Abstract

Health care workers (HCWs) such as nurses are usually exposed to infectious diseases. Some infectious diseases do not have any offered vaccination or complete treatment, thus blood-borne infections are a serious cause of anxiety for HCWs. Objective of this study was to assess nursing students’ knowledge, observation of environmental risk factors, and compliance with recommended universal precautions about the prevention of infectious diseases by needlestick injury. Methods: descriptive research design was used. Setting of this study was conducted in the college of nursing at Jazan University. Sample: convenient sample of 120 students was used in the present study. Tools of data collection were consisting of four tools first; socio-demographic characteristics sheet, second; students’ knowledge assessment sheet, third; students’ compliance actions assessment sheet; fourth observations of environmental and risk factors. Results of the study revealed that, most dominant place for taking first teaching about prevention of blood borne organisms is classroom (46.4%) for 8^th level students, while labs is taking the highest response (42.2%) with in 3^rd level students. The majority of the 3^rd level students (87.5%) had fair knowledge scores related to the subject compared to (89.3%) of the 8^th level students. More than two thirds (68.7%) of the first year students had fair compliance scores with mean scores (29.10±4.17) compared to (48.2%) of the fourth year with mean scores (29.30±5.31). Conclusion: Majority of the studied students had average knowledge about prevention of infectious disease related needlestick injuries. Minority of the students in both first and fourth year had good compliance with recommended universal precautions. More than half of the students in third level and near half in eighth level had poor environmental risk factors. Recommendations: Establishing educational and awareness’ programs for all nursing students about the dangerous and prevention of occupational exposure to blood borne pathogens, infectious diseases and needlestick injury.

1. Introduction

Hospital-acquired infections continue to be the main focus for all facilities in health care services worldwide. It is understood that majority of infections occur from contaminated hands of caregivers, which has pointed to the current attention on hand-hygiene actions and it is one of the basic reasons for morbidity and mortality linked with clinical, diagnostic and therapeutic procedures ^{1, 2}. Whereas there have been remarkable benefits in moving health-care workers to cleanse their hands, compliance rates usually decline when an intervention ends. Furthermore, caregivers usually neglect hand washing if they are occupied. Recent effort has tinted the role of the clinical environment in transmitting the hospital-related infection. Nosocomial bloodstream infections (NBSIs) in are linked with significant morbidity and mortality, in addition to prolonged stay time and healthcare expenses ^{3, 4, 5}.

Needlestick injury (NSIs) is the main reason of infections transmitted through blood among health-care personals. Needle-stick injuries are cuts induced by needles that puncture the skin unintentionally. An accidental skin puncture wound can be created by hollow-bore needles like subcutaneous injection, needles used for blood sampling, intravenous cannulas, needles used to attach parts of IV delivery system, and scalpels. Needle-stick & sharp injuries (NSSI) happens accidentally during performance the duties of healthcare workers that dealing with blood or probably dangerous elements by a hollow bore gauge or sharp devices, including, but not limited to, needles, lancets, scalpels, and infected shattered glass ^{6, 7}.

There are over twenty types of blood borne diseases can be transmitted through needlestick injuries, mainly liver hepatitis viruses (B and C) and human immune deficiency (HIV) virus. Furthermore, with reference to information from WHO concluded that in developing sectors, 40%-65% of liver hepatitis viruses (B and C) within health care personnel are related to percutaneous work hazards, also it reported that nurses experienced sharp injuries specially needlestick more frequently than other healthcare workers ⁸. Regarding reported cases of needlestick injuries per year, there are two million reported ones, but in developing countries, it thought that 40-70% of needlestick injuries cases are unreported ⁹.

Data have been collected from twenty one health care settings from beginning of January to end of March, 2012 and reported in Needlestick and Sharp-Object Injury Report in Saudi Arabia. The report showed that nurses were the main injured staff, equaling two third of the sample, as compared to 7.8% of which are physicians. The places where these injuries occur ordering as the following; first at inpatient unit (48.9%), then Emergency unit (13.6%) and lastly the Operating/Recovery Room (11.5%). Nearly ninety percent of the sharp objects associated with the injuries are infected. The primary procedure in which injuries occur is injection (17.9%), followed by blood specimens (17.2%), and 14.8% related to suturing. Injuries happen mostly at the time of using the object, then after use, but before disposal. The major instrument causing the injuries is disposable syringes (slightly more than fifty percent). Hands’ staff are the primary part injured. Two thirds percent of wounds related sharps when the caregiver wore a separate set of gloves, 26.9% did not wore gloves at all, and only around five percent wore two pairs of gloves, which may have lessened the total cuts from sharps ¹⁰.

