Accidents with biological material involving clinical medicine nurses
Larissa Pereira CostaI; Paula Raquel dos SantosII; Alessandra da Terra LapaIII; Thelma SpindolaIV
Nurse. Master degree student in Nursing in the Nursing School of the State University of Rio de Janeiro. Residence in Nursing in Medical Clinic by the
State University of Rio de Janeiro. Brazil. E-mail: email@example.com
II Nurse. Ph.D. in Nursing. Assocaite Professor of the Public Health Nursing Department. Nursing School of the State University of Rio de Janeiro. Brazil. E-mail: firstname.lastname@example.org
III Nurse. Master degree in Nursing at the Nursing School of the State University of Rio de Janeiro. Substitute Professor of the Public Health Nursing Department. Nursing School of the State University of Rio de Janeiro. Brazil. E-mail: email@example.com
IV Nurse. Ph.D. in Nursing. Associate Professor in the Department of Nursing Fundamentals. Nursing School of the State University of Rio de Janeiro. Brazil. E-mail: firstname.lastname@example.org
V Part of the research report entitled: Occupational accidents with biological material involving nurses in clinical medicine approved in the Graduate Program - Nursing and Medical Clinic Residence, State University of Rio de Janeiro, in 2013.
In order to establish whether accidents with biological material among clinical nurses occur more frequently among nurse residents, a descriptive, quantitative study was conducted at a university hospital in Rio de Janeiro city in 2013. Data were collected by document analysis technique following a structured guide. Information was drawn from forms completed between 2007 and 2011 reporting accidents with biological material involving the institution's nursing personnel. The results show that in the study period there were 260 accidents involving staff at the institution. Of the 27 (100%) accidents involving clinical medicine nurses, 21 (77.7%) involved nurse residents. From the sample analyzed, it can be concluded that clinical medicine nurse residents are involved in most of the accidents recorded.
Keywords: Nursing; exposure to biological agents; nursing work; clinical nursing.
This study aimed to the occurrence of accidents with biological material involving resident nurses of medical clinic.
Health care workers are exposed to situations that can cause infections transmitted by microorganisms present in the blood and body fluids. This problem is accentuated in hospitals where there is a large number of nursing workers. Thus, biosecurity measures should be adopted by the institutions and workers to minimize such exposure1.
The experience as nurses and the provision of direct care to clients raised the choice of this subject considering that nurses, by developing activities with the patients, are at imminent risk of being injured with biological materials.
Acting in a university hospital, it can be observed that in the group of nurses, nursing residents are highly exposed to occupational risks due to the structural conditions of the workplace and the lack of appropriate biosecurity measures, as well as high weekly working hours that contributes to the physical and mental fatigue, leading to lower efficiency and attention to the work, closely linked to the occurrence of accidents.
The workplace does not always provide adequate materials and quantity necessary for the performance of services, such as gloves, aprons, masks and goggles. Besides there is absence of adequate environmental lighting, sinks for hand washing, dispenser with alcohol gel for hand hygiene and containers for disposal of cutting material, which are fundamental structures to enable the application of the methods of biosecurity by workers.
The major way of microorganisms transmission during care provided to patients are the hands of professional, because the skin is a possible reservoir of various microorganisms, which can be transferred through direct or indirect contact, through contact with contaminated objects and surfaces2.
When it comes to biosecurity, the risk of acquiring infection or the possibility of contamination through work, it is just think about ways to avoid and/or minimize these risk factors.
The proper hand hygiene is the main method for preventing and controlling infections in the hospital environment and is also the most important and less expensive. However, many health professionals do not do it satisfactorily without observing the recommendations, not performing hand hygiene in approximately 60% of the time that would be necessary or indicated. Therefore, this measure has still been a challenge due to the low adherence of health professionals to handwashing3.
According to Regulatory Rule 32 (NR-32), which provides for the safety and health of health services workers, the use of gloves does not replace the process of washing the hands, which should take place at least before and after use them4.
Personal protective equipment (PPE) have the function of reducing damage and injuries in case of accidents and are adopted as standard precautions, and its use is essential in patient care. However, many accidents still happen in the health services, being imperative to notice them and monitoring of professionals.
Occupational accidents involving exposure to potentially contaminated biological material are considered in Brazil, a compulsory disease notification and must be reported in a standardized records by the Ministry of Health in the Notifiable Diseases Information System (SINAN) and in sentinel networks, such as the Workers Health Reference Centers (CEREST)5.
