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Factors surrounding and strategies to reduce recapping used needles by nurses at a Venezuelan public hospital

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Title:
Factors surrounding and strategies to reduce recapping used needles by nurses at a Venezuelan public hospital
Physical Description:
Book
Language:
English
Creator:
Galindez Araujo, Luis J
Publisher:
University of South Florida
Place of Publication:
Tampa, Fla
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Subjects

Subjects / Keywords:
Accidents, Occupational -- prevention & control   ( mesh )
Needlestick Injuries -- prevention & control   ( mesh )
Nursing Staff -- education   ( mesh )
Safety Management -- organization & administration   ( mesh )
Health Knowledge, Attitudes, Practice   ( mesh )
Focus groups
Intervention
PRECEDE-PROCEED Model
Dissertations, Academic -- Global Health -- Doctoral -- USF   ( lcsh )
Genre:
non-fiction   ( marcgt )

Notes

Summary:
ABSTRACT: Nurses as health care workers are at risk of biological agents such as bacteria, viruses and others. At health care settings exposure to bloodborne pathogens can cause infections through needlestick injuries. The objectives of this research were to determine factors surrounding recapping needles in hospital nurses and to implement an educational strategy to reduce the recapping practices. It was a descriptive and exploratory approach where the PRECEDE component of the PRECEDE/PROCEDE Model was used as the framework to systematize and analyze the information obtained from the focus group sessions. A total of 120 nurses participated from four different departments. The study was conducted in three phases: diagnosis, implementation and evaluation of the educational strategy. The results obtained from the focus group sessions revealed that predisposing, reinforcing, enabling and environment factors were related to the practice of recapping and needlestick injuries.Most of this information represented the essential basis for the implementation of the educational strategy. During the diagnostic phase, the percentage of needles without recapping was 24% contrasting with 40% found after the educational strategy. The percentage difference (16%) was statistically significant (p<0.001). The odds ratios calculation in the departments studied showed that the educational strategy was a protective factor to avoid the recapping of used needles. An important conclusion is that the educational strategy, which focused on the practice and habit of what should be done (e.g., NOT recapping used needles), contributed to the decrease in recapping practice. However, nurses perceived did it not provide a safe working environment. The implications are focused on: nurses and hospital management have to engage in an active role to promote a safety work environment where nurses and other health care workers can be protected.The incorporation of educational strategies, continuous and updated training, as well as the evaluation and monitoring process can play a determinant role in the control of hazard exposures. It is imperative that a safe and healthy workplace for the personnel be provided; not less important is the acquisition of equipment and devices for sharp handling and disposal, to complement the prevention of accidents related to needlestick injuries.
Thesis:
Dissertation (Ph.D.)--University of South Florida, 2009.
Bibliography:
Includes bibliographical references.
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Mode of access: World Wide Web.
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System requirements: World Wide Web browser and PDF reader.
Statement of Responsibility:
by Luis J. Galindez Araujo.
General Note:
Title from PDF of title page.
General Note:
Document formatted into pages; contains 224 pages.
General Note:
Includes vita.

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University of South Florida Library
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University of South Florida
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All applicable rights reserved by the source institution and holding location.
Resource Identifier:
aleph - 002063799
oclc - 557421822
usfldc doi - E14-SFE0003166
usfldc handle - e14.3166
System ID:
SFS0027482:00001


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Factors Surrounding and Strategies to Reduce Recapping Used Needles by Nurses at a Venezuelan Public Hospital by Luis J. Galindez Araujo A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Global Health College of Public Health University of South Florida Co-Major Professor: Boo Kwa, Ph.D. Co-Major Professor: Donna Haiduven, Ph.D. Aurora Sanchez-Anguiano, Ph.D. Ricardo Izurieta, Dr.P.H. Date of Approval: September 21, 2009 Keywords: focus groups, interven tion, PRECEDE-PROCEED Model Copyright 2009, Luis J. Galindez A.

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DEDICATION This dissertation is dedicated to the nurses and other health care workers from Maracay Central Hospital who selflessly perform thei r jobs despite the very hard working conditions.

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ACKNOWLEDGMENTS This doctoral program would not have b een possible without the support of several individuals and organizations I would like especially ac knowledge Dr. Donna Haiduven, my major professor, for her support throughout the whole doctoral program and for her attention to detail in review ing the numerous drafts of th is dissertation. I would like to acknowledge my dissertation committee for thei r recommendations during the program. I thank the University of Carabobo and the Heal th Science College for the institutional and financial support. I thank the Maracay Ce ntral Hospital Management, Epidemiology Office and the Director of Nu rsing who allowed me to develop this dissertation at the institution. I thank CORPOSALUD’s Occupatio nal Safety and Health Department and Chief Nursing Officer for their support. I th ank my colleagues from the Department of Public Health and the Center for the Study of Worker’s Health (Centro de Estudio en Salud de los Trabajadores, CEST) from Univ ersity of Carabobo Campus Aragua for their emotional support. I would like to acknowledge those nurses from the Emergency Room, Neonatology Intensive Care Unit, Obstetri cs and Surgery wards who shared their experiences and feelings with me in the focus group sessions. And finally, this doctoral program would not have been possible w ithout the support of my family and many friends. To all of them, I would like to expr ess my deepest gratitude for helping me to achieve this dream.

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i TABLE OF CONTENTS LIST OF TABLES ............................................................................................................. vi LIST OF FIGURES ........................................................................................................... ix ABSTRACT ...................................................................................................................... ...x CHAPTER ONE: THE STUDY PROBLEM ......................................................................1 Introduction to the Problem .....................................................................................1 Bloodborne Exposure and Needlestic k Injuries as a Public Health Concern ............................................................................................2 Needlestick Injuries Accord ing to Job Classification ..................................4 Where Do Injuries Occur? ...........................................................................4 Works Practices or Procedures Associated with Needlestick Injuries ...................................................................................................5 Safety Culture and Health Care Workers .....................................................5 Causes of Percutaneous Injuri es with Hollow-Bore Needles ......................6 Impact of Needlestick and Sharps Injuries ..................................................7 Statement of the Problem .........................................................................................8 Purpose of the Study ................................................................................................9 Aims of the Study ..................................................................................................10 Research Questions ................................................................................................10 Significance of the Study .......................................................................................10 Rationale for the Study ..........................................................................................11 CHAPTER TWO: BAC KGROUND AND LITERATURE REVIEW .............................13 Recapping Used Needles as a Specific Problem ....................................................13 Bloodborne Pathogens ..........................................................................................14 Hepatitis B .............................................................................................................15 Worldwide Distribution .............................................................................15 Modes of Transmission ..............................................................................16 Clinical Characteristics ..............................................................................16 HBV and Health Care Workers .................................................................17 Prevention ..................................................................................................17 Health Care Workers Vaccination .............................................................18 Hepatitis C ............................................................................................................19 Worldwide Distribution .............................................................................19 Modes of Transmission ..............................................................................20

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ii Clinical Characteristics ..............................................................................20 HCV and Health Care Workers .................................................................21 Prevention ..................................................................................................21 HCV and Health Care Institutions .............................................................22 Human Immunodeficiency Virus ...........................................................................23 Worldwide Distribution .............................................................................24 Clinical Characteristics ..............................................................................24 HIV and Health Care Worker ....................................................................25 Prevention ..................................................................................................28 Needlestick and Sharps Injuri es Prevention Strategies .........................................29 Hierarchy of Controls ................................................................................30 Administrative Controls .............................................................................33 Personal Protective Equipment ..................................................................34 Safety Culture and Health Care Workers ...................................................34 Combination of Measures ..........................................................................35 New Safety Devices ...................................................................................36 Preventing Needlestick Injuries and Quality Health Care .........................37 Needlestick Injuries and Cost ....................................................................37 Health Care Workers and HIV or Hepatitis Status ....................................38 Needlestick Injuries and Developing Countries ........................................38 CHAPTER THREE: VENEZUEL AN HEALTH SECTOR .............................................40 Characteristics about Venezuela ............................................................................40 Demographic Context ................................................................................40 Legal Framework of Health in Venezuela .................................................40 Organization of Venezuel an Health Sector ................................................41 Venezuela Health Profile ...........................................................................43 Occupational Health and Safety Laws .......................................................44 Aragua State Characteristics ..................................................................................46 Health Sector Organization ........................................................................46 The Structure of the System of Health of Aragua ......................................47 Maracay Central Hospital ..........................................................................47 CHAPTER FOUR: THEORETICAL FRAMEWORK PRECEDE-PROCEED MODEL PPM ..............................................................................................................49 Background ............................................................................................................49 Components of the Model ......................................................................................49 PROCEED Component ..........................................................................................52 Applications of the PR ECEDE-PROCEED Model ...............................................53 CHAPTER FIVE: METHODOLOGY ..............................................................................56 Methodological Triangulation ...............................................................................56 Study Design ..........................................................................................................57 Threats to Internal Validity ....................................................................................58 Focus Groups Overview ........................................................................................59

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iii Characteristics of Focus Groups ................................................................59 When To Use Focus Group Interviews ......................................................60 Advantages of Using Focus Groups ..........................................................60 Disadvantages of Using Focus Groups ......................................................60 Participants in a Focus Group ....................................................................61 Developing Effective Questions ................................................................61 Analysis in Focus Groups ..........................................................................62 Reliability and Validity of Focus Groups ..................................................64 Procedure for the Focus Group Sessions in the Study ...........................................66 Study Phases ..........................................................................................................69 Setting of Intervention ...........................................................................................70 Data Collection Methods and Da ta Collection Instruments ..................................71 Data Analysis Methods ..........................................................................................76 Target Population/ Study Sample/Sample size ......................................................77 Inclusion/Exclusion Criteria ..................................................................................78 Recruitment of Subjects .........................................................................................78 Ethical considerations ............................................................................................79 CHAPTER SIX: RESULTS ..............................................................................................84 Quantitative Results ...............................................................................................84 Qualitative Findings ...............................................................................................97 First Level: Descripti on and Categorization ..............................................97 Circumstances Related to Recapping of Used Needles and Needlestick Injuries .................................................................98 Perceptions of the Nurses a bout Needlestick Injuries ..................103 Needlestick Injuries Pr evention Strategies ..................................104 Second Level: Analysis of Findings ........................................................106 Predisposing Factors ....................................................................107 Reinforcing Factors ......................................................................109 Enabling Factors ..........................................................................110 Environmental Factors .................................................................111 Relationships Between Factors in the ............................................... PRECEDE-PROCEED MODEL .................................................113 Third Level: Interpretation ...........................................................116 CHAPTER SEVEN: DISCUSSION ................................................................................124 Quantitative Findings ...........................................................................................124 Qualitative Findings .............................................................................................132 Circumstances Related to Recapping of Used Needles and Needlestick Injuries ...........................................................................132 Environmental Factors .................................................................132 Physical Conditions .........................................................132 Organizational Climate Factors .......................................133 Hospital Policies to Preven t Needlestick Injuries ....................................143 Perceptions of Nurses about Needlestick Injuries and Recapping Used Needles .........................................................................144

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iv Needlestick Injuries Pr evention Strategies ..............................................145 The PRECEDE Component .....................................................................148 Predisposing Factors ..........................................................................148 Reinforcing Factors ............................................................................150 Enabling Factors ................................................................................153 Environmental Factors .......................................................................154 Limitations and Strengths of the Study ................................................................154 Regarding Aims .......................................................................................154 Study Design ............................................................................................155 Focus Group .............................................................................................155 Sample Selection ..........................................................................155 Methodological Issues .................................................................156 Operative Issues ...........................................................................156 Limited Previous Qualitative Studies ..........................................157 CHAPTER EIGHT: CONCLUSION S AND IMPLICATIONS .....................................158 Implications/Recommendations for Clinical Practice .........................................159 Organizational/Administrative .................................................................160 Educational/Training................................................................................161 Future Research ...................................................................................................161 REFERENCES ................................................................................................................165 APPENDICES .................................................................................................................177 Appendix A: Recommended Post Expos ure Prophylaxis for Exposure to Hepatitis B ...................................................................................178 Appendix B: Recommended HIV Perc utaneous and Mucous Membrane Post Exposure Prophylaxis ..........................................................179 Appendix C: PRECEDE-PROCEED Model ....................................................181 Appendix D: Moderator Introduction for Focus Group in English and Spanish .........................................................................................182 Appendix E: Field Notes Form Used in Focus Group in English and Spanish .........................................................................................184 Appendix F: Sample Cover Letter Used for Member Checks in English and Spanish and Sample of Materials Used for Member Checks in Spanish ........................................................................190 Appendix G: Study Phases ................................................................................196 Appendix H: Focus Group Questions in English and Spanish ..........................197 Appendix I: Data Sheet about Demogr aphic Information in English and Spanish .........................................................................................199 Appendix J: CORPOSALUD Needlestic k Injuries Surveillance Report Data Sheet ....................................................................................201 Appendix K: Data Sheet of Used Need les at the Departments Surveyed .........202 Appendix L: Pamphlet Used in the Educational Strategy .................................203 Appendix M: Venezuelan Organic Act and the Regulation of Organic Act ......205

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v Appendix N: Organic Law Article s Discussed in the Focus Group Sessions ........................................................................................206 Appendix O: American Nurses A ssociation (ANA) Recommendation about Needlestick Injuries in English and Spanish ......................207 Appendix P: INPSASEL and CATDIS Pamphlet.............................................209 Appendix Q: Pretest and Posttest App lied in the Educational Strategy ............210 Appendix R: IRB Approval Application ...........................................................213 Appendix S: Proposed Consent Form in English and Spanish .........................214 ABOUT THE AUTHOR ....................................................................................... End Page

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vi LIST OF TABLES Table 1 Number of Nurses in th e Focus Group Sessions Distributed by Departments and Shifts, MCH, Maracay, 2006-2008......................................80 Table 2 Number of Focus Group Sessi ons Distributed by Departments and Shifts, MCH, Maracay, 2006-2008. .................................................................80 Table 3 Number and Percen tage of Total Nurses of the Departments Studied and Nurses Participants in the Focus Group Sessions, MCH, Maracay, 2006-2008. .......................................................................................................81 Table 4 Number of Beds of the De partments Studied, MCH, Maracay, 20062008..................................................................................................................81 Table 5 Number of Visits to Each Department to Collect Used Needles Distributed by Months and Weeks Before the Educational Strategy, MCH, Maracay, 2006-2008. ............................................................................82 Table 6 Number of Visits to Each Department to Collect Used Needles Distributed by Months and Weeks after the Educational Strategy, MCH, Maracay, 2006-2008. ............................................................................82 Table 7 Number of Participants in the Educational Strategy Sessions Distributed by Departments and by Shifts, MCH, Maracay, 2006-2008. ........83 Table 8 Number of Educa tional Strategy Sessions Di stributed by Departments and Shifts, MCH, Maracay, 2006-2008. ..........................................................83 Table 9 Age, Experience in Profession and Experience of Hospital Nurses, MCH, Maracay, 2006-2008. ............................................................................83 Table 10 Demographic Characteristics of the Focus Group Participants at MCH, Maracay, 2006-2008. .......................................................................................85 Table 11 Antecedents of Exposure of the Focus Group Participants at MCH, Maracay, 2006-2008. .......................................................................................86

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vii Table 12 Age, Experience in Profession, E xperience at Hospital, Experience in Position, Daily and Weekly Work Hours of the Focus Group Participants, MCH, Maracay, 2006-2008. .......................................................87 Table 13 Number of Needle s at all Four Departments Studied Before and After Educational Strategy, MCH, Maracay, 2006-2008. .........................................87 Table 14 Number and Percentage of Needles Counted by Departments Studied Before and After Educational Strategy, MCH, Maracay, 2006-2008. .............88 Table 15 Percentages of Needles No t Recapped by Departments Studied, by Months After the Educational St rategy, MCH, Maracay, 2006-2008. ............89 Table 16 O.R. of Needles Recapped C ounted by Departments Studied Before and After the Educational Strategy, MCH, Maracay, 2006-2008. ...................90 Table 17 Results of Answers from Pretest and Posttest Applied during Educational Strategy, MCH, Maracay, 2006-2008. .........................................91 Table 18 Number and Percentage of Compliance with Hepatitis B Vaccine 3Doses Schedule in Nursing Staff Who Participated in the Educational Strategy, MCH, Maracay, 2006-2008... ...........................................................92 Table 19 Needlestick Injuries by Years at MCH, Maracay, 2004-2009. ........................93 Table 20 Number and Percen tage of Needlestick Injuri es Distributed by Nurses, Nursing Students and Other Health Care Workers by Years, at MCH, Maracay, 2004-2008. .......................................................................................93 Table 21 Number and Percen tage of Needlestick Injuri es in Nurses from all Four Departments Studied vs. Othe r Units For 2007 and 2008 at MCH. ........94 Table 22 Number of Needle stick Injuries in Nurses and Nursing Students from Each of the Departments Studied vs. Those Departments Not included in the Study At MCH, 2007 and 2008. ............................................................95 Table 23 Rates of Needle stick Injuries per Occupi ed Hospital Beds, MCH, Maracay, 2004-2008. .......................................................................................95 Table 24 Rates of Needlestick Injuries in Other Health Care Workers, Nurses from Other Units and Nurses from the Departments Studied by Occupied Hospital Beds in 2007 and 2008, MCH, Maracay, 20062008..................................................................................................................96

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viii Table 25 Rates of Needlestick Injuries in Nurses from the Departments Studied by Occupied Departments Beds in 2007 and 2008, MCH, Maracay, 2006-2008. .......................................................................................................96

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ix LIST OF FIGURES Figure 1 Diagram of the PRECEDE Component ...........................................................54 Figure 2 Diagram of the PRECEDE Com ponent Applied to the Study Problem: Factors Surrounding Recapping Used N eedles as Cause of Needlestick Injuries in Nurses at the Maracay Central Hospital. ........................................55 Figure 3 Incorporation of the Cate gorization Scheme into PRECEDE Component .....................................................................................................115 Figure 4 Potential Use of PROCEED Component of the PPM for Future Research .........................................................................................................164

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x FACTORS SURROUNDING AND STRATEGI ES TO REDUCE RECAPPING USED NEEDLES BY NURSES AT A VENEZUELAN PUBLIC HOSPITAL Luis J. Galindez A. ABSTRACT Nurses as health care workers are at risk of biological agents such as bacteria, viruses and others. At health care settings exposure to bloodborne pathogens can cause infections through needlestick injuries. The objec tives of this research were to determine factors surrounding recapping needles in hospita l nurses and to implement an educational strategy to reduce th e recapping practices. It was a descriptive and exploratory a pproach where the PRECEDE component of the PRECEDE/PROCEDE Model was used as th e framework to systematize and analyze the information obtained from the focus group sessions. A total of 120 nurses participated from four different departments. The study was conducted in three phases: diagnosis, implem entation and evaluation of the educational strategy. The results obtained from the focu s group sessions revealed that predisposing, reinforcing, enabling and environment factors were related to the practice of recapping and needlestick injuries. Most of this inform ation represented the essential basis for the implementation of the educational strategy. Duri ng the diagnostic phase, the percentage of needles without recapping was 24% contra sting with 40% found af ter the educational strategy. The percentage diffe rence (16%) was statistically significant (p <0.001). The

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xi odds ratios calculation in the departments st udied showed that th e educational strategy was a protective factor to avoid the recapping of used needles. An important conclusion is that th e educational strategy, which focused on the practice and habit of what should be done (e.g., NOT recapping used needles), contributed to the decrease in recapping pract ice. However, nurses perceived did it not provide a safe working environment. The implications are focused on: nurses and hospital management have to engage in an active role to promote a safety work environment where nurses and other health care workers can be protected. The incorpora tion of educational strategies, continuous and updated training, as well as the evaluation and monitoring process can play a determinant role in the control of hazard e xposures. It is imperative that a safe and healthy workplace for the personnel be provided; not less important is the acquisition of equipment and devices for sharp handling and disposal, to complement the prevention of accidents related to needlestick injuries.

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1 CHAPTER ONE: THE STUDY PROBLEM Introduction to the Problem Nurses as health care workers (HCWs) have several challenges every day in their workplace in order to provide the best care to their patients. One of these challenges is to perform their work within numerous risks pr esent in health care settings such as: biological, chemical, mechanical, physical psychosocial and ergonomic factors. The occupational health of this group has long b een neglected both organizationally and by governments (Lipscomb & Rosenstock, 1997). The misconception exists that the healthcare industry is “clean and without hazard” (Wilburn & Eijkemans, 2004 p. 1). Leading the risks to HCWs including nurses ar e exposures to biological hazards that may result from needlestick or cuts from othe r sharp instruments contaminated with an infected patient’s blood or through contact of the eyes, nose, mouth or skin with a patient’s blood or bloody body fluids. Needlest ick injury is defined “as the parenteral introduction into the body of a health care worker, during the performance of his/her duties, of blood or other potentially infecti ous material by a hollow bore needle or sharp instrument, including but not limited to, needle s, lancets, scalpels, and contaminated broken glass” (Bandolier, 2003, p. 1). Shar ps mean hollow bore needles or sharp instruments, including but not lim ited needles, lancets and scalps. Needlestick injuries and other sharp relate d injuries due to occupational exposure to bloodborne pathogens are an important public he alth concern because of the severity of some of the infections that can result, in cluding Hepatitis B virus (HBV), Hepatitis C

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2 virus (HCV), Human Immunodeficiency Viru s (HIV), and other infectious agents. Globally, needlestick injuries (NSIS) ar e the most common source of occupational exposure to blood and the primary cause of bloodborne infections of HCWs (CDC, 2003b). The most common cause of injuries ha s been associated with certain work practices such as recapping, and the unsafe collection and disposal of sharps waste containers (WHO, 2003). In general, in developed countries, occ upational surveillance ev aluates and monitors the hazard related to bloodborne pathogens and prevention measures reduce the risk of transmission (Canadian Center for Occupational Health and Safety, 2000). There are problems that still happen worl dwide but in particular in developing countries. These are related to recapping used needles as a cause of needlestick injuries due to personnel work practices especially in hospital nurses, and because of lack of availability of safety devices, due main ly to the high cost of these devices. For these reasons there is an immediat e need to develop means for preventing needlestick injuries caused by recapping used needles and consequently prevent the risk of infection in health care workers, especi ally nurses who are th e group with the highest risk worldwide and mainly in developing c ountries (Prss-stn, Ra piti, & Hutin, 2003). Bloodborne Exposure and Needlestick Inju ries as a Public Health Concern The healthcare workforce, 39.5 million people worldwide, represents 13% of the working population (WHO, 2006). In the United St ates, there are an estimated more than 8.8 million health care workers who work in hos pitals and other health care settings (NIOSH, 2002). Epidemiologic data on sharps injury events, including the circumstances associated with occupational transmission of bloodborne viruse s are essential for

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3 targeting and evaluating interventions at the local and national levels. The CDC estimates 385,000 needlesticks and other sharps injuries per year among hospital workers in the United States (CDC, 2004). The true magnitude of the problem is di fficult to assess because information has not been gathered on the frequency of injuries among healthcare personnel working in other settings (e.g., long-term care, home healthcar e, private offices). In addition, although CDC estimates are adjusted for it, th e importance of underreporting must be acknowledged. Surveys of health care personnel indicate that 50% or more do not report their occupational percutaneous in juries (Abdel & Sepkowitz, 2000). Data from the EPINet system suggest th at at an average hospital worker incurs approximately 26 needlestick injuries per 100 beds per year for teaching hospitals and 18 injuries per 100 beds occupied for non-teac hing hospitals (US, EPINet, 2001). Some of these injuries expose workers to bloodborne pathogens that can cause infection. The National Institute for Occupational Safety and Health (NIOSH) in 1999 estimated that each year between 600,000-800,000 needlesticks and other sharps-related injuries are sustained in health care settings. Percut aneous exposure to blood, blood products, and infectious body fluids presents the greatest risk for disease transmission in the health care setting (Prss-stn, et al., 2003). Needlestick injuries account for approximately 80% of percutaneous exposures to blood among HC Ws. In November 2002, the World Health Report published data demonstrating that 2 million needlestick injuries occur in HCWs worldwide each year. It is al so estimated that 2.5 % of HIV, and 40% of Hepatitis B and Hepatitis C cases among health care workers worldwide are the result of occupational exposure (WHO, 2002a). The risk of transmi ssion to a HCW from an infected patient