Universal precautions awareness education has not been evident among health care providers, mainly in developing countries. This may not be unrelated to the insufficiency of curriculum in schools of training and inadequate training of health worker ¹. In this process in each individual blood, specific blood fluids as well as fresh tissue and cells of human source are handled as if identified to be contaminated with HIV, HBV and or other blood borne infections. Moreover, these rules are intended to avoid infection from injection; contact with mucous membranes such as mouth or eye, or through skin abrasions such as cuts ¹¹.

Centre for Disease Control defined these universal precautions as "a group of precautions intended to stop transition of Human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other blood borne pathogens while administering health care in any health care setup. According standard precautions, blood and certain body fluids of all clients are recognized probably contagious for HIV, HBV and other blood borne pathogens ¹². Others defined it as the global expression utilized by the medical industry to define the collection of rules added to provide medical team to harmlessly manage materials that may carry blood or body fluids contaminated with infections" ¹³.

Universal precautions are standard of practices intended to prevent the opportunity of carrying of bloodborne diseases, it recommended hand washing before and after procedures, use of barriers such as donning gloves, gowns and aprons when dealing with blood or other body fluids containing visible blood; masks and protective eyewear or face shields should wear when there is an expected infection of mucous membranes of the mouth, nose, and eyes. Other recommendations regarding NSIs; take care to prevent injuries caused by needles, scalpels and other sharp instruments or devices, do not recap, bent or break used needles, place all needles and sharp items in puncture-resistant containers. These precautions are recommended for doctors, nurses, patients and all health-care workers who have exposures to blood. Finally, the precautions give us recommendations related respiratory hygiene and environmental cleaning ^{1, 14}.

Compliance is the level of precision and constancy in following prescribed standard protocols to accomplish the wanted results ¹⁵. The level of compliance can be affected by many elements involving cultural, economic and social factors. Additionally, the level of the person’s self-efficacy and knowledge can impact on their compliance level. Various researches announced that applying universal precautions decreased the susceptibility to hazards of blood and body fluids. Besides, they confirmed that compliance with universal precautions associated with nurses’ understanding of dangers, type of instructions obtained, skills level, and the kind of activities performed ¹⁶.

Sufficient knowledge and performance of standard precautions is a valuable method of avoiding infection because it provides safety not only for caregiver, but also for the patient. Strict observation of these activities guarantees that health care personnel and patients are protected against infection. Nursing students because of their training they are liable to infections and injuries; as such imperative to gain sufficient information about universal precautions. Awareness about universal precautions will make its usage regular at any situation. There are some factors that may influence the practice of these precautions and understanding them will be useful in ensuring that health care providers, students and patients are safe in hospital ¹⁷.

Needlesticks injuries are serious threat to health-care personnel, who are at high risk because of their low experience during their practical training. Nurses exposing to a lot of procedures and activities put them at great risk to sharp injuries including; administering injection, withdrawing blood-sample, replacing syringe with specimen containers, recapping and disposing needles, waste disposal and contaminated sheets ¹⁸. Nurses protection against work setting-related wounds and diseases is critically necessary to nurses themselves as well as to the patients they serve. Providing a good quality patient care, attentive observation, empathic patient care, and powerful support require a healthful and well-rested nurse. Although nurses are known to be a high-risk subgroup for these situations, nursing students may be at even higher risk for catching several infections and injuries during clinical training related to their insufficient practical background ¹⁹. Also, increased the incidence of needlestick injury and infection among health care providers makes necessary need to assess student knowledge and practice of universal precautions with a view to establishing a baseline data. Data about knowledge and practice of universal precautions among nursing students in kingdom of Saudi Arabia is scanty. Therefore, this study will provide information and bridge the knowledge gab that exists.

2. Methods

The current study aimed to:

1. Assess knowledge of the nursing students regarding universal precautions measures

2. Evaluate the environmental risk factors

3. Assess the compliance with recommended universal precautions regarding control of infectious pathogens by needlestick injuries at Jazan collage of Nursing.

1. Are nursing students having knowledge about prevention of infectious pathogens through needlestick injuries?

2. Are eighth level nursing students' had a higher knowledge more than third level about prevention of infectious diseases by needlestick injury?

