ORIGINAL RESEARCH

Biosafety in the view of final-year nursing students

Juliana da Silva Oliveira^I; Maiara Pimentel Macedo^II; Roberta Laíse Gomes Leite Morais ^III ; Manuella Serra Tanan^IV; Sérgio Donha YaridV

^I Nurse. PhD student in Nursing. State University of Southwest of Bahia. Jequié, Bahia, Brazil. E-mail: juli.silva.oliveira@gmail.com
^II Nurse. Resident in Emergency Care. Federal University of Bahia. Vitória da Conquista, Bahia, Brazil. E-mail: mayy.pimentel@gmail.com
^III Nurse. Master in Nursing. Professor at the State University of Southwest of Bahia, Department of Health II. Jequié, Bahia, Brazil. E-mail: robertalaise@hotmail.com
^IV Nurse. Graduated in Nursing. State University of Southwest of Bahia. Jequié, Bahia, Brazil. E-mail: manuella.serrat@gmail.com
^V Dental surgeon. PhD in Preventive and Social Dentistry. Professor at the State University of Southwest of Bahia. Jequié, Bahia, Brazil. E-mail: syarid@hotmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.14074

ABSTRACT

Objective: to ascertain nursing students' knowledge of Regulatory Standard 32 and conduct pre- and post-exposure to biological materials, in addition to identifying their vaccination status. Method: in this descriptive, quantitative, cross-sectional study, data were collected using a questionnaire, from 163 students at Southwest Bahia State University, Jequié, between August and September 2014, and were analyzed using the Statistical Package for Social Sciences (SPSS, 21.0). The study was approved by the Research Ethics Committee (Opinion No. 242.588/2013, CAAE: 04830812.7.0000.0055). Results: only 34% reported knowledge of NR 32; hepatitis B immunization rates were low (only 22.7% performed the anti-HBs test); and only one of the students exposed to biological materials had performed care according to the Ministry of Health protocol. Conclusion: nursing students are at risk in their practical activities, where greater need can be seen for teaching to address biosafety.

Keywords: Occupational health; nursing students; occupational risks; exposure to biological agents.

INTRODUCTION

Occupational health aims to understand the relationship between work and the health/disease process, aiming at the promotion and protection of health and the reduction of damages to people who are exposed to risks and damages during the development of their work activities¹.

Health workers are exposed to numerous occupational hazards caused by physical, chemical, biological, ergonomic and psychosocial agents, which can cause bodily injury, functional disturbance, reduced work capacity or psychological problem^2-4. Among these, due to their work routine, nursing professionals present a greater exposure to biological risks⁵.

For nursing students, these risks are also present, because during the development of their field practices, they deal directly with blood, saliva, urine and other fluids, since they develop academic activities in situations similar to nursing professionals and may suffer accidents during the procedures performed⁴.

Thus, as the biological risk is imminent for nursing, there is a need for follow-up during the training of future professionals regarding the development of educational strategies and awareness about the importance of vaccination, use of biosafety equipment, prevention of occupational accidents, in addition to the establishment of a continuing educational health program focused on notification and mainly on the knowledge of how to proceed after occupational exposure^{6, 7}.

In this perspective, this study aims to verify the knowledge of the students of a nursing course about Regulatory Norm 32 (NR32) and the conducts before and after exposure to biological materials, in addition to identifying the vaccination status of the students.

LITERATURE REVIEW

The practical activities of nursing training requires that students of this course, even though they are not yet health professionals, are exposed to the same risks, since they perform procedures that allow contact with biological material and this can lead to transmission of diseases. Some factors may contribute to a greater occurrence of accidents among students, namely: dealing with sharp materials, acting at different times and places, experiencing situations of anxiety and stress, lack of use of personal protection equipment, inexperience and absence of a specific discipline on biosafety and/or occupational health in the academic curriculum as mandatory⁸.

In view of the aforementioned problem, professors should emphasize the relevance of the biosafety theme, so that, in this way, students are able to understand the importance of content, even in undergraduate studies, which will consequently have a positive impact during their professional life^4,6.

Exposure to biological risks for any individual may have consequences such as diseases, including hepatitis B (HBV), hepatitis C (HCV) and acquired immunodeficiency syndrome (AIDS)⁹. After an accident involving the percutaneous route to hepatitis C, the risk is 1.8%, ranging from 1 to 10%. If the source patient is HBsAg positive for hepatitis B, the estimated risk is 6 and 30%, and may reach up to 40%. Regarding HIV, when no prophylaxis is done after exposure and the source patient is positive, the risk is 0.3 to 0.5% and 0.09% after reaching the mucous membrane ¹⁰.

In order to minimize the risks for health professionals, the Centers for Disease Control and Prevention (CDC) has established protection measures through the creation of standard precautions, which is a very relevant event in the field of public health¹¹.

In addition, there are also regulatory standards (RS) that aim at the adequacy of the work environment by ensuring the safety of workers in general. For health workers, there is, specifically, the RS 32, which aims to determine the safety behaviors of these workers who provide services to health facilities¹².

