Background: Despite growing research, knowledge about nurses’ occupational health and safety status, and engagement with occupational health and safety (OHS), services remain sparse.
Objectives: The aim of this research was to explore the OHS of nurses in three Free State hospitals, focusing on OHS-related training, vaccinations and work examinations, OHS-related practices, nurses’ engagement with hospital-based management, OHS services, and health and safety representatives.
Methods: A cross-sectional baseline survey was conducted among Free State public hospitals. Data were collected from a sample of 363 nurses, using self-administered questionnaires.
Results: One-fifth (22.3%) of nurses had experienced sharps injuries; vaccination rates were low; and 69.0% had not been screened for tuberculosis at work. A large proportion (38.5%) of nurses reported always recapping needles (a hazardous process). One-quarter (24.9%) never wore N95 respirators when required. The majority (89.8%) were aware of the procedure for contacting the occupational health services but 27.5% did not know how to report an occupational injury or disease.
Conclusion: The study highlights the precarious working contexts of nursing in Free State hospitals, adding to a growing body of knowledge on public hospital OHS in low-to-middle income countries.
Keywords: nurses, hospitals, occupational health and safety, unsafe clinical practices, reporting occupational injury
Against the background of a global shortage of nurses,1,2 the international community is increasingly concerned about the precarious working conditions under which nurses perform their daily tasks.3 Epidemiological factors, such as the seroprevalence of human immunodeficiency virus (HIV) and hepatitis B virus (HBV) in the population, combined with exposure to infected sharps, provide a context of increased risk for the acquiring of blood-borne diseases.4,5 Given the nature of nursing tasks, nurses are also at increased risk of suffering from occupational illness and injury, including strains, sprains, needlestick injuries, infectious diseases, diseases due to toxic chemicals and other hazardous substances, dermatitis, and thermal burns related to everyday practices.6-13 Nurses in low-to-middle income countries (LMICs) are especially at risk to contract infectious diseases or suffer occupational injury.8,14 This fact is especially underlined in terms of nurses’ exposure to tuberculosis (TB), one of the most common occupational health infections in South Africa,15-17 and a particularly worrying feature of the South African health care environment.18-23
Several valuable contributions towards building scholarship around the issue of nurses’ occupational health and safety (OHS) have been made during the last decade, including studies on OHS precautions,4,24,25 investigations into hand hygiene among nurses,26,27 needlestick injury reporting,6,9,28 the prevention of falls among hospital staff,29 and the use of facial personal protective equipment (PPE) against respiratory infections.30 In South Africa, an area of scholarly investigation that has been receiving increasing attention is that of infection control in health facilities.22,31 Due to indications of alarming TB infection rates in healthcare workers (HCWs) in South African health facilities,18-23 TB infection control investigations in these areas have steadily gained prominence.17,21,32,33,34 The importance of attending to infection control in public health facilities is underlined by a recent finding that HCWs from three public hospitals in KwaZulu-Natal were approximately twice as likely to be infected with TB than the general population over the study period.23 Proper infection control practices have been suggested to be inhibited by staff shortages, heavy workloads, limited resources and poor communication,26,27 contributing to nurses’ poor job satisfaction in South African settings.35
The significance of proper infection control in the protection of nurses and other HCWs from TB and other occupational infections is well established. Nevertheless, infection control practices do not occur in a vacuum; rather, the surrounding environment within which nurses perform clinical duties plays a crucial role. LMICs such as South Africa are struggling with basic equipment shortages, inadequate policies and insufficient resources for implementation of needed measures.5,36 Concerns over poor hospital work environments and the related risk of exposure to drug-resistant TB37 further add to challenges to safe working spaces. There is a pressing need to ensure environments in which nurses can perform safe clinical practices. The issue of working conditions, nevertheless, is often framed without consideration of professional resources such as occupational health services that have a role to play in addressing these issues. For example, there was no mention of occupational health services in a recent examination of “Job conditions, job satisfaction, somatic complaints and burnout of female East African nurses working in public and private hospitals”,38 indicating that considerable room exists for exploring the contributions that can be made by occupational health nurses and other occupational health professionals to improving working environments of nurses and other HCWs.
