6. A BRIEF RESUME OF THE INTENDED WORK

“IGNORANCE IS BLISS”

INTRODUCTION

Nurses are the largest work force of the health care industry.1There are more than 1 million licensed nurses currently working all over the world2. India produces over 2,50,000 doctors annually in the modern system of medicine and a similar number of nurses and para-professionals3. Accidental needle-stick exposure poses the greatest hazard to health care workers.4

A needle stick injury is a percutaneous piercing wound typically set by a needle point, commonly encountered by people handling needles in the medical setting. Such injuries are an occupational hazard in the medical community.5

Nurses incur about 60-90% of the reported needle stick or sharp injuries with negligence in safety practices. 1

The nursing staff plays a major role in looking after the diagnostic needs, therapeutic health and psychological support of the patients. The nursing students share this responsibility especially in the overcrowded government hospitals. They are mainly responsible for collection of blood, administration of oral and injectable drugs, preparing bed, sending laundry, collection and sending laboratory specimens etc. The risk of accidental needle stick injuries is greater during invasive procedures such as collection of blood and giving injections.6

When drawing blood, administering an intramuscular or intravenous drug, or performing other procedures involving sharps, the needle can slip and injure the health worker. This sets the stage to transmit viruses from the source patient to the recipient. These injuries also commonly occur during needle recapping and as a result of failure to place used needles in approved sharps containers.5

While the needle stick injuries have the potential of transferring bacteria, protozoa, viruses and prions,[7] from a practical point of view, the transmission of the hepatitis B and hepatitis C viruses and the Human Immunodeficiency Virus (HIV) is important.4 It is estimated that annually, as a consequence, there are 66,000 infections with HBV, 16,000 with HCV and 1,000 with HIV world wide.8

In addition, a needle stick injury may lead to significant stress and anxiety for the affected injured person. Taking care of needle stick injury is costly, estimated to be about $ 2,500 in the short term in US.9

Among healthcare workers, nurses and physicians appear specially at risk.10

Nurses have the highest rate of needle-stick injury among health workers. Needle-

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stick injuries are not treated seriously by nurses. Majority of the nurses have self-medicated and only a few have sought the attention of doctors and some through “corridor consultation.”11

6.1 NEED FOR THE STUDY

Needle stick injuries are a common event in the health care environment.5

Needle stick injuries, being accidental self-inoculation, are seldom reported or where reportable are usually under reported.12 One study found that needle-stick injuries represented one third of all work-related accidents and two-thirds of work-related injuries to nursing staff.13

An investigation estimates the rates of injuries on a global level to affect about 3.5 million individuals.8 Needle-sticks are virtually undocumented in developing countries, but probably equal or exceed those in the industrial world.10 In the absence of statistics from India, statistics from United States provide some insight into the occupational risk.14 American health workers suffer 800,000 to 1 million needle-sticks annually, not including the vast number that go unreported. There are more than 100,000 needle-stick injuries in UK hospitals each year.10

Accidental needle-sticks account for 86% of all occupationally related

infectious disease transmission.10The total number of needle stick injuries that the average nurse in India experiences is likely to be higher, given the absence of training and protective devices, thus increasing the total exposure to possibly infected blood or body fluids.14 The emotional impact of a needle-stick injury can be severe, even when serious infection is not transmitted, particularly when the injury involves exposure to HIV. In a study conducted among 20 health care workers with an HIV exposure 11 reported acute severe distress, 7 had persistent moderate distress, and 6 quit jobs as a result of their exposure.10

Student health care workers become more involved in patient contact during their training, they are at risk of exposure to pathogens. Many students reported non-sterile occupational injuries that increase risk of infection.15 It has been proposed that student health care workers are at increased risk of injury because of inexperience in performing invasive procedures.16

The prevalence and nature of needle stick injuries among nursing students from a large university nursing school in Australia was assessed using a questionnaire method which revealed that, of all nursing students 13.9% reported a needle-stick/sharp injury during the previous 12 months and 39.5% of needle-stick injuries were not reported. The study concluded that it is important that the principles of infection control training and reporting of all needle stick and sharps continue to be emphasized throughout undergraduate nursing education.17

