alertness is related to the occurrence of NSIs in preventable situations because of an excessive workload and resulting lack of caution or lack of alertness to the risk of NSIs. In South Korea, it was noted that typical situations involving NSIs included handling or removing needles or other sharp tools, disassembling instruments or equipment, disposing of used tools, moving to a sharps container, putting a tool into a sharps container, and sharp
tools placed in an inappropriate location, and 64% of NSIs could have been avoided with preventative measures.18 Taken together, the participants’ opinions indicate the need for each medical institution to provide information about various situations associated with NSIs to their employees to alert them to this type of injury. The strength of this study is that, unlike previous investigations, in-depth interviews were conducted to evaluate the various types of psychologic discomfort experienced by health care workers who had sustained an NSI and to investigate how they coped with such problems. In addition, this study demonstrated that anger and guilt were experienced by the study participants in addition to depression and anxiety, as described in previous investigations. CONCLUSIONS NSIs mainly occurred because of excessive workloads and failure to take preventive measures. Individuals who sustained an NSI experienced anxiety, anger, and feelings of guilt. Some actively coped with their injuries by seeking first aid or reporting the incident to the department in charge of follow-up care, and others coped passively because of fear of their superiors’ rebukes, a vague expectation that everything would be fine, an excessive workload, or religious beliefs. To prevent NSIs, medical institutions need to repeatedly provide education to employees so that they are familiar with guidelines for preventing NSIs and to increase their realization that these injuries can occur at any time, in any place, and to anyone. References 1. Cho E, Lee H, Choi M, Park SH, Yoo IY, Aiken LH. Factors associated with needlestick and sharp injuries among hospital nurses: a cross-sectional questionnaire survey. Int J Nurs Stud 2013;50:1025-32. 2. Green B, Griffiths EC. Psychiatric consequences of needlestick injury. Occup Med 2013;63:183-8. 3. Sohn JW, Kim BG, Kim SH, Han C. Mental health of healthcare workers who experience needlestick and sharps injuries. J Occup Health 2006;48:474-9. 4. Wicker S, Stirn AV, Rabenau HF, von Gierke L, Wutzler S, Stephan C. Needlestick injuries: causes, preventability and psychological impact. Infection 2014;42: 549-52. 5. Zhang MX, Yu Y. A study of the psychological impact of sharps injuries on health care workers in China. Am J Infect Control 2013;41:186-7. 6. Worthington MG, Ross JJ, Bergeron EK. Posttraumatic stress disorder after occupational HIV exposure: two cases and a literature review. Infect Control Hosp Epidemiol 2006;27:215-7. 7. Naghavi SH, Shabestari O, Alcolado J. Post-traumatic stress disorder in trainee doctors with previous needlestick injuries. Occup Med 2013;63:260-5. 8. McManus S, Meltzer H, Brugha T, Bebbington P, Jenkins R. Adult psychiatric morbidity in England 2007: results of a household survey. London, England: National Centre for Social Research; 2009. 9. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005;15:1277-88. 10. Kessler BL, Bieschke KJ. A retrospective analysis of shame, dissociation, and adult victimization in survivors of childhood sexual abuse. J Couns Psychol 1999;46:335-41. 11. Kübler-Ross E. On death and dying. New York, NY: Macmillan; 1969. 12. Feiring C, Taska LS, Chen K. Trying to understand why horrible things happen: attribution, shame, and symptom development following sexual abuse. Child Maltreat 2002;7:26-41. 13. Gibson LE, Leitenberg H. The impact of child sexual abuse and stigma on methods of coping with sexual assault among undergraduate women. Child Abuse Negl 2001;25:1343-61. 14. Andrews B, Brewin CR, Rose S, Kirk M. Predicting PTSD symptoms in victims of violent crime: the role of shame, anger, and childhood abuse. J Abnorm Psychol 2000;109:69-73. 15. Coffey P, Leitenberg H, Henning K, Turner T, Bennett RT. Mediators of the longterm impact of child sexual abuse: perceived stigma, betrayal, powerlessness, and self-blame. Child Abuse Negl 1996;20:447-55. 16. Seo JM, Jeong IS. Post-exposure reporting of needlestick and sharp-object injuries among nurses. Korean J Nosocomial Infect Control 2010;15:26-35. 17. Kim OS, Jeong JS, Kim KM, Choi JS, Jeong IS, Park ES, et al. Underreporting rate and related factors after needlestick injuries among healthcare workers in small-or medium-sized hospitals. Korean J Nosocomial Infect Control 2011;16:29-36. 18. Jeong JS. Development and administration of needlestick injury surveillance system for healthcare personnel. Ulsan, South Korea: University of Ulsan: Occupational Safety & Health Research Institute report; 2013.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Qualitative content analysis of psychologic discomfort and coping process after needlestick injuries among health care workers Jae Sim Jeong RN, MPH, PhD, KAPN a, Haeng Mi Son RN, PhD a, Ihn Sook Jeong RN, PhD b, *, Jun Seok Son MD, PhD c, Kyong-sok Shin MD d, Sung Won Yoonchang RN, PhD e, Hye Young Jin RN, PhD f, Si Hyeon Han RN, MSN g, Su Ha Han RN, PhD h a
