Written by Grace Emeny
Nurses encounter a variety of occupational risks during their career. Needle-stick injuries (NSIs) are a significant health hazard to nurses due to the risk of contracting blood-borne pathogens following a contaminated NSI. These injuries not only have the ability to cause serious health consequences, but can also result in severe psychological impacts and economic burden to the healthcare system (Wicker, Stirn, Rabenau, Gierke, Wutzler & Stephan, 2014). This literature review will study the relationship between NSIs and the psychological impact that overworking produces in acute hospital nurses. From this literature, recommendations have been made to enhance the prevention of NSIs amongst acute New Zealand hospital nurses.
NSIs have been a common cause of concern for nurses throughout history; however the incidence of NSIs within the nursing population is still high, despite the extensive number of available preventative measures (Ilhan, Durukan, Aras, Türkçüoğlu & Aygün, 2009). Given that the consequences of acquiring a NSI results in severe physical and psychological harm, I was curious about what factors are responsible for NSIs and the circumstances under which they occur. We must first analyse the potential causes of NSIs in order to find successful prevention methods. Nurses are known to work very hard within their profession; consequently, could the psychological impacts generated from overworking, such as stress and fatigue, have contributed to the high incidence of NSIs?
“When nurses are overworked in an acute hospital is there an increase in needlestick injuries?”
Through reviewing the relevant evidence-based literature I will explore the relationship between NSIs and nurses who overwork in acute hospitals, with a particular focus on New Zealand working legislations. This will give the base to unearth prevention strategies that will benefit my future nursing colleagues and myself in our nursing careers.
Needle-stick injuries have been defined as a percutaneous piercing wound by a needlepoint or other sharp instrument, which is potentially contaminated with the body fluid of another person (Adib-Hajbaghery & Lotfi, 2013). NSIs are the most frequent occupational hazard that healthcare workers (HCW) are exposed to during day-to-day practice (Gabriel, 2009). Nurses are at the greatest risk of acquiring a NSI due to being directly involved in patient care. This is shown in a recent study that reported 52.8% of nurses administer between 1 and 10 injections a day (Fourie & Keogh, 2011). Numerous international studies have investigated the incidence of NSIs, showing that the occurrence varies between different countries, with NSIs more prevalent in developing countries. Furthermore the exact number of NSIs is uncertain due to the lack of reporting; NSIs recorded through standard occupational recording systems can underestimate the true incidence by ten times the amount (Elder & Paterson, 2006). However, the most recent World Health Organisation (WHO) study reported that the global burden of NSIs average to 0.2-4.7 NSI per HCW annually, which is approximately three million HCWs affected yearly (Prüss-Üstün, Rapiti & Hutin, 2003). A New Zealand study of NSI incidence found that 7.6% of nurses had sustained one or more NSIs in the past year (Fullerton & Gibbons, 2011). This data shows that the exact amount of NSIs varies, although it is recognised that they do occur within the nursing profession. Whether the true NSI incidence is high or low, prevention strategies must still be put into place, as every injury can pose significant health issues for nurses.
NSIs have severe physical, psychological and economical implication on the individual nurse and healthcare system. It is reported that more than 25 blood-borne viruses have been recorded following NSIs (Tarantola, Abiteboul & Rachline, 2006). According to the WHO, the annual proportion of HCWs exposed to blood-borne pathogens globally was 5.9% for Hepatitis B, 2.6% for Hepatitis C and 0.5% for HIV. This correlates to approximately 1000 HIV cases annually, which is a severely debilitating and potentially fatal disease (Prüss-Üstün, Rapiti & Hutin, 2003). One brief needle handling error can put a nurse at risk of contracting one or more of these blood-borne disease report above, which can lead to extreme implications on a nurse’s life and career. Hence not only are physical implications damaging to a nurse’s health, but the psychological impacts are also immense. It is reported that after a NSI, anxiety commonly increases along with the development of phobias and elevated stress (Wicker et al., 2014; Smith, Choe, Jeong, Jeon & Chae, 2006). Additionally it is stated that immediately after the NSI, 85.1% of HCWs developed a feeling of fear (Pattnaik, Pattnaik & Rout, 2012). This emotional distress can result in missed workdays and directly affect healthcare services and resources (Elder & Paterson, 2006). Leigh, Wiatrowski, Gillen & Steenland (2008) highlighted this in their study, which showed 7% of NSIs in California resulted in more than one months leave from work. While these studies suggest that the psychological burden is immense, one must also consider that individuals will have different reactions depending on the perceived risk of the NSI. These varied reactions could depend on a nurse’s knowledge, culture or personal beliefs.
