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1 Perception Regarding Needle Stick and Sharp Injuries among Clinical Year Medical Students Muhammad Hanafiah Juni* 2, Amir Aiman M 1, Asma Nabilah A 1, Ng J.H. 1, Wong S.J 1, Faisal Ibrahim 2. 1 Faculty of Medicine and Health Sciences, UPM 2 Department of Community Health, Faculty of Medicine and Health Sciences, UPM *Corresponding author: Associate Professor Dr Muhamad Hanafiah Juni Health Service Management Unit, Department of Community Health Faculty of Medicine and Health Sciences, Universiti Putra Malaysia UPM Serdang, Selangor Darul Ehsan, MALAYSIA hanafiah_juni@upm.edu.my ABSTRACT Introduction: Medical students are exposed to needle stick and sharp injuries (NSSIs) in their everyday routine whether in handling sharp medical instruments or contacting with patients. Thus, it is important to assess the perception of medical students regarding needle stick and sharp injuries, as it is an important feedback to medical school on the effectiveness of their teaching in reducing NSSIs. Objective: To determine the level of perception regarding NSSIs among clinical year s medical students in a public university, and its association with the knowledge an attitude towards NSSIs. Materials and Methods: A cross sectional study was conducted among 320 clinical year s medical students from a local public university in Malaysia. The respondents were selected according to the year of study by using stratified random sampling. The study was conducted in May and June 2011 for a period of two months. Self-administrated questionnaires were used in the study. The questionnaires were developed by researchers, and were pre-tested among nursing students in one of the local hospital. Results: Response rate was 93.8%, in which 300 out of 320 respondents were participating in the study. The result showed that 51% of respondents attained good level of perception regarding NSSIs. Meanwhile 53.3% achieved good level of attitude and 55.3% of the respondents attained good knowledge level towards NSSIs. The 5 th year medical students got the highest level of perception (21%) on NSSIs as compared to 4 th year (10%) and 3 rd year (19.6%).There is significant association between level of perception and year of study (P= 0.002) as well as between level of perception and level of knowledge (P = 0.001) and attitude (P 0.001). Conclusion: Overall there were high proportion of clinical year medical students are having inappropriate perception, unsatisfactory knowledge and inappropriate attitude toward NSSIs. Knowledge and attitude regarding NSSIs showed significant association with perception toward NSSIs. Keywords: Needle Stick and Sharp Injuries, Perception, Knowledge, Attitude, Medical Students. Muhamad Hanafiah, Amir Aiman M, Asma Nabilah A, Ng J.H, Wong S.J, Faisal I 69

2 1. INTRODUCTION Needle stick and sharp injuries(nssis) is defined as an introduction into the body ofhealth care providers during the routine performance of their duties, of blood or other potentially hazardous material by a hollow bore needle or sharp instruments e.g. needles, lancets and contaminated broken glass (Waqar et al, 2011). It is one of the serious safety issues in every healthcare environment. NSSIs are important occupational hazards threatening healthcare workers (HCW) who working in hospital or other health setting (Khushdil et al, 2013), and considered as a major occupational hazard among HCWs since needles and sharp objects are commonly used in hospitals (Firas et al, 2014).World Health Organization (WHO) reported that 2.5% of HIV and 40% of Hepatitis B and C cases among HCW worldwide are results of occupational exposures (WHO, 2002). Worldwide about three million HCWs experience percutaneous exposure to blood-borne viruses each year, in which 2,000,000 are Hepatitis B; 900,000 are Hepatitis C and 300,000 are Human Immuno deficiency virus (WHO, 2002).Medical students are also exposed to NSSIs because in their everyday routine involved in handling sharp medical instruments or contacting with patients,and it puts them under the risk of obtaining blood-borne pathogens like HIV, Hepatitis B Virus (HBV), or Hepatitis C Virus (HCV), which are serious threats to their well being or even to their lives (Apisarnthanarak et al, 2006).Students being inexprience in handling needles and other sharp instruments are more predisposed to unsafe practice and subsequently at greater risk of needle stick and sharp injuries. In a study carried out in the