Department of Nursing, University of Ulsan, Ulsan, Republic of Korea College of Nursing, Pusan National University, Busan, Republic of Korea c Department of Occupational and Environmental Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea d Seegene Medical Foundation, Seoul, Republic of Korea e Department of Nursing, Chungwoon University, Chungnam, Republic of Korea f Department of Infection Control Office, Ajou University Hospital, Suwon, Republic of Korea g Infection Prevention and Control Team, Dankook University Hospital, Cheon-An, Republic of Korea h Infection Prevention and Control Team, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea b
Key Words: Needlestick injuries Health personnel Qualitative research Adaptation Psychologic
Background: This study was designed to survey psychologic discomfort and coping processes of health care workers that suffered needlestick injuries (NSIs). Methods: This qualitative analysis was performed with 15 health care workers who experienced NSIs. Data were collected using face-to-face interviews. The study subjects were asked the following: please describe the psychologic discomfort that you experienced after the NSI incidence. Data were evaluated by qualitative content analysis. Results: Types of psychologic discomfort after NSI among health care workers included anxiety, anger, and feelings of guilt. Some personnel adopted active coping strategies, such as seeking first aid or reporting the incident to a monitoring system, whereas others used passive coping methods, such as avoidance of reporting the incident, vague expectancy to have no problems, and reliance on religious beliefs. Recommended support strategies to improve the prevention of NSIs were augmenting employee education and increasing recognition of techniques for avoiding NSIs. Conclusion: Medical institutions need to provide employees with repeated education so that they are familiar with guidelines for preventing NSIs and to stimulate their alertness to the risk of injuries at any time, in any place, and to anybody. Copyright Ó 2016 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Health care workers risk viral infection when they handle sharp tools such as injection needles; in one report, 70.4% of nurses (n ¼ 3,079) working at 60 hospitals reported having experienced a needlestick injury (NSI).1 An NSI exposes health care workers to
* Address correspondence to Ihn Sook Jeong, RN, PhD, College of Nursing, Pusan National University, 49 BusanDaehak-ro Mulgeum-eup Yangsan-si, 626-870, Gyeongnam. E-mail address: [email protected] (I.S. Jeong). Funding/Support: Supported by the Korea Occupational Safety and Health Institution in 2012. Conflicts of interest: None to report.
patient blood or body fluids and increases the risk of infection with bloodborne viral pathogens, such as hepatitis B, hepatitis C, and HIV. In addition to physical risk by NSI, employees who have experienced NSI show significantly higher levels of depression2,3 and anxiety3-5 than those who have not had an NSI. The level of anxiety was even higher if the infection status of the patient involved in the NSI was unknown.4 If such psychologic discomfort is not managed properly during the early stages, it can worsen or develop into a chronic condition, such as post-traumatic stress disorder.6 It was found that 12% of medical doctors who had experienced NSI also experienced post-traumatic stress disorder, and this level was 4.28 times higher than the rate (3%) of the general population.7,8
0196-6553/$36.00 - Copyright Ó 2016 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2015.09.002
blood blood blood blood blood blood blood little little little little little little little skin, skin, skin, skin, skin, skin, skin, through through through through through through through Penetrate Penetrate Penetrate Penetrate Penetrate Penetrate Penetrate Blood Blood Blood Blood Blood Blood Blood 8 y, 4 mo 9 mo 1 y, 1 mo 17 y, 4 mo 1y
Anti-HCV Anti-HCV None HBsAg Unknown Unknown Unknown 11 mo
M F F M F M F 4 5 6 7 8 9 10
MD (intern) RN Technician Technician Housekeeper Technician RN
F 3
F, female; IV, intravenous; M, male; MD, medical doctor; RN, registered nurse; HBsAg, Hepatitis B surface antigen; ID/SC, intradermal/subcutaneous; HCV, hepatitis C virus.