From this context, as a problem for research it was selected: What is the occurrence of occupational accidents involving residents nurses of medical clinic, involving biological material? As the objective, it was determined to ensure if accidents involving biological material in medical clinic nurses occur more frequently among nursing residents.
It is expected that the results of the study may increase the interest of health professionals in the use and correct use of personal protective equipment, in order to minimize the occurrence of occupational accidents involving biological material.
The work routine in health facilities requires to the worker being aware of biosecurity rules to ensure protection of their health. Biosecurity is conceived as a set of measures aimed at preventing, reducing or eliminating risks inherent to research, production, education, technological development and provision of services4.
Occupational exposure to biological material causes damage to physical, mental and social integrity constituting accidents, frequent among nursing workers. Some factors predisposing to these diseases are the insufficient number of workers, work overload, stressful days, continuity of care in night shifts and other shifts, physical and emotional exhaustion, poor technical capacity, lack of attention, overconfidence, use of inadequate materials, stress and the non-adoption of precautions rules6.
This exposure should be evaluated for potential transmission of Human Immunodeficiency Virus (HIV) and Hepatitis B Virus (HBV) and Hepatitis C (HCV), the type of exposure, type and amount of fluid and tissue type, serological font status, serological status of the injured individual and susceptibility of exposed professional1.
In Brazil, occupational accidents, the illness and absenteeism among health professionals are aware by the Ministry of Work and Employment that answering to requests from organizations representing the various categories of health workers, inserted in legislation in 2005, the NR. 32 - Security and health at Work in Health Facilities. This is considered of utmost importance as it addresses safety and health at work, in the health area7.
Such Regulatory Rule recommends that health institutions should implement promotion, protection and recovery actions of the workers' health who are active in providing health care. The NR-32 has three main areas: the continuous training of workers; programs dealing with risks; and protective measures against risks7.
Descriptive and quantitative study, using documentary analysis technique.
It was conducted in a university hospital in the city of Rio de Janeiro in 2013. Data were collected using documentary analysis technique with the aid of a structured script. The information was captured in notifications records of accidents with biological material, from 2007 to 2011, involving the institution's nursing professionals. The records are available in a digital database, in the sector responsible for notification and assistance to injured workers. They contain information such as the date of the accident, age, gender, occupation, the type of accident, the causative object, the biological material involved, among other information.
The nursing staff at this teaching hospital consists of effective nurses, nurses in the Professional Training Scholarship (TPB), effective nursing technicians, hired nursing technicians, nursing assistants, nursing residents, and in practical classes, nursing teachers and internal nursing.
The hospital headquarters of the research is composed of 303 effective nurses, 278 TPB nurses, 934 effective nursing technicians, 435 hired nursing technicians. Altogether there are 581 nurses and 1,369 nursing technicians. Out of this total, 40 nurses and 84 nursing technicians are medical clinic. Another category adds the nursing residents. Altogether there are 141 nursing residents, with 73 nursing residents of the first year and 68 nursing residents of the second year. Among them, 23 are medical clinic nursing residents, 12 nursing residents of the first year and 11 nursing residents of the second year.
For data collection, a structured questionnaire with nine closed questions was used, built on literature, in the notification record of work and occupational diseases of the research institution and in the notification record of accidents with exposure to biological material built by SINAN - Ministry of Health.
Inclusion criteria were: being a nurse and/or nursing resident; have suffered an accident with biological material in a medical clinic unit; be within the time of 5 years. Exclusion criteria were: not being a nurse and/or nursing resident; have not suffered any accidents for biological material; accidents that occurred more than five years old; from 2007 to 2011 accidents that not occurred in medical clinic.
The study was approved by the Research Ethics Committee of the institution, according to Resolution 466/12 of the National Health Council, obtaining numbering 285,692.
Being a research involving humans beings indirectly, since the data were obtained by the management of the professional accident notification records, the amount of individuals who were involved and considering that some of them could not have more employment with the hospital, headquarters of the research, it was asked the Research Ethics Committee authorization for data collection without the need of obtaining the Informed Consent Form (TCLE).
The data presented were collected in two months, after the approval of the Ethics Committee, in the reporting area and professional service for the victims of this hospital.