The prevalence and characteristics of needle-stick injuries among student nurses from 16 hospitals randomly selected from the 132 accredited hospitals in Taiwan was assessed using a self-administered questionnaire which revealed that

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61.9% of students reported needle-stick injury during internship. The study concluded that needle-stick injuries and non-reporting of needle-stick injuries were highly prevalent in nursing students and more intensive educational programs should be directed at students to increase their awareness and compliance with universal precautions before commencing their practical work experience. Students need to practice prompt post-exposure evaluation and the need for early intervention can be assessed.18

A retrospective, descriptive survey was conducted to describe the rate of needle stick injuries among 473 students from 3 nursing schools of Ankara university faculty of health sciences, Ankara, Turkey. Questionnaire method was used to collect data. Results revealed that 49% of the students who responded sustained injuries; of these 74% were injured while in wards and 43.9% reported their injuries to administrators. The study showed that nursing students frequently sustain needle stick injuries.19

Despite their seriousness as a medical event, needle-stick injuries have been neglected: most go unreported and ICD-10 coding is not available.7 On the other hand, as needle-sticks have been recognized as occupational hazards, their prevention has become the subject of regulations in an effort to reduce and eliminate this preventable event.8

There is an urgent need to develop a coordinated approach for the provision of information, support and referral for health care workers who sustain occupationally related needle sticks injuries. Assessment of exposures and initial management of occupational exposures varies between institutions and often reflects the level of staff education and previous experience in areas of infection control and transmission of blood borne diseases.6

All the above mentioned factors have urged the researcher to consider a public general approach; using intervention-based measures for needle stick injuries and its management to gain knowledge and its practices among student nurses.

6.2 REVIEW OF LITERATURE

A review of literature enables one to get an insight into the various aspects of the problem under study. It covers promising methodological tools, throws light on ways to improve the efficiency of data collection and suggests how to increase effectiveness of data analysis and interpretation. Review of literature is therefore an essential step in the development of the research project

.The result of studies conducted in various aspects on needle stick injuries is presented below:

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6.2.1-Review of literature related to prevalence of needle stick injuries among nurses.

6.2.2-Review of literature related to knowledge and practice of needle stick injury and its management among healthcare workers.

6.2.3-Review of literature related to effectiveness of structured teaching programme on needle stick injuries and its management.

6.2.1-Review of literature related to prevalence of needle stick injuries among nurses.

A retrospective survey was conducted regarding accidental needle stick injuries among 526 nurses in the Prince of Wales teaching hospital in Hong Kong, using a self-administered questionnaire. Of the total 526 nurses approached, only 31% responded. The results revealed that among respondents, 95% reported needle stick injury since joining the nursing profession. The study found that almost all nurses have been pricked by needle stick during their career among respondents.11

A cross sectional survey was conducted to assess the incidence of needle stick and sharp instrument injuries among 93 healthcare workers in Mauritius. A questionnaire-based survey involving qualified nurses and medical laboratory technicians was conducted. Results revealed that needle stick injuries were the most common type of injury sustained by 72% of the nurses. The main cause of injuries was related to disposal of used needles (52.2%).In conclusion the results of the study confirm the need for implementation of data collection tool and a proper framework to provide support and follow-up to those who sustain sharp injuries.20

A prospective descriptive study was conducted on the details of needle stick injuries in a year among 1022 healthcare workers working at Hamad Medical Corporation, Doha, Qatar. Questionnaire and face-to-face interview methods were used to collect data. The result revealed that, of the total studied subjects 214 were victims of needle stick injuries. Sharp injuries constitute a considerable proportion of needle stick injury incidents (21%) and could pose the greatest risk of blood-borne virus transmission. The study concluded that the healthcare workers may fully know the risk of needle stick injuries but impediments to prevention of needle stick injuries exist.21

A retrospective study was conducted to assess the risk of needle stick injury among nurses caring for patients with diabetes in 381 different hospitals throughout the United States. The study was based on responses to an internet-

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based survey. Result revealed that of 400 nurses who responded, 313 (78.3%) reported experiencing at least one needle stick injury. The study found that nearly 80% of nurses experience needle stick injuries caring for patients with diabetes.22

