April 28, 2020
The safety of health workers is paramount. Nursing students, while on placement, are considered to be at high risk of Healthcare Associated Injury(HAI) during clinical placement. In an Australian study, 13.9% out of 319students reported a needle or sharp injury during the first two semesters of their nursing course (1). On the contrary, another study performed on 2 047 students reported only 135 injuries (6.6%) (2). An Italian study compared the incidence of students’ injuries within the nursing population over a period of11 years and found 171 out of 909 biological HAI in nursing students (18.82%) (3). It is interesting to notice that whenever anonymous questionnaires were used to collect the HAI data, the results showed higher percentages than the retrospective studies in which written reports were used, with incidence rates of 25.2% (4) and 32% (5).
The level of knowledge of the procedures, the lack of experience in delivering them, and the first impact with the professional environment are factors that are directly associated with HAI during the period of clinical training (1). Therefore, the acquisition of preventive strategies including the proper use of safety devices is essential in order to minimize the incidence of HAI in the clinical setting (6).
The greatest risk factors for student injuries are stress, haste, inadequacy, inexperience and a low level of training. The risk of injury is higher in the initial semesters and lower in the last university year. In fact before completing their studies, undergraduate nursing students may benefit of a comprehensive theoretical and clinical learning experience and therefore they will be able to participate more actively and consciously in delivering patients’ care.
Furthermore they will learn how to properly use safety devices which are also considered as an effective measure of prevention to lower the number of injuries (3, 7). Furthermore, simulation and hospital based clinical training, which promote the proper use of safety devices, is proven to reduce the risk of injury in nursing students and to provide a better patients’ care (8). In addition to the proper use of safety devices, first aid recommendations should be provided in case of an incident, according to the different types of injury and all incidents must be systematically reported (1) Furthermore, it is well known that indifferent clinical settings, where clinical training is carried out, safety devices are randomly used due to lack of time or to the unavailability of the devices. This scenario is further worsened by the frequent inattention of students in using security devices and the lack of reporting of any incident occurred (1).
Needle and cutting injuries are a significant risk for the transmission of infectious diseases, including Hepatitis C Virus (HCV),Hepatitis B Virus (HBV), and Human Immunodeficiency Virus (HIV). The WorldHealth Organization (WHO) has estimated 16 000 cases of hepatitis C, 66 000cases of hepatitis B and 1 000 cases of HIV as a consequence of needle injury (9). Moreover, percutaneous exposures account for 75% of all biohazard exposures reported by nurses (10).
Needle stick injury appears to be the most frequent incident, and usually occurs during the clinical procedure or immediately after while discharging the needle. In 19,9% of cases the injury occurs when using butterfly needles, in 18,6% when using standard needles, in 15,2% when using insulin needles and in 3.4 % when using blood lancets. The syringe needle determines 37% of injuries (4).
The areas most affected by the injuries are the hands (83,4%), specifically the fingers of the hand opposite to the dominant one (11). The mucocutaneous contacts with biological fluids are prevalent with 62,2% of exposures, with a 66,6% localization in the face and 91% in the ocular area (12).
The objective of this study is to describe the number and type of injuries occurred to students attending the nursing degree in a university inNorthern Italy that has activated simulation laboratories and professional activities preparatory to the clinical placement.
1 403 students took part in the present study; 481 (34.28%) were enrolled in the first year, 451 (32.14%) in the second year and 471 (33.57%) in the third year.
Distribution of injuries according to working hours
On the dynamic characteristics and the anatomical sites affected by injury, there are no differences related to the years of the course. Needle stick injury shows a higher percentage (n = 45, 51.72%); injury mostly occurred (n = 57, 65.52%) during medication administration, mostly affecting the hand / finger area (n = 62, 72.09%)
Table 3 describes the trend of incidents during the eight academic years considered and demonstrates that needle injury significantly occurs during the procedure (P = <,0001).