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4 after such an injury has been one in three (1 /3) when a source patient is infected with HBV and is e-antigen positive, one in 30 (1/30) when the patient is infected with HCV, and one in 300 (1/300) when the patient is infected with HIV. HBV is the most easily transmitted bloodborne pathogen. Hepatitis B is 100 times more likely to be acquired than HIV after exposure to infected blood (Alter, 1997). Needlestick Injuries Accordi ng to the Job Classification Data from the United State National Survei llance System for Health Care Workers (NaSH) show that nurses experience the highest number of n eedlestick injuries. However, other professionals (physicians, t echnicians, and laboratory staff as well as support personnel as housekeeping) are also at risk (Wilburn, 2004). Nurses experience the majority of needlestick injuries in the wo rld including half of th e exposures that occur in the US (Prss-stn et al., 2003), and 70% of exposures occurring in Canada (CCOHS, 2000). In a study of 60 U.S. hospitals in a 4-year period, nurses were the most likely to experience a blood or body flui d exposure, nurses 44%, physicians 29%, technicians 13%, housekeeping 3%, and others 11% (U.S. Department of Labor, 1999). According to a European survey of occupa tional exposure of HCWs to needlesticks injuries, nurses are exposed more commonly (91%) than doctors (6%) or phlebotomist (3%), (Sulsky, Birk, Cohen, Luippold, Heid enreich, & Nunes, 2005). Consistent with patterns reported in the literature, HCWs most likely to be in direct patient contact were at the highest risk of needlestick injuries. Where Do Injuries Occur? Although sharp devices can cause injuries anywhere within the health care environment, NaSH data show that the major ity (40%) of injuries occur on patient units,

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5 particularly medical floors, intensive care units, and in th e operating room (CDC, 2004). According to Perry, Parker and Jagger (2005) the three most common sites for injuries are the operating rooms (33%), patient room ( 27%), and emergency department (10%). In the study of Sulsky et al., 2005, in European coun tries, NSIS were most likely to occur in patient room and operating room, locations wher e sharps were most possible to be used. Works Practices or Procedures Asso ciated with Needlestick Injuries Needlestick injuries have been associat ed with certain work practices such as recapping, transferring a body fluid between containers and failing to properly dispose of used needles in puncture-resistant sharps cont ainers. Injuries most often occur after use and before disposal of a sharp device (41 %), during use of a sh arp device on a patient (39%) and during or after disposal (16%) (CDC, 2004). NSIS are most likely to occur during use, with the second hi ghest rate associated with recapping used needles and disposal of used sharps. Safety Culture and Health Care Workers Some industrial sectors are finding that a strong safety culture is correlated with productivity, cost, product quality, and empl oyee satisfaction (Ger shon, et al., 2000). Organizations with strong safety cultures consistently report fewer injuries than organizations with weak safety cultures. This happens not only because the workplace has well developed and effective safety progr ams, but also because management, through these programs, sends cues to employees about the organization's commitment to safety. The concept of institutionalizing a culture of safety is relatively new for the healthcare industry and there is limited lite rature on the impact of such efforts. However, healthcare organizations are linked measures of safety culture with both employee compliance with

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6 safe work practices and reduced exposure to blood and other body fluids, including reductions in sharps related injuries (Gershon, 1996). According to Clarke, Sloane, & Aiken (2002), the risk of sharps in juries in nurses is significantly related to nurse staffing levels and working climate. System analysis strategies, used by many healthcare organizatio ns to improve patient safety, also can be applied to the prevention of sharps related injuries to healthcare personnel. Causes of Percutaneous Injuries with Hollow Bore Needles According to CDC (2004), and the Unite d State National Surveillance System for Hospital Health Care Workers (NaSH, 1999), th e main causes of percutaneous injuries with hollow bore needles were: manipulating ne edle in patient (27%), disposal related causes (12%), clean up (11%), improperly di sposed sharp and handling/passing device during or after use with 10%, collision with health care wo rker or sharp and IV linerelated causes with 8%, and hand ling/transferring specimens a nd recapping with 5%. It is important to emphasize that although recapping by hand has been prohibited under the OSHA bloodborne pathogens standard (29 CFR 1910.1030), (1991), needlesticks injuries are still related with this practice. Health care workers use many types of needles and other sharp devices to provide patient care. However, according to CDC (2004), and the NaSH (1999), only a few needles and other sharp devices are associated with the majority of injuries, 59% were associated with hollow bore needles. For Wilburn (2004), six devices are responsible for near ly 80% of all injuries, dispos able syringes (32%), suture needles (19%), winged steel needles (12%), scalpel blades (7%), intravenous (IV) catheter stylet (6%), and phlebotomy needles (3%).

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7 NIOSH in 1999, recognized that the characte ristics of devices wh ich increase the risk of injury included: devices with hollow bore need les; needle devices th at need to be taken apart or manipulated by the health care worker such as blood drawing devices that need to be removed after use; syringes that retain an exposed needle after use; and needles that are attached to tubing such as butterflies that can be difficu lt to place in sharps disposal containers. It is important to state th at technology exits that can pr otect HCWs from needlestick injuries but less than 15% of the hospitals in the United State use safer needle devices because of the cost in purchasing these de vices. Figures for other countries are not known, but uptake of safer devices is almost certainly lower outside the US, where there has been specific legislation (Bandolier, 2003). Impact of Needlestic k and Sharp Injuries Another aspect concerning needlestick and sh arp injuries is the emotional impact that can be severe and long lasting, even when an infection is not transmitted. This impact is principally severe when the injury involves exposure to HIV. But is not only the HCWs who are affected; the family member may su ffer emotionally from the needlestick and sharp injuries. In addition to their physical and emoti onal consequences, accidental needlestick injuries produce an enormous economic im pact. According to the American Hospital Association, a single case of serious bloodborne pathogen in fection from an accidental needlestick leads to more than $ 1 million in expenditures, from testing, follow-up, lost time, and disability payments. Current recommended drug regimens for high-risk exposures run from $850 to $1,000 for a 28 day supply (Shelton & Rosenthal, 2004).

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8 Statement of the Problem In Venezuela, inadequate industri al hygiene and unsafe conditions characterize many workplaces, including healthcare settings Venezuelan healthcare workers are faced with the challenge of providing the best ca re to their patients while facing risks of exposure to biological agents, particularly Hepatitis B, C and Human Immunodeficiency Virus (HIV). One of the greatest risk s for HCWs acquiring a bloodborne pathogen infection is through a needlestick or sharps injury in Venezuel an health care settings. Few studies have been done to date in hospitals to determine risk factors, which personnel may be exposed to a specific type of ri sk, the numbers of injuries/accidents among HCWs, activities more frequently involved in su ch injuries, or the relation between risk and associated health problems, etc. Cons equently, few measures of intervention are being taken to prevent or to correct risk factors to avoid health problems in people who work in health care settings In addition, Venezuela does not have safer needle device legislation mandating their use. The inform ation about the frequency of needlestick injuries reported in Aragua State in the years 2004 and 2005 was approximately 186 events; most of these events came from Mar acay Central Hospital w ith an average of 5 events per week (CORPOSALUD, 2004). It is im portant to point out th at according to the Maracay Central Hospital needlestick and sh arps injuries survei llance report the number of injuries has increased in the last 2 years, from 104 in 2004 to 113 in 2005, an 8% increase (MCH Surveillance report, 2005). Th e personnel involved in NSIS were nurses, nursing students, physicians and medicine st udents; the locations more frequently associated with NSIS were adult emergency room and operating room; the device involved were scalpels and needles representi ng the 77% (104/134) of the total accidents

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9 in the hospital for 2004 (MCH Surveillance report, 2005). It is important to indicate that the circumstances related to NSIS were not described in the surveillance report. The problem under study in this project is to understand the factors surrounding recapping used needles and needlestick inju ries as cause of bloodborne pathogens in nurses at the Maracay Central Hospital. Th e identification and exploration of these factors is necessary in order to gain a ri cher understanding of the conditions under which these nurses are working. O bviously, the identification of these factors is a very important step before interventions can be pla nned to reduce the incidence of this practice and the most important aspect is that if reducing recapping used needles, needlestick injuries and blood exposure can be preven ted in these workers. The educational intervention implemented was based on the acco mplishment of the Standard Precautions (OSHA, 2001) as a measure to avoid unsafe work practices (recappi ng used needles) and to prevent bloodborne pathogens diseases from needlestick injuries. The analysis was based on the measure of recapping used needle s proportion/rates in each of the four (4) selected departments as a uni que opportunity to evaluate the effectiveness of the intervention program. Purpose of the Study The purposes of this study were: a) to determine the factors surrounding recapping used needles in nurses in four (4) departme nts at the Maracay Central Hospital; b) based on the finding, design and implement an educat ional strategy in orde r to reduce recapping used needles practice as a cause of needle stick injuries and to prevent bloodborne pathogens diseases; c) to evaluate the intervention.

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10 Aims of the Study The primary aims of the study were as follows: 1. To determine reliable estimates of the incidence of needlestick injuries from needles and sharps in nurses working in four (4) departments at the Maracay Central Hospital. 2. To determine reliable estimates of the proportions/rates of recapping used needles used by nurses working at the four (4) departments of the Maracay Central Hospital. 3. To design an educational strate gy based on the factors surrounding recapping used needles. 4. To apply the educational strategy. 5. To evaluate the effectiveness of the educational strategy. 6. To report the results and suggest to the hospital and health authorities modifications regarding work safety practices. Research Questions 1. What are the factors related to recapping used needles in nurses working at the four (4) departments at the Maracay Central Hospital? 2. Does an educational strategy modify the proportions/rates of recapping used needles as an unsafe work practices? Significance of the Study This study provided important informa tion about the circumstances or factors associated with recapping used needles and how an educational strategy can modify such factors. Results from this study will inform Maracay Central Hospital and

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11 CORPOSALUD authorities on approaches that should be purposed to reduce recapping used needles practices in nursing personne l as a cause of NSIS, and to prevent bloodborne pathogens diseases initially in th e Maracay Central Hosp ital and after, in other public hospitals in the st ate. According to several stud ies, needlesticks and sharps injuries are preventable almost in 80% of situations. Obviousl y, one of the most important aspects is related to the educati on of health care work ers about occupational risks and adherence to infection control pr ocedures which are important to prevent exposure to bloodborne pathogens Rationale for the Study Little work has been performed at Venezuelan hospitals to determine the circumstances related to recapping used n eedles, needlestick injuries and bloodborne pathogens diseases. There are f actors associated with recappi ng used needles, needlestick and sharp injuries that can produce bloodbor ne infection. These factors could be environmental, educational, behavioral, a nd organizational among ot hers. According to Haiduven 2000b, health care professionals involve d in the prevention of needlestick and sharp injuries would benefit from the informati on that identified such factors in order to promote interventions. According to the study of Galindez a nd Haiduven, done in 2004 at the Maracay Central Hospital, Aragua, Venezuela, a volunt ary survey was applied to 129 health care workers, approximately 10% of the total hospital workers (2000 HCWs). The results showed 39 (30%) reported sustaining a need lestick or other sharps exposure and 113/129 (88%) reported routinely recapping used need les. The two activities most frequently involved in the exposures were blood w ithdrawal and disposal-related activities,

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12 involving 14.7% and 12% of the injuries resp ectively. Professional nurses sustained the majority of injuries (21/39) with the next highest frequency occurri ng in physicians and lab assistants (4/39). The laboratory and Obstet rics wards were locations with the highest frequency and percent of injuries (5/13 %) followed by the pathology and surgery room (4/10%). The circumstances most frequently re ported to contribute to needlestick injuries were recapping of used needles (23%) and ma nipulating the needle in the patient (21%). It is important to note that 35/39 (90%) of respondents w ho had sustained needlestick injuries reported recapping used needles as a routine procedure. Forty eight percent (18/39) recommended education and training programs in a manner to reduce the number of NSIS. Even though these results were obt ained from a voluntary and small sample the most important conclusion was the widespread practice of recapping used needles is an alarming and important finding i ndicating an area for possible intervention that could be targeted to prevent future needlestick and sharps injuries and consequently bloodborne pathogens diseases. Exploration into wards with the highest frequency of injuries should be conducted. For these reasons, this study has been designed to i nvestigate the factors surrounding recapping used needles and needlest ick injuries. After the identification of the factors is necessary to implement an educational strategy th at could reduce the number of recapping used needles and the numbe r of events of needlestick injuries in order to prevent bloodborne diseases.

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13 CHAPTER TWO: BACKGROUND AND LITERATURE REVIEW Recapping Used Needles as a Specific Problem Accidental needlestick injuries account fo r up to 80% of reported occupational needle exposures, and 45% of needle stick injuries o ccur at recapping (Dalton Blondeau, Dockerty, Fanning, Johnston, et al., 1992). In pa rticular, recapping used needles has been noted as a major risk factor for injury, lead ing to the US Occupational Safety and Health Administration (OSHA) prohibi ting the practice in most ci rcumstances. The habit of recapping persists, however, and interviews with HCWs suggest that their rationale for recapping has been management of competing risks (Sulsky, et al., 2005). Nevertheless, recapping or disassembly activity is not actually an important cause of NSIS in developed nations. According to the countries surveillanc e data, for example, in France, represent 4.6%, in Germany 3.98%, in Italy 1-18%, Sc otland 5%, in Spain 10%, in USA 3.6-6%, and UK 5.7% (Sulsky et. al., 2005). However, in developing countries compliance with no recapping needle policies is not a regular practice where there are similar situations such as unsafe work conditions in health ca re centers, unsafe work practices of the personnel and lack of safer needle device legislation ma ndating their use. Although of these problems, the frequency of recapping needle by health car e workers including nursing personnel has not been adequately reported. Additionally, there are few studies worldwide including U.S. about recapping used needles as a cause of needlestick injuries Most of the studies focus on needlestick injuries as main outcome measure and not about recapping practices. In the study of

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14 Henry, Campbell, Collier, and Williams (1994) they used recapping rates for comparison overall, all needles (370) were recapped 51% of the time. This rate did not differ significantly from the mean h ealth care workers self-repo rted rate of recapping. The observed recapping rates for different n eedles types was significantly different (phlebotomy needle recap rate, 55.9%; injection need les recap rate, 53%; IV needle recap rate, 34.2%. p< 0.01). It is notew orthy that 5% of all needles were left uncapped and then placed in the trash or left at bedside. Most of the needles that were recapped (79%) were recapped by two hand technique. They affirm that the study was focused on needle techniques and disposal. The major problem observed with needle technique was the high rate of recapping. Most of the recapping ra te observed among both nurses and physicians involved the use of two hands. According to Sulsky et al., (2005), a compre hensive literature s earches on MEDLINE identified more than 2,300 publications, about needlestick/sharp injuri es, initial searches were complete on November 4, 2004 and update on April 26, 2005. Sixty one (61) publications on interventions were selected to be included in the Quality Based Critical Review (QBCR) in those papers the main out come measure was need lestick injury rate. The possible reason for this difference would be related to that recapping procedure was forbidden in US in the 1990s (OSHA legisl ation) and new safety device has been incorporate into the health care industry and then numerous studies are focus on needlestick rates as outcome measure than other types of measurements. Bloodborne Pathogens Twenty years after the onset of the AIDS epidemic and widespread recognition of health care providers’ risks of occupati onal exposures to bloodborne pathogens,

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15 needlestick injuries remain a prominent issue for health professionals (Clark et al., 2002). To understand the severity of the problem about the factors rela ted to needlestick injuries, it is necessary to revi ew the main diseases associated to this problem. There are more than twenty bloodborne pathogens but th e most related to needlestick injuries are Hepatitis B virus, Hepatitis C virus and Human Immunodefiency Virus (HIV). Concern about these diseases has prompted research to find out why these in juries occur and to develop measures to prevent them. Hepatitis B Hepatitis B is a serious disease that is caused by the Hepatitis B virus (HBV) which usually exists in the blood and bodily fluids of the infected (or HBV+) person. The virus infects people of all ages and every year; about 200,000 people are newly infected in the United States (AMA, 2004). Of these people, 90 % eventually recover and clear the virus, but over 11,000 will have to be hospitalized and over 20,000 (10%) will become chronically infected with the virus (A MA, 2004). Chronic HBV is found in 0.5% of adults in the United States and in 0.1%-20% of people from other part of the world (Chin, 2000). In the U.S. more than 4,000 people die ea ch year from Hepatitis B related liver disease. An estimated 15%-25% of pers ons with chronic HBV infection will die prematurely of either cirrhosis or hepatocellular carcinoma (Heymann, 2004). Worldwide Distribution Hepatitis B is distributed worldwide. The World Health Organization (WHO, 2002b) estimates that more than 2 billion persons ha ve been infected with HBV. Of this, more than 350 million have chronic (lifelong) in fections. The prevalence of chronic HBV infection varies markedly around the world. High rates of infection, defined as prevalence

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16 greater or equal to 8%, occur in China, S outheast Asia, the Paci fic Basin, sub-Saharan Africa and the Amazon Basin. In Western Eu rope, North America, Australia and New Zealand, the prevalence of ch ronic infection are low (< 2%), and infection occurs predominantly in adults. Intermediate preval ence of infection, betw een 2% and 7%, occur elsewhere in the world (WHO, 2002b). Modes of Transmission Major modes of HBV transmission include sexual or household contact with an infected person, perinatal tran smission from mother to infa nt, injecting drug use and nosocomial infection. In health care settings the transmi ssion occurs by percutaneous (intravenous (IV), intramuscu lar (IM), subcutaneous (SC), or intradermal) and permucosal exposure to infective body flui ds (Heymann, 2004). The concentration of HBV in body fluids is high for blood, seru m and wound exudates, moderate for semen, vaginal fluid, saliva and low/not detectable for urine, feces, sweat, tears and breast milk (CDC, 2003b, WHO, 2002b). Clinical Characteristics The clinical presentation of acute HBV ra nges from asymptomatic, subclinical illness to fulminant hepatic failure. The disease has a long incubation period from 45-180 days, with an average of 60-90 days (Heymann, 2004, Chin, 2000). Initial symptoms are nonspecific, and typically include malais e, anorexia, vomiting, fever, rash, and polyarthritis; these symptoms last 3-10 days This is followed by the onset of jaundice and/or dark urine. Fulminant vi ral hepatitis is defined as th e development of severe acute liver failure with hepatic encephalopathy with in 8 weeks of the onset of symptoms with jaundice. About one-third to one-half of pe rsons with acute HBV infection develops

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17 symptoms of hepatitis such as jaundice, fever, nausea, a nd abdominal pain. Most acute infections resolve, but 5% to 10% of patie nt develop chronic infection with HBV that carries an estimated 20% lifetime risk of dyi ng from cirrhosis and 6% risk of dying from liver cancer (Shapiro, 1995). HBV and Health Care Workers The rate of HBV transmission to susceptib le health care workers ranges from 6% to 30% after a single needlestick exposure to an HBV-infected patient (CDC, 1997). However, such exposures are a risk only fo r health care workers who are not immune to HBV. Health care workers who have anti bodies to HBV either from pre-exposure vaccination or prior infection are not at ris k. The most distinctive laboratory finding of viral hepatitis is dramatic elevations of aminotransferases (ALT and AST), but the diagnosis of HBV rests on specific serologi c testing, with the finding of HBV surface antigen (HBsAg) in the serum during the acute phase. Any person seropositive for Hepatitis B surface antigen is potentially infectious. Prevention The Hepatitis B vaccine has been ava ilable since 1982. Two types of Hepatitis B vaccines have been licensed in the USA and Canada. Both have been shown to be safe and highly protective against all subtype s of HBV (Heymann, 2004). The vaccines currently used in the Unite d States are made with recombinant DNA technology, and contain protein portions of HBV (usually part s of the outer protein or the surface antigen of HBV). Thus, the vaccines do not contain any live virus. The vaccine is administered intramuscularly in three doses usually gi ven on a schedule of 0, 1, and 6 months, but there can be flexibility in this schedule (WHO, 2002b & CDC, 2003a). More than 95% of

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18 children and adolescents and more than 90% of young, healthy adults under the age of 40-50 years develop adequate immunity fo llowing the recommended three doses (CDC, 2003a). Persons who respond to the vaccine are protected from bot h acute Hepatitis B infections as well as chronic infection. The higher the anti body titer after vaccination, the longer anti HBs persists. Vaccine-induced antib odies decline gradually with time, and as many as 60% of those who initially respond to vaccination will lose detectable anti-HBs by 8 years (CDC, 2001a). Boosters doses of vaccine are not routinely recommended, because persons who respond to the initial vaccine series remain protected against clinical hepatitis and chronic infection even when their anti-HBs level become low or undetectable (CDC, 2001a). Older age, obesity, heavy smoking, and immunologic impairments have been associated with lowe r anti HBs responses. One of the problems is that the vaccine is expensive, particularly considering that three shots are required, and for now, beyond the reach of poor countries (Krasner, 2002). Health Care Workers Vaccination Hepatitis B vaccination of hea lth care workers who have contact with blood and other potentially infectious materials (body flui ds) can prevent transm ission of HBV and is strongly recommended (CDC, 2003b). However, such exposures are a risk only for health care workers who are not immune to HBV. If a susceptible worker is exposed to HBV, post-exposure prophylaxis with Hepatitis B im mune globulin and ini tiation of Hepatitis B vaccine is more than 90% effective in pr eventing HBV infection (NIOSH, 1999). Even though exposure to HBV causes a high risk fo r infection, administration of pre-exposure vaccination or post-exposure prophylaxis to wo rkers can considerably reduce the risk. In these recommendations, the treatment is based on the type of the source (positive,

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19 negative or unknown) and the status of hea lth care workers vaccination (Appendix A). Nevertheless, there is no known cure for Hepa titis B. Thus, prevention is the best option to dealing with this disease. Hepatitis C Hepatitis C virus (HCV) infection is th e most common chronic bloodborne infection in the United States affecting an estimated of 3 million of people (Krasner, 2002). At the same time it is one of the most significant causes of chronic liver disease (NIAID, 1998; Krasner, 2002). Approximately 75%-85% of these persons are chronically infected and may not be aware of their infection due to a l ack of clinical symptoms. However, infected persons can serve as a source of transmission to others and are at ri sk for chronic liver disease or other HCV-related chronic diseas es during the first two or more decades following initial infection (AMA 2004). Chronic liver disease is the tenth leading cause of death among adults in the United States. It is estimated from population-based studies that 40% of chronic liver disease is HCV-related, resulting in an estimated 8,000–10,000 death each year (NIAID, 1998; Krasner, 2002). HCV associated end-stage liver disease is the most frequent indication for liver tran splantation among adults. Because most HCV infected persons are aged 30–49 years, the numbe r of deaths attributable to HCV-related chronic liver disease could increase substa ntially during the next 10–20 years as this group of infected people reaches ages at wh ich complications from chronic liver disease typically occur (Krasner, 2002). Worldwide Distribution The distribution of the Hepatitis C is worldw ide. The prevalence is directly related to the prevalence of persons who routinely share injection equipment a nd to the prevalence

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20 of poor parenteral practices in health car e setting (Heymann, 2004). WHO estimated that as of the late 1990s, about 1% of the worl d’s population was infected with HCV. In Europe and North America the prevalence is between 0.5% and 2.0%; in parts of Africa prevalence is over 4%. Modes of Transmission The Hepatitis C virus is primarily pare nterally transmitted (transfusion, and or parenteral contact with blood products). Sexual transmission has been documented to occur but is far less efficien t or frequent than parenter al route (Heymann, 2004). The high risk groups are drug users; pe ople who receive blood transfus ion; employment in client care or clinical laboratory work; exposure to a sex partner or hous ehold member with a history of hepatitis; exposure to multiple sex partners and low socioeconomic level (Krasner, 2002). Clinical Characteristics The clinical presentation of acute HCV is usually insidious, with anorexia, vague abdominal discomfort, nausea and vomiting; pr ogression of jaundice is less frequent than with Hepatitis B. The incubation period for He patitis C is 6 to 7 weeks, and nearly all persons with acute infection will have chr onic HCV infection occur with persistent viremia and the potential for transmission of HCV to others. Alt hough initial infection may be asymptomatic or mild, a high percentage (between 50% and 80%) will develop a chronic infection (Chin, 2000). Of these chro nically infected persons, about half will eventually develop cirrhosis or ca ncer of the liver (Heymann, 2004).

