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��������	�	�����d����'''����'7�p????�6�6�6�6�6�6�6'<��>H�6��6��??��6�"�"�"z�?�?�6�"�6�"�":l't<(?����09x��[�'� �'
�6�607�'R?�!?<(<(?�P(T�"�6�6�"7��������������������������������������������������������������������?�		�:	Effect of warning poster on use of safety box by nurses of Milad Hospital, Kashan, Iran, 2012
Sharif MR.1, Madani M.*2, Sharif AR.3 

1 Associate Professor of Pediatrics, Kashan University of Medical Sciences, Kashan, Iran
2, Nursing Department, Committee for Student Research, Kashan University of Medical Sciences, Kashan, Iran
3 Associate Professor of Infectious Diseases, Kashan University of Medical Sciences, Kashan, Iran

 

 
ABSTRACT   
                                                             
Background:  Injuries caused by needles and sharp objects are of the main causes of blood deadly infections among healthcare providers. One of the effective ways to prevent needle stick is proper disposal of the needles and correct and appropriate use of safety box. Studies have shown that despite being trained, nurses do not observe this point. Thus, this study aimed to evaluate the effect of warning poster on use of safety box by nurses working in Milad Hospital, Kashan, Iran, 2012.
Methods: Use of safety box was assessed through the camera in the vessel chamber. Then a warning poster was placed in the same room and the use of safety box was studied again and compared with the previous assessments. 
Results: Before intervention, 19.8% did not use the safety box, 53% misused it and 27.2% used the safety box correctly. After the intervention, it was reported that 9.7% did not use safety box, 22.3% misused it and 68% correctly used it denoting a significant difference in the use of safety box before and after the intervention (P<0.001).
Conclusions: With regard to the increased trend in the use of safety box after placing the warning posters, application of warning devices are recommended in addition to teaching the personnel for safety precautions.
Keywords: Needle stick; safety box; warning; nurse



























 1. Introduction

General precautions such as washing hands, wearing protective glasses, and proper discarding of used bloody needles are the main preventive methods for contagious blood diseases1. Health care providers in the developing countries are at high risk for infection with blood-borne pathogens2. Needle stick and sharp objects injuries along with contact with patients� secretions are of the potential risks threatening them3. Vaz (2010) conducted a study on 200 health providers in India in which 81.5% had direct contact with patients� secretion while two third of them had experienced needle stick injuries. Contact with patients� secretions, needle stick injuries, and punctures are considered as common events among health care providers4. Injuries of hospital employees from needles and sharp objects may expose them to blood-borne pathogens among which HIV infections, HCV, and HBV are of main significance5. Needle stick and sharp devices injuries are the primary cause of fatal blood infections among care providers. Annually, 600 to 800 thousand cases of these injuries occur in 8 million health-care workers in the United States3. Nurses are seen as the most prevalent group at risk of needle stick6. Estimated cost of sharp objects injuries such as needle stick has been reported up to $3000 in America7. As studies show, managing a serious case of blood-borne infection costs about one million dollars for doing tests and follow-ups along with disability and energy costs8. Today, errors and carelessness of individuals in every occupation are most likely to result in majority of injuries9. ANA (2000) in a study on safety of nurses concluded that unawareness of the nurses of the potential risks had a meaningful correlation with contact with sharp objects or devices10. Also, Alemie (2012) in his study on healthcare workers� perceptions on occupational risk of HIV transmission at the university of Gondar Hospital, Northeast Ethiopia stated that accidents like needle stick injuries are apparently common and consequently healthcare workers are exposed to diseases especially AIDS while they are less aware of the potential risks11. Bakry (2012) in his research on knowledge, attitude, and practice of health care workers towards Hepatitis B virus infection in Sudan came to the same conclusion. Majority of the study community knew that HBV is transmitted via blood while healthcare workers had poor knowledge about Universal Standard Precautions Guidelines and did not fully appreciate their occupational risk regarding hepatitis B infection12. Studies show that safety and proper discard of the used needles are the main ways for decreasing needle stick injuries13. In a study in Iran, 65.5% of needle stick injuries among Fars vaccinators was due to incidental exposure to needles discarded improperly after injection. Recapping was also found to be significantly contributing to the injuries. This indicates that care workers are still unaware of the importance and safe discard of used needles after injection. 87.2% of the care workers stated that they had participated in classes for preventing needle stick injuries; nonetheless, these classes have not made them using preventive devices14. Also, junior workers have been greatly injured mainly due to improper disposal of needles and other sharp objects by nurses15, while in the developed countries such as Canada and even Saudi Arabia this rate has been less than 10%. This is because of educating care workers about using disposal boxes and non-recapping the used needles16, 17. Based on statistics in Iran, the matter of recapping is still dealt with despite educations and protocols in this regard18, 19, 20, 21. Therefore, it seems that proper disposal of needles and proper use of safety box are the most effective ways for preventing needle stick injuries. However, despite educations in this respect, most of the nurses do not follow the instructions1. Due to the high prevalence of HIV, HCV, and HBV in Kashan22 and nurses� contact with these diseases, this study aimed to evaluate the effect of warning poster on use of safety box by nurses working in Milad Hospital, Kashan, Iran, 2012. 
  