University of Kerman, Iran among 269 medical and dental students reported that 25.8% of the respondents had reported one, 39.6% had reported two, 17.6% had had three, and 17% had reported more than three episodes of NSIs; it is during their clinical routine in surgical ward and the emergency room, and followed by orthopaedics and internal medicine wards (Hashemipour & Sadeghi, 2008). Hospital being non-stop workplace of process and outcome exposed health workers including medical students to occupational hazards of NSSIs. There are various factors that increase the risk of needle stick and sharp injuries among HCWs and medical students in the hospitals. Factors like re-capping needles after use, ignoring the use of needle-disposing containers, job stress, lack of experience, and emotional distress are common reasons for NSSIs among HCWs and medical students during their routine procedures.among the medical students due to lacking in experience and skill, eagerness to learn new things and material, and poor perception toward NSSIs resulting greater risk to needle stick and sharp injuries. These expose healthcare workers and medical students to occupational transmission of blood-borne pathogens (Firas, 2014). There are numerous serious pathogens that can be transmitted by NSSIs; there are more than 30 known dangerous blood-borne pathogens that can be transmitted to HCWs through the incidence of anssis (Kebede et al, 2012), and more than 80% of NSSIs are avoidable with the use of correct precautions measures (Zaidiet al, 2010). Because of important of NSSIs among HCW, the universal precaution was developed and practiced worldwide. Despite detailed guidelines of prevention of NSSIs in universal precaution, the knowledge and attitude of HCWs and medical students toward NSSIs is still inadequate; even in developed countries (Robert C, 2000). Hence present study was conducted among clinical year medical students at a public university with the following objectives: Muhamad Hanafiah, Amir Aiman M, Asma Nabilah A, Ng J.H, Wong S.J, Faisal I 70

3 1. To determine the medical students level of perception, knowledge and attitude towards needle stick and sharp injuries 2. To determine association between level of perception with level of knowledge and attitude of the medical students toward needle stick and sharp injuries. The study was conducted with the hypothesis of level of perception of clinical year medical students towards NSSIs is associated with knowledge and attitude towards needle stick and sharp injuries. The result of the study benefited the hospital and university to strategize activities to prevent future incidence of needle stick and sharp injuries among medical students and other health care workers. 2. Materials and Methods The cross sectional study was conducted in May and June 2011 among clinical year medical students of a public university in Malaysia. The sampling frame of the study is list of clinical year medical students enrolled in the Faculty of Medicine and health Sciences of the University. The list was obtained from Academic Office of the Faculty. Sample size were calculated based on single proportion formula, and a total of 320 clinical year s medical students comprising of third, fourth and fifth year of study were recruited in the survey using stratified random sampling. The study used questionnaire developed by researchers. The questionnaire consists of four sections; socio-demographic characteristic, perception towards NSSIs, knowledge on NSSIs and attitude towards NSSIs. The breakdowns of the questionnaire are as follows; No. Sections/Sub-Sections No. of Questions 1. Socio-demographic characteristics 2. Perception towards NSSIs: Perceived severity 5 Perceived susceptibility 5 Perceived benefits 6 Perceived barriers 5 TOTAL Knowledge on NSSIs: Risk factors of NSSIs 8 Practices contributing to NSSIs 10 Stages of procedures (phlebotomy) with risk of NSSIs 7 Blood-borne diseases as result of NSSI 5 Knowledge of preventions of NSSI 9 Post-exposure measure 5 Universal precautions 5 TOTAL 49 Muhamad Hanafiah, Amir Aiman M, Asma Nabilah A, Ng J.H, Wong S.J, Faisal I 71