Patient movement Transfer device During sampling blood Transfer to needle box Needle in an inappropriate place During use of item Disassembling device or equipment Needle attached to syringe Suture needle Phlebotomy needle Phlebotomy needle ID/SC needle Needle attached to syringe Needle attached to syringe
During arrangement after IV injection Needle attached to syringe Penetrate through skin, little blood Blood HBsAg 2 mo
M M 1 2
RN
Situation
Arterial venepuncture Venous puncture
Sex Participant
This study was approved by the Asan Medical Center Institutional Review Board, Seoul, South Korea (approval no. 2011-0683). Data were collected between September and October 2011 by an expert (H.M.S.) in qualitative research. Each participant was interviewed one-on-one using the open-ended question: How would you describe your NSI experience? If necessary, additional and more detailed questions were asked, such as (1) In what situation did the NSI occur?; (2) How did you feel and what did you think just
Table 1 Characteristics of participants
Data collection
Occupation
Job experience
Source blood
Type of fluid
Depth of injury
The participants in this study included 15 health care workers who sustained an NSI. These individuals were selected based on occupation, exposure to bloodborne pathogens (eg, hepatitis B, hepatitis C, HIV), medium of exposure (eg, blood, body fluids), and instruments involved (eg, needles, mess). The participants were selected through purposive sampling from employees who were monitored for follow-up because of an NSI up to 6 months before the start of data collection. The study participants were health care workers who reported an NSI to data collectors working at 1 of 53 medical institutions participating in the national NSI surveillance system organized by the Korea Occupational Safety and Health Research Institute. The 15 participants included 10 women and 5 men. Three of the participants were doctors, 8 were nurses, 2 were clinical pathologists, 1 was a sanitation worker, and 1 was a medical engineer. The periods of employment varied from 2 months to 17 years and 4 months. Most of the NSI cases involved blood as the medium of exposure, and the injuries sustained were described as needle penetration of the skin with a small amount of bleeding. The results of antibody screening for hepatitis B were positive at the time of exposure in most cases (14/15). Many cases involved needles attached to syringes, among other appliances. The situations during which the NSIs occurred were variable, and a great number of cases took place during or after use of the involved appliances (Table 1).
HBsAg (þ) HBsAg () HBsAb (þ) HBsAg () HBsAb (þ) HBsAb (þ) HBsAb (þ) HBsAb (þ) HBsAb (þ) HBsAb (þ) HBsAb (þ) HBsAb (þ)
Device
Study participants
Penetrate through skin, little blood Penetrate through skin, little blood
In this study, a qualitative analysis was performed to understand and describe the experiences of health care workers after an NSI.
Blood Blood
Study design
Anti-HCV HBsAg
Health care personnel
METHODS
4 y, 7 mo 4 y, 8 mo
Most previous studies on psychologic discomfort experienced by health care workers after an NSI have been quantitative. These investigations have focused on the level or severity of a specific type of psychologic discomfort but have failed to identify patterns of psychologic discomfort. Moreover, it is unclear how medical professionals who have suffered NSIs cope with the accompanying psychologic distress. There is therefore a need to examine the experiences of health care workers who have sustained NSI through in-depth interviews and surveys on the methods used to cope with the accompanying psychologic discomfort and to prepare strategies to support this ability to cope effectively. In recognition of these needs, this study was conducted to identify the patterns of psychologic discomfort experienced by nurses after an NSI by administering an in-depth survey to understand how they cope with the stress from this event. Strategies for effectively preventing and managing NSI were formulated based on the survey results. The key research question in this study was as follows: What were the experiences, characteristics of psychologic discomfort, and coping strategies of health care workers who experienced an NSI?