The RS 32 comes to determine to every health worker vaccination as a measure aimed at prevention and protection. Vaccines should be provided free of charge through the active immunization program against tetanus, diphtheria, hepatitis B and other vaccines according to the vaccination schedule recommended by the Ministry of Health (MoH)¹².

Thus, the greatest occupational hazards are related to biological materials, especially sharps. Students are not exempt from this exposure during curricular practices and not even after their professional training ^{4, 6, 13}.

METHODOLOGY

This is a descriptive cross-sectional quantitative study. The field and scenario was the State University of Southwest of Bahia (UESB).

The target population of the study was 190 undergraduate nursing and midwifery students. Inclusion criteria were those who were regularly enrolled and attending classes, and the exclusion criterion were those who were enrolled but dropped out of the course. It should be noted that after adopting the inclusion criteria, the study was composed of all 163 undergraduates, considering that there were no refusals.

For data collection, a questionnaire was used, distributed and applied in the classroom, composed of five blocks, in which sociodemographic information, accidents with biological material, biosafety, knowledge about RS 32 and vaccination were evaluated, as they were relevant to the study object.

The data collection of this research was carried out from August to September 2014. Data collected were tabulated through Epidata 3.1 program, with double entry, and later compared. The existence of typing errors was verified, followed by the correction of the database. After the tabulated data, the statistical analysis was performed through the Statistical Package for Social Sciences (SPSS), version 21.0.

The participants of this research were informed about the objective and then they signed the Free and Informed Consent Form. Respecting the legislation on research on human beings, the project was submitted to the Research Ethics Committee of the UESB, being approved under the opinion of 242,588/2013 and CAAE: 04830812.7.0000.0055.

RESULTS AND DISCUSSION

The study was composed of 163 (100%) nursing students. The distribution of the data by gender, age and marital status revealed that 135 (85.4%) were female, 112 (68.7%) were between 16 to 22 years old and 143 (88.8%) were single, which shows a predominance of women among nursing students, justified by the history of the course itself, which corroborates with other studies^{4, 14} that have reported that women are prevalent in the nursing area.

From the results of this study, the following categories emerged: biosafety in the perspective of health prevention, (re) thinking about vaccination and immunization, and (re) evaluation of the conducts related to accidents with biological materials.

Biosafety in the perspective of health prevention

Biosafety is a recently studied field of knowledge, which is a challenge for health professionals and nursing students. There is a gap between the theoretical field and the daily practice, since biosafety norms are often adhered only in theory¹⁵.

The research carried out with nursing students identified that most of the students had knowledge about biosafety, and 83 (52.2%) of the participants had attended a course or lecture on the theme. It also found that there is a low index of doubts about this subject.

Nursing students present greater clarification about biosafety issues compared to other courses in the health area, since they showed the best scores in relation to the subject, considering that there is a high amount of topics discussed among the curricular components involving the theme¹⁶. One of the situations that may aggravate insufficient knowledge is the lack of a specific discipline on biosafety as mandatory in the academic curriculum⁸ .

When questioning about the knowledge of some standard of biosafety directed to health professionals, 74 (47.7%) reported knowing about the subject, which showed a dichotomy, since only 34 (21%) knew about RS 32.

RS 32 establishes basic guidelines for the implementation of biosafety measures for workers' health in health facilities, discusses occupational risks, emphasizes biological risks, reinforces the importance of using the Personal Protective Equipment (PPE) and weighs on the obligatory nature of vaccination, among others¹².

Another relevant fact is that 79 (50.3%) know what occupational risks are and 87 know (55.1%) the meaning of occupational diseases. As a measure to reduce the risks inherent to the work environment, students demonstrated the knowledge of the meaning of PPE - 236 (84.5%) -, as well as adherence to its use, which included 132 (84.1%) of the students in the course studied. It is known that in defining biosafety norms, the MoH and the Ministry of Labor (ML) reinforce the prevention of occupational accidents, since most of these can be avoided by using PPE.

It is well known that the knowledge of the students is acquired in part through the subjects that are taught by the teachers. In relation to biosafety teaching and learning, they should explore the correct instruction in undergraduate courses in order to train professionals capable of carrying out their activities in the workplace with safety, as well as to know the legislations pertinent to ocupational health ^{4, 6} .

(Re) thinking about vaccination and immunization

Immunization can be achieved through vaccination, which is an effective measure for the control of immunopreventable diseases¹⁷. The prevention of these diseases for nursing students is of the utmost importance, since they are a vulnerable group, mainly because they are exposed to biological risks ¹¹.

Regarding the vaccination card, 157 (96.3%) of the students had a vaccination card, 2 (1.2%) did not respond and 4 (2.5%) did not yet have one. Of those who presented vaccination card, 125 (79.6%) reported having the card updated.

This study evaluated the vaccination status of nursing students for hepatitis B and diphtheria and adult tetanus (dTa), considering that these are the main vaccines recommended by the MoH and the ML. In relation to hepatitis B, 130 (79.8%) students reported having taken the vaccine and 14 (8.6%) did not know or did not remember, which shows that there are students susceptible to immunopreventable diseases in the practical field of primary healthcare and in the hospital network.