4 4. Attitude towards NSSIs: Workplaces and risk towards NSSIs 6 Universal precautions 3 Risk factors 4 Preventive measures 4 Reporting 5 Risk toward blood-borne diseases 2 TOTAL 24 The questionnaire were pre-tested among nursing students in one of the local hospital to estimate it reliability, the Cronbach s Alpha was Face and contents validity of questionnaire was determined by the experts. Self-administrated questionnaire method was employed for data collection. The questionnaire was distributed to the respondents by researchers after the respondents consented to participate in the study. The respondents answered the questionnaire immediately and returned it to the researchers. In the study, level of perception toward needle stick and sharp injuries defines into appropriate perception and inappropriate perception. Appropriate perception toward needle stick and sharp injuries is respondents in category of scoring above the median of perception score toward needle stick and sharp injuries, while inappropriate perception is respondents in category of scoring below the median of perception score toward needle stick and sharp injuries. Level of knowledge on needle stick and sharp injuries defines as satisfactory knowledge and unsatisfactory knowledge. Satisfactory knowledge toward needle stick and sharp injuries is respondents in category of scoring above the median of knowledge score toward needle stick and sharp injuries, while unsatisfactory knowledge is respondents in category of scoring below the median of knowledge score toward needle stick and sharp injuries. Level of attitude toward needle stick and sharp injuries defines as appropriate attitude and inappropriate attitude. Appropriate attitude toward needle stick and sharp injuries is respondents in category of scoring above the median of attitude score toward needle stick and sharp injuries, while inappropriate attitude is respondents in category of scoring below the median of attitude score toward needle stick and sharp injuries. The Statistical Package for Social Science (SPSS) version 21.0 was used to enter and analyze the data. Comparison between the categorical and qualitative groups was employed using Chi-square test. Significant levels were set at P < RESULTS 3.1 Response rate Out of the 320 respondents selected into the study, only 300 were responded by returning back completed answered questionnaire, this gave the response rate of 93.8%. 3.2 Socio-demographic characteristics of respondents Muhamad Hanafiah, Amir Aiman M, Asma Nabilah A, Ng J.H, Wong S.J, Faisal I 72

5 As shown in Table 1, majority of the respondents are female and Malay. The average age of the respondents was between 22 to 23 years old, and the mean age is 22.79±1.03 years old. Table 1: Distribution of Respondents by Gender, Ethnicity, and Age (N=300) Socio-demographic Distribution of Respondents Characteristic Frequency (n) Percentage (%) Gender: Male Female Ethnicity: Malay Chinese Indian Age: Levels of perception, knowledge and attitude towards NSSIs Table 2 below showed that majority (51.0%) of the clinical year medical students studied having appropriate levels of perception toward NSSIs. There are 50.8% of female and 51.3% of male have appropriate level of perception, and among races there are 51% Malay or Bumiputra students, 51.2% Chinese students and 50% Indian students are having appropriate level of perception. Further examination of the data, showed that amongst year of study 59.4% fifth year students, 35.2% of fourth year students and 55.7% of third year students showed appropriate level of perception. However the finding also showed that high proportion of the students (49.0%) are having inappropriate perception towards NSSIs. Further examination of individual questions in sub-section of perception towards NSSIs, the following questions are poorly answered by the students: in perceived severity 39.0% of respondents perceived that NSSIs is not a serious event require reporting; in perceived susceptibility the respondent perceived that they are not at risk of NSSIs (59.5%) and 38.7% of medical students perceived that they are not at risk of acquiring a blood-borne diseases; and in sub-section of perceived benefits that wearing glove not important during performing simple procedure such as phlebotomy (51.0%) and recapping of needle is normal practices among healthcare worker (49.5%). Levels of knowledge of the clinical year medical students studied showed 44.7% the respondents are having not satisfactory knowledge regarding NSSIs (Table 2). Further examination of individual questions in each sub-section, the following questions are poorly answered by the respondents: in sub-section of risk factor 47.8% of respondents don t know recapping of needle is risk factors of NSSIs; in sub-section of stage of procedures with risk of NSSI 47.0% respondents don t know recapping during phlebotomy is high risk of NSSI; in sub-section prevention of NSSIs 47.0% don t know double gloves will reduced risk to NSSIs; in sub-section of standard precaution 45.0% of respondents don t know guideline on recapping of needle and33.5% don t know on contents of standard precaution; and in subsection of post-exposure measure 31.0% don t know that incidence of NSSIs should be reported. Muhamad Hanafiah, Amir Aiman M, Asma Nabilah A, Ng J.H, Wong S.J, Faisal I 73