3. What are the environmental risk factors for infectious diseases by needlestick injury?

4. Are eighth level nursing students had an implement higher compliance with recommended universal precaution more than third level about prevention of infectious diseases by needlestick injuries?

Research design that used in the current study was descriptive.

The current study was conducted at kingdom of Saudi Arabia.in the faculty of Nursing, Jazan city.

A convenient sample of one hundred and twenty (120) student nurses in the third level which is the first clinical course and in the eight level which is the last clinical course, who agree to engage in the study. The questionnaire was given for a period from (first of September 2017 to January 2018). Sample of female nursing students aged 18 and over was selected.

A four sections instrument was developed by Logan, (2002) ²⁰ to collect data from nursing students that contained the following sections: (a) demographic data and educational program related data, course outline and teaching methods. (b) knowledge of the students regarding needlestick injuries and transmission of blood-borne virus; (c) students’ compliance with protective skills; (d) opinions of the students regarding environmental risk factors.

Section I: Socio-Demographic Characteristics and Institutional Data Sheet:

This sheet includes socio-demographics characteristics of female nursing student such as: name, age, academic level. Institutional data involved; knowledge of first instructions related protection from blood borne infections hazards, properties of first instructions included within the nursing curriculum regarding this topic, program syllabus, methods of teaching applied during teaching compliance with universal and transmission-based precautions, and number of needle-stick injuries reported by nursing students.

Section II: Students’ knowledge assessment sheet:

This assessment sheet included thirty MCQ questions performed to measure students’ knowledge about transmission mode of blood-borne diseases through needle-stick injuries in addition to recommended instructions for control of occupational exposure to blood-borne organisms and transmission of HIV, hepatitis B virus, and hepatitis C virus. This sheet has correct answer takes score 1 and incorrect answer takes score zero.

Scoring system: Total number of questions was 30 equal (100%).Good knowledge was considered at > 70%. Average knowledge ranged between 50 - >70%. Poor knowledge was reported for < 50%.

Section III: Students’ Compliance Actions Assessment Sheet:

It contained 11 items arranged as a Likert scale using four point type, items from thirty one to forty one, intended to measure the participants students’ activities focusing the application of recommended instructions for control and minimize exposure to blood-borne infections during clinical practice.

Scoring system of 11 questions was 44. Total =44; (Poor=Less than 26.5; Fair=26.5-33; Good more than 33).

Section IV: Observations of Environmental Risk Factors Form:

This form involves 12 questions created as four points Likert-type scale, questions from forty two until fifty three planned to measure selective environmental conditions remarked by participants that are related to the performance of recommended instructions for the control of the exposure to blood- borne organisms during clinical practice.

Scoring system of 12 questions was 48. Total=48; (Poor=Less than 29; Fair =29-36; Good more than 36).

Five experts of nursing staff from faculty of nursing tested the content validity of the study tools (I and II).

Test-retest and Pearson Coefficient factor was used to measure tool reliability, after applying the questionnaire on 10 students (r=90.8). After two weeks the questionnaire retested, then measure Spearman’s rank correlation coefficient (0.82).

Ethical and official permission was obtained prior to conduct this study. Oral approval was obtained from each student after producing an overview introduction, purposes of the study and its significance that offered by the researchers. The students informed that participation in the study is voluntary and they assured that their identity information and responses would be confidential. It was clear for each participant that she has full right to refuse to participate in the study or to withdraw at any time without giving any reason.

A pilot study was conducted on 10 students who registered in the college of nursing in Jazan University, not only to determine the suitable time required to complete the sheets, but also to assess the applicability of tools and evaluate the clarity and simplicity of the included questions. The students who included in the pilot study didn't include in the principal study. Finally, Necessary modifications were done prior develop the final form of the tools.

Data collection tools prepared after reviewing related literature and experts' opinions, followed by obtaining official permission from the dean of the faculty. Data collected over a period of 2 months, two days per week; grouping the students from 3 to 5 students according their free time. Collection of the data was performed after arrangement with students schedule during their free time. The pre-structured questionnaire filled in about 20 to 30 minutes.

Data were coded before computerized entry. Data analysis and tabulation achieved by the Statistical Package for Social Science (SPSS) application, version 20.0. Descriptive data were shown as mean ± Std. Deviation for quantitative data, while the qualitative data were applied as frequency and percent. Paired t-test and Chi-square test used for significance. When p<0.05, it is reflected as a significant level value.