A survey was conducted on epidemiology of needle stick injuries among health care workers working in Buraidah Central Hospital in Buraidah, Saudi Arabia. The data was collected by a retrospective survey of all self-reported documents related to needle stick injuries. Result revealed that of the total 73 injuries reported, nurses were involved in 66% of instances, physicians in 19%, technicians in 10% and non-clinical support staff in 5.5%.The study emphasized the importance of awareness, training and education of health care workers for reporting and prevention of needle stick injuries.23

A study was conducted on risk of needle stick injuries among healthcare workers of L.T.M. Medical College and General Hospital, Sion over a period of one year. The data collected was based on self-reported incidence of needle stick injuries and other exposures to patient’s blood and body fluids. Result revealed that a total of 38 cases were reported and no sero-conversion in any of the reported accidental injury cases. This data emphasized that needle stick injuries present the single greatest risk to medical personnel and the importance of increased awareness and training is in universal safety precautions for prevention of nosocomial infections.24

A study was conducted on the prevalence of needle stick injuries among medical, dental, nursing and midwifery students at Shiraz University of Medical Sciences, Iran. A self- administered questionnaire was used to collect data. The results revealed that out of 688 students responded, 71.1% of the students had needle stick injuries and 82% of the injuries were not reported. The study concluded that needle stick injuries and non-reporting of needle stick injuries were highly prevalent in these students.25

6.2.2 Review of literature related to knowledge and practice of needle stick injury and its management among health care workers.

A survey was conducted on non-sterile occupational injuries and infection control practices among the final year dental, medical and nursing undergraduates at the University of Western Ontario. A self administered anonymous questionnaire was used as study method. The results revealed that 82% of dental, 57% medical and 27% of nursing students reported non-sterile occupational injuries; Dental students (97%) were more aware of post exposure protocol than medical (45%) or nursing (585) students. Of those reported injuries, 77% of medical, 48% of dental and 59% of nursing students also reported using no follow-up procedures.15

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A study was conducted to assess the knowledge, attitude and practices regarding needle stick injuries among 70 nurses and paramedical staff from different departments of 100-bedded armed force’s hospital, Sharourah. Data collection was carried out using a standardized questionnaire. The results revealed that 21% and 30% of the healthcare workers, respectively, were unaware of the fact that AIDS and Hepatitis C can be transmitted by needle stick injury. A total of 74% had a history of needle stick injury and only 4% reported the injuries. The survey concluded that knowledge of healthcare workers about the risks associated with needle stick injuries and use of preventive measures is inadequate.27

A study was conducted to assess the knowledge, attitude and practices on needle stick injuries among 70 nurses and paramedical staffs from different departments of Kathmandu Medical College and Teaching Hospital. A 15-item questionnaire was administered for analysis. Result revealed that 4% and 61% of healthcare workers, respectively, were unaware of the fact that hepatis B and hepatitis C can be transmitted by needle stick injuries. 74% had a history of needle stick injuries and only 21% reported the injuries. Only 23% were in the habit of using gloves for phlebotomy procedures all the time.79% were of the impression that needle should be recapped after use. Only 66% were aware of universal precaution guidelines. The study concluded that knowledge of health care workers about the risk associated with needle stick injuries and use of preventive measures is inadequate.28

A study was conducted to assess the knowledge, attitude and practices of healthcare workers regarding needle stick injuries among 29 doctors and 51 registered nurses at Aga Khan University hospital. A structured pretested questionnaire was administered. Results revealed that about 45% reported having a needle stick injury in the past. The most common reason identified was stress or being over burdened followed by careless attitude. Two-third of the participants were familiar with the prevention protocols. The study concluded that despite knowing the risk frequency of needle stick injury, higher and mandatory reporting, proper follow-up and constant reinforcement are recommended to reduce the rate of nosocomial transmission to healthcare workers.29

6.2.3 Review of literature related to effectiveness of structured teaching programme on needle stick injuries and its management.