6 As shown in Table 2, the study also showed that high proportion of clinical year medical students studied having inappropriate levels of attitude towards NSSIs (46.7%). Further examination of individual questions, following questions are poorly answered by the respondents; in sub-section of prevention 53.2% of the respondents think that double gloving doesn t increase protection against NSSIs; in sub-section of risk factors 43.5% of respondents think that recapping of needle does not increase risk of NSSIs; and 35.0% of the students said reporting of NSSIs incidence is not important. Table 2: Levels of perception, knowledge and attitude regarding NSSIs (N=300) Variables Frequency (Percentage) Levels of perception, Appropriate 153 (51.0%) Inappropriate 147 (49.0%) Levels of knowledge, Satisfactory 166 (55.3%) Not satisfactory 134 (44.7%) Levels of attitude, Appropriate 160 (53.3%) Inappropriate 140 (46.7%) 3.3 Association between levels of perception and socio-demographic characteristics In Table 3 below showed that there is no association between levels of perception with gender and race. However there is significant association between levels of perception with year of study of the medical students, where P = Table 3: Association between levels of perception and socio-demographic characteristics (N=300) Socio-demographic characteristics Levels of perception High Low n (%) n (%) Gender Male 59 (51.3) 56 (48.7) Female 94 (50.8) 91 (49.2) Race Malay 80 (51.0) 77 (49.0) Chinese 62 (51.2) 59 (48.8) India 11 (50.0) 11 (50.0) x² df P- value (chi-square) Muhamad Hanafiah, Amir Aiman M, Asma Nabilah A, Ng J.H, Wong S.J, Faisal I 74

7 Year of Study 3rd year 59 (55.7) 47 (44.3) 4th year 31 (35.2) 57 (64.8) 5th year 63 (59.4) 43 (40.6) Significant level: P< Association between levels of perception with level of knowledge Table 4 shows that there is significant association between level of perception and level of knowledge, whereas P = Table 4: Association between levels of perception with level of knowledge (N=300) Levels of knowledge Levels of perception High Low n (%) n (%) x² df P-value (Chi-square) Satisfactory 99 (59.6) 67 (40.4) Not satisfactory 54 (40.3) 80 (59.7) Significant level: P< Association between levels of perception with levels of attitude In Table 5 shows that there is significant association between levels of perception and levels of attitude, whereby P = Table 5: Association between levels of perception with levels of attitude (N=300) Levels of attitude Levels of perception High n(%) Low n(%) x² df P-value (Chi-square test) Appropriate 47 (33.6) 93 (66.4) Not appropriate 106 (66.3) 54 (33.8) Significant level: P< DISCUSSION Doctors and HCWs including clinical year medical students are exposed to the risk of occupational-related hazards associated with their daily clinical routine and laboratory activities. The risk to NSSIs is a serious problem among doctors, HCWs and medical students Muhamad Hanafiah, Amir Aiman M, Asma Nabilah A, Ng J.H, Wong S.J, Faisal I 75

8 because they are exposed with infected patients and contaminated materials or instruments. The transmission of blood-borne diseases such as HIV, Hepatitis B and Hepatitis C among doctors, HCWs and medical students are commonly associated with NSSIs. This study conducted among clinical year medical students revealed that majority (51.0%) of clinical year medical students studied are having appropriate level of perception regarding NSSIs, but there is still high proportion (41.0%) among clinical year medical students shows inappropriate level of perception towards NSSIs. In study among juniors doctors in National Health Services UK found that significant numbers of junior doctors having worse awareness of the local NSSIs protocols as compared to other categories of healthcare workers (Adams et al, 2010). In this study 59.5% of the medical students perceived that wearing glove is not important during performing simple procedure such as phlebotomy and 43.2% of the students revealed that double gloving doesn t