Among health professionals, nursing professionals are at a higher risk of becoming infected with the hepatitis B virus, justified by the duties inherent to the practice of the profession, such as performing invasive procedures, continuous exposure to biological materials and working conditions, often precarious, provided by the institution¹⁸.

Still referring to hepatitis B, only 70 (47.6%) students reported that they have completed the vaccination schedule, that is, with three doses. Regarding the 1st and 2nd doses, 16 (10.8%) were delayed in the vaccination schedule, which diverges from studies that describe that nursing students have high rates of adherence to hepatitis B vaccine ^{7, 19}. A relevant data to be mentioned is that 61 (41.5%) of the informants said they did not know or did not remember if they took this vaccine.

Regarding immunization for hepatitis B, 50 (30.7%) reported that they had already been immunized. However, it was found that only 35 (21.5%) performed the anti-HBs test, demonstrating low values regarding proof of immunization, which suggests that there is still a lack of knowledge between the difference in vaccination and immunization. Thus, it was observed that the majority of nursing students may be susceptible to hepatitis B if there is biological exposure.

Studies that address hepatitis B vaccination in this population have not discussed the performance of this exam^{7, 19, 20}, which is a gap in knowledge, because only this exam can evidence immunization for this disease.

Regarding diphtheria and tetanus, 150 (93.2%) students took the vaccine, of which 60 (39, 2%) had the schedule updated, with three doses. In relation to the 1st and 2nd doses, 31 (19.2%) students had been vaccinated, corroborating with other studies⁷ that have identified delayed or ongoing cases of vaccination schedule. A study carried out with nursing professionals when investigating the diphtheria and tetanus vaccination schedule showed low vaccine adherence, which can be reflected later, since these nursing students could perpetuate the delay of the vaccination schedule even after entering the labor market²¹.

Accidents with biological materials: (re) evaluation of the conducts

Nursing students in the development of their activities carry out procedures that keep them in direct contact with clients, thus enabling exposure to various risks, which may lead to acquiring occupational diseases⁴.

Among the 163 students who participated in the study, 6 (3.9%) reported having been exposed to potentially contaminated biological material during the development of practical-field procedures, with blood being the organic fluid mentioned in all accidents. These results are also evidenced in other studies that show that students and health professionals have been at high risk for accidents with biological material, and blood has been the most frequent exposure element ^{4, 13}.

Regarding the type of exposure, the percutaneous route was the most recurrent - 4 (66.7%) -, followed by intact skin - 2 (33.3%). The material involved in the work accident was sharps, in which scalpel blade represented 3 (50%) cases; needle 1 (16.7%) case; and others 2 (33.3%). The region of the body most affected is the toe - 5 (100%) - because it is in direct contact with the materials used.

Accidents occur mainly through the percutaneous route^{22, 23} because there is a greater manipulation of these materials in the accomplishment of the procedures. However, the needle is the greater responsible, opposing the finding of this study ^{13, 24}.

Regarding the time of the accident, 3 (50%) occurred in the morning, 2 (33.3%) in the afternoon, 1 (16.7%) at night, justified by the schedule of practices and internships that occur in the daytime period. The accident that happened in the night shift can be explained by fact that the student had an employment bond as a nursing technician.

Of the students who suffered accidents with biological materials, only 1 (16.7%) had provided care. However, when asked if they knew what to do after an accident with biological material, 85 (54.1%) reported knowing what to do.

In relation to chemoprophylaxis, 6 (100%) students did not perform it after the accident. It can be inferred that this fact happened due to the lack of communication to the teaching supervisors, neglect of care for fear of judgments from colleagues, teachers, or the non-need for chemoprophylaxis, which leads to underreporting and acquiring of complications ¹¹ . However, no student has been away from work or academic activities or suffered any kind of problem that made it difficult to perform activities of daily living.

Thus, it is necessary to emphasize the responsibility and commitment that must exist between nurses and their staff in the quest for safety at work ²⁵ , which is not different from the responsibility that the teacher should have towards the students.

CONCLUSION

This study enabled verifying the vulnerability of students regarding the inherent risks of the teaching-practical environment. Nursing students were found to be vulnerable to immunoprevalent diseases, since low levels of immunization against hepatitis B, diphtheria and tetanus were evidenced, as well as insufficient knowledge about biosafety and RS 32.

This study has the memory bias as a limitation, in view of the fact that the vaccination schedule and the results of the tests for the confirmation of the information described here were not requested.

It is of fundamental importance that teachers and supervisors of practices and internships advise students on the adherence of personal protective equipment, vaccination and conducts after accidents with biological materials. In addition, training institutions should create stricter norms regarding confirmation of the vaccination card that should be updated at the time of admission to university, as well as the monitoring by the teachers of each discipline, especially those who carry out activities in health facilities. It must also be considered the possibility that this confirmation occurs in the university at the time of enrollment of each semester.

It is also suggested that a discipline on biosafety should be inserted as a compulsory curricular component in undergraduate nursing courses so that students have a greater possibility of becoming more protected and safe professionals, and to consequently guarantee protection to the clients who will be under their care.

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