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21 HCV and Health Care Workers The exact number of healthcare personne l who acquire HCV occupationally is not known. Healthcare personnel exposed to blood in the workplace represent 2% to 4% of the total new HCV infections occurring annua lly in the United States, a total that has declined from 112,000 in 1991 to 38,000 in 1997 (A lter, 1997). However, there is no way to confirm that these are occupational transm issions. Prospective studies of health care workers exposed to HCV through a needlestick or other percutaneous injury have found that the incidence of anti-HCV seroconve rsion (indicating infection) averages 1.8% (range, 0% to 7%) per injury (CDC, 1998a). Prevention Currently, it is not possible to prevent HCV infection after exposure. However, recent data suggest that early treatment of acute HCV infection with interferon may be highly effective in preventing chronic HCV in fection (Sulkowski et al, 2002). Recently, ribavirin is available for the treatment of HCV infection but, unfortunately, the results are disappointing (Krasner, 2002). Fu rther clinical studies are under way, and it now appears that the combination of inte rferon and ribavirin clears th e virus from about 40% of patients, whereas only 20 to 30% are help ed with interferon al one (Krasner, 2002). At present, no vaccine exists to prevent HCV in fection. In fact, the only means of preventing new cases of Hepatitis C are to screen the blood supply, encourage hea lth professionals to take blood and body fluid precautions, and to inform people about high risk behavior (NIAID, 1998, CDC, 1998b). Neither imm unoglobulin nor antiviral therapy is recommended as post-exposure prophylaxis. He alth care workers with known exposures

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22 should be monitored for seroconversion and re ferred for medical follow up if conversion occurs. The primary method of preventing occupa tional HCV transmission is to reduce exposures by implementing the Bloodborne Pa thogens Standard, using safer devices for accessing blood, and providing education and counseling for health care workers (Haiduven, 2000a & Sulkowski et al., 2002). Th e importance of such administrative, technical and educative measures is undersco red by the lack of commercially available vaccinations to prevent HCV infection. HCV and Health Care Institutions Health care institutions should consider implementing recommended policies and procedures for follow up for HCV infection af ter percutaneous or mucosal exposures to blood. CDC Personnel Health Guidelines (1998a & 2001c), affirms immune globulin not to be administered to health care work ers who have exposure to blood or body fluids positive for antibody to HCV. Instead, the gui delines recommend that administration should consider implementing policies for post-exposure follow-up at baseline and 6 months for health care personnel who have ha d a percutaneous or mucosal exposure to blood containing antibody to HCV. Acco rding to Haiduven, (2000a) health care institutions have an ethical and moral respon sibility to educate health care workers, who are at risk for the disease about screening, treatment and prevention, and to identify and compensate those who acquire HCV in the course of their employment. It is important for infection control and employee health to mon itor the literature and regulatory standards for changes requiring policy revision (Haiduven, 2000a).

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23 Human Immunodeficiency Virus Human Immunodeficiency Virus (HIV) is the virus that causes Acquired Immunodeficiency Syndrome (AIDS). HIV inf ection is a complex disease that can be associated with many symptoms. The virus attacks part of the body’s immune system, eventually leading to severe infections and other complications producing a condition known as AIDS a fatal disease. In the summer of 1981, the U.S. Centers for Disease Control and Prevention (CDC) reported the unexplained occurrence of Pneumocystis carinii pneumonia in previously healthy homose xual men in Los Angeles and of Kaposi's sarcoma (KS) in other homosexual men in Ne w York and Los Angeles. Within months, the disease became recognized in injection drug us ers and soon thereafter in recipients of blood transfusions in hemophili acs. As the epidemiologic pattern of the disease extended, it became clear that a microbe transmissi ble by sexual (homosexual and heterosexual) contact and blood or blood produc ts was the most likely etio logic agent. The evaluation of the patients showed that they had in co mmon a marked deficiency in cellular immune responses. The term Acquired Immunodeficien cy Syndrome (AIDS) first appeared in 1982 in CDC Morbidity and Mortality Weekly Re port and was described as “a disease, at least moderately predictive of a defect in cell-mediate d immunity, occurring with no known cause with diminished resistance to that disease” (CDC, 1982, p. 508, CDC, 2001). In 1984, the HIV virus type 1 (HIV-1 ) was discovered as the primary causative viral agent. In 1986, the virus ty pe 2 (HIV-2) was isolated fr om patients in West Africa, where it may have been present decades earlier (UNAIDS, 2004).

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24 Worldwide Distribution According to the Joint United Nations Program on HIV/AIDS, between 2000 and 2020, over 68 million people will die of AIDS prematurely in the 45 countries most affected by the disease (UNAIDS, 2004). In the year 2003, the number of people living with HIV worldwide was 38 million (UNAIDS, 2004). Just fewer than 5 million people became infected with HIV more than any y ear before and almost three million were killed by AIDS (UNAIDS, 2004). As many as 950,000 Americans may be infected with HIV, one-quarter of who are unaware of thei r infection. The epidemic is growing most rapidly among minority populati ons and is a leading killer of African-American males ages 25 to 44. AIDS affects nearly seven tim es more African Americans and three times more Hispanics than whites (UNAIDS, 2004). Cu rrent trends show cases increasing in injecting-drug users, women, blacks, hisp anics, adolescents/young adults, and among persons infected through heterosexual contact wi th a partner at risk for or known to have HIV infection or AIDS. AIDS is the fourth l eading cause of death worldwide, the number one cause of death due to infectious diseas e, and has exceeded malaria as the number one killer in Africa (Krasner, 2002). Clinical Characteristics The spectrum of HIV infection ranges fr om an asymptomatic state to severe immunodeficiency and associated opportuni stic infections, neoplasms, and other conditions. Initial infection can be followed by an acute flu-like illness. Features include fever, lymphadenopathy, sweats, myalgia, arth ralgia, rash, malaise, sore throat, and headache (Strickland, 2000). The natural histor y of HIV infection can vary considerably from person to person. Infection with HIV viru s does not initially constitute AIDS. The

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25 term AIDS applies to the most advanced st ages of HIV infection after an incubation period that can vary from a few years to as many as 15 years. CDC's definition of AIDS in 1993 included all HIV-infected people w ho have fewer than 200 CD4+T cells (Thelper cells) per cubic millimeter of blood (Goldsby, Kindt, Os borne, & Kuby, 2003). In addition, the definition includes 26 clinical cond itions that affect people with advanced HIV disease. Most of these conditions are oppor tunistic infections that generally do not affect healthy people. In people with AIDS these infections are often severe and sometimes fatal because the immune system is so destroyed by HIV that the body cannot fight off certain bacteria, viruses, fungi, pa rasites, and other microbes. One of the best examples is the TB and HIV relationship. Each accelerates the other’s progress. TB is the leading cause of death in HIV infected popul ations, accounting for about 15% of deaths (Krasner, 2002). HIV and Health Care Workers To estimate the rate of HIV transmissi on, data were combined from more than 20 worldwide prospective studies of health care workers exposed to HIV-infected blood through a percutanous injury (NIOSH, 1999) In all, 21 infections followed 6,498 exposures for an average transmission rate of 0.3% per injury (Ippolito et al., 1999). A retrospective case-control study of HCWs w ho had percutaneous exposures to HIV found that the risk of transmission was increased when the worker was exposed to a larger quantity of blood from the pati ent, as indicated by (1) a visibly bloody device, (2) a procedure that involved placing a needle in a patient's vein or artery, or (3) a deep injury (Cardo, Culver & Ciesilski, 1997). Preliminary data suggest that such high-risk needlestick injuries may have a substantially greater risk of disease transmission per

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26 injury (Bell, 1997). According to the CDC Surveillance of Hea lthcare Personnel with HIV/AIDS of the adults reported with AI DS in the United States through December 31/02, 24,844 had a history of employment in healthcare (CDC Surveillance, 2002)). These cases represented 5.1% of the 486,826 AIDS cases reported to CDC for whom occupational information was known. The type of job is known for 23,212 (93%) of the 24,844 reported healthcare personn el with AIDS. The “other” category is comprised of maintenance workers, administrative staff, a nd other nonmedical staff. Overall, 73% of the healthcare personnel with AIDS including 3,962 nurses, 1,407 nonsurgical physicians, 385 dental workers, 328 paramedi cs, and 92 surgeons, are reported to have died. Fifty-seven healthcare personnel in th e United States have been documented as having seroconverted to HIV following o ccupational exposures. Twenty-six have developed AIDS. The exposures resulting in infection were as follows: 48 had percutaneous (puncture/cut injury) exposure; 5, mucocu taneous (mucous membrane and/or skin) exposure; 2, both percutane ous and mucocutaneous exposure; and 2, an unknown route of exposure. Forty-nine h ealthcare personnel were exposed to HIVinfected blood; 3, to concentrated virus in a laboratory; 1, to visi bly bloody fluid, and 4, to an unspecified fluid. According to surveillance conducted by the CDC, of 57 healthcare workers with documented occupationally acquired HIV infec tion, most (86%) were exposed to blood, and most (88%) had percutaneous injuri es. The circumstances varied among 51 percutaneous injuries, with the largest pr oportion (41%) occurring af ter a procedure, 35% occurring during a procedure, and 20% occu rring during disposal of sharp objects. Unexpected circumstances difficult to anticip ate during or after pr ocedures accounted for

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27 20% of all injuries. Of 55 known sour ce patients, most (69%) had acquired immunodeficiency syndrome (AIDS) at the time of occupational exposure, but some (11%) had asymptomatic HIV infection. Eight (14%) of the hea lthcare workers were infected despite receiving post-exposure prophylaxis (Do, et al., 2003). Transmission of HIV in the health care setting may result from three types of exposures: percutaneous (e.g., needlestick or cut caused by a sharp object), mucous membrane (eyes, mouth, nose), and direct contact with nonintact skin (e.g., in case of dermatitis, eczema, laceration, or open wound). Contact of intact skin is considered to be a potential source of transmission of HIV, especially when extens ive areas of skin are contaminated and the duration of exposure is prolonged (e.g., at le ast several minutes). The main sources of HIV transmission among health care personne l are blood, visibly bl oody fluids, tissues, and HIV concentrates. Other sources include semen, vaginal secretions, and synovial, peritoneal, pleural, pericardial, cerebros pinal, and amniotic fluids (CDC, 1998c & 2001a). Specific characteristics of a high-risk e xposure have been defined by a case-control study of health care personnel that pooled data from the United States, France, United Kingdom, and Italy (Cardo, et al., 1997). Thir ty-three patients with seroconversion (case patients) were compared with 665 exposed c ontrols without seroc onversion, regarding to the specific characteristics of the exposure. Data analysis showed that significant risk factors for seroconversion included deep inju ry, injury with a de vice that was visibly contaminated with the blood of a source patie nt, a procedure involvi ng a needle placed in the artery or vein of the s ource patient, and exposure to a source patient who died of AIDS within 2 months of the exposure (Cardo, et al., 1997). Accordi ng to this study, the

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28 risk of transmission of HIV after percutan eous exposure when the source patient has terminal AIDS, for example, is increased ap proximately six-times compared with source patients with earlier infection. Prevention The bottom line is that there is no cure fo r AIDS, and there is no preventive vaccine. Actually, there are drugs that can be used fo r treatment of HIV infections such as the antiviral drug zidovudine (AZT) and recently, other drugs named protease inhibitors are used for HIV infection treatment. However, little information exists from which the efficacy of post exposure prophylaxis (PEP) in humans can be assessed. Seroconversion is infrequent following an occupational exposure to HIV-infected blood (CDC, 2001). The use of ZDV as PEP was associated with a reduction in the risk of HIV infection by approximately 81% (Cardo et al., 1997). Althoug h the results of this study suggest PEP efficacy, its limitations include the small numb er of cases studied and the use of cases and controls from differ ent cohorts (CDC, 2001). The risk of HIV transmission among health care personnel can be prevented by a twopart strategy. First, interventions must be directed to decrease the risk of occupational exposures, and second, if exposure has occurred, post exposure monitoring and prophylaxis should be delivered promptly (F erreiro & Sepkowitz, 2001) In this sense, the Center for Disease Control and Pr evention (CDC, 2003b) offers the following recommendations. Healthcare personnel shoul d assume that the blood and other body fluids from all patients are potentially infectious. They s hould therefore follow infection control precautions at all times. These precau tions include: the routine use of barriers (such as gloves and/or goggles) when an ticipating contact with blood or body fluids;

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29 washing hands and other skin surfaces imme diately after contact with blood or body fluids; and the careful handli ng and disposing of sharp instruments during and after use. Although the most important strategy fo r reducing the risk of occupational HIV transmission is to prevent occupational exposures, plans fo r postexposure management of health care personnel should be in place. CD C has issued guidelines for the management of HCP exposures to HIV and recommendati ons for post-exposure prophylaxis (PEP) (Appendix B). The recommendations are based on the type of postexposure (percutaneous injuries or mucous membrane exposures and nonintact skin exposures). The criterions are exposure time and infec tion status of source (HIV-positive-class 1/class2, unknown HIV st atus, HIV-negative). In addition to providing emotional support, the counseling of health care workers with high-risk exposures must stress nece ssary behavioral changes (CDC, 1998c & CDC, 2003b). These include sexual abstinence or condom use for up to a 6-month period, avoidance of pregnancy among female worker s, and discontinuati on of breast-feeding. Other measures include refrai ning from donating blood, organs, tissue, or semen, even in those sustaining low-risk exposures. Ther e is no indication to alter patient-care responsibilities. Health care workers should be strongly a dvised to report any syndrome that may indicate acute HIV infection, such as mononucleosis-like syndrome, fever, rash, malaise, fatigue, nausea, arthralgia, lym phadenopathy, and neurologic symptoms, among others (CDC, 2003b). Needlestick and Sharps Inju ries Prevention Strategies Prevention of percutaneous injuries and othe r blood exposures is an important step in preventing the transmission of bloodborne viru ses to healthcare pe rsonnel. The current

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30 Federal standard for addressing needlestick injuries among health care workers is the OSHA Bloodborne Pathogens Standard ( 29 CFR 1910.1030; 56 Federal Register 64004, 1991). The standard applies to all occupationa l exposures to blood or other potentially infectious material. Important elements of th is standard require the following: a) written exposure control plan designed to eliminat e or minimize worker exposure to bloodborne pathogens, compliance with universal precauti ons; b) engineering controls and work practices to eliminate or minimize workers e xposure; c) personal protective equipment (if engineering controls and wo rk practices do not eliminat e occupational exposure); d) prohibition of bending, recapping, or removing contaminated needles and other sharps unless such an act is required by a specific pr ocedure or has no feasible alternative; e) prohibition of shearing or breaking contaminat ed needles; f) free Hepatitis B vaccinations offered to workers with occupational expos ure to bloodborne pathoge ns, worker training in appropriate engineering controls and work practices post-exposure evaluation and follow-up, including post-exposure prophylaxis when appropriate. Hierarchy of Controls In the last years healthcare organizations have adopted as a prevention model the hierarchy of controls concept used by the health and safety profession to prioritize prevention interventions (CDC, 2004). In the hierarchy for sharps injury prevention, the first priority is to eliminate and reduce the use of needles and other sharps where possible using substitution control measures. Next is to isolate the hazard, thereby protecting an otherwise exposed sharp, th rough the use of an engineer ing control. When these strategies are not available or will not provide total protection, the focus shifts to workpractice controls and persona l protective equipment.

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31 Substitution is the best alternative to e liminate or reduce the hazard. Prevention of needlestick injuries is possible by analyzi ng the hazards and applying control measures using a hierarchy of controls starting with the elimination of unnecessary sharps and injections to eliminate the hazard. Needlele ss IV systems, recommended by the Food and Drug Administration in 1992, remove an unnecessa ry sharp and reduce the risk of injury (Gartner, 1992; Yassi, McGill, & Khokhar, 1995). Eliminating unnecessary injections by using oral instead of injectable medications eliminates the hazard (u nless not available or less effective). According to the Sharps Injury Pr evention Workbook (CDC, 2004), healthcare organizations are working to eliminate or redu ce needle use in several ways. The majority (70%) of U.S. hospitals (Pugliese, Bart ley, & McCormick, 2000) have eliminated unnecessary use of needles through the implem entation of IV delivery systems that do not require (and in some in stances do not permit) need le access. Other important strategies for eliminating or reducing needle use include: using alternate routes for medication delivery and vaccination when av ailable and safe for patient care, and reviewing specimen collection systems to identify opportunities to consolidate and eliminate unnecessary puncture s, a strategy that is good for both patients and healthcare personnel. Engineering controls use principles of substitution, isolation, enclosure, or ventilation. In the context of sharps inju ry prevention, engineering controls include sharps disposal containers and needles and other sharps devices with an integrated engineered sharps injury prevention featur e. The emphasis on engineering controls has led to the development of many types of devices with engineered sharps injury

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32 prevention features (ECRI, 2000) and there are suggested criteria for the design and performance of such devices. Safety f eature characteristics listed by NIOSH for evaluating and selecting need lestick injury prevention pr oducts (NIOSH, 1999) include: the device is needleless; the safety feature is an integral part of the device; the device preferably works passively (re quires no activation by the user). If user activation is necessary, the safety feature can be engaged with a single-handed technique and allows the worker’s hands to remain behind the exposed sharp; the user can easily tell whether the safety feature is activat ed; the safety feature cannot be deactivated and remains protective through disposal; the device performs reliably; th e device is easy to use and practical; the device is safe a nd effective for patient care. The 2000 U.S. Needlestick Safety and Preven tion Act established the requirement for health care settings to use engineering cont rols known as safer n eedle devices (OSHA, 2001). Safer needle devices have been shown to reduce 62% to 88% of all needlestick injuries (Jagger, 1996; CDC, 1997). These devi ces blunt, sheath, or retract the needle immediately after use and are available in injection equipment (syringes), IV access devices, lancets, and phlebotomy needles. Res earch suggests that no si ngle safety device or strategy works the same in every facilit y. In addition, no standard criteria exist for evaluating safety claims, although all ma jor medical device manufacturers market devices with safety features. Therefore, em ployers must develop their own programs to select the most appropriate technology and ev aluate the effectiveness of various devices in their specific setting.

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33 Administrative Controls Effective needlestick injury prevention m easures include poli cies, administrative procedures and work practice controls such as educating workers about hazards, implementing standards precautions, elimina ting needle recapping, and providing sharps containers for easy access that are within sight and arm’s reac h (Haiduven, DeMaio, & Stevens, 1992; Jagger, 1996). Standard Precautions (Universal Precautions) is an infection control principle that treats a ll human blood and other potentially infectious materials as infectious. This is an importan t concept and an accepted prevention approach with demonstrated effectiveness in prev enting blood exposures to skin and mucous membrane. Standard Precautions also mean that healthcare workers use personal protective equipment to prevent direct cont act with a patient's blood or body fluids. Standard Precautions are designed to reduce the risk of transmission of bacteria, viruses among others from both recognized and unrecognized s ources of infection in health care settings. The constant practice of Standard Pr ecautions is one of the best methods that healthcare workers can use to protect th emselves from occupational exposure. According to CDC 2004, another important element of a sharps injury prevention program is the education and training of hea lthcare personnel in shar ps injury prevention. As part of the program planning process, careful thought should be given to how and when training is provided to en sure that those who need traini ng receive it, the training is relevant to those who are being trained, and that educational effo rts are sustained over time.

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34 Personal Protective Equipment Personal protective equipment (PPE) is sp ecialized clothing and equipment worn by an employee for protection against a hazard such as blood or other potentially infectious materials. PPE includes gloves, gowns, masks, eye protection, face shields and any equipment that can protect health care workers in their daily tasks. General work clothes for instance, uniforms, pants, shirts not inte nded to function as prot ection against a hazard are not considered to be personal protective equipment (OSHA, 1991). PPE should be readily available and provided to the empl oyee at no cost. Employees should never put themselves at risk of exposure to bloodbor ne pathogens by not using the appropriate protective equipment. PPE should be removed after use. Care should be taken not to contaminate the skin. Soiled gowns, gloves, et c. should be disposed of in a biohazard container immediately at the point of use and hands thoroughly washed. Safety Culture and Health Care Workers Some industrial sectors are finding that a strong safety culture correlates with: productivity, cost, product quality, and empl oyee satisfaction (Gers hon, et al., 2000). The concept of institutionalizing a culture of safety is relatively new for the healthcare industry and there is limited lite rature on the impact of such efforts. According to Clarke et al., 2002, the risk of sharps injuries in nur ses is importantly related to nurse staffing levels and working climate. System anal ysis strategies, used by many healthcare organizations to improve patient safety, also can be applied to the prevention of sharpsrelated injuries to healthcare personnel. Th ese strategies include the following: defining "Sentinel Events" and performing a "Root Ca use Analysis" to determine their underlying

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35 cause; applying "Failure Mode Analysis" to a problem pre-event to systematically identify how to prevent it from occurring (CDC, 2004). Other important aspect is related to healthcare personnel who have difficulties changing long-standing practices. This observa tion is borne out by studies conducted in the years following implementation of unive rsal precautions, when observed compliance with recommended practices was not satisfactor y (Evanoff, et al., 1999), especially in older nurses who may be more resistant to adopt new ways of wo rking (Osborne, 2003). The same holds true for devices with safe ty features-healthcare organizations have difficulty convincing healthcare personnel to adopt new devices and procedures (Gershon, et al., 1999). Psychosocial and organiza tional factors that slow the adoption of safety practices include: risk-taking personal ity profile, perceived poor safety climate in the workplace, and perceived conflict of in terest between providing optimal patient care and protecting oneself from exposure (Ger shon, et al., 1995). Pe rsonnel most readily change their behavior when they think that they are at risk, the risk is significant, behavior change will make a difference, and the change is worth the effort (Simpkins, Haiduven & Stevens, 1995). Combination of Measures In the literature reviewed, a ll the researchers are in agre ement that to effectively reduce the problem about needlestick and sharp injuries, more than one measure needs to be taken. In fact, a combinati on of measures should be inst ituted and directed towards healthcare workers: education and informati on about standard precautions, adoption of devices with safety features and review of th e critical point in th e practical procedures, disposal and elimination of de vices (IV catheters, IV stylet phlebotomy needles, butterfly

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36 needles, and syringes). In this aspect, the utilization of multi component prevention approach is a way to diminish the needlesticks and sharp injuries in health care setting. Experts agree that safety devices and work practices alone will not prevent all sharps injuries (Davis, & AHA, 1999). Significant dec lines in sharps injuries also require: education, a reduction in the use of invasive procedures (as much as possible), a secure work environment, and an adequate staff-to -patient ratio. These are parts of something called multi-component prevention approaches. One report detailed a program to decrease needlestick injuries that involv es simultaneous implementation of multiple interventions: formation of a needlestick pr evention committee for compulsory in-service education programs; out-sourcing of replacement and disposal of sharps boxes; revision of needlestick policie s; and adoption and evaluation of a needleless IV access system, safety syringes, and a prefilled cartridge needleless system (Gershon, Pearse, Grimes, Flanagan & Vlahov, 1999). This strategy showed an immediate and sustained decrease in needlestick injuries, leading researchers to conclude that a multi-component prevention approach can reduce sharps injuries. New Safety Devices Obviously, the introduction of devices with safe ty features could l ead to a significant reduction in the number of injuries from n eedles because healthcare are protected even when there is behavior indicating lack of education on a specific, or hurried maneuvering in urgent situations, or major attention to the care to the patient rather than to one's own safety. But the elevated costs of these device s do not currently allow their large-scale use in hospitals (Clarke, et al, 2002). In consideration of cost containment and reduction of the number of injuries, a compromise soluti on would be to identif y those hospital units

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37 where percutaneous injuries could be prevente d with devices with sa fety features and to introduce their use in these alone. However, the choice to adopt devices with safety features should not be based on economic aspect s alone, as even if the number of HBV, HCV or HIV preventable infections in healthcare workers is not great, it bears ethical and legislative implications. Preventing Needlestick Injuries and Quality Health Care Preventing needlestick injuries and resulting infections is possible and necessary to provide quality health care. While Clarke et al., (2002) demonstr ated the relationship between short staffing and needlestick injuri es, appropriate staffing is difficult to maintain when health care workers are unable to work due to work-related injuries and illness. Nursing shortages are exacerbated by uncontrolled occupational hazards and further made worse by the nurses’ fear of bringing a life-threatening illness home to their families. In 2000, 88% of nurses responding to a web based occupational health survey, indicated that the risk of o ccupational hazards determine whet her they will continue to work in nursing and in what clinical area (ANA, 2001). Needlestick Injuries and Cost The risks and costs associated with a blood exposure are serious and real. Costs include the direct costs associated with th e initial and follow-up treatment of exposed healthcare personnel, which are estimated to range from $500 to $3,000 depending on the treatment provided (USGAO, 2000). Costs that are harder to quantify include the emotional cost associated with fear a nd anxiety from worrying about the possible consequences of an exposure, direct and indir ect costs associated w ith drug toxicities and lost time from work, and the societal cost associated with an HIV or HCV

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38 seroconversion. The latter includes the possible lo ss of a worker's services in patient care, the economic burden of medical care, and the cost of any a ssociated litigation. Health Care Workers and HIV or Hepatitis Status Other essential aspect to be considered is not discriminating against health care workers on the basis of real or perceived HIV status or hepatitis infection. According to the International Labor Orga nization (ILO, 2001), HIV inf ection is not a cause of termination of employment indicating that pe rsons with HIV-related illnesses should be able to work for as long as medically fit (ILO, 2001). Nurses who are infected with HIV or Hepatitis whether from occupational exposur e or not, should be able to work in the health care workplace as long as their health a llow. In the case that the disease has been acquired from a previous undocumented exposure, the health care provider has a moral and ethical responsibility to counsel and educate these empl oyees and to protect their confidentiality, illustrating the principles of beneficence and autonomy (Haiduven, 2000a). Needlestick Injuries and Developing Countries According to Wilburn, (2004) in developing countries, where the prevalence of HBV, HCV and HIV infected patients is the highest in the world, the number of needlestick injuries is also the highest. For example, African health care workers suffer on average two to four needlestick injuri es per year and over half of the hospitalized patients in South Africa are HIV positive (Pruss-Ustiun et al., 2003). In some regions of Africa and Asia close to half of all Hepatitis B a nd C infections among health care workers are attributable to contaminated sharps. In some areas of the Eastern Mediterranean region over two-thirds of Hepatitis B and C infections in health care workers are attributable to

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39 contaminated sharps. Over two thirds of all Hepatitis B in Central and South American are the result of occupational expos ure (Pruss-Ustiun et al., 2003). As consequence, the problem to face in these countries is multifaceted and requires more than one way to solve the situation about needlestick and sharp in juries. In this case is not only that some governments can not afford the new technological devices and vaccines (Hepatitis B), but also how to convi nce health authoritie s to promote policies and regulations to be implemented in health care settings to avoid needlestick injuries. According to Prss-stn et al., (2003), th e measures could be: to acquire preventive Hepatitis B vaccine to be used not only in health care workers but also in the general population, to establish a written exposure cont rol plan, to use engineering controls, to enforce work practice controls, to provide adequate personal prot ective equipment, to make available Hepatitis B vaccine, to pr omote and develop procedures to follow up people exposed to bloodborne pathogen; to us e labels and signs to communicate hazards, to provide information and training to em ployees, to maintain employee medical and training records, and to promote and develop a cu lture of safety in health care setting. In summary, the OSHA’s Bloodborne Pathogens Sta ndard needs to be implemented. On the other hand, aspects related to human beings need to be aboard, for example, change behavior in daily tasks, open mind to ne w technology and procedures, and to be stimulated to an ongoing educati on and training program (CDC, 2004).

