Occupational exposure to blood and body fluids in Chinese registered nurses is still common, and the rate of exposure under-reporting is high. Work experience, work department, region of hospital, hospital level, working hours per day, following standard prevention practices, perceived level of risk of occupational exposure in the workplace, awareness of occupational safety and the protection of the people around you, number of types of PPE provided by the hospital, number of types of safety-engineered injection devices provided by the hospital, and frequency of training related to occupational safety can all impact the occurrence of nurses’ occupational exposure to blood and body fluids.
There is a high prevalence of occupational exposure to blood and body fluids among nurses in China, and this result is consistent with previous studies [27, 28]. The most common route of exposure is percutaneous (needlestick, sharp injuries, broken skin, etc.), accounting for about 2/3 of all incidents, followed by mucous-membrane exposure, which accounts for about 1/3. Globally, there is a high incidence of percutaneous injury among healthcare providers who directly care for patients that increases their risk of infection from bloodborne viruses such as HBV, HCV, and HIV . In this study we found that disposing of discarded sharps and withdrawing needles were the most common circumstances associated with occupational exposure, and the most common cause of occupational exposure was disposing of sharp objects without following the correct procedures, which is also similar to previous findings [4, 30]. However, most current training courses for nursing technical procedures do not emphasize sharp injury prevention enough . This suggests that such training content should be added to future textbooks and training courses.
In addition, this study showed that the more comprehensive the provision of safety-engineered sharps, the lower the occurrence of occupational exposure, which agrees with the results of a multicenter study in Japan that showed that the application of safety-engineered syringes significantly reduced the incidence of needlestick injuries . Moreover, a meta-analysis also demonstrated that sharp injury prevention syringes lowered the incidence of needlestick injuries . As previously mentioned, in 2015, the WHO appealed for worldwide use of safety-engineered syringes by 2020 . However, safety blood collection needles, safety arterial blood collection needles, safety syringes, and needleless infusion connectors remain scarce, especially safety syringes. Less than 1/2 of the nurses in this study had received these. Compared to secondary hospitals, the tertiary hospitals in our study provided more comprehensive safety injection tools. Despite this, only about half of the nurses in the entire study had access to safety arterial blood collection needles. Hence, promoting the use of safety-engineered sharps in hospitals should help to reduce the occurrence of exposure to blood and body fluids.
Our results also show that receiving adequate education and training on occupational exposure and standard prevention practices is beneficial for reducing the risk of exposure. Over 1/10 of the occupational exposures in this study occurred due to noncompliance with standard practices, and about 1/4 of the nurses do not wear or only occasionally wear gloves during encounters with high-risk patients. Thus, nursing administrators in China may want to strengthen education and training on occupational exposure and standard practices and increase the frequency of training sessions.
One previous study in the Netherlands showed that there were some safety engineered devices related to needle stick injuries, such as nadroparin calcium needles and infusion needles . The top two causes of safety engineered devices related to needlestick injuries were needles being unsafely disposed and problems with safety engineered devices . Furthermore, a meta-analysis showed that safeguarded intravenous cannulas reduced the incidence of needlestick injuries but at the cost of increased incidence of blood exposure . These results may be attributed to the fact that these new devices are more difficult for healthcare providers to use . Therefore, in addition to the knowledge of standard prevention practices, the skills of how to operate new safety-engineered syringes are quite important and should be trained regularly.
Additionally, absent-mindedness during procedures is a common cause of occupational exposure. Nursing is a high-intensity profession that requires nurses to focus intently, sometimes for long periods of time. Long working hours can lead to a loss of concentration that can increase the risk of accidents including occupational exposure [36,37,38]. A study in Taiwan showed that nurses who work 41–50 hours per week and > 50 hours per week had 1.17 times and 1.51 times the risk of needlestick injuries, respectively, compared to those who worked no more than 40 hours per week . This implies that the problem of how to ensure nurses on duty concentrate on the task at hand needs to be addressed directly.
Apart from that, as with previous studies [10, 28], the present study also showed that the self-reporting rate of occupational exposure among nurses is low, with a rate reporting of less than 2/3. The major reason given for this was that bloodborne pathogens had failed to be detected in the source patients. Additionally, the reporting procedure was often described as burdensome, which was the second most common reason given for not reporting. This suggests that a simpler reporting procedure should be applied. Some participants in this study were even unaware of the reporting process entirely. Similarly to a previous study, some nurses expressed that they did not know where to report such incidents . In addition, some participants thought they would not be infected even after the exposure, and some expressed fear of being criticized and facing discrimination. Reporting the occupational exposure is of great importance for both PEP and for the diagnosis of potential infections as early as possible [40, 41]. With earlier and more reporting, psychological stress of the exposed nurses could potentially be reduced. This study showed that over 70% of exposed nurses had high stress after exposure, especially female nurses who had worked for less than 10 years. Thus, it makes sense for hospitals to pay proper attention to exposure incidents, to encourage staff to report every one of them, and to provide prompt counseling to the exposed.
Despite it merits, this study still has several limitations. First, this study was a recall survey of whether nurses had experienced occupational exposure, and recall bias may not have been entirely excluded. But the frequency of occupational exposure was not investigated in this study, and recall bias was small. Finally, primary hospitals were not analyzed due to the small proportion of nurses (about 1.1%) from primary hospitals.
Recommendations for future research
The impact of the use of safety engineered devices on occupational exposure should be further explored in future work, along with the development of devices that are more conducive to both nurse and patient safety.
Clinical implications for nursing managers and policymakers
Based on the results of this study, we recommended strengthening precautionary measures aimed at preventing occupational exposure to blood and body fluids, including occupational safety training, training on the use of new safety engineered devices, provision of adequate PPE, and creating a culture of safety in the workplace. We also recommend conducting clinical trials and recording factors that may cause occupational exposure during use before formally introducing safety engineered devices, and implementing policies that schedule shifts in a way that ensures adequate rest for nurses in order to reduce occupational exposure due to absent-mindedness. Finally, we recommend simplifying the process of reporting occupational exposure, and strengthening post-exposure support resources.