A quasi- experimental study was conducted to assess the impact of structured training on prevention of occupational exposure to blood-borne pathogens on knowledge, behaviour and incidence of medical sharp injuries among 106 student nurses in Changsha, People’s Republic of China. The 106 students taken for the study were divided into two classes, one class served as experimental

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group while the other served as a control group. Students in the experimental group participated in structured training interventions. Results revealed that the group that received the structured training scored significantly higher than the standard education group on both knowledge and behavior.30

A study was conducted to assess the effectiveness of a training program on reducing needle stick injuries/sharp object injuries among soon graduate vocational nursing school students in Southern Taiwan. The study method consisted of a lecture to the students after the internship training and a self-study brochure for them to study. This study used the pre-test questionnaires completed by the students and the post-test questionnaires completed by 107 graduates after work experience as licensed nurses. The results revealed that, the incidence of needle stick injuries / sharp injuries decreased significantly from 50.5% pre-test to 25.2% post-test, and the report rate increased from 37.0% to 55.6%, respectively. In conclusion, this intervention significantly reduced the incidence of needle stick injuries/sharp injuries and increased the report rate of such events.31

A study was conducted to assess the knowledge and existing practices of staff nurses regarding needle stick injuries and to evaluate the guidelines developed for the prevention and management of needle stick injuries in a selected government hospital of Delhi. The study revealed that 70% of the staff nurses had sustained needle stick injuries. There was lack of awareness among staff nurses regarding prevention and management of needle stick injuries. Among the nurses who sustained needle stick injuries, the majority (71%) did not report it. The developed guidelines regarding, prevention and management of needle stick injuries was found to be effective in enhancing the knowledge and improving the practice of staff nurses. The study concluded that it is useful to the British nurses to be able to compare their experience of needle stick injuries with that of nurses in Delhi. 32

A study was conducted to assess the impact of introduction of sharp containers and education programmes on the pattern of needle stick injuries in a tertiary care centre in India. Introduction of large sharp containers, accompanied by an intensive education programme was used as the study method. Details of documented injuries were analysed using the epi-info software for a selected period of time. Result revealed that a total of 347 injuries occurred mainly due to improper disposal of needles, recapping and carelessness during use. After the education programme the percentage of injuries attributed to disposal fell from 69.2% to 38.5%.A further decrease was noted after the additional introduction of small sharp containers. The study concluded that relatively simple intervention decreased the number of injuries.33

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6.3 STATEMENT OF PROBLEM

A study to assess the effectiveness of structured teaching programme on knowledge regarding needle stick injuries and its management among nursing students in a selected college, Bangalore.

6.4 OBJECTIVES OF THE STUDY

1. To assess the knowledge level of nursing students on needle stick injuries and its management.

2. To evaluate the effectiveness of structured teaching programme on knowledge of nursing students on needle stick injuries and its management.

3. To find out the association between the post test knowledge of students on needle stick injuries and its management, and selected demographic variables.

6.5 OPERATIONAL DEFINITIONS

1. AssessAssessment is the process of collecting, interpreting and communicating data. In this study assessment is done on knowledge about needle stick injuries and its management among nursing students by using structured questionnaire method.

2. Effectiveness

Effectiveness is to have a definite or desired effect. In this study desired effect of structured teaching programme on knowledge regarding needle stick injuries and its management is assessed.

3. Structured teaching programme

It is the systematically planned teaching programme provided in order to improve the knowledge on a selected topic. In this study it is used to provide knowledge regarding needle stick injuries and its management

4. Knowledge

It is the theoretical or practical understanding of a subject. In this study knowledge refers to the correct responses obtained from the nursing students to the

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questionnaire regarding needle stick injuries and its management. It is measured by the structured knowledge questionnaire.

5. Needle stick injuries

It is an accidental injury with a needle that may be contaminated with blood or body fluids. The term is also used to include other sharp injuries. In this study it refers to only the injuries caused by needles.

6. Management

It is the process of managing or being managed. In this study it refers to first aid after immediate exposure and self-reporting by the client, followed by reviewing the circumstances of the exposure, assessing risk, counselling and educating the client, provision of post-exposure prophylaxis, collecting blood for baseline testing, documentation and follow up of the client by hospital authority.