Needle attached to syringe Needle attached to syringe
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MD (resident) MD (intern)
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after the NSI; (3) How severe was the psychologic discomfort you experienced after the NSI?; (4) What did the NSI mean to you?; (5) How did you cope with the NSI?; and (6) What do you think should be done to prevent NSIs? Each interview was conducted until data saturation, that is, until the same information was repeated by the participant. The contents of the interviews were recorded and transcribed exactly as spoken by the participant. Each interview took about 1 hour, and each participant completed 1-2 interviews. Data analysis Qualitative content analysis is a method used to interpret the meanings of extensive and complicated textual data.9 Data of this study were evaluated through qualitative content analysis. After reading the transcribed texts to identify meaningful words, phrases, and sentences, open coding was performed. Subcategories were established according to the relationships among codes in terms of the continuous comparative analysis of differences and similarities in open coding. Finally, relationships among the subcategories were further elaborated, and more abstract categories were established. Study rigor This investigation was designed to adhere to criteria for credibility, fittingness, auditability, and confirmability.10 For credibility, the researchers participated in an educational qualitative research course, directed by an expert in qualitative studies, and all researchers actively engaged in discussions throughout the course of the research to obtain convergence. Findings of this study were based on vivid experiences of health care workers who had sustained an NSI, and the data analysis followed the coding scheme suggested by the qualitative content analysis technique. The categories established during the course of data analysis were elaborated in continuous comparative analysis. For auditability, which indicates whether readers can evaluate the researcher’s analytical processes and research outcomes, the data collection process was described in detail. For fittingness, which indicates the diversity of situations, various types of health care workers who had experienced an NSI were invited to be interviewed, and data were collected until the participants’ statements reached the state of saturation. For confirmability (which indicates the adequacy of categories derived from data analysis by experts in qualitative research, experts in infection control, and interviewees), the categories were refined through continuous comparative analysis. A bilingual translator translated the article into English under the guidance of the research team, and the translated contents were confirmed by the research team. RESULTS NSI circumstances Excessive workload Environments in which NSIs frequently occurred included operating rooms, departments of clinical pathology, and hospital wards, where things are routinely busy. As a result, many NSIs were attributed to carelessness and mistakes associated with excessive workload. The participants frequently felt that they were exposed to an environment of risk of NSIs. Additionally, the participants felt they needed to be careful with each other to prevent accidents. In addition, they often thought that it would be difficult for them to continue their jobs in such a dangerous environment. One participant stated the following:
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“First of all, the problem is an excessive work load. It can be an insurmountable problem. Two of the three stabbing instances occurred within a short time when I had a lot of work.I needed to do some sampling work in the intensive care unit (ICU), but the workload was enormous.thus, I was stabbed while being hasty. I also thought that I might not have been stabbed if I had not been hasty, if I had had enough time to complete my tasks more carefully.” Another example is as follows: “We are excessively busy in our operating rooms. We should really deal with all patients while wearing gloves, but since we are excessively busy, we frequently touch and move patients or arrange appliances with bare hands.although we make a great effort to remember to put gloves on.” Lack of attention among health care workers The participants generally thought that NSIs were trivial. Doing their jobs repetitively out of habit, they helped cause the NSIs because of overlooked precautions and insufficient performance of preventive measures. Despite their knowledge and training, health care workers had a low level of recognition of the seriousness of frequent NSIs. After the NSIs, the participants belatedly realized their carelessness and lack of adherence to the guidelines provided by their hospitals. One participant stated, “When I was first stabbed, I was afraid that something serious would happen, but everyone around said it was alright. As for hepatitis B infection, we have medications for it, and therefore hepatitis B infection is considered trivial.” As a second example, “I would not have had such an incident if I had followed the manual for preventing injuries. Even though I knew that I should not recap needles, I still made the mistake because I thought I would be fine and overlooked the possibility of a mistake. I believe that this kind of mistake would not have happened if I had done my job as I had been taught.”
Psychologic discomfort after an NSI Anxiety about disease onset Having experienced an NSI, most of the participants suffered from overwhelming stress because of worries and concerns about the negative impact to their health, job, and influence on their lives overall. Most NSI cases involved stabs from syringes contaminated with blood from patients with hepatitis. The participants tried to determine the seriousness of their injuries by reviewing the relevant patients’ medical records. The injured employees reported that they felt great fear of disease onset because as health care workers they were well aware of the clinical development of hepatitis and its possible threat to their lives. One participant stated, “Regardless of others’ thoughts, I considered my injury to be an extreme situation. Beginning with what should I do if I had been infected with hepatitis C, I was also concerned with questions such as how I could quit my job, tell other people, or get married.” A second participant stated, “What was the patient’s history? I first of all wondered this, and I also feared whether there was any chance that the patient had an infection.” The participants also had difficulty facing their current situations and had serious concerns about their future because they were aware of other cases of infection because of NSI. For example, “It was said that an intern was infected last year. We witnessed the incident and are anxious. The ideal romantic partner does not have hepatitis. In addition, we now are experiencing enormous stress due to this incident. We have suffered more serious stress because we have observed such cases directly.”