To prevent these physical and psychological costs to nurses and the healthcare system, the various factors responsible for these injuries and the circumstances under which they occur must be examined. Ihan et al. (2006) found that most NSIs took place in operating theatres, intensive care units and emergency rooms. Further stating that nurses working in intensive care units had a 2.6 times higher risk of NSIs than for those working in outpatient services. The majority of these injuries occurred during the administration of injections, recapping of needles, disposing of needles and whilst transferring body fluids from a syringe to the sampling container (Foure & Keogh, 2011). Factors that have been found to increase NSI include improper use of protective equipment, inadequate training, high workload, long working hours, stress, inadequate staff, lack of experience, excessive working hours and fatigue (Gholami, Borji, Lotfabadi & Asghari, 2013). Ilhan et al. (2006) agreed that nurses working more then eight hours a day with less then four years experience encountered an increase in NSIs, but also noted that nurses under 24 years also had an increased risk. These studies show that NSIs most often occur in fast-paced and high-stress locations within acute hospitals, although it can be argued that NSIs can occur in any environment and situation that requires the handling of needles. This is expressed by Gholami et al., (2013) who noted above that many different factors could provoke a NSI. Arguably, these factors are interconnected and thus do not occur in isolation, such as working long hours could lead to stress or fatigue.
The Encyclopaedia of Public Health (2008) describes overworking or work overload as when a job’s demands exceed an individual’s ability to cope. This includes the burden of long hours, the inability to complete tasks in the time given and the sacrifice of time at the expense of the worker’s personal life (Kirch, 2008). Working long hours can increase worker fatigue, as quality and duration of sleep is decreased, resulting in impaired ability to recover adequately (Härmä, 2006). In agreement, a study by Arimura, Imai, Okawa, Fujimura and Yamada (2010) outlined that working overtime, rotating shift work and long work hours were found to be associated with increased fatigue and increase risk of work error. When a nurse is subjected to these factors, worker fatigue rises due to inadequate recovery, exceeding the individual’s ability to cope, which may factor into increased NSI risk. However the nature of the person and type of work will also determine the impact and level of fatigue.
Overworking is a key contributing factor to stress and fatigue within the nursing population (National Institute for Occupational Safety and Health, 2008). Shift work, heavy workloads and time pressures are potential workplace stressors (Overton, 2005). Stress can trigger severe cognitive consequences, such as a lack of concentration, constant fatigue, increasing inattention, and reduced short and long-term memory (Rodrigues & Santos, 2016). Furthermore fatigued nurses have been shown to have slower reaction times, decreased motivation and reduced attention to detail (Gholami et al., 2013). Wicker et al., (2014) revealed that stress and tiredness were the most common contributors to NSIs among their sample of nurses. They also found that 40.7% of respondents stated working under immense time pressure was the cause of obtaining their NSI. Overworking can trigger the cognitive effects produced by both fatigue and stress in a working nurse, which is dangerous. These events not only put the patient’s safety at risk, but also the nurse at risk of occupational hazards such as NSIs, which have severe physical and psychological consequences. Although it must be noted that the determinants and effects of stress and fatigue are multifactorial and don’t alway result form overworking.
The amount of hours that nurse’s work needs to be monitored to discontinue the flow of events occurring before a NSI. The Occupational Safety and Health Administration (2013) agree, as they caution nurses against working more then eight-hour shifts. Concurrently, Ilhan et al., (2006) recommends nurses work no more then eight hours a day, as they found that nurses had a 13% higher NSI incidence when working over 8 hours. They also stated that nurses received their most recent injury after working an average of 15.8 hours continuously. In correlation HCWs who worked more then 30 shifts a month were 2.4 times more likely to acquire a NSI than those working less then 30 shifts per month (Gholami et al., 2013). These studies indicate a positive relationship between NSIs and overworking. According to this literature, NSIs will decrease with shorter hours and less shifts per month, although many nurses may not find this compelling evidence to change their working schedule. This may be due to the many other lifestyle factors influencing their desire for working long hours. Furthermore, the risk and consequences of NSIs may not be observable and evident if the incidence is relatively low within the nurses’ work environment.