Table 3 describes the trend of incidents during the eight academic years considered and It is interesting to note that the percentage of injury occurring during needle disposal (n = 9, 60%) in the2009-10 AY almost halved in the following years. However, needle injury remains steadily high during the administration technique.
Overall the percentages of Healthcare Associated Injury (HAI) occurred to students in the eight academic years taken into consideration, were lower than reported in the literature (6,20%). (1, 3) However, these results could underestimate this phenomenon. In fact, it has been reported that half of the injured students tend not to report the incident (1, 15) and this explains the higher rate of injuries detected through an anonymous questionnaire administered to students (2, 4, 5).
Although the study does not highlight statistically significant differences between the number of injuries in the academic years taken into consideration, first-year students were more subject to incidents despite laboratory tests, safety courses, and tutoring. The number of injuries, although very small, depends on the student’s individual difficulty in perceiving risk (17) within an organizational context in which the student has no previous experience (7). Another factor that can affect this result is the area in which the injuries occurred. In fact, first-year students spent 420 hours of training in the medical areas. This supports previous findings by Giuliani et al. (17) who showed that 63,7% of incidents occur in medical departments.
Another relevant figure is the percentage of incidents in third-year students (37,9%) that differ from percentages reported in the literature (7, 13). Possible explanations could include the clinical complexity encountered in the clinical area and the use of advanced techniques and complex devices, despite the fact that available studies suggest the adoption of less complex procedures, which might expose students to a higher risk of injury (7, 18).
Regarding the dynamics and the characteristics of the injury, the needle injury is the most frequent injury (51,72%). This occurs during the administration phase (65,52%); with 26,44% of injury occurring in the disposal phase. The most affected anatomical site is the hand / fingers with a 72,09%. The results are in accordance with those provided by previous studies (4, 11, 16).
Students following injuries report negative feelings such as anxiety, fear, anger, worry, low self-esteem, insecurity, frustration and perception of insecurity (15). These feelings could lead students to drop out of their course, especially in the first year (19). From the analysed data none of the injured students dropped out. All students exposed to biological fluid risk followed the occupational medicine recommendations. This result contrasts with results reported by Almeida et al. (16), which recorded a drop-out rate of 32,8%. This discrepancy could reflect the activity of university tutors that met the injured students in one-on-one meetings or in small groups in which the internship experiences are re-elaborated together. This practice is essential and it will have to be implemented in the future. It is also very important to collect data on how incidents occurred in order to develop strategies to be shared in safety courses and simulation laboratories before the beginning of clinical placement.
The percentages of Healthcare Associated Injury (HAI) occurred to students in the eight academic years taken into consideration were lower than reported in the literature (6,20%).
The university has favored a model in which the training is planned and valued with preparatory and introductory professional activities. Students were engaged in a learning process consisting of simulation laboratory classes, in-depth seminar activities, nursing science classes, safety courses and dedicated tutoring activities. Professional activities were delivered by university nursing lecturers, clinical laboratory tutors, members of the prevention and safety service of the health authority and university tutors.
This model requires a close collaboration between the university and the healthcare regional system institutions. The activities described above were managed by clinical staff who were supported and supervised by university tutors, responsible for the teaching and learning process. The clinical placement was monitored by university tutors through meetings with small groups of students. These meetings took place throughout the academic year with the purpose of promoting students’ self-reflection on care planning, sharing good practice and enhancing critical reasoning.
Students recruitment limited to a single campus in a university with multiple campus and the small sample size represent the limitations of this study.
Given the importance of the topic, it is advisable to conduct across-sectional study involving students from different nursing degree programs throughout the national territory. This would allow to compare different teaching and organizational models and to indicate what could further limit the incidence of HAI.
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Incidence and type of health care associated injuries among nursing students: an experience in northern Italy – ACTA Biomedica
Rubbi Ivan,1 Cremonini Valeria,1 Butuc Adriana,2 Cortini Carla,1 Artioli Giovanna,3 Bonacaro Antonio,4 and Pasquinelli Gianandrea5
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