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In particular, the participants grew increasingly worried and concerned about their NSIs if they experienced any sort of illness after the occurrence. Most of the participants had difficulty controlling their feelings when imagining their bad physical condition to be related to their injury. Because they strongly wished that the situations were not real, they considered the correct test results to be wrong or they hoped the test results were not accurate. For example, “I felt very bad because I was tired and in bad physical condition, even though I have antibodies. I also worried about getting cancer since the mess was used for cancer patients. I suffered such serious stress that I doubted the results of the test.” The participants were anxious and distressed as a result of the recurrence of memories of the injury. Their anxiety was caused by fear of the possibility that they could experience repeated NSIs because of their carelessness. Therefore, the participants were nervous when they performed tasks that they would usually complete with confidence. One participant stated, When stabbed, I suffered short-term rather than long-term stress .with the highest stress on that day or for a few days thereafter. However, I felt better when I thought it would be alright. Nevertheless, the memory of the moment continued . always when I flushed something. Then I thought, this is my fault, isn’t it? This also is a kind of stress. The stress, it seems to overwhelm me. The worst thing seems to be the short-term stress.” Another participant stated the following: “I couldn’t even sleep.I couldn’t perform my tasks properly, fearing that it would happen again.if I did things wrong.again.fearing that such a thing would happen again.I just hesitated about things that I had usually performed without any problem.” Respondents reported some relief after receiving negative test results, but they still experienced anxiety about disease onset, along with the fact that they had sustained an NSI. For example, “Then came the results. I read them and saw that I was alright. I was at ease, but then had a follow-up phone call. They said I was alright and should repeat the test one month later. I heard from the department of infection management, and then the painful feelings disappeared.” Anger The participants were also angry about their NSIs. In particular, they showed more serious emotional reactions in cases of infection by agents with high infectivity rates. They also experienced negative feelings projected toward their patients. Some felt resentment toward patients with infected blood and complained that the NSIs hindered their busy everyday work routines. For example, “Why me? In this case, I questioned why it happened to me. Why me? Anybody could be stabbed, but why me? Why did this particular patient have to have a high HBV titer and be rapid plasma regainpositive? It’s such a misfortune. Why am I so unfortunate?” As a second example, “I wondered why I had to be stabbed by the needle during a busy moment when I needed to work.” One of the participants expressed regret, saying that the injury might not have occurred if a safe environment had been created for the avoidance of NSIs. They stated, “Although it was primarily due to my carelessness, the probability of being stabbed due to carelessness would have decreased if there had been things like safety needles, which would have made it easier to properly cope with such situations.” Such resentful thoughts gradually disappeared over time, and the participants found relief based on their medical knowledge and data. For instance, “Based on figures, objective data on the occurrence of the bloodborne diseases by stabbing, then.nonetheless, I took solace in the thought that I would be unlikely to be included. And, well, time will handle the rest.ha ha (laugh).”
Guilty feeling Some participants experienced regret and blamed themselves for their careless behavior. They also felt uncomfortable and ashamed as people around them tended to devalue their performance rather than seeing the incidents as simple mistakes. One participant stated the following: “My case was more serious. I naturally tend to think bad things are due to me.since I have emphasized that everyone should always be careful and attentive.I thought such a thing would not happen if I were careful.Then, I believed that it would be my fault if such a thing happened.” A second participant stated, “I was careless when it happened. The needle should have been oriented more inwardly, but I was stabbed by it because I oriented it upwardly instead. Why did I do that despite the fact that I typically never did so? This idea came to my mind, and I blame myself somewhat.” Coping with NSIs Active coping Most of the participants coped with the NSIs according to the guidelines for first aid treatment and care provided by their hospitals’ infection management department. They reported that the department of infection management normally communicated the guidelines for NSIs to employees and that their hospitals had established appropriate policies. However, some participants were embarrassed because of their ignorance of first aid treatment and measures. For example, “After first squeezing blood sufficiently by pressing on the stab site, I hurried to the faucet for running water, squeezed more and disinfected, and then immediately went down to the ER to take precautionary measures.” A second participant stated, “I provided primary treatment. I immediately took off my gloves and poured alcohol, betadine, and then more alcohol on the wound.” Most participants were satisfied with the follow-up care provided through the monitoring system of hospitals after sustaining an NSI. During follow-up care, they underwent blood tests conducted by infectious disease physicians and nurses and were provided with sufficient information about test results and treatment plans. One participant stated, “I made a phone call, and then they took blood samples, provided guidance, and informed me of test results. I felt they provided good care. Thus, I was satisfied.” A second participant stated, “I felt rather relieved as I was in a hospital. They performed blood tests and took care of me, and even if I were to be infected, I felt I would be taken care of because I was in a hospital.” A third participant stated, “I received a text message that I needed to give blood for tests due to the incident. Our hospital took good care of such things.” Passive coping The participants coped passively for various reasons. First was fear of their superiors’ rebukes. They experienced mental conflict