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40 CHAPTER THREE: VENEZU ELAN HEALTH SECTOR Characteristics about Venezuela Demographic Context According to Pan-American Health Orga nization (PAHO, 2002), the population in 2000 was estimated at 24,896,379 inhabitants with a demographic density of 26.37 inhabitants by km2. In 2000, 87.2% of the inhabitants liv ed in urban areas and 12.8% in rural areas. Of this population, 50.3% are me n and 49.7% are women. In terms of age, 45.2% are younger than age 19, while 50% ar e between 19 and 65, and 4.3% are older than 65. Between 1995 and 1999 the life expectancy at birth remained steady at 72 years (PAHO, 2004). Legal Framework of Health in Venezuela The Constitution of the Boliv arian Republic of Venezuela (1999) establishes in the Article 83 that health is a fundamental social right and the responsibility of the State, which must/shall guarantee it as part of the right to life. All persons have the right to protection of health, as well as the duty to participate actively in their protection, and to fulfill with such health and hygiene measures as may be established by law, and in accordance with international conventions and treaties signed and ratified by the Republic. In order to guarante e the right to health, the St ate is promoting a National Public Health System integrated with the Social Security System and governed by the principles of gratuity, universality, comp leteness, fairness, so cial integration and

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41 solidarity according to the ar ticle 84. Furthermore, the St ate is responsible for the financing of the Public Health System as was established in the Article 85. Organization of Venezuelan Health Sector The public health sector is composed by the Ministry of Health and Social Development, the Venezuelan Social Security Institute, the Social Welfare Institute of the Ministry of Education, and the Armed Forces In stitute of Social Welfare. In Venezuela, more than 2,400 institutions exist in the ar ea of health (PAHO, 2002). These institutions belong to the public as well as the pr ivate sectors, including nongovernmental organizations (e.g. Red Cross). The public sect or bears the greatest responsibility for providing health services to the general popula tion. There are serious lim itations in health services coverage and the network ability to respond to health care is insufficient. Health expenditures as a percentage of Gross Do mestic Product (GDP) were 4.06% showing a tendency to decline. Such decline is shar per in the area of pu blic spending (PAHO, 2004). All the public health establishments are part of a network of hospitals and outpatient clinics, and conduct promotional activiti es, prevention, and health education. The outpatient and hospital establishments belong to the National Public Health System and are organized according to their level of comple xity and problem solving capacity such as primary level and secondary level of care (PAHO, 2004). Primary level of care: Establishments which seek to deliver comp rehensive health services of the public subsector should adjust to the characteristics that pertain to them in keeping with the following classification: Rural Outpatient T ype I and II, which provide comprehensive, general, and family medical care at the primary level, except for hospitalization, and

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42 which are located in populati ons of less than 10,000 inhabitants. Urban Outpatient Type I, II and III, which provide comprehensive ge neral, family, and specialized medical care, do not provide hospitalization, and are locate d in populations of over 10,000 inhabitants. In practice, coverage is limited, and most interventions of health promotion, community participation, and disease prevention are c onducted by the physicians during their year of social service, and by Simplified Medicine A uxiliaries in the Outpatient Rural I and II setting, oriented to scatte red rural environments and populations of less than 1,000 inhabitants. Secondary level of care: Facilities that seek to deliver hospitalization services to the public subsector provide comprehensive me dical care at the primary, secondary, and tertiary level. They are classified as Type I, II, III, and IV Hosp itals, as a function of several characteristics, most notably by the population served, numbe r of beds, and level of complexity. Type I Hospitals are located in populations of up to 20,000 inhabitants, with a demographic catchment area of up to 60,000 inhabitants. They have between 20 and 50 beds and are organized to provid e medical services, surgery, pediatrics, gynecology and Obstetrics. Type II Hospitals are located in populati ons of more than 20,000 inhabitants, with a demographic catc hment area of up to 100,000 inhabitants. They have between 50 and 150 beds and are or ganized to provide services of greater complexity than the previous level. Type III Hospitals are located in populations of more than 60,000 inhabitants, with a demographic catchment area of up to 400,000 inhabitants. They have between 150 and 300 beds and are or ganized to provide services of greater complexity than the previous level. Type IV Hospitals are located in populations of more than 100,000 inhabitants, with a dem ographic catchment area of up to 1,000,000

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43 inhabitants. They have more than 300 beds and are organized to provide services of greater complexity than the previous level. The hospitals with the highest problemsolving ability are located in the capital c ity and in the State capitals. The problemsolving ability of the hospitals is very limite d; there are long waiting lists for surgery and outpatient care, and there are often shortages/de ficiencies in essential supplies for care. In Venezuela, there are 296 hospitals in th e network of public establishments and 344 hospitals in the private sector. In 2000, there were 40,675 public hospital beds in the governmental sector (17.6 beds per 10,000 popul ation). A public hospita l receives all of its funding from the government (PAHO, 2004). Approximately 53,818 physicians, 14,676 professional nurses and 31,629 nurse's ai des are registered in the MSDS. In 1999, there were 19.7 physicians and 7.9 nurses per 10,000 populations (PAHO, 2004). It is important to notice that there are more phys icians than professional nurses. Venezuela suffers a shortage of professional nurses. The Venezuelan professional nurses have undertaken a deep transformation in the last 15 years. At this mome nt the organizations responsible for the formation are the Un iversities or Colleges and Technological Institutes. The technological on es supply the formation of supe rior technicians in nurses with three (03) years of study. The Universiti es are training profe ssionals (License in nurses) in five (05) years. Venezuela Health Profile During the period of 1983 to 2000, 8,047 cases and 4,726 deaths due to HIV/AIDS were reported. According to UNAIDS, underrepo rting in Venezuela was estimated at around 80% basically for lack of adequate su rveillance systems. At the same time 62,000 people throughout the country were HIV carriers in 2000 (PAHO, 2004).

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44 Blood banks conduct tests to detect HIV, He patitis B, and Hepatitis C among others. In 1999, the highest prevalence found from the screening of 202,515 donors was for Hepatitis B at 5.9%; for Hepatitis C at 0.8%; and for HIV at 0.4% (PAHO, 2002). There are not available statistics related with wh ich percentage would be associated with occupational exposure. The incidence of He patitis B in Venezuela is 2%. There are 450,000 HBsAg positive persons in a populat ion of 24,000.000 (19/ 1 000 population) (PAHO, 2004). There are not data ava ilable for occupational exposure. Occupational Health and Safety Laws The National Constitution of the Bolivarian Republic of Venezu ela was enacted in 1999 and it was the first Venezuelan Constitution that included aspects related to health and workplace conditions. In ar ticle 87, it stipulates that a ll persons have the right and duty to work. The State guarantees the adopti on of the necessary measures so that every person must/shall be able to obtain productive work providing him or her with a dignified and decorous living and guarantee him or her full exercise of this ri ght. It is an objective of the State to promote empl oyment. Measures tending to gua rantee the exercise of the labor rights of self-employed persons sha ll be adopted by law. Freedom to work must/shall be subject only to such restric tions as may be established by law. Every employer must/shall guarantee employees adeq uate safety, hygiene and environmental conditions on the job. The State must/shall adopt measures and create institutions such as to make it possible to control and promote these conditions. The Organic Law of Prevention, Conditi ons, and Workplace E nvironment published on 26 July 2005 states that its purpose is to guarantee conditions of safety, health, and well-being to workers in a suitable work e nvironment that is propitious for exercising

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45 their physical and mental capabili ties, recreation, use of free time, and social tourism. Its purpose is also to regulate the responsibili ties of employers in cases of occupational illness or injury caused by their fraud or negligence. The National Institute of Occupational Prev ention, Health and Safety at Workplace has assumed the responsibility for the policy of workers' health, in accordance with the Organic Law on Prevention, Conditions and E nvironment at Workplace by means of the control and the promotion of safety and hea lth in the workplace. The objective is to achieve the commitment of all sectors of workers and employers to develop diverse programs directed to the education and in formation of workers regarding the risks inherent in the activities undertaken, in order to avoid occupa tional accidents and diseases. The promotional work on the health of workers itself is focused on specific activities for communication and education fo r the creation, constituti on and operation of the of Occupational Safety and Health Committees; educational agreements with Universities that provide for Postgraduate Studies in Occupationa l Health and with International Agencies; and programs for upda ting technicians and professionals on the disciplines that make up this area. Accordi ng to the Institute, in Venezuela 17 industrial accidents occur each hour, 410 occur every da y, 2,885 occur each week, 12,500 occur in a month and 150,000 occur every year. Of the to tal industrial accidents, 15,000 result in permanent injury with some level of disa bility in the workers. Approximately 1,500 (10%) die every due to such industrial a ccidents (INPSASEL, 2004). These numbers are greater than the rate s of any epidemic of dengue, malaria, HIV/AIDS, and even car accidents. It is a serious public health problem that must be targeted with great priority (INPSASEL, 2004). Regarding occupational dise ases, musculoskeletal disorders, noise-

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46 induced hearing loss, and pulmonary diseases are the most common reported according to the Institute statistics. There is not in formation about health care workers. There are also guidelines of the hygiene a nd industrial safety conditions which were enacted in 1968 and modified in 1973. These gui delines are specifically oriented to apply to the manufacturing industry. Additionally, there are some guidelines called "Normas Covenin." Some of these are related to hygi ene and safety in hospital settings, but the majority of these guidelines are oriented to the manufacturing industry. In summary, Venezuela has general laws related to hygi ene and industrial safety conditions in workplaces but there are few guidelines related to HCWs and hospital ac tivities. Aragua State Characteristics The State of Aragua is located in the north -central region of Venezuela, approximately 100 km west of Caracas, Venezuela. In 2001, Aragua had an estimated population of 1,450,000. Maracay is the capital and most importan t city of the Aragua State. Most of it falls under the jurisdiction of the Girardot Municipality. The populat ion as per the 2001 census was 750,000 (PAHO, 2004). Health Sector Organization The Health in the State is administrated by the Corporation of Health in Aragua, CORPOSALUD, that is an autonomous in stitute which dependent on the State Government created by law to develop the Stat e Health System and to administrate and operate health care facilities around the state. CORPOSALUD represen ts and applies the policies of the Ministry of Health and Social Devel opment (CORPOSALUD, 2004).

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47 The Structure of the System of Health in Aragua The organization is the same illustrated for Venezuela. There are 203 establishment of health care in Aragua State, 30 are in the capital of the State (M aracay). Additionally, there are 5 hospitals in entire State; the biggest is the Maracay Central Hospital located in the capital (CORPOSALUD, 2004). Maracay Central Hospital The Maracay Central Hospital is a tertiary hospital of reference and short stay (Type IV). It serves not only the stat e of Aragua but also the neighb or states as well as to other states of the country. It has been an institu tion founded for more than 30 years, represents the most important health center in Aragua State, with a capacity of 470 beds and a worker population of 2,000 people approximately The Maracay Central Hospital is one of the main reference centers in the central area of Venezu ela. One of the most recent outpatient specialties of the hospital is the Occupational Medicine Service, with a physician in Occupational Health. Also, the hospital has one Epidemiologist physician (Ph.D.) and one Infection Control Specia list who works to prevent and control nosocomial infections. One of the functions is to perform surveillance for occupational accidents including needlesticks injuries. Ther e is a teaching hospita l affiliated with the Medical School of the Univer sity of Carabobo and others Universities and it provides clinical education for me dical and nurses students (CORPOSALUD, 2004). In 2003, physicians and nurses, represent more than 70% of the total workers in the hospital (CORPOSALUD, 2004). The occupational risks found are similar among hospitals of Venezuela. These include physical, chemical, biological, a nd psychological risks as well as risks of musculoskeletal

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48 disorders. There is not information about the number of occupational diseases. The information about the incidence of needlestick injuries reported in Aragua State in 2004 and 2005 was approximately 186 cases per year; most of these cases came from Maracay Central Hospital (MCH) with an average of 5 cases per week (CORPOSALUD, 2006).

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49 CHAPTER FOUR: THEO RETICAL FRAMEWORK PRECEDE/PROCEED MODEL Background The PRECEDE-PROCEED Model (PPM) is a theoretically strong model that addresses comprehensive planning in health promotion and health education (Greene & Kreuter, 1999; Social and Behavioral Sciences Applied to Health l ectures, University of South of Florida, 2003). This model was orig inally developed by Lawrence W. Green in 1968 in order to evaluate health education programs and guide their development. The PROCEED component was added to the model by Marshall Krueter in the late 1980s in recognition of the emergence of and need fo r health promotion interventions that go beyond traditional educa tional approaches to changing unhe althy behaviors. This model is multidimensional, founded in the social/behavioral sciences, epidemiology, administration and education. Components of the Model The model has two components: the PREC EDE and the PROCEED (Appendix C). The PRECEDE stands for predisposing, reinfo rcing, enabling, environmental assessment factors and the PROCEED com ponent incorporates policy, re gulatory, and organizational constructs. There are two propos itions emphasized throughout this model: a) health and health risk have multiples determinants, and b) because health and health risks are determined by multiples causes, efforts to affect behavioral, environmental, and social

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50 change must be multi-dimensional or multisectoral (Haiduven, 2000b; Social and Behavioral Sciences Applied to Health lect ures, University of South of Florida 2003). There are six basic phases involved in the complete PPM; however, valuation of the interventions in the PROCEED portion can exte nd the model to many as nine phases. The six basic phases are as follows: (a) social a ssessment, (b) epidemiological assessment, c) behavioral and environmental assessment, d) educational and ecological assessment, e) administrative and policy assessment, and f) implementation and evaluation (Green & Kreuter, 1999). The goals of the model are to explain health-related behaviors and environments, and to design and evaluate the interventions needed to influence both the behaviors and the living condi tions that influence them and their consequences. The comprehensive nature of PRECEDE component allows for applicati on in a variety of settings such as school health education, pa tient education, commun ity health education, and direct patient care setti ngs (Green & Kreuter, 1999). The PRECEDE model component contains predisposing, reinforcing, enabling, and environmental assessment factors (Fig. 1). All these factors can influence a given health behavior or decision. Predisposing factors are an individual’s or group’s knowledge, attitudes, beliefs, values, and perceptions that positively or negatively influence motivation for a behavioral change (Green & Kreuter, 1999, p. 40). According to Green & Kreuter, (1999), attitudes are relatively constant feelings directed toward something or someone that always contain an evaluative dimension. Attitudes can always be categorized as posit ive or negative” (Green & Kreuter, 1999, p. 164). In the perspective of this study, it refers to attitudes toward recapping of needles, safety, report a needlestick injury, and comp liance with Standards Precautions (Universal

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51 Precautions) among others. Beliefs are convictions that a phe nomenon is true or real (Green & Kreuter, 1999, p. 162). A potent motivator related to beliefs is fear (Green & Kreuter, 1999, p. 163). In the context of this st udy, it refers to beliefs that consequences of a needlestick injury are tr ue or real linked to bloodborne diseases (e.g., Hepatitis B, Hepatitis C or HIV). Knowledge is the cognitive learning that results from awareness. ( Green & Kreuter, 1999, p. 158) It is usually a necessary bu t not always a sufficient cause of individual or collective behavior change. In other words, at least some awareness of a particular health or quality-of -life need and of some behavior that can be taken to address that need must exist before that behavior will o ccur (Green & Kreuter, 1999, p. 159). For example, in this study was th e awareness of nurse s’ experiences or experiences of others regarding needlestic k injuries, recapping of used needles, bloodborne diseases, etc that mi ght predispose nurses toward or against the goal behavior (safe practices). Values are preference for life goals or ways of life that are often shared within a culture or commun ity (Haiduven, 2000b). In this study, examples are values placed on safety of patients, quality care, and values placed on personal safety and other colleagues’ safety. Reinforcing factors are those consequences of acti on that determine whether the action receives positive or negative feedback and are supported socially after it occurs (Green and Kreuter, 1999, p. 171). Reinforci ng factors are the rewards and punishments received. Rewards may sustain continuation of the target behavior while punishments might influence cessation of the behavior (Haiduven, 2000b). Reinforcing factors are factors following a behavior that provide th e continuing reward or incentive for the persistence or repetitio n of the behavior.

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52 Enabling factors facilitate the performance of an action by individuals or organizations. These include “availability, acce ssibility and affordability of resources” (Green & Kreuter, 1999, p. 167). This category al so includes skills, reso urces or barriers that can affect behavioral and environmen tal changes (Haiduven, 2000b). It is important to add that enabling factors are cond itions of the environment (Haiduven, 2000b). According to Green and Kreuter (1999) environmental factors are those external to an individual, often beyond of his her control, determinants outside the person that can be modified to support behavior, health, or quality of life of that person or others affected by that persons’ actions.” (p. 40). Environmental conditions can either positively or negatively influence behavioral risk factors for a disease, condition, or health related behavior (Haiduven, 200b). PROCEED Component The PROCEED component incorporates policy, regulatory, and organizational constructs with the purpose of designing interventions to overcome barriers that may be identified in the PRECEDE component. In Green and Kreuter work (as cited in Haiduven, 2000b), policy is the set of objectiv es and rules guiding activities in an organization, which also provides authority for resource allocation. Regulatory refers to the process of enforcing polic ies, rules or laws. Organiza tion refers to the act of implementing a program, including coordi nation of necessary resources. The identification of priorities a nd setting of objectives from PRECEDE provide the objects and criteria for PROCEED.

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53 Applications of the PRECEDE-PROCEED Model The PPM assessment has been applied in community settings across several health problems, including domestic violence smoking among women, cervical cancer screening among African Ameri can women among others (G reen & Kreuter, 1999), as well as the health care or counseling setting, including patient education, nutrition counseling, smoking-cessation, and self care programs (Green & Kreuter, 1999). Also the PPM have been applied to assist in school settings for curriculum planners, administrators, parents, teachers, and advocates for children to meet the ongoing challenge creating health promoting school s (Green & Kreuter, 1999). For example, Ransdell in 2001 used the PPM to increase productivity in he alth education faculty. The PPM also has been used as a framework for studying worker self-pro tective behaviors in the construction industry (Dedobbeleer & Ge rman, 1987). Brosseau, Parker, Lazovich, Milton, and Dugan, in 2002, used the model for designing interven tion effectiveness studies for occupational health and safety in the Minnesota wood dust study. In 2004, the model was used in a health science teachi ng in the Democratic Republic of the Congo (Parent, Kahombo, Bapitani, Garant, C oppieters, Levque1 and Piette, 2004). In this, study, the PRECEDE component (e ducational and ecologi cal assessment) was used as a theoretical framework to identify the circumstances surrounding recapping needles as cause of needlestick injuries in nurses in the Maracay Central Hospital, using the predisposing, reinforcing, enabling and environmental factors (see Figure 2). In studying the circumstances in this nursing staff, it was necessary to utilize a theoretical framework that accounts for all the factors th at interact in influe ncing this behavior.

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56 CHAPTER FIVE: METHODOLOGY The purpose of this chapter is to explain in detail the different methodological tools that were incorporated in this investiga tion. A before and after design, with focus group sessions and a theoretical model base of th e PRECEDE/PROCEED mode l were part of a triangulation methodology wher e qualitative and quantitativ e methods were used. Methodological Triangulation According to Bryman (1988) “triangulati on refers to the use of more than one approach to the investigation of a research question in order to enhance confidence in the ensuing findings” (p 1). Sometimes this mean ing of triangulation is taken to include the combined use of quantitative research and quali tative research to determine how far they arrive at convergent findi ngs. For example, a study in the United Kingdom by Hughes et al., (1997) of the consumption of “des igner drinks” by young people employed both structured interviews and focus group. The two sets of data were mutually confirming in that they showed a clear patte rn of age differences in attitudes toward these types of alcoholic drinks. Triangulation is sometimes used to refer to all instances in which two or more research methods are employed. Thus, it might be used to refer to multimethod research in which a quantitative and a quali tative research method are combined to provide a more complete set of findings than could be arrived at through the administration of one of the methods alone. This study was planned and developed usi ng different methodologies: quantitative (descriptive analysis), qualit ative (focus group), Wolcott tr ansformation qualitative data

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57 methodology, and the PPM approaches. The quantitative approach allowed the description and analysis of the information obtained in the questionnaire to be applied before the beginning of each focus group as well as the data obtained from each department about the used needles counted before and after the educational strategy. Aspects related to work hours and problems w ith continued educati on were discussed in the focus group sessions. The qualitative appr oach was conducted through focus groups that allowed obtaining information that was us ed later to prepare th e educational strategy. In order to analyze the information obtai ned in the focus group sessions, the author followed the methodology suggested by Wolcott to use three levels (Description/Categorization, Analysis and In terpretation). The PRECEDE component of the PPM was used to systematize and integrate the information obtained in the focus group sessions. In summary, all these methodolog ies were used as a complementary tool to accomplish the objectives as well as to answer the research questions of the investigation. It is im portant to emphasize that triangulation allowed th e author to get the results obtained that may not have been achieved by only one method alone. Study Design In this study, a before-and-after design was proposed, a type of non-experimental design commonly used in safety studies. Th e word terminology, “before” refers to a measurement being made before an interv ention is introduced to a group and “after” refers to a measurement being made after its introduction (CDC, 2001c). This type of study provides preliminary evidence for safety intervention effectiveness. A safety intervention is defined as an attempt to cha nge how things are done in order to improve safety (CDC, 2001c). Within the workplace it could be any new program, practice, or

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58 initiative intended to improve safety (e.g. engineering intervention, training program, or administrative procedure). There are some reasons to select this desi gn: a) is most useful in demonstrating the immediate impacts of short term programs, in fact, is less useful for evaluating longer term interventions; b) there are not previous studies related to recapping used needles and needlestick injuries in Venezu elan public hospitals; c) this preliminary study attempts to implement an educational strategy based on th e factors surrounding recapping needles as a cause of needlestic k injuries and bloodborne diseases in nursing staff at the Maracay Central Hospital. Threats to Internal Validity Threats to internal validity are possi ble alternative explanations for observed evaluation results. According to the CDC guide to evaluating the effectiveness of strategies for preventing work injuries (2001c), there are some possible threats to internal validity that can affect the before-after-desi gn such as history and the Hawthorne effects. History effects: this threat occurs when one or more events, which are not part of the intervention but could affect the outcome, ta ke place between the “before” and “ after” measurements. The opportunities for history th reats to arise in safety intervention evaluations are considerable because of th e complex nature of the workplace and its environment. This effect was not present at the time this research was conducted. The Hawthorne effect involvement of outsiders could have an effect on the outcome, independent of the key intervention component. To avoid this potential Hawthorne effect, the researcher visited on a daily basis until his presence seemed to no longer create a reaction and the visits became c onstant during the study period.