Addressing the needs of the contemporary nursing workforce calls for hospitals to become healthy working environments where nurses can perform safe clinical practices.17 In this regard, important policy initiatives have been developed.39 In particular, in South Africa, the Occupational Health and Safety Act (No 85 of 1993) and its amendments (No 181 of 1993)40 established a foundation for the implementation of OHS services in health facilities (as well as in other workplaces). Chief among these were the introduction of health and safety representatives and health and safety committees. Nevertheless, national OHS directives are yet to cypher down to the level of health facilities, especially in the absence of hospital-focused OHS policies.37 In cases where health facilities do have OHS and infection control-related policies in place, these are more often than not poorly implemented.22
Many recent studies have focused on describing OHS and infection control-related aspects of HCWs’ clinical environments in South Africa.22 Nevertheless, there is a need to provide a focus on the OHS practices of nurses, the so-called “backbone of the health system”.35 The objective of the research described in this paper was to explore the OHS practices of nurses in three Free State hospitals. The scope of this research included preventive aspects such as OHS-related training, workplace screening and vaccinations, OHS-related practices, nurses’ engagement with hospital-based management, OHS services, and health and safety representatives.
The data for this paper derive from a more expansive, collaborative effort between South African and Canadian teams, which sought to guide the implementation of an OHS information system in public hospitals in the Free State province. The systems were designed to allow for improved systematic collection of occupational health and infection control data. Three large hospitals (one tertiary and two regional) in the Free State province were purposively selected in consultation with the Free State Department of Health as pilot sites for the implementation of the occupational health and safety information system. Before the implementation of the health information system, a cross-sectional baseline survey was conducted from February to March 2012, to collect data on OHS as well as on infection control practices.
A self-administered questionnaire (offered both in English and the local language, Sotho) was developed, following an extensive literature search, and then pilot-tested. In the pilot study, the questionnaire was distributed to 20 workers from one of the study hospitals. Twenty pilot study respondents were randomly selected in consultation with the OHS unit of the hospital. These respondents were excluded from participating in the baseline survey. Following corrections to the instrument, hard copies were randomly distributed to nurses in all clinical wards (medical, surgical, paediatric, casualty, maternity, orthopaedic and intensive care wards), as well as in outpatient departments.
A 20% representative sample of nurses across the three hospitals (410 of the total of 2 052 nurses) was calculated to be large enough to provide a valid reflection of the various outcomes of interest in the study population. In order to achieve this sample size, almost double the number of required questionnaires was distributed to potential respondents.
The data were coded, captured and analysed using IBM SPSS 20. Frequencies were produced of nurses’ responses related to preventive measures such as training, workplace screening and vaccinations; health and safety-related behaviour such as infection prevention and control; safe and unsafe clinical practice; and nurses’ engagement with management, OHS services and health and safety representatives in the respective hospitals.
Pearson’s Chi Square tests were conducted to explore associations between risky work practices and nurses’ age and work experience in the hospitals. Risky work practices were defined as follows: not wearing a N95 respirator when needed; not using eye protection during clinical practices; not washing hands between working with patients; recapping needles after use; and washing gloves after use. Demographic characteristics collected were nurses’ age and work experience in the hospital. Age was categorised as 20-29, 30-39, 40-49 and 50-59 years; and work experience as less than five years, six to 10 years, and more than 10 years.
The study adhered to accepted ethical research practice. Participation was rooted in informed consent; that is, the study objectives were explained to respondents verbally, as well as in writing, and respondents were requested to provide written consent. Given the potential sensitivity of occupational data, steps were taken to assure anonymity and confidentiality of information by not using any identifying information except for basic demographic data, and by keeping all questionnaires secure. Further, given the challenging contexts of public hospitals, researchers were instructed to be sensitive to nurses’ time and work and to not interfere in any clinical duties. The study was authorised by the Free State Department of Health. Ethical approval was obtained from the Ethics Committee at the Faculty of Health Sciences, University of the Free State (ethical clearance number 87/2010), as well as the University of British Columbia’s Research Ethics Board.
Description of the respondents
A 44% response rate resulted in an 18% (n=369) sample of nurses, with 363 nurses successfully completing the questionnaire. The majority of nurses (n=333; 91.7%) were female. Ages ranged from younger than 20 to older than 60 years, with one-third aged 40 to 49 years (n=123; 33.9%). The nurses were distributed as follows across the hospitals: 28.5% in surgical wards (n=91); 22.6% in medical wards (n=72); 20.1% in paediatric wards (n=64); 17.2% in maternity wards (n=55), and 22.3% (n=81) in casualty, orthopaedic and intensive care wards, and outpatient departments. Most were professional nurses (n=214; 59.0%), 28.1% were assistant nurses (n=102), and 12.9% were staff nurses (n=47).
OHS training to prevent infections
As illustrated in Figure 1, 30.9% (n=112) of nurses had not received any training on TB infection control and 31.7% (n=115) had not received training on how to report injuries occurring while at work.