3. Results

Table 1 illustrates that, 53.3% of the sample size were in the third level, while 46.7% of them were in eight level. It also represents that, the majority (98.4%) of the third level students were at age group from 19-20 years old with mean age (19.75 ± 0.47), while (80.4%) of the eight level, their age ranged between 21 – 23 year old with mean age (23.17 ± 0.43).

Figure 1 shows that the most dominant place for taking first teaching about prevention of blood borne organisms is classroom (46.4%) for 8^th level students, while labs is taking the highest response (42.2%) with in 3^rd level nursing students.

Figure 2 declares that (73.2%, 67.2%) of 8^th level and 3^rd level students respectively contact their teachers several times regarding prevention of blood borne organisms.

Figure 3 shows 6.2% of students in 3^rd level emphasized on ideal time frame for reporting needlestick injuries was greater than given any area compared to (3.6%) among 8th level.

Figure 4 nearly half (51.6%) of 3^rd level students mentioned that reporting needle stick injuries was less than given any other area compared to(50%) of 8^th level students reported less than given any area.

Table 2 represents the used teaching methods for needlestick Injuries education. More than half of the students (57.8, 53.6%) respectively in both 3^rd and 8^th level considered lecture as main teaching method. while one quarter (25 %) of them considered it as most helpful method. Also, only 6.2% of 3^rd level students compared to (10.7%) in 8^th level considered demonstration as most helpful method of teaching.

Table 3 reveals that the majority of the first year students in the sample (87.5%) had fair knowledge scores compared to (89.3%) of the fourth year. While only (12.5%) of first year students had poor knowledge scores compared to (7.1%) of the fourth year. The table represents a significant statistical difference between both levels of the students related to knowledge scores (p=.000).

Table 4 clarifies students total compliance scores. More than two thirds (68.7%) of the first year students had fair compliance scores with mean scores (29.10 ± 4.17) compared to (48.2%) of the fourth year with mean scores (29.30±5.31). While only (9.4%) of first year students had good compliance scores compared to (21.4%) of the fourth year. The table founds a significant statistical difference between both levels of the students regarding compliance scores (p=.000).

Table 5 clarifies students total environment scores. Nearly half (51.6%) of the first year students had poor environment risk factors with mean scores (28.12±4.66) compared to (48.2%) of the fourth year with mean scores (28.92±7.33). While only (3.1%) of first year students had good environment scores compared to (12.5%) of the fourth year.

Table 6 displays that compliance is week positively correlated with the environmental risk factors and total knowledge within the 3^rd level students, but these relations are not statistically significant. While total knowledge in the same level correlated negatively with the environmental risk factors. This table also reveals that, in 8^th level, Knowledge score is positively correlated with compliance and negatively correlated with environmental risk factors with no statistically significant. In addition, there is a positive correlation between compliance and environmental risk factors with statistically highly significant percent among the student in 8th level as r= .623 and P=.000.

4. Discussion

Needlesticks and sharps injuries draw a serious professional risk within the healthcare activities; the major percent from healthcare personnel facing that risk is nurses. Nursing students have to complete a competent level of nursing skills in clinical practice hence, they continuously at high risks for infections during performing procedures using needle and sharps items in different health care settings ²¹. Related to the limited background of the nursing students, they are at high risk for NSIs. They are exposed to more serious hazards in clinical areas; they are facing more unintended or accidental injuries and become more liable to blood-borne microorganisms ^{22, 23}. Their clinical abilities are undeveloped yet, and their manual skills are insufficient, but they are excited to acquire different procedures ²². So, the present study aimed to measure the students' compliance with recommended universal precautions about prevention of infectious pathogens by needlestick injury at Jazan collage of Nursing.

First, for basic properties of the sample; there were total of 120 nursing students with regular studying status registered to third level and to the eighth level. Among these students, more than half were recruited in the third level while less than half were recruited in the eighth level with mean age of third level students 19 years compared to 23 years old of eight level students.

Regarding to teaching methods used in education of needlestick Injuries subject, More than half of the students (in both 3^rd & 8^th level) considered lecture as main teaching method about blood borne infection. This study result corresponds with a study by Norsayani MY et al., ²⁴ who mentioned in their study, that medical students gained their information related blood-borne pathogens basically by lectures with near hundred percent followed by books.