when reporting their NSIs to the supervising office of their hospital. They were concerned about reporting their NSIs to their hospital, which they felt would indicate poor work performance. Fear and concern about reporting incidents to a supervising department or a supervisor was a phenomenon predominantly observed in cases with novices or less experienced nurses. Some participants tried to conceal their NSIs, fearing that their supervisors would blame them for their injury. These participants did not file a report because they thought they would be fine or they did not consider their condition to be serious after obtaining patient information. For example, “Momentarily, I was conflicted, wondering whether I should report the incident or if it would be okay. I happened to think that the best thing I could do for myself would be to make a report for the sake of my safety and to receive an examination and systematic follow-up care.” A second example, “I was stabbed again a short time after I
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reported my NSI. I was afraid I would be blamed if I made another report. I didn’t say anything about it but quietly dealt with things by myself since I felt that I was a careless nurse who always caused trouble, and things seemed to go well.” Another reason for not filing a report was the vague expectation that everything would be fine. Respondents recognized the importance of reporting because it was necessary for follow-up management of NSIs and their own health care. However, they sometimes did not report trivial or repetitive incidents to the monitoring section of their hospitals. For example, “The reason why I made a report was that I was concerned with my health because I was stabbed.” As a second example, “First of all, I look at the patient’s information. If there is nothing special in the information, I just overlook the incident; however, when there is something of note in the patient information, I see someone about it. That is, I first look at the patient’s information before I enter the reporting system.if there is nothing special, I don’t report it.” The third reason for not reporting an NSI was excessive workload. There were cases in which individuals were not able to take proper measures for NSIs because of the characteristics of their job. Nurses who experienced NSIs in the operating room reported that they could not receive immediate first aid because they were in the middle of performing a surgical procedure. As health care workers they placed priority on patient safety and treatment. One participant stated, We say that we should go immediately to the infection control unit, but I was involved in an operation with betadine disinfection administration and had to put on gloves because we were in the middle of an operation, even though the NSI might result in an infection. I cannot stop everything to go down to the department of infection management after I have just been stabbed in a situation where a patient’s life is in greater danger. The final reported reason for not informing superiors of an NSI was strong religious belief. A few participants assumed a calm air about the NSIs or put priority on their jobs rather than their injuries because of their work-oriented mindset. A participant who was ardently engaged in religious activities had faith that they would not suffer negative effects as a result of their injury. One participant stated, “I don’t believe that my health will go bad just because I was stabbed by this one needle, ha ha. I don’t think I will need an operation like those patients who receive a liver transplant.after their livers have gone bad.” A second participant stated, “Because I believe in Jesus, I just pray, saying that I believe in him. I just believe. Trust!”
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provide more education about previous cases and about what to do in various types of cases.” A second example is as follows: “I now will shout ‘needle cap, cap, cap!’ Now, when new employees arrive, I will tell them what I have experienced and to be careful. I feel it is important to gather substantial and vivid data from various cases and then to advise others about being careful.” Additionally, participants mentioned the importance of announcement for the prevention of NSIs. They suggested that announcement should involve the use of some spaces in the hospital (eg, examination rooms) and be available for all health care workers. In addition, study participants emphasized the need to dispose of dangerous medical waste in appropriate receptacles. Some participants suggested that continuous development of appliances used for blood sampling would be helpful for preventing NSIs. One participant suggested, “It would be good to inform every medical office about precautions.” A second suggested, “We have medical waste boxes, which are frequently used by patients and healthcare workers to get rid of garbage.It’s good to dispose of garbage properly. That is, it’s good to throw garbage into these boxes.” Enhanced recognition about the prevention of NSIs Most of the study participants reported being more careful and paying more attention to the prevention of NSIs after their experiences. They were aware that the most important factor for avoiding NSIs is proper care and attentiveness at work. The participants practiced careful arrangement of syringes and needles after blood sampling and use of separate garbage receptacles for disposable sharps and reported that they started to pay attention to the actions of their coworkers when evaluating their own safety. One participant stated, “First of all, it is individuals themselves who are most responsible. It is us after all who have to use syringes, and there are many cases where interns are required to take blood samples. It is important to have proper awareness when performing a procedure. We should be careful.” A second stated, “I never forget the feeling at the moment, and I’m just really careful when dealing with syringes. Even more important, I remove what I used in order to prevent others from being stabbed. In addition, I am careful myself. When culturing, I insist that I throw syringes into garbage boxes. Previously, I used to hand them over without care.” These participants recognized that such injuries cannot always be avoided even if they are very careful, simply because of the dangerous working environment. For example, “Even though I was careless in that moment, we are continuously exposed to NSI risks at work. As such, I’ve come to believe that I should be more careful. It was a chance to place more consideration on safety issues.”