increase protection against NSSIs, such perception may be as a result of observation by medical students on other healthcare workers practice during performing procedure. O Sullivan in his study in two teaching hospitals among Irish intern doctors that only 26% interns reported wearing gloves while performing intravenous cannulation (O Sullivan et al, 2011), while 43.5% did so from observing other healthcare workers (Al-Dabbas et al, 2010). Because of this poor perception several studies reported high incidence of needlestick injuries among medical students during posting requiring them performing phlebotomy and other simple procedures such as setting-up drip and parenteral injections (Naing et al, 1999; Norsayani et al, 2003). The study revealed significant association between levels of perception toward NSSIs with year of study of the students (P = 0.002).This finding was similar with the findings of other studies in which years of experience significantly associated with perception toward NSSIs (Firas et al, 2014).Yet, in another study by Mehrdad et al reported that no statistical significant association between history of training with perception on NSSI prevention and the exposure to blood-borne pathogens (Mehrdad et al,2014). These contradicting finding explaining reason the perception of year four of medical students toward NSSIs (32.5%) is lower as compared to third year (55.7%) and fifth year medical students (59.4%). It can be also explained by the presence of response bias wherepeople tend to present themselves in a favorable way (Firas et al, 2014). A cross sectional survey was conducted among the clinical year medical students of third, fourth and fifth years at a teaching hospital of Karachi, Pakistan to ascertain knowledge, attitude and practices of medical students regarding needle stick injuries. The final year students scored better knowledge in universal guidelines about prevention of needle stick and sharp injuries, they also knew the full details of these needlestick injuries prevention protocols. Final year medical students have better preventive practices than 3 rd and 4 th year which indicated that final year medical students were much more experienced in protecting themselves from needlestick injuries; in which significant association between year of study with perception toward NSSIs such as avoidance of needle recapping (P = 0.001) and avoidance of breaking needles by hand [(P = 0.015) (Saleem T. et al, 2010)]. A guideline regarding recapping of needle stated that recapping a needle is prohibited in order to reduce risk of transmission of blood-borne pathogens (USA OSHA s Blood-Borne Pathogens Standards, 2003). Several studies had indicated that needles should not be recapped because of the risk of needlestick injury as the sharp point. Yet in this study 49.5% of the medical students perceived that recapping is a normal practice by the healthcare workers and 39.5% said recapping of needle does not increase risk of NSSIs. In a study by Naing et al Muhamad Hanafiah, Amir Aiman M, Asma Nabilah A, Ng J.H, Wong S.J, Faisal I 76

9 showed that 67.4% of the students recapped needle after used (Naing et al, 1999), and 60.7% of staff in Accident and Emergency Department of Hospital Kuala Lumpur recapped needle after use (Azmi, 1997). Thus HCWs who are more experience than medical students also carried out wrong practice. High proportion of the medical students (38.7%) perceived that they are not at risk of acquiring a blood-borne diseases. In which similar high proportion of nurse they were not under any risk of acquiring a blood-borne diseases ( Kable et al, 2011), and in another study 87.0% of HCWs consider themselves as low risk (Voide et al, 2012). The medical students also considering NSSIs is not a serious event that require reporting, as revealed by this study about 39.0% of medical students having perception of NSSIs is not a serious event require reporting and 35.0% of the students said reporting of NSSIs incidence is not important. The study also revealed that only 32.0% of the medical students know that the incidence of NSSIs needs to be reported. Poor perception, attitude and knowledge regarding NSSIs such as the important of reporting of NSSIs lead to incorrect practices regarding NSSIs, Voide et al reported that under reporting of NSSIs occurred 67.1% among doctors and 30.0% among nurses (Voide et al, 2012); and low prevalence of needlestick injuries are mainly due to under reporting (Patrician et al, 2011). Inappropriate