Furthermore; the findings of this study represented the majority of "both third level and eighth level" had low mean score of total knowledge. These results were consistent with a study carried out by ²⁵ as they stated that about two- thirds of students have a low level of knowledge regarding usage of gloves as a protective precaution and the percent of first year students wearing gloves was also concluded to be small. The researcher's point of view is that, the incidence of needlestick injuries is high. This means that students' knowledge is not good regarding the prevention of occupational hazards or they miss the importance of avoidance risks during their practice. Consequently, the nursing students should be improving their knowledge and awareness of professional risks, and they should also be empowered to perform protective precautions during dealing with patients.

Regarding to nursing students’ compliance with recommended universal precaution Table 4, the present study found that, there were significant difference between third and eighth level students. Minority of the students in both first and fourth year students had good compliance with recommended universal precautions. Similar result was reported in the study of ²⁶ (Paul et al., 2014), they found that low compliance level with universal precautions among health-care personnel and also, in another study it was reported that the students did not compliant to gloves wearing during contacting with patients, furthermore, wearing eye shields in operating room and emergency department is neither complaint by medical nor nursing students ²⁷. The researcher's point of view for reduced compliance than expected is that may be due to an incomplete understanding of the principles underlying universal precautions among nursing students and that affected their practices and led to noncompliance.

Moreover, the present study declared the significant difference that found among third and eighth level students regarding their observation of environmental risk factors regarding occupational exposure to Blood Borne in Table 5. More than half of students in third level and near half in eighth level had poor environmental risk factors. This study is consistent with Abdel Moneim ²⁸ who observed that sixty percent of students enrolled in their first practical course stated poor level of environment. It is important to emphasize on that working circumstances around nurses are correlated to the quality of care that is afforded to patients and their protection ²⁹. Circumstances around nurses' work are connected with health and safety consequences, and as such, studies directed to safety issues of nurses and their health is very necessary.

Lastly, our current study mentioned poor positive correlation between compliance level and knowledge score within both studied students levels. While compliance correlated strongly positive with environmental risk factors among nursing students of eight level with statistically significant. In addition, Table 6 presented negative correlation between environmental risk factors and knowledge score in both levels. These results are consistent with ²⁸ Abdel Moneim who found positive relation between knowledge and compliance however, negative relation between knowledge and environmental factors, but these relations are not statistically significant.

This study finding is similar with Y. Luo et al. ³⁰, they noticed that there was greatest commitment with hand hygiene and disinfection and sharps management. This is mainly related to hospital policy and frequent education with supporting this education by providing the equipment that is required. But they also reported that the greatest of the hospital units were not provided with another appropriate protection supplies like eye protection, protective masks, gowns, and footwear coverings.

The researchers' suggest that, it should be highly cooperation among hospital units to equip personnel with infection control and universal precautions facilities and acquire them with periodical training programs related to this issue emphasis on compliance with preventive precautions and proper sharps handling skills. Moreover, the impact of teaching and clinical training on nurses' compliance attitudes on long run has not been surely recognized. Because commitment with universal precautions and diseases transmitted-based instructions are necessary for avoiding spread of blood borne organisms, furthermore, assessment of the factors that affecting the compliance is important ^{31, 32}.

5. Conclusion

Largest proportion of the participant students had average knowledge about infectious disease prevention of needlestick injuries. Also, minority of the students in both first and fourth year students had good compliance with recommended standard precautions. Nearly half of the students in third level and near half in eighth level had poor environmental risk factors.

6. Recommendations

In the light of the result of the present study, the subsequent recommendations are proposed:

1. Establishing educational and awareness’ program for all nursing students about the dangerous and avoidance of occupational exposure to bloodborne, infectious diseases and needlestick injury.

2. Further researches needed with lager sample for raising nursing students awareness' the about prevention of infectious diseases by needlestick injury.

3. All nursing students should receive a training program about implementing universal precautions to reduce susceptibility to blood and blood-borne pathogens which would support and or empower students on training to report incidents out of fear from consequences.

4. Immunization against infectious diseases of students undergoing training.

5. A proper working environment could be directed through supplying of satisfactory equipment in the unit.

6. Routine demonstration sessions should be introduced for growing skills related universal precautions.

7. Provide proper guide and supervision to each student during their clinical exposure

8. Using different effective teaching methods while teaching the universal precautions in nursing curriculum to enhancing these skills.

Acknowledgements

The authors would like to acknowledgment thanks to the respected administration personnel of Jazan collage of Nursing and also thanks all the students who accept to participate in this study.

Conflicts of Interest Disclosure

The author declares that there is no conflict of interest statement.

References