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59 Focus Groups Overview Focus groups were originally called "focus ed interviews" or "group depth interviews.” The technique was developed during World War II to explore morale in the U.S. military (Krueger & Casey 2000) and after World Word II was used to evalua te audience response to radio programs (Stewart & Shamsdasani, 1990). Since then social scientists and program evaluators have found focus groups to be useful in unde rstanding how or why people hold certain beliefs about a topic or program of interest. Focus group is a descriptive design with a qua litative data collection me thod. According to Kruger and Casey (2000), a focus group is a special t ype of group in terms of purpose, size, composition, and procedures. The purpose of a focus group is to listen and gather information. It is a way to better understand how people feel or think about an issue, product or service. It is po ssible with this technique to generate discussion among participants about topics that they mi ght not bring up in everyday conversation (Haiduven, 2000b). Participants are selected because they have certain characteristics in common that relate to th e topic of the focus group. Characteristics of Focus Groups According to Krueger and Casey (2000), fo cus group interviews have some features: are people, who possess certain characteris tics, provide qualitative data, in focused discussion, to help understand the topic of intere st. Focus group participants are similar to each other in a way that is important to the re searcher. The nature of this homogeneity is determined by the purpose of the study. The goa l of a focus group is to collect data that are of interest to the researcher in order to find the range of opinions of people across several groups.

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60 When to use Focus Group interviews Focus group interviews should be considered when: (a) the research er is searching for the range of ideas or feelings that people ha ve about a specific t opic; (b) the purpose is to uncover factors that influence opinions, behavior, or motivation. Focus groups can provide insight into complicated topics when opinions are conditional or when the area of concern relates to multifaceted behavior or motivation (Krueger & Casey, 2000). Advantages of using Focus Group According to Marczak and Sewell (1998), ther e are several advantag es of the use of focus groups to study a specific topic, for in stance, provide data more quickly and at lower cost than if individuals were interv iewed separately; groups can be assembled on shorter notice than for a more sy stematic survey; the researcher can interact directly with respondents (allows clarification, follow-up questions, probing); can gain information from non-verbal responses to supplement (or even contradict) verbal responses; data uses respondents' own words; can obtain de eper levels of meaning, can make important connections. Additional advantag es are designed to produce a great deal of information, including experiences an d opinions of participants, in a relatively short time (Morgan & Krueger, 1998). Disadvantages of using Focus Group Focus groups are not without disadvantage s, which include the threat of social desirability; attempts of group members to c onform and therefore be unwilling to express different opinions; the risk of some persons not responding at all or group reluctance to discuss sensitive issues; or one or more members monopolizing the conversations or exhibiting unnecessarily nega tive behavior (Haiduven, 2000b) Other disadvantages are

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61 small numbers and convenience sampling severely limit the ability to generalize to larger populations; requires a carefully trained in terviewer who is knowledgeable about group dynamics; and the moderator may knowingly or unknowingly bias results by providing cues about what types of responses ar e desirable (Marczak & Sewell, 1998). Participants in a Focus Group Participants should be systematically a nd purposefully selected. In focus groups, the goal is to have a homogenous (similar in terms of background, employment level, experiences etc.) audience, but with sufficien t variation among the participants to allow for contrasting opinions. To achieve this goal is very important to select people who are close to the objective of the st udy, in this case, nurses who ha ve certain characteristics in common, such as experience with circumstan ces regarding needle stick injuries and experience with recapping used needles that are helpful in the study. They are what are called “information-rich” cases. They are purposef ully selected so that the researcher can learn, in detail, about issues of central importance to the study (CDC, guidelines to evaluating the effectiveness of strategies for preventing work injuries, 2001c). Developing Effective Questions According to Krueger & Casey (2000, p. 40, 41), focus group questions should be carefully structured and sequenced, and based on the purpose of the st udy, a review of the literature and consultation with experts has to be done. There are some qualities that a good question has to meet: a) sound conversationa l questions help create and maintain an informal environment; b) use words the partic ipants use when talking about the issues. The questions have to be reviewed by people si milar to the target audience to make sure the language is understandable; c) questions have to be clear, participants should

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62 understand what is the moderator asking; d) qu estions have to be short, lengthy questions can be confusing to respondents, f) questi ons are usually open-ended, are a hallmark of focus group interviewing. This type of ques tion allows the responde nts to determine the direction of the respon se (Kruger & Casey, 2000). Analysis in Focus Group In focus group the analysis begins by goi ng back to the intent of the study. A key principle is that the depth or intensity of analysis is determined by the purpose of the study. According to Krueger and Casey ( 2000, p. 128), there are some characteristics related to analysis process: systematic, sequential, verifiable and continuous Systematic analysis is deliberate and planned. Systematic analysis means that the analysis strategy is documented, understood, and able to be clearly articulated by each member of the research team. As the same time analysis is a sequential process. Systematic and sequential analyses procedures help ensure that results will reflect what was shared in the groups. Verifiable: researcher must continually be careful to avoid the trap of selective perception. For analysis to be verifiable th ere must be sufficient data to constitute a trail of evidence. The data stre am begins with field notes and recordings taken during each focus group, continues with the oral summary (verification) of key points during each group, and goes into the debriefing with the moderator team immediately following the groups. Continuous: in focus group analys is begins in the first focus group. The analysis is done concurre ntly with data collection. Each subsequent group is analyzed and compared to earlier group. Different ways of capturing data are used as the basis for analysis: transcripts, audiotapes, notes and memory (Krueger & Casey 2000, p. 130, 131). Transcript based

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63 analysis uses full-length transcripts of the focus group as a basis for the analysis. These are often supplemented with field notes take n by researchers. The researcher reads the transcript and makes notes, codes sections, or develops categories. It is used for academic purpose. Tape based approach relies on listeni ng to a tape recording of each focus group and then developing a condensed transcript of the relevant and useful portions of the discussion. According to Wolcott (1994), data from th e transcripts will be analyzed doing a process entitled “ transformation”, where the transforma tion of qualitative data can be broken down into three ways. The first level is called “description” and is designed to answer the question, “What is going on here?” In this le vel, the “data consist of observations made by the researcher and/or reported to the re searcher by others” (Wolcott, 1994, p. 12). It is important during th e descriptive level th at researchers allow the data to speak for itself, using the partic ipants’ own words whenever possible. Wolcott offers ten strategies for completing this leve l of transformation. In order to develop this level, the author used as strategy to follow an analytical framework. The second level of transformation is “analysis” which addresses th e identification of essential features and the systematic description or interrelationships among them-in short how things work (Wolcott, 1994). This level requires that there be systematic and caref ul attention to the data to identify key factors and relati onships (Wolcott, 1994). Wolcott offers ten strategies for completing this level of transf ormation. For this level, the author used the PRECEDE component as analy tical framework to guide th e data collection. The third level of transformation is “int erpretation” is designed to a ddress questions of meanings and contexts to answer the que stions, “How does it all mean?” “What is to be made of it

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64 all?” It is important in this level that th e links between the qualitative and descriptive inquiry and the interpretation are clear and relevant (Wolco tt, 1994). Wolcott lists eleven ways to conduct interpretation and states that interpretati on is where “the researcher transcends factual data and cautio us analyses and begi ns to probe into what is to be made of them” (p. 36). For this purpose, the author followed to extend the analysis part as a strategy mentioned by Wolcott. Reliability and Validity of Focus Group Concern about reliability and validity apply to qualitative data, just as they do to quantitative data. According to the CDC guidelines to evaluate the effectiveness for preventing work injuries (2001c), there are ways to guard against bias: a) outlining explicit methods for data collection and data analysis; b) adhering to these methods; c) having more than one researcher collect data; d) having a second, non-biased person summarize and/or draw conclusions from th e data; e) letting the data speak for themselves and not forcing them into a framework designed by the researcher. In qualitative research, the terms “internal vali dity, external validit y, and reliability” are analogous to “credibility or trustworthiness, transferability or fittingness, and auditability or dependability” (Miles & Huberman, 1994; Lincoln & Guba, 1985). In order to strengthen internal validity the use of member checks to document group responses and then verify with group is suggested. The use of member checks is another step in the planning process to strengthen the credibility or trustworthiness of the data (Haiduven, 2000b). The purpose of the member checks is not only to test for factual and interpretative accuracy but al so to provide evidence of cr edibility (Lincoln & Guba, 1985). To strengthen external validity some au thors recommend: a) repeat focus groups;

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65 b) validating findings with questionnaires of the target population; and c) conducting focus groups in different settings. To strength en reliability it is important to: a) tape record the sessions; b) take detailed field no tes; and c) conduct de briefing sessions. a) Tape recording sessions are a way to get us eful information from the focus group. b) Take detailed field notes should capture information on any necessary changes in the list of questions, participant characteristics, desc riptive phrases or words used by participants as they discuss the key questions, themes in the responses to the key questions, subthemes indicating a point of view held by participants with common characteristics, description of partic ipant enthusiasm, consistency be tween participant comments and their reported behaviors, and body language (Morgan & Krueger, 1998); c) Debriefing sessions will be held immediately after the focu s group by the researcher and assistant(s) to discuss impression, problems or possible m odification that would be needed to be made in questions with the remaining groups. Also, this meeting would be important to share perceptions about points, notable quotes, and immediate reactions to the group that may later help in the analysis (Morgan & Krueger, 1998). The uses of field notes and debriefing sessions will be designed to strengt hen both the credibility and dependability of the data (Haiduven, 2000b). Can focus group results be generalized? Focus groups involve a limited number of people who may not be selected in a random manner; however, the concept of transferability can be used. This means that those who seek to use the results look over the study, examine procedures, methods and the analysis strategies and they decide the degree to which this might be applied to their situation. Transferability, according to Lincoln and Guba (1989), is parallel to the pos itivistic concept of ge neralizability, except

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66 that it is the receiver (not th e researcher) who decides if the results can be applied to the next situation. Procedure for the Focus Group Sessions in the Study The purpose of focus group as data collec tion technique was to obtain information about factors associated with recapping used ne edles as cause of needlesticks injuries in nurses. There were 120 participants in tw elve (12) focus group conducted on working hours at the different departments and shifts (Tables 1 & 2). The meeting rooms for the sessions were located at each department. It was not possible to find a common place to conduct the sessions, because nursing staff had to be close to the job area. However, in general, the environment was comfortable in each department. The nursing staff was greeted at the door of the meeting room by the moderator (researcher) and the assistant moderator. Nurses were asked to read and sign a consent form and fill out the demographic questionnaire. The research team tried in each session to have a friendly, warm and comfortable environment. The focus group sessions were led by the moderator who was seated in front of the group and the research assistant was seated at the back side taking field notes and hand ling the recorder device. At th e beginning the participants were asked to introduce themselves. After the last nurse presentation, the moderator read the introduction (Appendix D), presenting himsel f and the assistant moderator, explained the overview of the topic (res earch goals), the purpose of the focus group, and the ground rules for the activity and bega n with the first question. The focus group sessions were audio-tape recorded and lasted two hours. At the conclusion of each focus group, the nurses were asked to verify the assistant moderator’s brief summary comments. The moderator as ked for any explanation, modification or

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67 corrections. After each session, debriefing se ssions were held by the researcher and assistant to discuss impression, problems or possible modification to be made in questions with the remaining groups. Als o, this meeting was important to share perceptions about points, not able quotes, and immediate reactions to the group that helped in the analysis (Morgan & Krueger, 1998). In order to show appreciation and make the atmosphere more comfortable refreshment was served in each focus group session. After each focus group, the researcher transcribed the audio tapes. The fulllength transcripts and the fiel d notes taken by the assistant moderator were used in the analysis process. In this investigati on, there were some actions taken to ensure that good quality data were collected such as: a) to minimize the problem of the moderato r (researcher) bias in the questioning, focus group questions were designed colaboratively with a group of experts in the topic of recapping used need les and needlestick injuries as well the questions were built based on the previous information regarding health care workers work conditions at the Maracay Central Hospital during a survey done by the researcher in 2004; b) the questions were tested, with a group of professi onals including the facilitator Dr. Richard Krueger during a focus group course at the USF during Spring 2006 to guarantee that questions were unders tood; (c) the dynamic of the focus group allowed to the investigator to listen carefu lly to nurses; d) the team observed how they answered and sought clarifica tion on areas of ambiguity; e) at the conclusion of each focus group, the participants we re asked to verify the team summary comments; and f) field notes sheets (Appendix E) were developed for the assistant in order to achieve reliability between the assistant and the mode rator (researcher). In order to strengthen

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68 internal validity, member checks were us ed to verify group responses. The member checks were conducted by the key informants who helped the researcher to find the nurse participants in each of the focus group sessi ons. The moderator developed a procedure for the member checks that were planned to be ca rried out with one member from each of the twelve (12) focus groups. The materials presen ted to the participants included a cover letter describing the purpose of the memb er check, a summary of the categorization schema (Appendix F) and three questions. Members were asked to provide an overall opinion regarding the believability of the findings and identify missing themes or additional items. In summary, the focus gr oup sessions were conducted in a manner to ensure accuracy of the results. According to experts in focus groups, there is a term called “saturation” which is used to describe the point when th e researcher will have heard the range of ideas and is not getting new information (Kruger & Casey, 2000) Typically, the first two groups provide a considerable amount of new information bu t by the third or fourth session, a fair amount may have already been covered (CDC, Guidelines for evaluating the effectiveness of strategies for preventing work injuries, 2001c). In this study, the researcher intentionally worked with twelve (12) focus groups in order to hear the comments from the nurses in the different shifts in the same department selected (Table 2). Nevertheless, at the conclusion of the ei ght focus group session, it did not appear that any complement information regarding the factors surrounding recapping used needles and NSIS was gathered.

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69 Study Phases This study consisted of three phases : diagnosis period, intervention period and, evaluation/ follow up period (Appendix G). The duration of the study was 15 months (November 2006 to February 2008). 1.Diagnosis period: the duration of this phase was six (6) months (November 2006, April 2007). Th e purposes of this phase were: a) to collect data that was used as baseline for evaluation purpose (for instance, the number of recapping used needles was counted); b) to gain understanding about predisposing factors of knowledge, attitudes, belie fs, values, and perceptions of nurses that influence motivation for a behavior, in this case, a bout recapping used needles and needlestsick injuries, work practices, culture of safety, po licies, procedures and any education/training on needlestick injury prevention applied at th e Maracay Central Hospital; c) to use the information obtained in a and b to develop an educational strategy. 2.Implementation/intervention period: the duration of this phase was five (5) months (Jun–October 2007). In order to deve lop the educational strategy, the researcher used the information obtained from the the focus group sessions. The material prepared was related to information about epidemio logy and transmission of bloodborne pathogens such as Hepatitis B, Hepatitis C and HIV; ep idemiology of needlestick injuries, concepts and techniques of Standard Precautions (ha nd hygiene, the use of personal protective equipment, and the safe disposal of n eedles); and information about post exposure management. 3.Evaluation/Follow up period : the duration of this phase was of four (4) months (November 2007, February 2008). The objective of this phase was to evaluate the effectiveness of the educational strategy.

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70 Setting of Intervention The Maracay Central Hospital is a teaching university hospital located in Maracay the capital city of Aragua state (Chapter 3). This hospital wa s selected for this study for several reasons: a) it is the largest hospital in th e state; b) it is the he alth care setting with the highest number of NSIS in the state (m ore than 140 in a year and more than five events every week); and c) the prelim inary study of circumstances surrounding needlestick/sharp injuries among healthcare workers in a Venezuel an (Maracay Central Hospital) Public Hospital done by Galindez & Haiduven, 2004 showed a high percentage of recapping used needles according to the health care workers interviewed. Four (4) hospital departments were used for the study. The departments were Adult Emergency Room, observation area with 38 nurses and 16 beds, Neonatology Intensive Care Unit (NICU) with 32 nurses and 12 inc ubators, Surgery wards with 28 nurses and 66 beds and Obstetrics wards with 36 nurses and 64 beds (Tables 3 & 4). The justification to select the de partaments was based on the the data of needlestick injuries surveillance carried out by the Epidemiology of fice and accessibility to each department to collect the containers with used needle s. The departments were comparable in the variable of study (number of recapping used need les). It is important to point out that the departments were similar, especially with re spect to any variables that might affect the measured outcome (number of recapping used needles). In all selected departments measurements of number of recapping used needles were taken before, and after the educational strategy. A baseline time tre nd was first establishe d by taking several outcome measurements before implementi ng the intervention (November 2006-February 2007). Similary, in order to establish a second time trend, several of the same

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71 measurements were made after the inte rvention (November 2007-February 2008). The count process was carried out at the Heavy Metal Laborat ory at the University of Carabobo. Data about hospital need lestick injuries surveillan ce reports were collected from the Epidemiology office. Recapping used needles rates/proportions, odd ratios and needlestick injuries rates results were the final outcome. Data Collection Methods and Data Collection Instruments Data collection methods and data collection instruments were structured according to the primary aims of the study: 1. To determine the factors surrounding recapping used needles as cause of needlestick injuries in nurses. To accomplish this objective the focus group sessions were used as data collection methods. These focus group sessions were applied in the first phase (diagnosis peri od). Data collection in struments: The two basic instruments used were a) focu s group questions: a list of focus group questions (Appendix H) were designed to answer the re search questi on about the factors related to recapping used needles in nurses in the Maracay Central Hospital. These questions were carefully pr epared by the researcher with the help of Dr. Donna Haiduven and Dr. Richar d Krueger who have experience in needlestick injuries and focus groups re spectively. The purpos e of the questions was the identification of circumstance s regarding recapping used needles. According to Krueger and Casey (2000, p. 43), there are two different questioning strategies used by focus group moderators : topic guide and questioning route. The topic guide is like an outline with a list of topics or i ssues to be pursued in the focus group. By contrast, the questioning route is a sequence of questions in

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72 complete, conversational sentences ofte n used in academic environments (Krueger & Casey, 2000). Advantages of the questioning rout e over the general topic guide are increased confidence of th e moderator, enhanced quality analysis by minimizing subtle differences in qu estions, and enhanced consistency of questions from one group to the other (K rueger, 1998). For this research, the questioning strategy selected was the questioning route (Opening, introductory, transition, keys and ending questions). Open -ended questions were used to allow the participants to determine the dir ection of the response (Krueger & Casey, 2000). The answer was not implied, and the type or manner of response was not suggested. Questions came from general to specific; the focus group began with general overview questions before to ask for more specific questions of critical interest and b) demographic questionnaire : (Appendix I) before the session started, nurses were asked to complete a short questionnaire. The purpose of this questionnaire was to get demographic, e ducation and work information used in the analysis process. 2. To obtain reliable estimates of the inciden ce of needlestick injuries from needles and sharps to nurses working in four (4) departments at the Maracay Central Hospital. To complete this objective a data collecti on sheet (Appendix J) from the Maracay Central Hospital surveillance epidemiology report was used to get information about the data of the ne edlestick injuries Additionally, the information for the years 2007, 2008 and 2009 was obtained from CORPOSALUD Occupational Safety and Health Department.

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73 3. To obtain reliable estimates of the propor tion of recapping used needles used by nurses working at the four (4) department s of the Maracay Central Hospital. To achieve this objective the researcher visite d the selected departments twice a week in the morning to get the disposal contai ners with the used needles. In summary, there were 192 visits to the selected departments during the investigation (15 months) (Tables 5 & 6). Data collection instruments: data sheet of recapped used needles (Appendix K) was used to get the information about the number of recapped used needles at the selected departments. 4. To design the educational strate gy based on the factors surrounding recapping used needles. To accomplish this objectiv e the researcher identified the problem with the information obtained in the dia gnosis phase. However, according to the literature about the topic and the results obtained in the volunt ary survey applied by Galindez & Haiduven, (2004), this type of intervention was considered by health care workers one of the most appropr iate to be used in this matter. The objectives of the educational strategy were to promote changes in knowledge, attitudes, and work practices regarding the avoidance of recapping used needles as a cause of needlestick in juries and acquisition of bloodborne pathogens. For example, it is important to promote campaigns that emphasize the disadvantage of recapping used needles and addre ssed employee misconceptions about knowledge, and training on safety issu es in recapping used needles and needlestick injuries prevention. 5. To apply the educational strategy The intervention phase was organized with the information obtained in the previous phase (focus group sessions). This

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74 educational strategy involved 144 nursi ng staff from four (4) Maracay Central Hospital departments (Table 7). Twelve (12) separate meetings were applied during the intervention peri od (Table 8). The educational strategy was conducted in sessions of two hours of duration at the same places where the focus group sessions were performed. The objectives of these meeting were: a) to provide knowledge and to encourage safe nursi ng practices for the prevention of recapping used needles and consequently to avoid needlestick injuries; b) to discuss information about epidemio logy and transmission of bloodborne pathogens such as Hepatitis B, Hepatitis C and HIV; c) to update concepts and techniques of Standard Precautions (ha nd hygiene, the use of personal protective equipment, and the safe disposal of need les); and d) to discuss information about post exposure management and the most appropiate preven tions measure to prevent needlestick injuri es. With the information obtained in the focus group sessions, the author prepared and distribut ed to each partic ipant an envelope containing material which included a main pamphlet (Appendix L), the Act and the Regulation on Prevention, Conditions and Working Environment Act (Appendix M), a guide with articles of the law discu ssed (Appendix N), American Nurses Association guidelines to follow after needlestick in juries (Appendix 0) and material from the National Institute for Prevention, Health and Safety at Work (INPSASEL) regarding the functions of delegate of prevention as promoter of health and safety at work sites (Appe ndix P) and a pamphlet of the Center for Workers with Disabilities (Appendix P). It is importa nt to emphasize that the brochure (Appendix L) provided to each par ticipant was also sent to colleagues

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75 that were unable to attend, due to depa rtmental duties, in order to communicate this information. At the beginning of the meeting, a pretest (Appendix Q) was given to each nursing staff in order to measure the degree of knowledge on issues relating to bloodborne pathogens agents, need lestick injuries, a nd legal issues. At the end of the meeting, the same test (A ppendix Q) was applied to measure if the acquisition of knowledge increased. 6. To evaluate the effectiveness of the educational strategy. To achieve this objective, the researcher compared the num ber of recapped used needles obtained during the two phases (first and third) The researcher applied the same metodology used during the first phase in order to obtain the number of recapped used needles. In summary, there was total of 24 visits in each department for a total of 96 visits in the study period (Table 7). Data collection instruments: a data collection sheet (Appendix K) was used to get the information about the number of recapped used needles at the selected departments. After the needles were collected at the MCH, the researcher and the assistants brought the boxes or plastic bottles to the Heavy Metal La boratory at the University of Carabobo, placed them in a big refrigerator to avoid blood decomposition. Fridays and Saturdays were the days used to count the needles. In order to avoid injuries the researcher wore personal protective equi pment (gloves, masks and grippers). The needles were separated into two grou ps (recapped needles and not recapped needles) and then were counted. The result s were incorporated to an Excel sheet. When the process was done the material was discharged into a pl astic bottle and it was sent to the hospital incinerator.