Blood and body fluid exposure, TB screening and vaccinations
During the two years preceding the survey, 22.3% of the nurses (n=80) had experienced exposure to blood or body fluids through a sharps or needle injury. Further, 10.8% (n=39) had experienced another type of work-related injury or illness during this period. In terms of vaccinations, 18.0% (n=63) had not received all three HBV vaccinations, while 46.0% (n=161) had never been vaccinated against influenza. Importantly, 69.0% (n=238) had never been screened for TB at work, while 24.0% (n=87) had not been examined at the occupational health unit.
Occupational safety practices
In terms of infection prevention and control practices (Table 1), numerous risky practices were identified: 38.5% of nurses always recapped needles (n=139); and 36.6 % never wore eye protection when required (n=133). Furthermore, 24.9% never wore N95 respirators when caring for patients with airborne diseases such as TB (n=90), and 16.9% (n= 61) indicated that they always washed their gloves.
The only statistically significant association found was between nurse age groups and the recapping of needles (p=0.004). Post-hoc analyses suggested that older nurses, i.e. those aged 50 to 59 years, were significantly more likely to recap than nurses aged 40 to 49 years (p=0.001) and 30 to 39 years (p=0.006).
Contacting occupational health and safety services
The majority of nurses knew how to contact the hospital OHS services (n= 326; 89.8%), the health and safety representative (n=297; 81.8%), and the infection control service (n=330; 90.9%). In terms of nurses’ perceptions of OHS information, 71.2% (n=203) indicated that it was easy to report workplace hazards, and 66.1% (n=183) reported that it was easy to obtain information about such hazards (Table 2).
In terms of making suggestions, 24.1% of the nurses indicated that they never made suggestions about safety issues to OHS services (n=74) and 21.3% indicated that they never made suggestions to health and safety representatives (n=70). While 81.2% (n=293) felt that they were encouraged to report health and safety issues, smaller proportions actually reported these issues to OHS services (n=205; 63.7%) or health and safety representatives (n=206; 60.1%).
The results of this study should be viewed against the background of nurses’ high-risk work contexts, where occupational infectious diseases are often misdiagnosed and under-reported.22,41 An astoundingly small proportion of nurses had been screened for TB at work in this study despite South Africa’s high TB incidence.42 The finding that 69% of nurses had not been screened for TB at work supports previous studies that found poor TB screening in South African public health facilities. Qualitative findings by Tshitangano43 suggested inadequate TB screening of HCWs in Venda hospitals, while Farley et al.33 reported that 50% of 24 drug-resistant TB health facilities assessed in their study conducted annual TB screening of HCWs. Claassens et al.21 reported that 36% of 43 health facilities assessed screened HCWs for TB, while Tudor et al.37 reported that 19% of HCWs from three public hospitals were screened for TB in a one-year period. Consistently low rates of TB screening are concerning, given the evidence that TB is a major occupational health risk in South African hospitals,18-23 especially for nurses.44
Given the concerns about TB, it was alarming to find that more than half of the nurses did not wear N95 respirators when caring for patients with infectious disease such as TB. This finding supports previous studies. Kanjee et al.,32 in a survey accompanied with observations in a rural district hospital, found inconsistent use of N95 respirators in TB wards. Farley et al.33 reported that 32.2% of HCWs surveyed indicated that they did not wear N95 respirators in TB wards. South African settings are not unique in this respect. For instance, in an observational study among HCWs in a Brazilian hospital, Biscotto and colleagues45 found that only 24.4% of nurses wore N95 respirators as a preventive measure against TB. Key barriers have been suggested to N95 respirator compliance. These include frequent shortages of respirators; poor quality N95 respirators; poor knowledge on N95 respirator use; and uncomfortable fit of N95 respirators.32,37,46 The present findings support the conclusion that there is much room for improvement in the use of facial PPE against air-borne infections.32-33 This is especially vital in situations where there are low screening rates, such as reported here. Importantly, since the completion of this study, a major campaign was launched to increase the proportion of health workers screened for TB across the Free State province.
The finding that 22.3% of nurses experienced a needlestick or sharps injury, is in line with the finding of Omorogbe et al.47 of 24.6%, and Bennett and Mansell’s24 finding of 21%. In a similar study, 18.8% of nurses indicated that they had experienced a needlestick injury during the 12 preceding months.28 The high percentage of needlestick injuries may be partly explained by the finding that around 47% of the nurses never recapped needles. Although older nurses were more prone towards the practice of recapping needles, it is unclear why. Due to the study design, no claims can be forwarded regarding why age is associated with recapping needles. Given the lack of current scholarship in this respect, more research is needed. Recapping of needles is risky practice, and has been shown to be a major cause of sharps injuries.10 Research has found varying rates of nurses stating that they never recap needles, ranging from 44.2%47 to 70.3%.28
The small proportion of nurses who reported washing their gloves after use was troubling. Gloves have been shown to be comparatively more contaminated by different bacterial strains than other protective clothing.48 Managerial measures such as restrictions placed on the use of multiple pairs, as well as the sourcing of low-quality gloves, have been suggested to contribute to incorrect glove use.49 As it is not an appropriate infection control measure,50,51 washing gloves may create a false sense of security.