2. Methods

In this semi-experimental study we try to evaluate the effect of warning poster on the use of safety box by nurses working in Milad Hospital, Kashan, Iran, 2012. Informed consents were taken from personnel and authorities of the hospital. Rate of safety box use was assessed by placing a camera in the vessel chambers of different wards. To avoid the behaviour change of the personnel in the presence of cameras, the study was practically begun one month after for the care workers to get used to the cameras. Educational brochures describing correct use of safety box and contagious blood diseases were given to the nurses. The cameras placed in the wards and a checklist filled in by the researcher while watching the recorded films were considered as measures throughout the study. The checklist includes:

Sex of the individual directing the procedure.
If the individual performs the procedure by himself/herself or in the presence of others
Way of using the safety box including three items: non-use, misuse (in this respect, the nurses have misused the safety box in case of recapping and removing the needle from the injection syringe), and proper use of the safety box.
As it was mentioned above, rate and manner of safety box use by the nurses was evaluated within one month and recorded in a primary checklist. Then, the posters were put in the vessel chambers of different wards. The posters read "Discard the needle properly into the safety box after vesselling or else needle stick injury will be mostly probable." After this intervention, personnel's behavior was again assessed in one month and another checklist was completed. Measure for evaluating the effect of warning poster was any decrease in the non-use and misuse state of the safety box along with any increase in the proper and complete use of the safety box. The data collected were then analyzed and compared using SPSS 16 by means of descriptive and inferential statistics.
 
3. Results

Out of the 1562 cases of the personnel�s function regarding using safety box before placing the posters in the wards which was evaluated and inserted in the checklists 19.8, 53, and 27.2% were cases of non-use, misuse, and proper use of safety box, respectively. 1652 cases of the personnel�s behavior after placing the warning posters were included in the checklist as well of which 9.7, 22.3, and 68% were cases of non-use, misuse, and proper use of safety box, respectively. Significant difference was detected in the manner of using safety box in McNemar-Bowker Test before and after the intervention (P<0.001). The results are given in table 1.

Table 1. Manner of using safety box before and after placing warning posters

BehaviourBefore PosterAfter PosterNon-use309(%19.8)160 (%9.7)Misuse828(%53)368 (%22.3)Proper use425(%27.2)1124(% 68)Total1562(%100)1652(%100)(P<0.001)
Out of the 1562 cases before placing the posters, 23.9 and 76.1% were male and female, respectively. 16.6% of the males did not use safety box. 57.1% misused it and 26.3% did no use the safety box properly. In the females, this rate was 20.8, 51.7, and 27.5%, respectively. Based on Tukey-Kramer test, no significant correlation was found between sex and personnel�s behaviour about safety box (P=0.12).
    Of the 1652 cases after placing the posters, 31.2 and 68.8% were male and female, respectively. 8.5% of the males did not use safety box. 21.5% misused it and 70.0% did no use the safety box properly. In the females, this rate was 10.2, 22.6, and 67.2%, respectively. Based on Tukey-Kramer test, no significant correlation was found between sex and personnel�s behaviour about safety box like that before placing the posters (P=0.44).