Efforts to improve the prevention of NSI DISCUSSION Necessity for employee education Although the participants had received education on NSI prevention from their hospitals, they were embarrassed that they did not perform proper preventive measures. Most participants wanted their hospitals to provide enhanced education at regular intervals. As one participant stated, I believe that hospitals should provide education about such things. I just had no idea what to do when I was stabbed. I just felt lost at sea, and I had no idea where to go. Even though I had previously learned what to do, nothing came to mind because I was embarrassed. Thus, it would have been better if my hospital had paid more attention and provided more education on how to respond to such things. Some participants emphasized the importance of preventing new employees from repeating their predecessors’ mistakes by providing more complete education about prevention of NSIs. For instance, “I believe that, with a focus on new employees, we should
Psychologic discomforts experienced after an NSI included anxiety, anger, and feelings of guilt about not preventing the injury. Anxiety was associated with the thought that the NSI might cause a disease that could prevent the individual from working and have a negative impact on life in general. In a previous study, the anxiety level was even higher if the infection status of the patient involved in the NSI was unknown.9 In this study, the participants’ anxiety increased when they perceived a deterioration in health status before receiving the results of their examination after the NSI. Their anxiety decreased on receiving the notification that the test results were negative. However, the participants were still anxious about the accuracy of the test results, showing that anxiety might persist for a relatively long period after an NSI incident. A few studies have shown that anxiety is a representative psychologic response to NSI,3-5 and it was reported that anxiety can continue for approximately 9 months after sustaining an NSI.2 When not managed adequately, anxiety can become chronic and cause serious mental problems such as post-
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traumatic stress disorder.6 Therefore, it is necessary to accurately measure the anxiety levels of individuals who have sustained an NSI and to monitor anxiety levels over a long period of time even after test results have been released. Anger and guilt are negative psychologic effects that have not been considered in previous studies on psychologic stress after an NSI.2-5,7 Anger is a representative response of individuals faced with an unwanted situation.11 Therefore, this emotion is also a type of psychologic discomfort that should be monitored in those who have experienced an NSI. The participants in this study reduced their anger and accepted the reality of their injuries by considering the low probability of getting a bloodborne infection after an NSI. This response suggests that health care workers with expert knowledge are able to calm themselves very quickly. Therefore, education is necessary to provide better knowledge not only for preventing NSIs, but also for adequately coping with these injuries. Participants who had sustained an NSI as a result of carelessness and mistakes tended to have feelings of guilt. This was mixed with self-criticism for not observing guidelines for preventing NSIs and shame about others being aware of their poor job performance. To our knowledge, no reports about the appearance of feelings of guilt after an NSI have been previously published; however, a previous study reported that individuals who have experienced sexual abuse or domestic violence suffer more severe post-traumatic stress symptoms when they have a guilty conscience.12,13 Furthermore, feelings of guilt were previously found to be associated with posttraumatic stress symptoms.10,14,15 Patterns of coping after an NSI are largely divided into active and passive methods. Active coping is responding promptly to an NSI with emergency care or control guidelines provided by an infection control department and reporting to the infection control department for follow-up. Passive coping includes avoiding follow-up because of fear of a superior’s rebuke for poor job performance, a vague expectation that it will be alright, difficulty with coping, and relying on religious beliefs. Participants in this study replied that they coped actively, but the rate of reporting NSIs to an infection control department has been shown to be as low as 14.3%16 to 29.8%17 in South Korea. This suggests a high possibility of passive coping, and generalization of our results requires further studies with a larger sample size. Because some of the participants who were coping actively expressed dissatisfaction with the follow-up care they received and individuals dissatisfied with follow-up are likely to adopt a passive coping strategy in the future, efforts should be made to reduce dissatisfaction by assessing followup care. Moreover, although some individuals were coping actively, not many were aware of the existence of emergency care and coping methods and were initially unsure of what to do before remembering the guidelines and responding properly. This suggests the need for continuous education. Finally, the participants mentioned greatly intensified education programs and repeated awareness as strategies for preventing further