7. Nursing students

Nurse is a person trained to take care for the sick or infirm. Nursing students are those, undergoing an educational course for becoming a nurse professional. In this study nursing student refers to selected Bsc nursing students of Roohi college of nursing.

6.6 HYPOTHESIS

H1: The mean post test knowledge score of the nursing students on needle stick injuries and its management after the structured teaching programme is significantly higher than the pre-test knowledge score.H2: There will be a significant association between post-test knowledge of nursing student on needle stick injuries and its management and the selected demographic variable.

6.7 RESEARCH VARIABLES

Dependent Variable

Knowledge level of nursing students, on needle stick injuries and its management.

Independent Variable

Structured teaching programme on needle stick injuries and its management.

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Demographic Variables

Age, sex, religion, marital status, educational level, sources of information.

6.8 ASSUMPTIONS

- All nursing students need to be educated regarding needle stick injuries and its management.

- Structured teaching programme provides information and enables the nursing students gain more knowledge on needle stick injuries and its management.

-Structured teaching programme could be an effective teaching tool.

6.9 DELIMITATION

-The sample size is limited to 60 nursing students.

-The period of study will be limited to one month.

-The study is limited to a selected college in Bangalore.

6.10 PROJECTED OUTCOME

The structured teaching programme will provide beneficial information regarding needle stick injuries and its management to the nursing student which will aid in improving their knowledge and practice level, and the findings of the study will elicit the relation between the information expected and the information received by nursing students subjected to needle stick injuries and its management.

7. MATERIAL AND METHODS

7.1 SOURCE OF DATA

7.1.1 RESEARCH DESIGN

The research design which is most suited for this study is quasi-experimental design.

(One group pre-test and post test)

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GROUP PRE-TEST INTERVENTION POST-TEST

Nursing students in a selected college in Bangalore

A1 X A2

KEYWORDS

A1- Pre-test to assess the knowledge of nursing students regarding needle stick injuries and its management.

X- Administration of structured teaching programme on needle stick injuries and its management.

A2 – Post test to assess the knowledge of nursing students regarding needle stick injuries and its management.

7.1.2 RESEARCH SETTING:

The study will be conducted at Roohi college of nursing, Bangalore. It is a private institution offering Bsc nursing programme to the students. A total of 204 students are studying in that institute.

7.1.3 POPULATION

The population of the study is all the Bsc nursing students studying in Roohi college of nursing, Bangalore.

7.1.4 SAMPLE

The sample consists of Bsc Nursing students studying in Roohi college of Nursing, Bangalore.

7.1.5 SAMPLE SIZE

A sample size for the study is sixty Bsc Nursing students who fulfil the inclusion criteria.

7.1.6 SAMPLING TECHNIQUE

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The study procedure adopted for the study will be simple random sampling technique. There are a total of 204 students in 4 batches from first year to fourth year, studying in Roohi College of nursing, Bangalore. From each batch 15 students will be selected using simple random technique so that a total number of 60 students can be uniformly obtained for the study.

7.1.7 SAMPLING CRITERIA

Inclusion criteria

-Nursing students of all age.

-Nursing students who are willing to participate in the study.

-Nursing students who can read and write English or Kannada.

-Nursing students who are present in the college at the time of data collection Exclusion criteria

-The nursing students who are not willing to participate in the study.

-The nursing students who are not present at the time of data collection.

7.2 METHODS OF DATA COLLECTION

Instruments used for study

The data collection will be done with the help of a structured questionnaire.

Section A- It contain demographic data like age, sex, religion, marital status, educational level, sources of information etc…

Section B- It consists of questionnaire regarding needle stick injuries and its management.

7.2.1 DATA COLLECTION METHOD

After obtaining consent of samples, the data collection procedure consists of knowledge questionnaire; to assess the knowledge of student nurses regarding needle stick injuries and its management. Structured teaching programme will be

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prepared on importance of needle stick injuries and its management. Content validity will be ascertained in consultation with the guides and experts in the field of medicine and nursing. Reliability of the tool will be established by test and re-test method.