Table 2. Manner of using safety box by sex

SexBefore PosterAfter PosterNon-useMisUseProper UseTotalNon-useMisUseProper UseTotalMale(16.6%)
62(57.1%)
213(26.3%)
98(100.0%)
373(8.5%)
44(21.5%)
111(70.0%)
361(100.0%)
516Female(20.8%)
247(51.7%)
615(27.5%)
327(100.0%)
1189(10.2%)
116(22.6%)
257(67.2%)
763(100.0%)
1136(p=0.12)(p=0.44)
Before placing the posters, 52.1% of the cases were alone during the procedure while 47.9% of the cases were not alone and the procedure was performed in the presence of others. While being alone, 21.3% did not use the safety box, 56.0% misused it, and 22.7% did not use it properly. In the case of being in the presence of others, this rate was 18.2, 49.7, and 32.1%, respectively. Based on Tukey-Kramer test, a significant correlation was found between presence of others and personnel�s behaviour about safety box (P<0.001).
After placing the posters, 54.7% of the cases were alone while 45.3% of them were not alone. While being alone, 14.0% did not use the safety box, 31.9% misused it, and 54.1% did not use it properly. In the case of being in the presence of others, this rate was 4.4, 10.7, and 48.9%, respectively. Based on Tukey-Kramer test, a significant correlation was found between presence of others and personnel�s behaviour about safety box (P<0.001).

Table 3. Manner of using safety box by the presence of others

AloneBefore PosterAfter PosterNon-useMisuseProper UseTotalNon-useMisUseProper UseTotalAlone(21.3%)
173(56.0%)
456(22.7%)
185(100.0%)
814(14.0%)
127(31.9%)
288(54.1%)
489(100.0%)
904In the Presence of Others(18.2%)
136(49.7%)
372(32.1%)
240(100.0%)
748(4.4%)
33(10.7%)
80(84.9%)
635(100.0%)
748(p<0.001)(p<0.001)

4. Discussion

All the cases under study were educated about proper and correct use of safety box previously. Nonetheless, these educations did not help improving the personnel�s behaviour. The results demonstrated that warning posters have decreased non- and mis-use cases of safety box. They have also contributed to a significant increase in the proper and correct use of this device. However, Dianati in his study in Iran concluded that education not only had affect on the personnel�s behaviour in recapping needles, but also has slightly contributed to their bad habit. This is notable that imperative requirements had resulted in decreased rate of recapping in this study. Of course, the personnel�s behaviours about recapping have not been precisely studied in the study and those recapped needles put in the safety box were merely counted1. In another study carried out in Saudi Arabia on the effect of active education on the prevalence rate of cutaneous injuries, it was revealed that education can reduce these injuries20. On searching for related sources, the researcher found no other study covering the effect of warning posters on the way of using safety box. Creedon (2005) in Ireland in a study on the effect of warning posters on improvement in compliance with hand hygiene guidelines personnel�s behaviour reported that implementation of this programme resulted in an overall improvement in compliance with hand hygiene guidelines (51�83%). Furthermore, an increase in their knowledge about handwashing guidelines was found23. Thus, it seems that in addition to teaching safety precautions to the personnel, application of warning devices are also necessary for the nurses to use their knowledge in this regard. Dianati has emphasized on the effect of reward and punishment and supervision which can modify wrong behaviours1. Also, in this very article, it was proved that those care providers working by themselves are not justified to use safety box truly, while in the presence of others, they are inclined to use it. This may necessitates dominance of a supervisory system to make them use safety box.

    
5. References

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