As shown in a review by Gammon et al.,52 adherence to routine or standard clinical precautions is suboptimal globally. On-going investment in infection control training for nurses53 as well as the use of interactive innovative OHS training methods54 can go a long way in better protecting nurses. However, the support of hospital management, OHS services and role players such as health and safety representatives, is vital. It is encouraging that the bulk of nurses knew how to contact these role players, and that more than half of them trusted these role players to keep the hospital workplace safe. However, while most nurses felt encouraged to report health and safety issues, more than 10% indicated that they never report such issues to OHS services or to the health and safety representative, with even larger proportions indicating that they never make OHS-related suggestions to these role players.
Hospital management and OHS units can make HCWs more comfortable by fostering a culture of reporting and by addressing barriers such as stigma.23 Further, while the majority of nurses stated that it is easy to report and get information on workplace hazards, more than half of them reported that it was not easy to get follow-up information from management on safety issues. Elsewhere, managerial support for nurses in protecting themselves from occupationally acquired infections has been noted to be insufficient.17,46,49,55 OHS-related feedback to employees is a vital aspect of a safe work environment. Behaviour that leads to occupational injury or disease is often due to embedded unsafe practices, and staff need to be empowered to not only identify unsafe behaviour but to change their own actions for the better; receiving appropriate feedback is important in this regard. Being able to suggest changes at the front-line level is also key in promoting a positive safety climate. It is noteworthy that perception of safety climate can differ quite markedly between management and the workforce;56 often policies and procedures have been developed by management but nurses may be unaware of these. Much is still left to be explored in this vital area of hospital OHS, namely the interaction between staff, hospital management, OHS services and health and safety representatives. A small number of studies have investigated these relations,37,55 and future research should strive to bring this aspect of HCWs’ protection into sharper focus. Given the prominence and importance of nurses, both in hospital OHS and within the make-up of hospital staff, the results of this research bolster a previous call20 for the targeting of nurses for prevention strategies and interventions in healthcare environments.
The results of this research should be viewed against the background of several study limitations. First, the 44% response rate that resulted in the achievement of an 18% sample (below the targeted 20%) is low, but nevertheless consistent with healthcare surveys that are known to yield low response rates.17,57,58 Second, the cross-sectional design merely provides a snapshot of nurses’ OHS at the time of the survey, and hence does not offer any insights into changes over time. This design also does not allow generalisability of the results to other facilities. Third, self-administered surveys often carry a social desirability bias, and nurses might have overstated adherence to safety practices out of concern that their supervisors might find out about their answers (despite assurances that all information would remain confidential). Fourth, participation in the survey was contingent of nurses’ availability and, as such, some wards and departments were over-represented. Fifth, the absence of accompanying qualitative work precludes deeper engagement with complex themes such as trust. Nonetheless, this article adds to current knowledge on hospital OHS, particularly pertaining to nurses and their interaction with OHS units and health and safety representatives.
The study highlights the precarious working contexts of nursing in three Free State hospitals. The proportion of occupational injuries sustained was troubling, as were the unsafe clinical practices and poor infection control exhibited by nurses. The low levels of work-based TB screening is a disconcerting failure in hospital OHS, while interaction between nurses and hospital management, OHS services, and health and safety representatives needs improvement. The results echo previous suggestions that hospital-based OHS needs much strengthening in South Africa. On-going training, hospital-based vaccinations, and screening for infectious diseases are vital measures in securing safe work spaces. Ultimately, the findings add to a growing body of knowledge on public hospital OHS in LMICs.
The authors would like to extend their gratitude to all the respondents for their participation, as well as to the hospital management and the Free State Department of Health for the facilitation of the study. Critical inputs offered by two anonymous peer reviewers significantly added to the final article, and are gratefully acknowledged.
The authors declare no conflicts of interest.
The authors gratefully acknowledge the funders of this study, the Canadian Institutes for Health Research (grants ROH-115212 and MOP-102669), as well as the Canada Research Council.
• Nurses in public hospitals remain at risk to contract occupationally acquired diseases such as TB and HBV
• Previous suggestions – that a worrying proportion of nurses putting themselves at risk of needlestick injury – are supported
• Nurses exhibit risky clinical practices, suggesting the need for on-going occupational safety training and support
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