7.2.2 PLAN FOR DATA ANALYSIS

Descriptive and inferential statistics will be used to analyze mean, standard deviation; frequency and percentage distribution will be used for the analysis of the data. A “t” test will be done to compare the pre and post test knowledge scores. Chi square ( χ2) test will be done to find out the association with the level of knowledge and selected demographic variables.

7.3DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR INTERVENTION ON PATIENTS OR OTHER HUMANS OR ANIMALS?

Yes, in this study structured teaching programme is given to the nursing students.

7.4 HAS ETHICAL CLEARENCE WILL BE SOUGHT FROM YOUR INSTITUTION IN CASE OF THE ABOVE .

1. The ethical clearance will be sought from the research committee of Acharya college of nursing.

2. Written permission will be obtained from concerned authorities.

3. Permission will be obtained from the student nurses who are involved in the study before collecting data.

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2. Wikipedia, the free encyclopedia. Answers[Online]. [cited 2009 Nov 27]. Available from:URL: http://wiki.answer.com

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4. Black JM, Hawks JH. Medical-surgical nursing-clinical management for positive outcome. 7th ed. New Delhi, (India): Saunders; 2004. p. 2378.

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10. International Council of Nurses. Fact sheet- ICN on preventing needle stick injuries. 2000 july [2009-Oct-17]. Available from: URL:http://www.icn.ch/matters_needles.htm

11. Chew TT, King YL. Accidental needle stick injuries among nurses in a regional hospital in Hong Kong .Journal of the Hong Kong Medical Association 1987; 39(1)

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12. Hamory BH. Underreporting of needle stick injuries in a university hospital. American journal of infection control 1983;70:174-7.

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16. Panagakos FS, Silverstein J. Incidence of percutaneous injuries in a dental school: a 4-year retrospective study. American Journal of infection control 1997;25:330-4

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18. Shiao J. Student nurses in Taiwan at high risk of needle stick injuries. Annals of epidemiology, 12(3):197-201.

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23. Jahan S. Epidemiology of needle stick injuries among health care workers in a secondary care hospital in Saudi Arabia. Ann Saudi Med 2005 May-Jun; 25(3):233-8.

24. Rele M, Mathur M, Turbadkar D. Risk of needlestick injuries in healthcare workers- A report. Indian J Med Microbiol 2002 Oct-Dec;20(4):206-7.

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25. Askarian M, Malekmakan L. The prevalence of needle stick injuries in medical, dental, nursing and midwifery students at the university teaching hospitals of Shiraz, Iran. Indian J Med Sci 2006 jun;60(6):227-32.26. Polit DF, Beck CT. Nursing research:generating and assessing evidence for nursing practice. 8th ed. New Delhi, (India): Wolters Kluwer; 2008.

27. Alam M. Knowledge, attitude and practices among healthcare workers on needle stick injuries. Ann Saudi Med. 2002;22(5-6).

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29.Zafer A, Aslam N, Nasir N, Meraj R, Mehraj V. Knowledge , attitudes and practices of health care workers regarding needle stick injuries at a tertiary care hospital in Pakistan. J Pak Med Assoc 2008;58(2):57-60.

30.Wang H, Fannie K, He G, Burgess J, Williams AB, A training for prevention of occupational exposure to blood borne pathogens: Impact on knowledge, behavior and incidence of needle stick injuries among student nurses in Changsha, Peoples Republic of China. J Adv Nurs 2003 Jan;41(2):187-94.

31. Ya-Hui-Yang, Saou-Hsing Liou, Chiou-Jong Chen, Chun-Yuh Yang, Chao-Ling Wang,Chiu-Ying Chen and Trong-Neng wu. The Effectiveness of a Training Program on reducing needle stick injuries / Sharp object injuries among soon graduate vocational nursing school students in southern Taiwan. Journal of Occupational Health 2007;49(5)424-9.

32.Simon LP. Prevention and management of needle stick injury in Delhi. Br J Nurs 2009 Feb 26- Mar11;18(4):252-6.

33.Richard VS, Kenneth J, Ramaprabha P, Kirupakaran H, Chandy GM. Impact of introduction of sharp containers and of educational programmes on the pattern of needle stick injuries in a tertiary care centre in India. J Hosp Infect 2001 Feb;47(2):163-5.

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