level of perception of the medical students toward NSSIs, also reflected by their inappropriate level of attitude towards NSSIs. The study found that 46.7% of the medical students having inappropriate level of attitude towardnssis. These may be as result of poor knowledge regarding NSSIs. The study revealed that the level of knowledge on NSSIs among the medical students studied showed that 55.3% of them having satisfactory levels of knowledge, and 44.7% having not satisfactory knowledge regarding NSSIs. High proportion of poor knowledge among medical students regarding NSSIs also reported by Al-Dabbas, in which 51.5% of interns and medical students studied considered themselves having insufficient level of knowledge (Al-Dabbas et al, 2012). Rampal et al in a study carried out in Serdang Hospital Malaysia revealed that 19.4% of the healthcare workers studied did not know that they need to wear gloves during handling phlebotomy administration (Rampal et al, 2010).In this study revealed that high proportion of medical students obtained low scored regarding knowledge on important of double gloves to reduced risk to NSSIs (47.0%), guideline of recapping of needle (45.0%), standard precaution (33.5%).The study also showed that significant association between level of perception on NSSIs and level of knowledge on NSSIs, (P = 0.001). The study also showed that significant association between level of perception on NSSIs and level of attitude on NSSIs, (P = 0.000). The finding of the study revealed that 46.7% of the medical students having inappropriate levels of attitude towards NSSIs. The students showed inappropriate attitude in the important of double gloving during performing procedure (53.2%), recapping of needle (43.5%) and reporting of NSSIs (35.0%). Inappropriate attitude of the students will be reflected when they are working, as reported that up to 92.0% of healthcare workers not reporting NSSIs (Maqbool, 2002), and another study reported that only 27% of the respondents use gloves for phlebotomy procedures at all time, 69% respondents use it occasionally, while the remaining 4% did not use it at all (Williams, 2005). The reasons stated by respondents for not reporting the incidence of NSSIs are because of the time constraint, lack of time, low exposure risk, reluctance to report for fear of not appearing Muhamad Hanafiah, Amir Aiman M, Asma Nabilah A, Ng J.H, Wong S.J, Faisal I 77

10 professional, discrimination, lack of perception of risk, stigmatization, and those who have been exposed before were more likely not to report it. 5. CONCLUSION AND RECOMMENDATION Overall high proportion of clinical year medical students are having inappropriate perception, unsatisfactory knowledge and inappropriate attitude toward NSSIs. Percentage of appropriatelevel perception on NSSIs among clinical year medical students only 51%, and thus having satisfactory level of knowledge and appropriate level of attitude toward needle stick and sharp injuries are 55.3% and 53.3% respectively. Year of study of the medical students, and their levels of knowledge and attitude shoed association with their level of perception towrd needle stick and sharp injuries. The study revealed that, clinical year medical students are venerable to needle stick and sharp injuries, it is important that training in universal precautions and prevention of needle stick and sharp injuries to be emphasize regularly in their clinical training. Ethical approval Ethicalapproval from the Medical Research Ethic committee of Faculty of Medicine and Health Science, UPM was obtained prior data collection for the research. Acknowledgment This research project is part of the requirement of Second Year Curriculum of the Medical Programme of Universiti Putra Malaysia. The researchers also would like to thank the Dean of Faculty of Medicine and Health Sciences, UPM for his permission to carried out the research in the faculty. Declaration The authors declare that, the manuscript never published in any journal or conference proceeding. References Adams, S., Stojkovic, S. G., & Leveson, S. H. (2010). Needlestick Injuries during Surgical Procedures. Occupational Medicine Oxford, Al-Dabbas, M.& Abu-Rmeileh, N.M.E., (2012). Needle injury among interns and medical studentsin the Occupaied Palestinian Territory. Eastern Mediteranian Health Journal. Volume 18, No. 7 (2012). Muhamad Hanafiah, Amir Aiman M, Asma Nabilah A, Ng J.H, Wong S.J, Faisal I 78

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