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76 7. To report to the nurses, ho spital and health authorities the results and suggest modifications regarding safety work practices. To accomplish this objective the researcher had meetings with the hospita l and regional author ities in order to discuss and analyze the preliminary resu lts and the corrective measures to be taken. Data Analysis Methods In this study, for qualitative informa tion, the analysis process was conducted according to the strategies and methodology used by experts in this type of research as well as to the material reviewed about focus group analysis (Chapter 4). Data from the transcripts were analyzed doing a process entitled “transformation” (Wolcott, 1994) (Chapter 5). The PRECEDE component of PRECEDE/PR OCEED Model PPM (Chapter 5) was used to analyze the factors of the description and categorization part developed in the first level of Wolcott’s methodology. This provide d a framework to understand factors or circumstances surrounding nurses’ safety prac tices specifically rela ted to recapping used needles. For the quantitative information, descriptiv e statistics were used to represent the demographic and work related variables from the demographic data sheet. Frequencies, rates and proportions were calculated usi ng Epi Info version 3.4.3 (November 2007). It was also used to calculate 95% confid ence intervals around proportions. Also the tstudent test was applied to measure the im pact of the educational strategy. For the recapped used needles proportion, the numerator was the total number of recapped used needles obtained from the se lected departments and the de nominator was the number of

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77 total used needles placed in the disposal container during the three months previous and posterior the educational stra tegy. The rate of needlestick injuries by hospital occupied beds was calculated using a numerator, the num ber of events of needlestick injuries reported for all health care wo rkers and nurses obtained in a year in the hospital from 2003 to 2009. The denominator was the total nu mber of occupied hospital beds (470) multiplied by 100. For the departments studied other rate was calculated using all the number of events reported in the all four departments and the denominator was the total number of occupied departments beds (158) multiplied by 100. Because the data were complete for 2007 and 2008, these were the y ears used. Also, odd ra tios and proportions of number of not recappe d needles were applied. Target Population/ Study Sample/Sample size The target population for this study is all nu rses who work in healthcare in Venezuela. Study sample: Nurses were the group selected as healthcare workers, because they are the biggest group in the Maracay Central Hospita l, Aragua, Venezuela (62% of the hospital healthcare workers workforce), and accordi ng to the literature is the group around the world with the highest risk of needlest sick injuries. The researcher used the administrative denomination used by Venezu elan hospitals. Graduate Nurses are the personnel who were attended in a training sc hool (National School of Nurses) during 3 years; this program was operating until 1970s; and the Licensed Nurses who are currently trained at the university level in 5 year programs. The Nurses aids are personnel who help the professionals’ nurses to do some specific du ties especially with patient care, such as (feed, bathe, dress, move patients, or change linens). This type of program was revoked by the Ministry of Health and Social Deve lopment; nevertheless pr ivate organizations

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78 exist that prepare this type of resource in a time that varies between six months and one year (PAHO, 2004). The last group was nursing students who are not hospital employees but are receiving training at the hospital and are exposed to needles tick injuries; in fact, according with the hospital needlestick survei llance report this group has high number of injuries (Maracay Central Ho spital Needlestick Injuries Surveillance, 2003, 2004, 2005). All nurses (women and men) from the four selected departments from the Maracay Central Hospital who have the potential to be exposed to needlestick injuries and who were interested in participating in the st udy were included. Sample size: for the focus group sessions, there were 120 par ticipants from the four (4) departments. In each group there were approximately 8 to 12 nurses in attendance. A convenience sample (purposeful sampling) of nurse s was used from each depart ment involved in the study. The percentage of nurses part icipating in the focus group se ssions was 86% (120/141) of the total of nurses working in the four departments (Table 3). Inclusion/Exclusion Criteria All nurses from the four (4) selected de partments who are exposed to needlestick injuries and who were interested in partic ipating in the study were included. Exclusion criteria: there were not exclusion criteria. Recruitment of Subjects The researcher used a person in each of the selected departments to serve as the contact person (key informant) for interested particip ants, maintain a list of potential subjects, and who scheduled a date and time for the fo cus group sessions with the researcher. The contact person was requested to attempt to recruit up to 12 persons for the focus group sessions. This allowed for up to 4 drop-outs a nd still has 8 focus group members. Each of

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79 these people received a date and time for the focus group sessions with the researcher. The contact in each facility was the intermedia ry to recruit participants. The researcher did not know the identity of the participan ts until the focus group sessions. The nurses were informed that participation in the i nvestigation was strictly voluntary and that refusal would not affect their employment st atus. For the educati onal meeting a general invitation to the all nurses’ personnel in each department was provided. Ethical Considerations An informed consent process was carried out before the study began. For that reason, this investigation on human subjects was submitted for the Institutional Review Board of the USF for evaluation. On December 7th 2005, the principal investigator (PI) received the approval letter from the USF-IRB to conduct the investig ation under the number 10.4241 (Appendix R). The informed consent forms in English and Spanish were approved (Appendix S). In both, the most importa nt aspect was that the participation in this study was voluntary; no one under any circ umstances was obligated to take part in the study. Nurses were informed that they coul d withdraw from the study at any time and that declining to par ticipate or withdrawing from the study not resu lt in any penalty or loss of benefits. The strategies used to prot ect the privacy of participants included: no identification of subjects, data kept in locked file cabinets, limiting access to the research data, and assuring that individual subjects c ould not be identified in any step of the research. All records and written communicati ons from individuals were secured in the office of the PI and were not available for public or unauthorized access. No names were written on sheets or associated with any response. Responses were transcribed into a computer file. Both the paper sheets and the computer file were ke pt in a locked area

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80 accessible only to relevant study personnel. Only summary reports of data were produced. There were no attempts to link resp onses to individual focus group participants or questionnaires in any summary reports. No identifying information was divulged in any summary reports of the study findings. Table 1 Number of Nurses in the Focus Group Sessi ons Distributed by Departments and Shifts, MCH, Maracay, 2006-2008. Departments/Shifts 7 am–1 pm 1 pm-7 pm 7 pm-7 pm Total Adult Emergency room 12 10 10 32 NICU 10 11 10 31 Surgery wards 08 09 09 26 Obstetrics wards 12 08 11 31 Total 42 38 40 120 Note : Focus group sessions Table 2 Number of Focus Group Sessions Distribut ed by Departments and Shifts, MCH, Maracay, 2006-2008. Departments/Shifts 7 am -1 pm1 pm-7 pm7 pm-7 pm Total Adult Emergency room 1 1 1 3 NICU 1 1 1 3 Surgery wards 1 1 1 3 Obstetrics wards 1 1 1 3 Total 4 4 4 12 Note Focus group sessions

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81 Table 3 Number and Percentage of Total Nurses of the Departments Studied and Nurses Participants in the Focus Group Sessions, MCH, Maracay, 2006-2008 Departments/Nurses Total Nurses in the departments # of focus group participants Percentage % Adult Emergency room 8 32 84 NICU 39 31 79 Surgery wards 28 26 93 Obstetrics wards 36 31 86 Total 141 120 86 Note Hospital Nurses’ Office Table 4 Number of Beds of the Departmen ts Studied, MCH, Maracay, 2006-2008. Departments/Beds Number of beds Adult Emergency room 16 NICU 12 Surgery ward 66 Obstetrics ward 64 Total 158 Note. Hospital Nurses’ Office

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82 Table 5 Number of Visits to Each Department to Co llect Used Needles Di stributed by Months and Weeks Before the Educational Strategy, MCH, Maracay, 2006-2008. Months/weeks/ Departments Adult Emergency room NICUSurgery wards Obstetrics wards Total Nov1 2006 2 2 2 2 8 Nov2 2006 2 2 2 2 8 Nov3 2006 2 2 2 2 8 Nov4 2006 2 2 2 2 8 Dic1 2006 2 2 2 2 8 Dic2 2006 2 2 2 2 8 Jan1 2007 2 2 2 2 8 Jan2 2007 2 2 2 2 8 Jan3 2007 2 2 2 2 8 Jan4 2007 2 2 2 2 8 Feb1 2007 2 2 2 2 8 Feb2 2007 2 2 2 2 8 Total 24 24 24 24 96 Note Researcher report Table 6 Number of Visits to Each Department to Co llect Used Needles Dist ributed by Months and Weeks After the Educational Strategy, MCH, Maracay, 2006-2008. Months/weeks/ Departments Adult Emergency room NICU Surgery wards Obstetrics wards Total Nov1 2007 2 2 2 2 8 Nov2 2007 2 2 2 2 8 Nov3 2007 2 2 2 2 8 Nov4 2007 2 2 2 2 8 Dic1 2007 2 2 2 2 8 Dic2 2007 2 2 2 2 8 Jan1 2008 2 2 2 2 8 Jan2 2008 2 2 2 2 8 Jan3 2008 2 2 2 2 8 Jan4 2008 2 2 2 2 8 Feb1 2008 2 2 2 2 8 Feb2 2008 2 2 2 2 8 Total 24 24 24 24 96 Note. Researcher report

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83 Table 7 Number of Participants in the Educational St rategy Sessions Distri buted by Departments and by Shifts, MCH, Maracay, 2006-2008 Departments/Shifts 7 am -1 pm1 pm-7 pm7 pm-7 pm Total Adult Emergency room 12 12 12 36 NICU 11 13 13 37 Surgery ward 10 11 13 34 Obstetrics ward 14 10 13 37 Total 47 46 51 144 Note Educational strategy sessions Table 8 Number of Educational Strategy Sessions Distributed by Departments and Shifts, MCH, Maracay, 2006-2008. Departments/Shifts 7 am -1 pm1 pm-7 pm7 pm-7 pm Total Adult Emergency room 1 1 1 3 NICU 1 1 1 3 Surgery ward 1 1 1 3 Obstetrics ward 1 1 1 3 Total 4 4 4 12 Note Educational strategy sessions Table 9 Age, Experience in Profession and Experience of Nurses, According Other Sources, MCH, Maracay, 2006-2008. Variables MCH data* Galindez data** Nurses 2007*** Nurses 2008*** Age (years) 36 37 35 35 Experience in profession (years) 12 14 12 12 Experience at hospital (years) 15 13 14 13 Note : Hospital Nurses’ Office. ** Field experience 2004. *** CORPOSALUD report

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84 CHAPTER SIX: RESULTS This part was divided in two sections. The first one is the presentation of the quantitative findings obtained from the questi onnaire applied in th e focus group sessions, the information about the number of the needle s collected in each of the four departments before and after the educational strategy, the information related to needlestick injuries obtained from the hospital surveillance report the data collected from the pretest and posttest applied in the educational strategy, a nd the information about needlestick injuries in the Maracay Central Hospital. In the sec ond one, the qualitative re sults were developed using the Wolcott and the PPM methodologies (Chapters 4 & 5). Quantitative Results Table 10 provides the demographic data information collected in the questionnaire applied to the study sample at the Maracay Central Hospital (MCH). Of the 120 nurses who were participating in the focus group se ssions, female nurses predominated with 106 (88%) and 14 (12%) male. According to educ ational level one hundred and thirty (94%) of nurses had a university/college level, a nd only seven (6%) had elementary or middle educational level. In relation to job position in the hospital, 81 (67%) of nurses were graduates personnel, 26 (22%) aid nurses and 13 (11%) students in the last year of nurses’ school. According to unit or depa rtment 32 (27%) of the respondents were working in the Adult Emergency Room (AER ), 31 (26%) in the Neonatology Intensive Care Unit (NICU) and Obstetrics wards, and 26 (21%) in the Surgical wards. In Venezuela hospital nurses work in three shifts In the sample, 42 (35%) were working at

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85 the first shift (7am.-1p.m.), 38 (32%) were working in the second shift (1pm-7pm.) and 40 (33%) in the third shifts (7pm -7am.). It is important to point out that thirty four (28%) of nurses reported to work in more than one shift. Table 10 Variables of the Focus Group Partic ipants at MCH, Maracay, 2006-2008 Variables FrequencyPercent Sex Female Male Total 106 14 120 88 12 100 Educational Level University/College Others Total 113 07 120 94 06 100 Job position Graduate Nurses Nurses Aids Nursing Students Total 81 26 13 120 67 22 11 100 Unit or department Adult Emergency room NICU Surgery wards Obstetrics wards Total 32 31 26 31 120 27 26 21 26 100 Shifts 7 a.m. 1 p.m. 1 p.m. 7 p.m. 7 p.m. 7 a.m. Total 42 38 40 120 35 32 33 100 Work in another institution No Yes Total 105 15 120 87 13 100 Note Questionnaire applied in the focus group sessions

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86 For the question asking if they were worki ng in other institutions 105 (87%) reported that they did not. From this information it a ppears that the majority of nurses do not work in other institutions but remains in the sa me hospital working in different shifts. Table 11 provides information regarding the an tecedent of a needlestick injury in the last year, only 35/120 (29%) responded affirmatively. Con cerning the question if the needlestick injuries were reported, all 35 nurse s (100%) reported the accident at the time. Table 11 Antecedents of Exposure of the Focus Group Participants at MCH, Maracay, 2006-2008. Variables Frequency Percent In the past year have been stuck with used needles? No Yes Total 85 35 120 71 29 100 If your answer about NSIS was yes, how many times? 1 2 Total 27 8 35 78 22 100 Note Questionnaire applied in the focus group sessions The mean age of nurses in the sample was 36.29 years. The age range was 21-56 years. The mean number of years of nursing expe rience was 13.68. The mean number of years of experience in the hospita l was 12.50 years and the mean number of years in the position was 9.59. The mean number of hours worked daily was 11.01 and the mean number of hours worked w eekly was 48.63 (Table 12).

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87 Table 12 Age, Experience in Profession, Experience at Hospital, Experience in Position, Daily and Weekly Work Hours of the Focus Group Participants, MCH, Maracay, 2006-2008. Variable Mean Standard Deviation (SD) Age (years) 36.2910.05 Experience in profession (years) 13.6810.24 Experience at hospital (years) 12.509.61 Experience in position (years) 9.59 8.58 Daily work hours 11.014.6 Weekly work hours 48.6317.88 Note. Questionnaire applied to focus group participants Table 13 provides information about the num ber of needles discarded for all four departments of the hospital before and after the educationa l strategy. Of the 33015 needles collected before the education strategy, 7 772 (24%) were not recapped in contrast with 33267 needles collected after the e ducation strategy, 13245 (40%) were not recapped. The difference of 16% was statistically significant (< 0.005). Table 13 Number of Needles at all Four Departme nts Studied Before and After Educational Strategy, MCH, Maracay, 2006-2008 Needles Before strategy After strategy Difference % P value Total needles 33015 33267 Recapped needles 25243 20022 No recapped needles 7772 13245 % of no recapped needles 24 40 16 0.001* Note Data sheet of used needles. p < 0.005 Table 14 shows the number of needles discar ded discriminated by departments before and after the educational stra tegy. The Obstetrics wards pres ented the highest percentage with 23% of no recapped needles after th e intervention, followed by NICU, AER and

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88 Surgery wards departments with 18%, 14% and 10% respectively. P-values in all departments showed stat istical significance. Table 14 Number and Percentage of Needles Counted by Departments Studied Before and After Educational Strategy, MCH, Maracay, 2006-2008. Note. Data sheet of used needles report. p < 0.005 Table 15 provides the information of th e percentages of needles not recapped by departments and by months after the educat ional strategy. Except for the Obstetrics wards, in all the departments studied the pe rcentage of needles not recapped decreased slightly in the last month of collection. Departments/Needles Before strategyAfter strategy Differences % P-value Obstetrics. Total needles 8875 8858 Recapped needles 5665 3678 No recapped needles 3210 5180 % of no recapped needles 36 59 23 0.001* NICU. Total needles 8080 8087 Recapped needles 6439 5033 No recapped needles 1641 3054 % of no recapped needles 20 38 18 0.001* AER. Total needles 8183 8198 Recapped needles 6668 5494 No recapped needles 1515 2704 % of no recapped needles 19 33 14 0.0001* Surgery. Total needles 7877 8124 Recapped needles 6471 5817 No recapped needles 1406 2307 % of no recapped needles 18 28 10 0.001*

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89 Table 15 Percentages of Needles Not Recapped by De partments Studied and by Months After the Educational Strategy MCH, Maracay, 2006-2008. Note. Data sheet of used needles report. Table 16 indicates the odd ratios (OR) at all four hospital departments were less than 1, indicating a protective effect, demonstrating that the educational strategy was associated with less recapped needles. For all four departments together the OR was 0.47, which means that the educational strategy increased the likelihood of not recapping used needles by 53%. The odds ratio discriminated by each departments also was less than 1 (protective effect), no ting that in the Obstetrics ward s the OR was 0.40, meaning that the educational strategy increased the likelihood of not recapping used needles by 60%. This department had the most successful respons e to the intervention, followed by the NICU and Adult Emergency Room (Observation area ) departments with an OR of 0.42 and 0.46 respectively. The Surgery wards had the highe st OR (0.55) but still showed a protective effect (<1). After educational strategy Departments/months Nov. % Dec. % Jan. % Feb. % Obstetrics wards 59 58 58 59 NICU 39 38 37 36 AER 33 33 33 32 Surgery wards 30 28 28 27

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90 Table 16 O.R. of Needles Recapped Counted by Departments Studied Before and After the Educational Strategy, MCH, Maracay, 2006-2008. Departments OR CI All departments 0.47(0.45, 0.48) Obstetrics wards 0.40(0.39, 0.45) NICU 0.42(0.41, 0.49) Emergency room 0.46(0.43, 0.50) Surgery wards 0.55(0.51, 0.59) Note. Data sheet of used needles report Table 17 shows that there were only 3 questions in the pr etest with a percentage of corrects answer above 50%, corresponding to the questions: need lestick accident as hazards or risk (1); ways to get Hepatitis B (4); and recapping as routine procedure (7). The other questions showed percentages of correct answers between 8% and 44%. The question No.2 that was related to the tran smission of Hepatitis B, C and HIV only 8% answered correctly on the pret est. In summary, the range for the correct answers in the pretest was 8%-100%. The posttest was applie d after the educatio nal strategy and the results improved, presenting a positive change between 9% and 59% (difference between percentage of correct answers in the pretes t and posttest). The range for the correct answers in the posttest was 63%-100%. When a t-student test was applied to observe if the variation of pe rcentage of correct answers before and after the test (pre and post) had a statistic al significance the questions (2, 3, 5 and 6) showed static ally significance (p<0.005), and three questions (1, 4 and 7) were not. It is important to note that the question No. 7 regarding if the recapping used needles is an important cause of NSIS, the number of co rrect answers did not significantly increase after the education strategy.

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91 The questions 9, 10 and 11 (**) were re garding the nurses’ knowledge about Occupational Law, National Institute for Pr evention and the existence of the hospital committee for health and safe prevention. The majority of nurses did not have information about those issues. It is importa nt to notice that these questions were not applied in the posttest because were used only to get info rmation about occupational and safety issues. Table 17 Results of Answers from Pretest and Posttest Applied during Educational Strategy, MCH, Maracay, 2006-2008. Pre-testPost-test Questions Correct % Correct % Dif. t-test p value 1. Needlestick accidents are very important risks because their consequences could be severe for the health care worker health 100 100 0 > 0.005 2. Which of these viruses are easily transmitted after exposure to contaminated blood 8 67 + 59 < 0.005* 3. Which is the global percentage of underreport needlestick injuries 36 87 + 51 < 0.005* 4. It is possible to get Hepatitis B through casual contact such as hugging or shaking hands 78 87 + 09 > 0.005 5. The Hepatitis B can cause liver cancer 44 70 + 26 < 0.005* 6. Effectiveness of Hepatitis B vaccine in preventing Hepatitis B virus in nursing staff 29 87 + 59 < 0.005* 7. Recapping used needles is an important cause of NSIS 54 63 + 09 > 0.005 8. Among the reasons for the underreporting of needlestick accidents are... 38 70 + 32 < 0.005* 9. Do you know about the Organic Law of Prevention, Conditions and Environment at Workplace? 10 ** ** ** 10. Do you know about the National Institute for Prevention, Health and Safety at Work? 22 ** ** ** 11. Do you know about the existence of the Committee on Occupational Health and Safety in the hospital? 36 ** ** ** Note Pretest y posttest applied *statistically si gnificant. ** No applied in the posttest

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92 Table 18 shows that only 55 (38%) of nurses staff who attended the meeting of the educational strategy had completed the 3 dose Hepatitis B vaccine schedule in contrast with 81 (44%) who only had only completed th e first and second doses. Additionally, it is important to note that 26 (18%) answered no to that question, s uggesting that nursing staff had not completed any immunization doses. It is important to point out that persons require the three doses of vaccine to obtain immunologi cal protection. Table 18 Number and Percentage of Compliance with Hepatitis B Vaccine 3-doses Schedule in Nursing Staff Who Participated in the Educ ational Strategy, MCH, Maracay, 2006-2008. Doses FrequencyPercent First dose 37 26 Second dose 26 18 Third dose 55 38 No doses 26 18 Total 144 100 Note Pre-test applied. Table 19 shows the number of needlestick injuries in the healthcare workers population at the MCH from 2004 to 2009. The to tal of NSIS had a range between 101 and 130 for the six years reported. The highest value was obtained in 2007 with 130 and the lowest in 2006 with 101 NSIS. In 2009, 75 NSIS have been reported through Jun. It is important to highlight that the researcher only received the data from CORPOSALUD Occupational Safety and Health Department for the years 2007 and 2008 that allowed it to obtain information from the departments studied, for the other years the information from these departments was missing. Of all the needlestick injuries reported in the MCH, the departments studied accounted for 44% (46/104) for 2004. For the year 2007 the

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93 percentage was 64% (83/130) and for the ye ar 2008 the percentage increased to 76% (84/111). Table 19 Needlestick Injuries by Ye ars at MCH, Maracay, 2004-2009. Note Hospital Surveillance Program and CORPOSAL UD data. Data available until Jun 2009. ND = no data available Table 20 provides information about the pe rcentage of nurses with NSIS which was stable around 37% until 2007 where the per centage diminished to 30%. In 2008, the percentage increased to a 37%. The nursi ng students’ percentage was increasing gradually in the five years from 11% in 2004, 19% in 2005, 18% in 2006 to 16% in 2007 and 17% in 2008. Nurses and nursing students represented 48%, 57%, and 54% of NSIS respectively until 2006. For 2007 and 2008, both gr oups sustained 120 NSIS representing 46% and 54% of needlestick in juries occurring in all hea lth care workers from MCH. Table 20 Number and Percentage of Needlestick Injuri es Distributed by Nu rses, Nursing Students and Other Health Care Workers by Years, at MCH, Maracay, 2004-2008. Note. Hospital surveillance program and CORPOSALUD data Years N Departments Studied 2004 104 46 2005 113 ND 2006 101 ND 2007 130 83 2008 111 84 2009 75* ND HCWs/Years 2004 2005 2006 2007 2008 N % N % N % N % N % Nurses 38 37 43 38 36 36 39 30 41 37 Nursing students 12 11 21 19 18 18 21 16 19 17 Other personnel 54 52 49 43 47 47 70 54 51 46 Total 104100113100101100130 100 111100

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94 In Table 21 there is the information about th e number of needlestic k injuries in nurses from the departments studied versus depart ments not studied at the Maracay Central Hospital. For the year 2007, of the 60 nur ses and nursing students with NSIS 45% (27/60) came from the departments studi ed and the 55% (33/60) came from other departments. For 2008, of the 60 nurses and nursing students with NSIS 43% (26/60) came from the departments studie d while 57% (34/60) was not. Table 21 Number and Percentage of Needlestick Injuri es in Nurses from all Four Departments Studied Versus Other Units for 2007 and 2008 at MCH. Note Hospital surveillance program and CORPOSALUD data Table 22 shows the numbers of NSIS sustai ned by nurses from each of the departments studied and other department s not studied for 2007 and 2008. For both years, of the 120 NSIS reported, 67% (80/120) were from nurse s and 33% (40/120) were nursing students. When comparing the departments participa ting in the study and other departments not studied, 44% (53/120) of NSIS came from departments studied and 56% (67/120) from other units. Of those nurses and nursing students from the departments studied (27+26=53), nurses represented 28% (34/120) and nursing stude nts had 16% (19/120). In the departments studied, the AER had the highe st percentage of NSIS with 26% (31/120), follow by Obstetrics wards with 10% (12/ 120), Surgery wards with 6% (7/120) and NICU with 2.5% (3/120). In all the departments studied nurses had the highest percentage of NSIS. In ER was 16% (19/120) 7% (8/120) in Obstetrics wards, 6% HCWs 2007 2008 N % N % Nurses from departments studied 27 45 26 43 Nurses from other departments not studied 33 55 34 57 Total 60 100 60 100