injuries after experiencing an NSI. Most participants had completed a course on the prevention of NSIs provided by their hospitals. However, when they were involved in such an incident, they were too overwhelmed to cope with it appropriately. This indicates a need for repeated education. In particular, many of the participants said that it would be helpful to describe possible situations leading to NSIs by introducing actual cases in the education courses and promoting the observance of guidelines related to NSIs in various places. Reduced alertness is related to the occurrence of NSIs in preventable situations because of an excessive workload and resulting lack of caution or lack of alertness to the risk of NSIs. In South Korea, it was noted that typical situations involving NSIs included handling or removing needles or other sharp tools, disassembling instruments or equipment, disposing of used tools, moving to a sharps container, putting a tool into a sharps container, and sharp
tools placed in an inappropriate location, and 64% of NSIs could have been avoided with preventative measures.18 Taken together, the participants’ opinions indicate the need for each medical institution to provide information about various situations associated with NSIs to their employees to alert them to this type of injury. The strength of this study is that, unlike previous investigations, in-depth interviews were conducted to evaluate the various types of psychologic discomfort experienced by health care workers who had sustained an NSI and to investigate how they coped with such problems. In addition, this study demonstrated that anger and guilt were experienced by the study participants in addition to depression and anxiety, as described in previous investigations. CONCLUSIONS NSIs mainly occurred because of excessive workloads and failure to take preventive measures. Individuals who sustained an NSI experienced anxiety, anger, and feelings of guilt. Some actively coped with their injuries by seeking first aid or reporting the incident to the department in charge of follow-up care, and others coped passively because of fear of their superiors’ rebukes, a vague expectation that everything would be fine, an excessive workload, or religious beliefs. To prevent NSIs, medical institutions need to repeatedly provide education to employees so that they are familiar with guidelines for preventing NSIs and to increase their realization that these injuries can occur at any time, in any place, and to anyone. References 1. Cho E, Lee H, Choi M, Park SH, Yoo IY, Aiken LH. Factors associated with needlestick and sharp injuries among hospital nurses: a cross-sectional questionnaire survey. Int J Nurs Stud 2013;50:1025-32. 2. Green B, Griffiths EC. Psychiatric consequences of needlestick injury. Occup Med 2013;63:183-8. 3. Sohn JW, Kim BG, Kim SH, Han C. Mental health of healthcare workers who experience needlestick and sharps injuries. J Occup Health 2006;48:474-9. 4. Wicker S, Stirn AV, Rabenau HF, von Gierke L, Wutzler S, Stephan C. Needlestick injuries: causes, preventability and psychological impact. Infection 2014;42: 549-52. 5. Zhang MX, Yu Y. A study of the psychological impact of sharps injuries on health care workers in China. Am J Infect Control 2013;41:186-7. 6. Worthington MG, Ross JJ, Bergeron EK. Posttraumatic stress disorder after occupational HIV exposure: two cases and a literature review. Infect Control Hosp Epidemiol 2006;27:215-7. 7. Naghavi SH, Shabestari O, Alcolado J. Post-traumatic stress disorder in trainee doctors with previous needlestick injuries. Occup Med 2013;63:260-5. 8. McManus S, Meltzer H, Brugha T, Bebbington P, Jenkins R. Adult psychiatric morbidity in England 2007: results of a household survey. London, England: National Centre for Social Research; 2009. 9. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005;15:1277-88. 10. Kessler BL, Bieschke KJ. A retrospective analysis of shame, dissociation, and adult victimization in survivors of childhood sexual abuse. J Couns Psychol 1999;46:335-41. 11. Kübler-Ross E. On death and dying. New York, NY: Macmillan; 1969. 12. Feiring C, Taska LS, Chen K. Trying to understand why horrible things happen: attribution, shame, and symptom development following sexual abuse. Child Maltreat 2002;7:26-41. 13. Gibson LE, Leitenberg H. The impact of child sexual abuse and stigma on methods of coping with sexual assault among undergraduate women. Child Abuse Negl 2001;25:1343-61. 14. Andrews B, Brewin CR, Rose S, Kirk M. Predicting PTSD symptoms in victims of violent crime: the role of shame, anger, and childhood abuse. J Abnorm Psychol 2000;109:69-73. 15. Coffey P, Leitenberg H, Henning K, Turner T, Bennett RT. Mediators of the longterm impact of child sexual abuse: perceived stigma, betrayal, powerlessness, and self-blame. Child Abuse Negl 1996;20:447-55. 16. Seo JM, Jeong IS. Post-exposure reporting of needlestick and sharp-object injuries among nurses. Korean J Nosocomial Infect Control 2010;15:26-35. 17. Kim OS, Jeong JS, Kim KM, Choi JS, Jeong IS, Park ES, et al. Underreporting rate and related factors after needlestick injuries among healthcare workers in small-or medium-sized hospitals. Korean J Nosocomial Infect Control 2011;16:29-36. 18. Jeong JS. Development and administration of needlestick injury surveillance system for healthcare personnel. Ulsan, South Korea: University of Ulsan: Occupational Safety & Health Research Institute report; 2013.