Heavy patient workloads can also contribute to overworking, which can lead to frustration, stress and fatigue. Nurses experiencing stress due to heavy workloads may not be able to perform efficiently and effectively because their cognitive and physical resources may be reduced (Hughes, 2008). Therefore, it can be argued that nursing staff ratios within hospitals will exhibit an influence on the incidence of NSIs. Clarke, Sloane and Aiken (2002) studied 40 inpatient wards in 20 hospitals, they stated that nurses were 3 times more likely to obtain a NSI on units with less adequate resources, less nurse leadership, low levels of staffing and higher levels of emotional exhaustion. In correlation, a recent study reported that the most common reason for acquiring a NSI was due to the impact of a heavy patient workload and having to complete tasks faster than desired (Hussain, Minhaj, Zeeshan, Iqbal & Adbul, 2011). These studies both conclude that staffing levels and patient workload influence NSI occurance. Although patient workload is not solely an individual problem, healthcare systems should have policies in place to ensure that nurses are not over stretched, as both the nurse and patients safety is impaired.
The New Zealand Health & Safety in Employment Act 1992 requires employers to take all steps to prevent harm in the work environment. According to the Multi-Employee Collector Agreement (MECA), when an employer is planning and implementing shift rosters, they must ensure they minimise personal health effects and fatigue associated with shift work (NZNO, 2015). Moreover, employees are required to work no more then 80 hours a fortnight, and should not change between day and night duties more then once. It is recognised by New Zealand Nurses Organisation (NZNO) that five eight-hour consecutive shifts or three consecutive twelve-hour shifts is the preferred maximum. Additionally when a nurse considers they have reached their limits of safe practice, they should not be required to take additional workloads until strategies have been implemented to address the immediate workload issues (NZNO, 2015). The NZNO suggests that nurses should only accept reasonable overtime, which varies depending on the person dong the work and type of work. NZNO furthermore states that they recognise that physical or mental fatigue will affect a person’s behaviour and is a hazard to themselves and others (NZNO, 2015). Due to this agreement being in place, nurses who are members of NZNO should not be subjected to overworking, if the terms of the union are practiced. Therefore prevention of NSIs relies heavily on unions within countries and government regulations.
Despite many prevention policies and programs available, NSIs are still common. Prevention of NSIs is essential for nurse’s well-being and to inhibit the spread of blood-borne diseases in the workplace. The World Health Organisation states that this can be achieved through promoting a culture of safety in the workforce (Prüss-Üstün, Rapiti & Hutin, 2003). This is supported by The Centre of Disease Control (2008), who also claims that their model, Hierarchy for Sharps Injury Prevention, will decrease NSI incidence. The first priority in the hierarchy is to eliminate and reduce the use of needles. Next is to isolate the hazard, through the use of safety devices. Lastly, the concentration moves to work-practice controls and personal protective equipment. To achieve these targets, regular education programs have been put in place in many healthcare facilities, which emphasized the importance of following needle handling safety regulations and follow up care after an injury. Healthcare organisations have also administered workplace controls, such as putting rules in place regarding recapping of needles. The use of safety engineered devices, including retractable needles and sharps disposals are also used routinely in many hospitals. Tarigan, Cifuentes, Quinn and Kriebel (2015) found that NSIs can be prevented with the implementation of training along with safety-engineered devices. They discovered that the two interventions must be applied together as safety devices reduce the exposure and isolates the hazard whilst training reduces the risk by modifying the behaviour of the HCW. Adams and Elliott (2006) drew the same conclusion after a four-year prospective study, although found that prevention was not sustained without continuous educational reinforcement.
While these prevention strategies have been successful in reducing NSIs, they have not completely eradicated them. Certain factors that increase the risk of NSIs can’t be changed, such as age and experience, although the psychological factors can be mitigated and managed. The current preventative strategies do not address that stress and fatigue are well-documented factors that influence the incidence of NSIs. Based on this knowledge through reviewing relevant literature the recommendations I suggest are focused on these psychological impacts that overworking can produce.
All these prevention strategies must be implemented together, as they interconnect and no single strategy alone will reduce or eliminate NSIs.
Nurses are most commonly affected by NSIs due to being directly involved in patient care. The majority of NSIs occur in acute care hospitals, such as emergency rooms and intensive care units. Overworking contributes to stress and fatigue within the nursing population, and these factors have been shown to increase NSIs directly or indirectly. Injuries must be prevented as they can produce serious physical, psychological and economical impacts on the individual and healthcare system. It is recommended through reviewing the literature that overworking needs to decrease and education should be provided on the psychological effects of overworking. There also needs to be an over-arching culture of safety established in order to reduce NSIs.
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