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95 (7/120) in Surgery wards and 2.5% (3/120) in NICU. However, nursi ng students also had high percentage of NSIS in the AER with 10% (12/120). Table 22 Number of Needlestick Injuries in Nu rses and Nursing Students from Each of the Departments Studied Versus Those Departments Not Included in the Study at MCH, 2007 and 2008 Nurses ER OBST NIUCSURGTotal number of nurses of departments studied Total number of nurses of departments not included in the study Total Nurses 19 8 3 4 34 46 80 Nursing Students 12 4 0 3 19 21 40 Total 31 12 3 7 53 67 120 Note Hospital surveillance program and CORPOSALUD data Regarding the rates of needle stick injuries and occupied beds, Table No. 23 shows that for 2004 there was a rate of 22 NSIS per 100 oc cupied beds. For the next two years, the rates were 24 and 21 respectively. The rate ha d an increase to 28 in 2007 and a decrease to 24 in 2008. The rate for 2009 is 16 NSIS per 100 occupied hospital beds but the report is only to Jun 2009. Table 23 Rates of Needlestick Injuries per Occupied Hospital Beds, MCH, Maracay, 2004-2008. Years Rates** 2004 22 2005 24 2006 21 2007 28 2008 24 2009* 16 Note. Hospital surveillance program and CORPOSALUD data. *until Jun ** Rate = Number of NSIS/ 470 occupied hospital beds x 100

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96 Table 24 shows the rates of n eedlestick injuries reported by other health care workers, nurses from others units and nurses from th e departments studied by occupied hospital beds in 2007 and 2008. All rates were similar fo r both years, except the rate of NSIS in other health care workers that decreased from 15 NSIS per 100 hospitals occupied beds in 2007 to 11 NSI per 100 hospital occupied beds in 2008. Table 24 Rates of Needlestick Injuries in Other Hea lth Care Workers, Nurses from Other Units and Nurses from the Departments Studied by Occupied Hospital Beds in 2007 and 2008, MCH, Maracay, 2006-2008 Rates* of NSIS in hospital/years 2007 2008 Rates of NSIS in other HCWs 15 11 Rates of NSIS in nurses 13 13 Rates of NSIS in nurses from departments studied 5.7 5.5 Note. Hospital surveillance program and CORPOSALUD data *Rates = Number of NSIS/ 470 hospital occupied beds x 100 When the denominator of the occupied hospita l beds is the number of beds (158) of the departments participating in the study (Table 4), the rates of NSIS are 17 and 16 NSIS per 100 occupied departments be ds respectively (Table 25). Table 25 Rates of Needlestick Injuries in Nurses from the Departments Studied by Occupied Departments Beds in 2007 and 2008, MCH, Maracay, 2006-2008. NSIS /Years 2007 2008 Rates of in nurses from departments studied 17 16 Note Hospital surveillance program and CORPOSALUD data Rate = Number of NSIS/ 158 occupied departments beds x 100

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97 Qualitative Findings In this part the first level “description and categorization” of Wolcott’s methodology (Wolcott, 1994) was used (Chapter 5). First Level: Descript ion and Categorization This part begins with a de scription and categorization of the findings from the focus group questions, using examples to illustrate themes. The themes that emerged from focus group information were: a) Circumstances related to recapping of used needles and needlestick injuries. b) Percep tion of nurses about needlestick injuries, and c) Needlestick injury prevention strategies. Circumstances Related to Recapping of Used Needles and N eedlestick Injuries Nursing staff were asked to describe circum stances or procedures related to recapping used needles and needlestick injuries. Accord ing to nurses there were several factors or conditions that were identifie d to contribute to needle stick injuries and promote recapping procedures. Regarding the causes of needlestick injuries, nurses mentioned that this situation occurs due to the high demands of work, multitasking and excessive pressure. “Sometimes the service collapses an d in order to fulfill the patients’ expectations we accelerate the speed of the wo rk and as a result the risk of needlestick injuries increases.” “The stress, patients’ overcrowding, the patients’ family exigencies and their disagreement with the quality of servic e, play a role in our accidents.” “This is terrible, it is like a war, we do our best unde r poor work conditions, here we work under the vineyard of God.” Among the factors associated with recappi ng, nurses said that this procedure was applied as a preventive measure to avoid n eedlestick injuries on nursing staff and other

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98 health care workers, such as hospital clean ing and maintenance pe rsonnel who handle the waste without adequate information or wit hout appropriate persona l protective equipment (PPE). Another influencing factor of the re capping was associated with the absence of availability of appropriate sh arps containers in the hospi tal. "There are opportunities where we have to recap because we do not ha ve the sharp container available and at the same time we can not release such quantities of needles on a tray because we have more risk." “We recap to protect the hospital’s clean ing and maintenance staff.” "One feels that recapping is a safe way to avoid needlestick inju ries.” "I do it because it is easy and fast.” “I recapped used needles until I got a needles tick injury.” “I never recap because I have seen many nurses get ne edlestick injuries.” In order to amplify the previous informa tion, the researcher developed two subthemes to provide an expanded description of th ese circumstances. The subthemes were: A) Environmental factors, and B) Hospital policies or guidelines to prevent needlestick injuries. The environmental factors were subdivided in a1) Physical conditions and a2) Organizational climate factors. a1) Physical conditions: Nurses describe d the hospital work ing conditions as characterized by many environmental constr aints and deficits. There were several conditions mentioned as problems that might a ffect the procedures that needed to be performed. Nurses related various situations such as poor lighting, inadequate or absence of handwashing facilities, and unsanitary conditions. Poor lighting is a problem that affects several hospital area s, it is present during the day, but it is obviously more perceptible at night, interfering with nursing staff

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99 procedures. Nurses stated "The re are deficiencies in ligh ting during the day as well as night.” “Sometimes we have to move patients to a better illumina ted area to provide treatment.” In addition, poor lighting is an unsafe condition that increases the likelihood of needlestick injuries. “I had a needlest ick injury because I was working in a poor lighting area.” “I know techni ques and I have knowledge about needlestick and recapping used needles but there are unsafe places to work as resu lt of poor lighting.” Inadequate or absence of ha ndwashing facilities ranged from lack or deficiency of them, to do not having running water, malfunc tion of faucets and absence of soap and paper towels. "Sometimes handwashing f acilities do not work." and “On occasion handwashing facilities are used for different activities such as cleaning equipment used for maintenance of floors.” “We use the handw ashing facilities to wash our hands, mouth, and instruments.” “We use the same handw ashing facility to wash everything.” “Sometimes we have paper towels but we do not have soap or viceversa.” Unsanitary conditions in the hospital were another issue mentioned by nursing staff. “The hospital environment isn't always as cl ean as you'd like it to be.” The reasons are lack of water, inappropriate biohazard disposal as well as deficiency of containers for waste disposal. “Hospital clean liness is poor.” “Sometimes there is no water.” “After treatments are done you do not find where to place the waste.” “The cleaning and maintenance staffs just work in the morning shift. Most of the time we are obligated to place the waste into a plastic bag or bottle to av oid the risk of needlestick injuries because other containers are full and there is not enough space to put it.” “Clearly, all these aspects can affect asepsis and antisepsis of nursing staff that would lead to possible infectious diseases transmission.”

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100 a2) Organizational climate factors: nursi ng staff mentioned co nsistently the high patients (beds) to nurse ratio linked to the problem of needlestick injuries and recapping procedure. Participants in the focus group sessio ns expressed that as result of the increase of population to be attended there is a disp roportion between patie nts and nurse staffing. According to the shortage of nursing staff the participants stated “The re is a big disparity between the ratio of number of beds a nd number of nurses.” “Most often there are insufficient nurses to care for patients.” “Pat ients demand care because we are here to help them, but sometimes we can not handle th is, because it is not only the patient care, but also to attend the family.” “Sometimes in advertently we have acc idents.” “There are a lot of functions here.” At college you lear n how to manipulate needles but we can not handle this at the hospital w ith lack of resources.” “Can you imagine the amount of needlestick injuries that may occur because th e number of patients to care by one nurse?” “There is too much multi-tasking.” “There are sometimes situations where one might administer the wrong treatment to patients.” “We assume that all this will impact negatively on the quality of service provided.” “There are too few beds for the number of patients we have.” “The staff is not sufficient to pr ovide good care (more quantity than quality of care); in ad dition, there is lack of space to perform some procedures.” “No one works with the adequate conditions one shoul d have.” “You have to work two or three times more because the lack of nursing staff.” “You need to work faster, even if it means taking shortcuts.” “If we would have comf ortable working conditions, we might reduce our major problems.” “At work, we have many limitations and work overload.” Derived from the above, nursing staff expressed that work overload and ove rcrowding conditions relates to the amount of peopl e and the small space they ha ve to work in creating a

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101 stressful workplace that affects the working environment, and increase the chances for error. The stress was mentioned by nurses as an aspect present on daily basis, which is related to occurrence of needlestick injuries The stress is generated by the large volume of patients, deficiency of nurses, lack of s ecurity and not having safety devices available, in addition to high demands from doctors as well as patients’ family members. “Stress inadvertently leads to accidents.” “I think it is a particularly stressful environment that you live in every day, except for days where th ere are 10 patients and 5 nurses for all.” One aspect linked to stress by nurses was the lack of security in the wards as an important issue mainly in the night shift. “There is lack of security members or police officers in the wards.” “There are many security problems in the night shift and nobody comes to help us.” “We can die and nobody knows about that.” “The security is deplorable in this hospital.” Another aspect highlighted by th e focus group participants was associated with violence. “Violence comes from patient patients’ family members or coworker.” Similarly, there were opinion about the cowork ers’ violence and how th ey try to solve the situation in a very difficult work envir onment. “We also are abused/mistreated by patients, doctors ... it all combines to be a hostile environment. Many times the nurses do “small share” to join a little more, but th at depends on the working group where you are. There are shifts where the staff is more friendly/committed”. B) Hospital policies to prevent needlestick inju ries: In response to the guidelines of the hospital related to needlestick injuries prevention, the comments were very critical. In general, nursing staff stated that there is not a policy regarding safe work conditions to protect personnel, neither for acquisition of sharps disposal containers, or other

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102 appropriate supplies to prevent accidents. The first aspect was regarding to the availability of sharps containers In this topic nurses related to the fact that there were not sharps containers available at the hospital. For this reason, the disposal of used needles does not follow an appropriate and consiste nt procedure in the hospital. The work practice is to use makeshift containers usi ng plastic bottles (soft dr inks, mineral water), cardboard boxes or any objects that allow some one to place used needles. Two or three years ago adequate sharps c ontainers were provided by th e hospital, facilitating the disposal of needles in a safe way but these containers were discontinued, and no information was given about what happened. Descriptions of these situations are mentioned: “Sometimes we use a box or a plas tic bottle or anything av ailable to disposal of used needles, trying to avoid putting it in a plastic ba g (to protect our cleaning and maintenance staff). “Any big container is “a ppropriate” for discarding needles.” “In fact, the nursing staff is frequently inventing.” “Family members sometimes provide us with bottles of water or soda and then we use those to discard it (the needle).” Also, they emphasized that ther e is not education or training in the area of occupational health. They pointed out that there is a s hortage of personal protective equipment (PPE) to be delivered, which hinders their protecti on because these could se rve as barriers to prevent accidents. “The hosp ital does not do anything.” “We do not have any special disposal containers to put used needles.” “T here is lack of protective barriers.” “We should have safety glasses and means for dis posal of needles.” “If we have masks, we don’t have gloves, if we have gloves …the n there is no mask.” “With the demand of patients that exist, the re sources are not enough.” “At the university we receive the information on how to work, but here at hospita l the reality is so different, we have to

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103 work with what we have.” “The information and training on health a nd safety is essential in the hospital, however, it is not the priority of the hospital management.” “There are no training workshops, we are not provided with adequate containers to dispose needles. Sometimes we work with supplies, of a very low quality.” “We work sometimes with our nails.” Another factor to be considered was th e lack of information regarding waste management within the janitorial pers onnel. “For janitorial personnel handling biohazards is the same task as picking up regular trash.” “They should have adequate utility gloves to grab bags in order to avoi d getting stuck.” “They carry the bags with waste using the public elevators.” Perceptions of the Nurses about Needlestick Injuries Thirty five nurses (29%) from all focu s group shared the experience of a past needlestick injury in the last year, and the re actions generated by the accident as well as the possible causes of it. In al l cases, there were several fee lings that emerged from the accident such as fear, stress, crying, or guilt y, followed by the action of applying first aid and finally searching for help or advice. Nurs ing staff often stated that the cause of the accident was associated mainly w ith recapping of used needles. The large volume of patients, work overload and the accelerated procedures performed in different hospital areas were the main factors that might be responsible for this type of accident. Fear and tears were often the first reactions that emerged, followed by impotence and anger. “When I got stuck I was scared. The first thing I did was look for the patient records, checked for the blood tests that he had, and then when I saw that the test were fine I went to epidemiology servic e to report the accident. ” “In my case I had a

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104 very strong feeling... it was horri ble; however, today I keep the doubt, thinking about it, I got stuck on my finger because I was trying to recap the used needle. There was work overload.” “A colleague of mine, who got stuc k in the adult emergency room, got ill after her patient died and no one knew what the pati ent died from. Appare ntly, her illness was related to the needlestic k injury. She was in therapy.” “I thought in the patient disease. I was recapping the used needle.” “I also got stuck, I was stressed and went to the epidemiology service, but I keep the doubt.” “I began to cry.” “It's an impact so strong that one tries to be under control and not aggressive, but you cannot control yourself because there are so many feelings and your mind becomes blank.” “The first thought is that you are going to die.” “There is an i ssue that concerns me. Sometimes nurses got stuck and even when you suggest them to re port the accident, they deny it because the patient’s diagnosis has nothing wrong. They only squeeze and wash the site of the puncture.” “When I got a stuck I was scared be cause there are many diseases that I could get. After that accident I never recap used needles.” “I was recapping needles for many years until I heard that a colle ague from other hospital got He patitis B from a needlestick injury.” Needlestick Injuries Prevention Strategies The several preventive measures proposed by the different focus group participants were organized in the following strategies: a) Engineering controls b) Administrative controls and c) Orga nizational factors. According to engineering controls, focus group participants st ated that hospital management staff has to purchase sharps disp osal containers in su fficient quantities to cover all hospital services. The purchases of safety devices (s yringes and IV catheters) to

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105 prevent needlestick injuries as well as adequate and timeless provision of personal protective equipment (PPE) were other sugge stions made by nursing staff. “Hospital management has to incorporate new technologies.” “The hospital management has to buy sharp containers." "We deserve better supplies to discard used needles." Regarding administrative controls nurses hi ghlighted the need to develop workshops for nurses and healthcare workers on a regular basis, on topics of needlestick injuries prevention, identification of risk factors a nd hazardous conditions at work, training in how to use and apply new safety devices, as well as aspects of law, regulations and technical standards on occupatio nal health and safety. “To avoid needlestick injuries the hospital management should promote work shops and guidelines for the healthcare workers including janitorial personnel.” “Fir st, educate the staff, emphasizing on safety issues and new developments. Do not leave us abandoned as they have done so far, and as a consequence of it each person seeks how to better resolve at the workplace.” “The orientation on safety issues applies to janito r staff. This is not onl y about to protect the nurses while the others continue sticking.” “I believe that it is difficult to eliminate the needlestick injuries at all but at least to reduce them.” In the discussions, the nurses recognized they have a weak knowledge about the Venezuelan legal aspects on hea lth and safety matters. Most of them were unaware about the existence of a figure named “preven tive delegates” (e.g. safety committee) established by the Organic Law on Prev ention, Conditions and Environment at Workplace (LOPCYMAT). Data from the pretes t y posttest results (Table 17) showed that only 10% of nurses were aware about the ex istence of the LOPCYMAT and 22% did not know about the National Institute for Pr evention, Health and Safety at Workplace

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106 (INPSASEL). In addition, only 36% knew of the existence of the Committee on Occupational Health and Safety in the hospital. "We have to reinforce the accomplishment of the law.” Among the organizational factors nurses pointed out: Increa sing the number of nursing staff, improving the work environment, pol icies to prevent needlestick injuries, among others. “There should be a commitment to the institution as employers, to ensure the safety of its employees by improving hospita l’s conditions and environment.” “The physical environment has to be adequate especially regarding to poor lighting condition.” “To change policies or the pe rsonnel who is responsible for them.” “Improving the policies or change them becau se they are not being followed.” “Improve the hospital work conditions.” “To reduce ove rcrowding of patients and increase trained nursing staff, because most of the accidents are related with the number of patients that we have.” “(Administration) needs to follows up needlestick injuries cases.” Second Level: Analysis of Findings According to Wolcott (1994) this second leve l requires systematic and careful attention to the data to identify key factors and relations hips. In order to develop this level, one of the Wolcott’s strategies is to use an analyt ical framework. Therefor e, the purpose of this part is to analyze the factors of the descrip tion and categorization pa rt developed in level one by integrating them into the PREC EDE component of the PRECEDE/PROCEED Model (PPM) (Green & Kreuter, 1999). This provides a framework to understand factors or circumstances surrounding nurses’ safety practices specifically related to recapping used needles.

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107 In this study, the nurses’ de sired health behavior was ta rgeted as not recapping used needles. The factors that nursing staff id entified in the focus group sessions were integrated into the PRECEDE component of the PPM framework of predisposing, reinforcing, enabling, and environmenta l factors (Green & Kreuter, 1999). Predisposing Factors Nursing staff’s opinions about recapping need les and needlestick injuries that might serve as predisposing factors for nurses' safe practices included nurses' knowledge, attitudes towards recapping, belief about n eedlestick injuries consequences, values towards patient care, personal and other health care workers safety and perceptions about recapping procedure. In this study, nurses’ answers to the focus group questions illustrate d that several of the nursing staff had knowledge about the risk of needlestick injuries and recapping needles as an unsafe practice, and at the same time, regarding the importance of disposing used needles into appropriate sharps containers to prevent bloodborne infections diseases. Some nurses shared the knowledge of the trauma tic (disturbing) experience that resulted after an occupational needles tick and how this exposure influenced nursing staffs’ future behavior in the trend of not recapping used needles. Nurses' previous experience with needlestick injury and its c onsequences on safe practice we re important issue extracted from the focus group sessions. These accidents may have occurred in nurses or their coworkers. This experience might increa se nursing staff knowle dge about bloodborne infections, and change nurses staffing att itude and perception towards the safety of practices previously not considered unsafe (e.g. recapping needles) in fact, actually several nurses believe that these practices were unsafe and therefore avoid them.

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108 In contradiction/paradoxically, it emerge d from focus group sessions that several nurses had lack of knowledge about Venezu elan occupational safety and health legislation/regulations and most of them were unaware about the existence of “preventive delegates” which main functions are inspec tion, control and eval uation of occupational safety and health conditions in the workplac e. This situation could be considered a negative predisposing factor because lack of knowledge in this matter prevents nursing staff to demand for better working conditions. The attitude assumed by nurses toward the safety of recapping used needles could change the recapping practice. Those nurse s who perceive recapping as an unsafe behavior avoided this conduc t. The reason why this might be perceived as unsafe included the potential risk of getting stuck when doing this practice or having already been stuck while doing it. In contrast, other nurses might pe rceive the recapping practice as a safer alternative to someone else who might be stuck if the needle is set down unsheathed in a place or thrown away in a pl astic bag. Therefore, it is important to emphasize that these attitudes could be a f acilitating/positive condition for some nurses and an obstacle/negative to safe practice for others. If nurses believe that a potential conse quence of a needlestick is to acquire a bloodborne pathogen infection, this belief ma y predispose those nurses towards safe practice. An example of this was the stat ements of some nurses who described the situation of health care workers who had He patitis B positive status. The connotation for that consequence influenced them towards not recapping needles. Values about recapping used needles as a sa fety issue for nurses and other health care workers was a topic that emerged from the focus group sessions. For some nurses

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109 recapping used needles is an unsafe procedure and then it is important to avoid this practice in order to prevent injuries for them On the other hand, most of the nursing staff explained that recapping practice was a proced ure used to protect not only themselves but also other health care workers (e.g. cleaning st aff) and other persons such as patients or patient’s family members. Therefore, the value placed on personal safety about recapping was higher for some nurses while the value pl aced on the safety of health care workers and other people was higher for other nurses. Additionally, most of the nursing staff explained that a very important value for them was the good patient care they provide despite the less than optimal workplace conditions. Perceptions that could influence the practi ce of not recapping used needles included the risk of getting a bloodborne infection fr om a needlestick. Some nurses described their fear and anxiety of getting a bloodborne dis ease from a needlestick and affirmed that these feelings influenced them in the routine of not recapping used needles. The effect of a past needlestick injury ma y influence the predisposing factors for safe practice of hospital nurses. For example, th ere were nurses who knew the low risk of acquiring bloodborne diseases, specifically Hepatit is C or HIV from a needlestick injury and therefore these nurses were not motivated to stop recapping needles. However, other nurses who have had the experience of a need lestick or knew someone who has had one, perceived that the risk was significant and e nough to influence them to not continuing the practices of recapping used needles. Reinforcing Factors According to Green and Kreuter (1999), "r einforcing factors in clude social support; peer influences; feedback and/or advice by health care providers; as well as physical

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110 consequences of behavior (1999, p. 171). Rewa rds may reinforce positive behavior while punishments can lead to the extinction of a positive behavior, therefore, reinforcement may sustain the continuation of pos itive and negative behaviors. In this study, there were si gnificant examples of nurses who had experienced or knew someone who had experienced accidents and cl aimed that now they would never recap a needle again. Thus, the perception of past n eedlestick exposure appears to fit into the reinforcing positive factors, because a negative consequence of not using safe practices would be the potential fo r a needlestick injury. Additionally, there was a situation that a ppears to fit into negative reinforcement factors to nurses’ safety pr actices. From focus group answers emerged that the hospital management’s attitude was not committed towa rd occupational safety and health policies to protect health care workers. Several nurse s verbalized dissatisfaction on how hospital management leads the safety issues. Nurses had a very critical position regarding the hospital support in this aspect which ranged from inadequate safety climate, no policies concerning safety work conditions to lack of education and trai ning in the area of occupational safety and health. Accordi ng to nurses’ perception there are not policies/procedures to prevent needlestick in juries; or those exis t but nursing staff does not have any information about them. In both cases the situation is concerning. Consequently, inadequate safety climate and absence of policies/procedures at MCH are negative reinforcement for nurses’ safety practices. Enabling Factors Often conditions of environment, enabling f actors facilitate the performance of an action by individuals or or ganizations. These conditions include "availability,

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111 accessibility and affordability of health car e and community resources. Enabling factors also include new skills that a person, organi zation, or community needs to carry out a behavioral or environmental change" (Green and Kreuter, 1999, p. 167, 168). “Any characteristic of the environment that fac ilities action and any skill or resource required to attain a specific behavior. Absence of the resource blocks the beha vior; barriers to the behavior are included in lists of enabling factors to be deve loped” (Green and Kreuter, 1999, p. 505). Enabling factors are antecedents to behavior that allow a motivation to be realized. Two subthemes of the categorization schema de scribed in the first le vel of analysis for phase two fit into this group of enabling factors. The first subtheme included lack of availability and accessibility of safety devi ces (sharp containers and personal protective equipment) to hospital areas. Nurses in the study stressed that those safety devices not only need to be purchased by the hospital ma nagement but also these devices must be physically accessible to nurses. The second subt heme was related to skills and experience to performa routine procedures by nursing st aff. There were several nurses who affirmed they had the ability and experience to carry ou t safe procedures but they got a needlestick injury because the accident was related to other circumstances that were out of their control such as physical work conditions, or ganizational factors and nurse/patient ratio. Obviously these subthemes were barriers to the goal behavior. Environmental Factors In this study, nurses described the ci rcumstances surrounding recapping needles and needlestick injuries at the MC H. These circumstances were related to physical conditions such as lighting, handwashing facilities, and unsanitary conditions as well as

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112 organizational climate regarding to a reduced nu rse/patient ratio (work overload, overcrowded workplace) and occupational safe ty and health issues (lack of sharp containers, lack or deficiency of personal protective equipment). It is important to mention that several nurses stated lack of secu rity in different hospital areas especially in the night shifts. The aggressive attitude from patients, patie nts’ family or coworkers was mentioned as very critical by nursing staff. Additionally, there were other situations stated by nurses that were more associated di rectly to the nurse/pa tient relationship such as distraction factors during j ob activities for example, lack of focusing, being called by someone else, and unexpected patient move ment during procedures as well as unpredictable patient’s status. Re garding patient’s attitude it is rational to think that any unexpected movement is a potential hazard to a needlestick injury and then might be a barrier to nurses’ safe performance. In fact, several of the accidents related by nurses were caused by the unexpected patient’s movement during performance of a routine procedure. Another situati on that was commented by nurses as obstacle to safe practice was the unpredictability of patient status. Several nurses recounted experiences where they found that the patient's status had cha nged (e.g., veins had collapsed and were hard to access, patient in very bad health condition), resulting in si tuations that made it more difficult to use safe practice. During the fo cus group sessions, nurses used the example of removing a port access needle from a port acces s device and the use of butterfly needle especially in children were th e most dangerous procedures that they performed in the hospital setting. Many of these c onditions were perceived as obstacles by nurses in their ability to perform safe practice, because of the very complex hospital work environment.