Information obtained were stored in Microsoft Office Excel 2007 software in spreadsheet and analyzed with descriptive statistics support.
RESULTS AND DISCUSSION
The data show that the occurrence of accidents with exposure to biological material is still high in the hospital environment and hence with the nursing staff.
In the time investigated, there were 260 accidents with the nursing staff, which 27 (10.3%) occurred with nurses in medical clinic. See Table 1.
TABLE 1: Profile of accidents in general. Rio de Janeiro, RJ, 2013.
Accidents involving nurses showed the following characteristics: seven medical clinic nurses had accidents in 2007. Out the seven, five were residents nurses. In 2008, were also injured seven nurses and six were residents nurses in medical clinic. In 2009, five accidents were reported, involving medical clinic nurses and all were residents. In 2010 there were six accidents reported with nurses, five occurred in internal medicine residents. In 2011, two accidents with nurses were reported, but there were not nursing residents.
Among the 27 (100%) accidents involving nurses in medical clinic, residents nurses were involved in most of them - 21 (77.7%) - and with exposure to biological material during the study period.
It is emphasized that the lack of experience and anxiety can contribute to accidents, Being constantly in learning situations, supervision and evaluation favors the increased anxiety and stress8.
Regarding the age group of professionals involved in accidents with biological material, five accidents of 2007 happened with professionals from 21 to 30 years old, in a total of seven. All seven accidents of 2008 records and five records in 2009 were conducted with professionals from 21 to 30 years old. The year 2010 had two notifications with professionals up to 20 years old and three notifications with nurses from 21 to 30 years old. In 2011, the two notifications involved professionals from 21 to 30 years old.
The large participation of young professionals in the occurrence of accidents with biological materials may explain the high number of accidents among residents' nurses. This index may be associated with reduced time for practicing the profession.
Young professionals have great expectations on the career starting and, when they enter the world of work, they realize the difficulties of reality that is found. This situation tends to lead this young man to stress and illnesses at work, including accidents9.
Considering gender, it was found that in 2007 and 2010, none of the reported accidents involved male professionals. In 2008, five professionals were female in a total of seven in 2009, four were female in a total of five. In 2011 only two accidents were recorded with nurses, one male and one female.
This increased occurrence of accidents among female workers can be justified considering that nursing is a predominantly female category and expressive representation in health services10.
Another justification is that the number of women who enter the higher level courses is high. The Higher Education Census of 2013 shows the growing number of women who enter, enroll and complete the degree, particularly in the health area courses11.
Classified according to the type of exposure, in 2007 and 2008 there were five percutaneous accidents reported among the total of seven. In 2009, three percutaneous accidents were recorded in the amount of five. In 2010, four were reported percutaneous accidents among the six, and in 2011, there was notification of a percutaneous accident and an accident with oral/ocular mucosa.
The needles are causing objects of the greatest number of accidents. However, much of the recorded accidents could have been avoided by the adoption of standard precautions, such as not recapping needles and proper disposal of cutting materials12.
In 2007, 2009 and 2010, all reported accident had the needle like object involved in the accident. In 2007, there were seven cases in 2009 were five and in 2010 there were six cases. In 2008, out of the seven accidents, six were with needles. Only one accident involved blades/lancet. In 2011 the object caused the accident notification was ignored in the two reported cases.
Blood is the most organic material involved in accidents with exposure to biological materials13.
In 2007, out of the seven notifications, all involved blood and, in 2009, all five records were involved with blood. In 2008, there were six accidents reported involving blood and one accident involving fluid with blood. In 2010, in the six accident records, four involved blood and two did not report the organic material involved. In 2011, the two notifications occurred, also they did not inform the involved organic material.
Wearing gloves is an internationally recommended practice, being an important preventive measure of exposure to biological material because it minimizes the risk of contact with blood and other body fluids capable of transmitting pathogenic microorganisms, like the HCV agents, HBV and HIV13 .
In sharps materials accidents, the use gloves can reduce the volume of blood injected by suture needles in 70% and by needles for intravenous treatment of 35% to 50%, considering that part of the fluid can remain in the bevel and/or inner needle. Thus, although not prevent drilling, gloves serve as a mechanical barriers to help decrease the risk of contamination in cases of accidents14.
Based on the Accident Notification Record and Labor Diseases of the research institution, the circumstances of accidents comprise three stages: during the procedure; after the procedure and before disposal; and during or after disposal.
In 2007 and 2008, there were five accidents notified that occurred during the procedure and two that occurred after the procedure and before disposal of the material used. In 2009 four accidents were recorded during the procedure and only one after the procedure and before disposal. There were reported in 2010, five accidents during the procedure and after the procedure and before disposal. In 2011, one accident was reported during the procedure and after the procedure and before disposal. See Table 2.
Circumstances of accidents. Rio de Janeiro, RJ, 2013.
Most accidents occurred when the professional was performing the procedure, which reinforces the importance of wearing gloves during these procedures, as shown in Table 2.
The profile of the medical clinic nurses involved in accidents with exposure to biological material, there is a similarity. They are registered nurses with the same age group (21-30 years old), gender (female), accident type - percutaneous, with the same cause object (needle) and contact with the same organic material - blood. It is observed also that accidents generally happen under the same circumstances, that is during the procedure being performed.
The use of personal protective equipment was recorded in disuse by the professional at the time of the accident, in most cases.
In 2007, out of the seven nurses´ accidents, four did not use personal protective equipment (PPE) when the accident occurred. In 2008 there were also seven nurses´ accidents, but six did not wear PPE. Of the five accidents in 2009, four were not wearing PPE. In 2010, four professional did not wear PPE at the time of the accident and two records did not inform about it, a total of six accidents. In 2011, the two reported accidents did not use PPE. See Table 3.
Use of personal protective equipment. Rio de Janeiro, RJ, 2013.
In the survey of which PPE was more used by the injured professionals, including those who were carrying the equipment at the time of the accident, the glove appears with one record and the mask with two in 2007. In 2008, only one accident with use of glove was notified. In 2009, there is a record using apron and in 2010 and 2011, there was no notification regarding the use of PPE.
Regular use of PPE is extremely important to prevent exposure to biological materials, offering greater security for professionals and patients. For this security to be effective, besides its use, they must use this equipment correctly, and always verified to be clean and conserved15,16.
Several circumstances predispose the occurrence of accidents with biological material. There are individual conditions, such as non-adherence to the use of PPE, the recapping of contaminated needles, improper disposal of contaminated material, as well as double shifts which leads to fatigue, exhaustion and lack of attention10. Moreover, there are also institutional constraints such as the lack of training and training offered by managers to professionals, agitation of the service, stress, lack of human resources, inadequate containers for disposal of contaminated materials, among others10,17.
In this context, it is important that managers encourage the use of PPE among healthcare professionals during the procedures, as well as make them aware of the need to adapt the articles reuse standards to reduce the level of exposure, especially during reprocessing not recommended. The guidance work on disposal and handling of biological waste must be strengthened among professionals too10,12-16.
The findings indicate the occurrence of accidents with biological material among nursing professionals, especially in nurses´ residents, by many factors such as low experience, the constant situation of collection and evaluation as a student/professional in improvement phase, the conditions of work, poor adherence to PPE use, excessive working hours, stress, among others.
The nursing residents, even though they are professionals registered in the regulatory Council of the profession, are still in the process of learning, practical-theoretical improvement and therefore need of tutors/supervisors in their daily activities. Also they need education about the practical conduct and the appreciation of the use of PPE, considering the risks to which they are exposed in the workplace.
Continuing education is an important resource that should be adopted in health institutions for retraining of health professionals and teams, for learning, and as a strategy to encourage the adoption of preventive measures to reduce the number of accidents with biological material in workers.
The objectives of this study were achieved, having shown that most accidents with biological material in medical clinic, in the analyzed period, was the involvement of residents nurses.
There were no difficulties in access to information described in the notification records of research headquarters institution, considering that the data is organized on a digital basis, which facilitated the capture.
Study limitations were the lack of certain information in the institution´s accident records, turnover of residents per year and the high workload of the residency program, which hampered the search for information and its further analysis.
This research brings contributions to research headquarters institution that can promote actions for the purpose of reducing the number of occupational accidents among nursing workers and monitor cases of underreporting. It is hoped that this type of accident in the hospital environment is increasingly reduced, offering better working conditions and quality of life for professionals. It is noteworthy that this issue is not limited to this research, new studies should be conducted to broaden the discussion and the scientific literature on the subject.
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