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113 Relationships between Factors in the PRECEDE-PROCEED MODEL The relationship between th e predisposing and enabling factors emerged from the description and categorization part of th e study (Figure 3). According to several examples, lack of knowledge about Venezu elan occupational safety and health legislation/regulation may aff ect the possibility to demand for preventive resources for safe practices. Also, what emerged from the da ta was that if nurses’ attitudes and beliefs maintain safety, this may affect personal ski lls in safe practices. But at the same time, enabling factors (e.g., lack of the availability and accessibility of sharp containers and personal protective equipment) influence negativ e nurses' attitudes against safe practices. The relationship between reinforcing a nd predisposing factors was unidirectional according the results of this study (Figure 3) Predisposing factors may be influenced by reinforcing factors. Some nurses may have c onfident attitudes and beliefs about safety work practices, but may be influenced toward or against such use by positives reinforcing factors as previous experience with needlestic k injuries (nurse or coworkers) or negative reinforcing factors such as hospital mana gement’s attitude toward prevention of needlestick injuries or nurses who not having had a needlestic k injury. It is important to point out that these experiences could in fluence knowledge, attitudes, belief and perceptions surrounding the circum stances of safe practices. Reinforcing and enabling factors were influe nced reciprocally (Figure 3). For example, the negative hospital management’s attitude toward safety an d safety practices regarding to lack of availability and accessibility of preventive resources influenced negatively the nurses’ participation in a goal behavior. On the other hand, absence of sharps containers

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114 and lack or deficiency of personal protectiv e equipment could act as negative reinforcing factor for nurses’ safe practices. Enabling and environmental factors were also influenced reciproca lly (Figure 3). There were several examples from the data where physical conditions in the hospital environment as well as nurse/patient relations hip factors influenced the ability of nurses to perform safe practice, even when skills to do it were present. Then, the environmental factors were not only influenced by but also could influence the enabling factors of nurses for safe practices. In summary, the predisposing, reinforci ng, enabling and environmental factors were influencing the actual and goal behavior (u se of safe work practices) of nurses. Furthermore, predisposing factors were infl uenced by reinforcing factors (Figure 3). Predisposing and enabling factors were influenc ed reciprocally as well as reinforcing and enabling factors (Figure 3). Enabling and e nvironment factors also were influenced reciprocally. Additionally, environmental factors and behavior were influenced reciprocally (Figure 3). Th e actual behavior described by nurses was influenced by predisposing, reinforcing, enabling, and envi ronmental factors identified in this study. For some nurses, the actual behavior was th e goal behavior of use safe work practices (e.g. not recapping). For others, it was not, as evidenced by unsafe practices (Figure 3).

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116 Third Level: Interpretation According to Wolcott (1994), the third leve l “interpretation” is conducted to derive meanings from the findings. In order to develop this level, one of the Wolcott’s strategies to extend the analysis part was used (p. 40). In this study, relationships between predisposing, reinforcing, enabling and e nvironmental factors found influencing the actual or goal behavior were developed from the results of the analysis part (Figure 3). Therefore, the purpose of this part was to inte rpret such relationships and their influences on safe practices of nursing staff from the Ma racay Central Hospital who participated in the focus group sessions. Predisposing and enabling factors were found to be influenced reciprocally in this study. That is, predisposing factors could pos itively or negatively influence enabling factors. Regarding the positive influence, nursi ng staff had predisposing factors related to knowledge, attitudes, beliefs, values and per ceptions about needles tick injuries and its consequences; as well as safe practices that could positively influence the performance of safe routine procedures in orde r to achieve safe practices (goa l behavior). For instance, if nurses have a positive attitude and belief to support safety and adequate knowledge about the consequences of a needlestic k injury, it is feasible to think that these factors can be a positive motivation to continue doing safe procedures. This example was illustrated with several nurses’ comments obtained from th e focus group sessions. In relation to the negative influence, one of the negative factors found was that nurses’ lack of information about Venezuelan occupational safety and h ealth legislation/regulations that might contribute to lower levels of knowledge about this matter. This situation was a very important predisposing negative factor th at could be influencing the hospital

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117 management’s attitude to be passive toward sa fety and safe practices It is feasible to infer that if nursing staff would have a cl ear understanding of th eir rights in the occupational health field, pr obably the hospital management’s attitude about occupational safety could be different in positive direction nurses’ abil ity toward achieving the goal behavior. But unfortunately, the reality wa s different and most of the nurses were engaged in the actual behavior (recapping need les). It is significan t to point out that predisposing factors are the main factors on wh ich all other factors may have their effect. In other words, if nurses and hospital mana gement have high enough levels of motivation or commitment, less effort might be needed from the other factor s to achieve the goal behavior. How enabling factors influenced in predis posing factors was also demonstrated in positive and negative ways. An example of a positive factor was the nurses’ skill to perform safe procedures that could be a positiv e factor to influence strongly the attitudes, beliefs and perceptions about th e use of safe practices. In the study, several nurses related that they knew about the techniques to perf orm safe procedures because this information was given in the university or college and may be they learned the right techniques to do safe procedures. If nurses can maintain thes e abilities, despite the less than minimal conditions in the hospital work environment, it is understandable, that predisposing factors can be influenced positively by the nurses’ ability, strengthening the goal behavior. With reference to ne gative factors, it was associated with how the lack of availability and accessibility of preventiv e resources could be a negative factor influencing in the nurses’ actual behavior. Fo r example, if hospital management decides not to acquire sharps disposal containers for whatever reasons, this could possibly

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118 negatively influence nurses’ attitudes, values and perceptions about safe practices. For instance, if there are not dis posal sharp containers availabl e in the hospital, some nurses will continue recapping needles because they ma y not perceive this procedure as a risk. In fact, the rationalization is that recappi ng needles is a “safe procedure” to protect themselves and other health care workers. Educational interventi on is imperative to promote changes in the actual behavior of these personnel. The hospital management has to assume the administrative and legal respons ibility for the prevention of exposures and on safety issues for nurses and other health care workers. Reinforcing factors were found to influen ce predisposing factors in this study. There were positive and negative factors. Regardi ng the positive reinforcing factors, nurses or coworkers as result of a negative event (n eedlestick injury) or not getting a bloodborne infection disease after a needlestick injury co uld influence positively in their attitudes and beliefs to maintain safe practices. This si tuation was demonstrated in this study when several nurses explained that they changed their unsafe pr actices after a personal or colleague experience with needlestick injury or not getting a disease after getting stuck. It is possible to think that this negative expe rience become a positive influence toward goal behavior. The possibility that nu rses have not had a needlestic k injury after sustained safe procedures is another example of positive reinforcing factor that could positively influence in attitudes and beliefs. For example, if a nurse is using safe practices and as result of that she/he has never been stuc k or has not acquired a bloodborne disease this could be considered a reward for sustaining the goal behavior (saf e practices). Another positive factor found in the study was the nurse s’ disapproval when other colleagues were doing unsafe practices and they advised them about the inconvenient of these procedures.

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119 This “social support” is a type of peer infl uences that emerged from the discussion of focus group sessions and apparently it work s in the hospital. Obviously, if nurses continue using safe practices that avoid them sustaining a needlestick or acquiring a bloodborne disease infection, this will impact thei r future behavior about safe practices of needles safety precautions (e.g., not recapping us ed needles and disposal of used needles into sharps containers). In summary, previ ous nurses’ experience of needlestick injury, the adverse consequence of a bloodborne diseas e and not having had a needlestick injury could positively influence the goal behavior. Regarding the negative factors, all the re inforcing factors that appeared could be paradoxically negative threaten against achievement of the goal behavior. For example, not having had a needlestick was an eviden ce of negative reinforcement for nurses’ attitudes. It reasonable to th ink that if nursing staff never have had a needlestick injury and they continue recapping used needles why do they need to change this practice? For these nurses, this could be a reason to keep doing their duties in the same way that they have been working for years. Another example of a negative reinforc ing factor could be a nurse who did not recap a used needle for what ever reason and left it at the patient’s bed or in any other place, resulti ng in either them getting stuck or a coworkers doing so later when picking it up. Consistentl y, in the study, most of the nu rsing staff expressed that recapping used needles was done to protect themselves and other coworkers (nurses, cleaning and maintenance staff). This example could be considered a negative reinforcing factor because nurses are/were prone to cont inue recapping as an unsafe practice despite of the risk of a needlestick injury and its consequences in order to protect others.

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120 The passive hospital management’ attitude toward safety and safety practices to prevent needlestick injuries play a roll very important to influence negatively the nurses’ attitudes and perceptions a bout safe practices (goal be havior). All the negative reinforcement mentioned above served to sustain the actual behavior. One aspect that emerged from the analysis part, and it was incorporated into hospital management’s attitude, was related to the e ducation and training as a necessary element of safe practices. Adequate or inadequate e ducation and training about safety issues is a critical condition to change behavior. Once more the hospital management has the responsibility to change the si tuation. In summary, not having had a needlestick injury, as well as hospital management’s attitude and the criterion to protect ot hers could negatively influence toward the goal behavior. On the other hand, from the analysis part did not emerge how pr edisposing factors can influence reinforcing factor. However, it is pos sible to assume how these influences could occur in a positive and a negative way. In the first situation (positive way) would be nurses with a strong belief that it is possi ble to get a bloodborne pa thogen infection from a needlestick could be motivated to continue safe practice. For example, if nurses know about a coworker who sustained a needlestick from recapping used needles and acquired Hepatitis B, it may positively influence the ot her nurses towards continuing their practice of not recapping, and consequently, it is possi ble to deduce that pr edisposing factors may positively influence reinforcing factors. Anot her example of a positive factor would be that nurses’ knowledge, attitudes, belief, valu es and perception about safe practices can be an influence to modify the hospital mana gement’s attitude to support safe practices. The negative way can be associated with the nurses’ lack of knowledge about

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121 occupational legislation whic h does not allow them to actively demand support from the hospital management for safety procedures and practices. As a result of this, some nurses could maintain the actual behavior. The relationships between reinforcing and enabling factors were demonstrated to be influenced in both directions. How enabli ng factors were influenced by reinforcing factors was found in positive and negative wa ys. The positive reinforcing factors of attitudes and behaviors of cowo rkers about previous experience with a needlestick injury, adverse consequences of recapping and not ha ving had a needlestick injury could be factors to reinforce the goal behavior because nurses’ skills can be influenced to develop safe practices. For example, if nurses have not had needlestick injuries or have not acquired a bloodborne disease as result of getti ng stuck by a needle, th is situation can be a positive reward for using safe practices and then be motivated to perform safe routine procedures. Another situation th at was not found in this stud y but can be an example of positive reinforcing factor would be if hospital management had positive attitude around safety that promotes/encourages prevention issu es, it is feasible that this might influence nurses toward the performance of safe routine procedures. Otherwise, negative reinforcing factors such as hospital management’s attitude toward safe practices could be expressed in the lack of availability and accessibility of preventive resources (sharp containers and personal prot ective equipment) and also in the nurses’ skills to perform safe routine procedures. At the same time, not having had a needlestick injury could be a negative reinforcing f actor because nurses may feel motivated to continue with the recapping used needles despite the risk. It is importa nt to point out that the antecedent of not having had a needles tick injury can be a positive or negative

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122 reinforcing factor and then this experience could reinforce some behavior, but it may or may not be the goal behavior. In summary, it is evident that all these factors could positively or negatively influence nurses toward desired behavior. How enabling factors could influence reinforcin g factors was also demonstrated in this study in a positive and negative way. In a posi tive way nurses’ skills to perform safe procedure could be a positive factors to influence in the positive reinforcing factors. As was mentioned to previously in the re lationship between enabling factors and predisposing factors about nurses’ skills on how to perform safe procedures, these skills could positively influence the goal behavior because nurses would be aware of the adverse consequences of recapping needles and then are/were prone to use safe practices. For example, if a nurse is doing safe routine pr ocedures it is possible that the reward for doing that would be not having had a n eedlestick and therefore not acquiring a bloodborne disease and then she/he is motivated to continue us ing safe procedures. In the negative way, the lack of availability and acces sibility of preventive resources could be a negative factor influencing in the nurses’ actual behavior beca use nurses are still performing unsafe practices like recapping needles. For example, if hospital management does not acquire sharps containers, safety devices and personal protective equipment (PPE) to prevent needlestick injuries, it is feasible that this might influence in nurses toward unsafe practices (actual behavior). In the focus group sessions several nurses stated that they will continue recapping needle s because of the lack of sharps disposal containers. Undoubtedly, the lack of availabili ty and accessibility of containers in the MCH is one of the main obstacles to achieve the goal behavior.

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123 Enabling and environmental factors were al so influenced reciprocally. Environmental factors such as physical conditions, inadequa te organizational climate and nurse/patient relationship were factors that negatively influenced in nurse s’ ability to perform safe practice. It is important to emphasize that these environmental conditions could influence not only in the unsafe practices but also could be responsible for needlestick injuries. In addition, lack of availability and accessi bility of sharps disposal containers and personal protective equipment were factor s that negatively influenced in the organizational climate as well as safe practi ces in the nurse/patient relationship. In summary, environmental and enabling factors are essential to maintain the actual behavior or to achieve the goa l behavior. The negative influen ces of both situations were sufficiently explained by nursing staff in the focus group sessions.

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124 CHAPTER SEVEN: DISCUSSION This chapter is oriented to follow a discussion integrating the quantitative and qualitative components of this study. In th e first section the mo st significant findings from the quantitative results are synthesized. In the qualitative section the discussion is framed around the first level of analysis of Wolcott methodology findings (Description and Categorization) and then PRECEDE com ponent of the PPM, including predisposing, reinforcing, enabling and environmental f actors. Finally, a br ief comment about limitations and strengths of the study are presented. Quantitative Findings Female nurses were the largest group in the sample (Table 10). Nursing in Venezuela is primarily a female profession, despite the progressive incorporat ion of men. Regarding the educational level (Table 10), the result shows that nurses in the MCH have been professionalized in recent years, as has happe ned in other Venezuelan public hospitals. This information is similar to data found in other countries, especially in Latin America (Marchan, 2005). Regarding the number of needlestick injuries sustained by nurses in the past year, in this study, 29% of the nurses studied reported th at a needlestick injury had occurred in the last year (Table 11). In a study done in an India’s tertiary care hospital by Jayanth, Kirupakaran, Brahmadathan, Gnanaraj, a nd Kang (2009), 37% of nurses reported a needlestick injury in one year period. In a university hospita l of Turkey, Mustafa, Elif, Aras, Sertac and Remz (2006) found that 68 % of nurses were exposed to sharp or

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125 needlestick injuries in the last year. Derek, Choe, Jeong, Jeon, Chae and An (2006) found in a study in a Korean hospital that NSIS were reported by 263 nurses (79.7%) in the previous 12-month period. Junco, Oliva, Ba rroso and Guanche (2003) found in research conducted in Intensive Care Units in La Ha vana, Cuba, that 39% of nurses had been injured in the last year. In a study carrie d out in home care nurses in California by Haiduven (2000b), 92% (48/52) of the nurse s from three home care agencies had a needlestick injury in the last year. It is important to emphasi ze that although the results in this study were low when were compared with other studies, the need lestick injuries in nursing staff at the MCH remains as an issu e of great concern a nd deserves better attention from health authorities. These data also show that needles tick injuries sustained at work are a frequent problem among nurses in different countries’ health care settings. In terms of the percentage of nurses w ho experience NSIS compared to other HCWs, Saulat in a study done in 2005 in a hospital from Saudi Arabia showed that nurses had the higher number of all incidences of needles tick injuries at 65.8%. In a study done by Galindez and Haiduven (2004) in the MCH 30% (39/129) of health care workers reported sustaining a needlestick injury. Of those 39 workers, 25 (64%) were nurses. Likewise, Palucci (2003) in a study conducted in four hospitals in Brazil found that 50% of needlestick accidents were reported in nurse s. According to data from the Maracay Central Hospital Surveillance for Needlestic k Injuries for the years 2007 and 2008 (Table 20), of all injuries reported in health care workers, nur sing staff represented 30% and 37% respectively. If the nursing students who reported NSIS are included, the percentages increased to 46% and 54% respec tively. All these findi ng confirm that the

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126 nurses are the occupational group among other he alth care workers at highest risk for needlestick injuries in hospital settings. Concerning the question if th e needlestick injuries were reported, in the study, all 35 (100%) nurses reported the accident at the tim e (Table 11), this result differs with the work of Junco et al., (2003) done in Hava na, Cuba, noting that 96% did not report the accident. In work done by Martinez, Alar con, Lioce, Tennasse and Wuilburn (2008), 80% of needlestick accidents were not reported in a populatio n of 20,000 health care workers in 4 Venezuelan states. In the same re port, health care workers expressed that the main reasons for not reporting the accident were they did not cons ider it important to report or did not know where to re port it. In this sense, it is imperative to take actions to reduce the underreportin g in order to have a true re presentation of the number of needlestick injuries, then to organize a nd develop programs to prevent accidents. According to published studies the percentage of underreporting has ranged from 40% to 80%. Elmiyeh, Whitaker, James, Chahal, Ga lea, and Alshafi (2004) found in a study done in a US hospital that 80% of respondent s were aware that n eedlestick accidents should be reported, but only 51% of those aff ected had reported all needlestick injuries. These data confirm that although doctors and nu rses are aware of the benefits of early reporting, a culture of silence persis ts (Doebbeling, Vaughn, Beekmann, & Ferguson 2003). This “culture of silence” has to be broken in orde r to implement changes in the bloodborne disease transmission. The mean number of years of nursing and the mean number of y ears of experience in the hospital (Table 12) show that the study group had work experience and had enough time working in the hospital to be familiar with procedures.

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127 Concerning the number of hours worked daily and weekly (Table 12) these results are similar to Loli`s work (2000) which reported th at nurses were working in public hospitals in Peru from 30 to 40 hours per week with 2 or 3 days off, while in private clinics work 40 to 48 hours per week with one day off. Re search data indicate that at MCH the hours worked by nurses per day and per week are gr eater than the established by Venezuelan Labor Act (1997) regulations (36 hours per w eek) and thus the nurses are not following the provisions of 149-1997 repor t of the International La bor Office (ILO, 1997), which recommended reducing the hours to a maxi mum of 35 hours per week. According to Marin, Alves, Gir and Martins (2008) in a st udy done in Brazil hospita ls found that a long work week entailed greater chances of pr oducing needlestick injuries, which may result from the worker's longer exposure to risk situ ations, not only the fact that long work days can produce fatigue but also increase the risk of injury. The results s howed that working 50 or more hours per week increased the chan ces of needlestick injuries (OR 2.47; CI: 1.07-5.67) and similar results were found for those working in mixed or in night shifts, as compared to those working only in regular da ily shifts. Studies on needlestick and sharp injuries, involving nursing professionals, also have reported that the chances of being victims of this kind of injury are higher in mixed shifts (Smith, Mihashi, Adachi, Nakashima, & Ishitake, 2006). Alison, R ong, Geiger-Brown, and Lipscomb (2007), stated that hours worked per day, weekends worked per month, working other than day shifts, and working 13 or more hours per day at least once a week were each significantly associated with needlestick injuries. In su mmary, it is imperative that MCH authorities supervise this situation and modify it, becau se according to the inte rnational literature, the excessive hours of work may not only cau se a negative impact on health, but also

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128 become a factor in accidents caused by ment al or physical fatigue. The percentage difference between number of needles not re capped before and af ter the educational strategy in all four department s (Table 13) was statistically significantly higher (< 0.001). The same situation was demonstrated in each department (Table 14). The departments with the greatest difference between pre and post-intervention were Obstetrics wards and NICU. In accordance with these results (Table 16), the odd ratios at all four hospital departments were less than 1, indicating a protective effect, demonstrating that the educational strategy was associated with fewe r recapped needles. The odd ratios in the Obstetrics wards and NICU were the lowest The statistical significance in all four departments could be explained by stating that nurses change d work practices from more instances of recapping to less instances of (r ecapping) after the educational strategy. This intervention has had a positive effect on the behavior of the recapping activity. These results are similar to studies of Marin et al., (2008) conducted in a tertiary hospital in Brazil, which revealed that "recapped need les" were an important predictor for percutaneous accidents among nursing professi onals. In addition, Doebbeling et al., (2003) found that the handling of hollow need les was considered a risk factor for percutaneous accidents (OR 1.02) among profe ssionals in the healthcare field and not recapping needles was identified as a protec tive factor (OR 0.74), after adjustment for potential confounding factors. The pretest applied in the educational strate gy (Table 17) demonstrated a lack of basic information on issues concerning to the ways to acquire a bloodborne viral infection. The test scores improved signifi cantly (Table 17) in the posttest. The comments expressed by

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129 nursing staff reflect that they need education and training in aspects related to specific topics regarding bloodb orne pathogens. The lack of knowledge about laws, institutio ns for occupational health prevention as well as the existence of the occupational sa fety and health committee in the hospital by nursing staff participants in the educational strategy sessions was demonstrated with the low percentage of correct answers of the que stions regarding these topics (Table 17). The data about the Hepatitis B immunizati on (Table 18) showed a low percentage of nurses (38%) who had completed the series. Th ese data contrast w ith those reported by Junco et al., (2003) in a re port from Havana, Cuba that 367/412 (89%) respondents had completed the full immunization series with Hepatitis B vaccine. Similarly, Palucci and Carmo (2004) have published results where 84.8% of health care workers had the three doses with Hepatitis B vaccine. According to data presented by Martinez et al., (2008) in a cross sectional study conducted in 4 states of Venezuela, with a total of 20,000 health workers, found that compliance with the full se ries for Hepatitis B did not exceed 65%. These findings should call for reflection because the Hepatitis B vacci ne is an excellent aid to prevent the disease and it complications Additionally, this vaccine is distributed free to each health worker who applies fo r MCH Health Department of Immunization (Epidemiology) or Occupational Medicine Depa rtment. This situation might reflect the limited knowledge that nursing sta ff have about the consequences of acute di sease (acute hepatitis) or long-term illness such as the development of liver cirrhosis or liver adenocarcinoma. In this aspect, both De partments, Epidemiology and Occupational Medicine, should to work together in order to implement a strategy to promote Hepatitis B vaccine immunization.

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130 Table 19 illustrates that th e number of NSIS in 2007 (130) had an increase of 22% when compared with 2006 (101). It is important to stress that this is the highest number reported in the last five year s in the hospital. This value does not denote that the number of NSIS has increased; it is possible to think that this re sult is consequence of a better attitude/behavior of the personnel to report NSIS. Ho wever, for the year 2008, the information about NSIS decreased 18%. As was commented in the previous paragraphs, the underreporting is a very concerning situa tion that needs a majo r effort by hospital management to reduce. It is important to highlight that in 2007 also was the year with the lowest percentage of NSIS in nursing staff (30%) when comparing wi th the other years (Table 20). In contrast, other health care workers had the highest pe rcentage (54%) when also compared with other years. Table 21 provides information about the number of needlestick injuries sustained by nurses from the departments studied and nur ses from other units or departments not included in the study. For both years, the data show that nurses from other units had the highest percentage of NSIS with 55% (33/60 ) and 57% (34/60) respectively. In contrast, nurses from the departments studied had 45% (27/60) and 43% (26/60) respectively of the all NSIS. Of the all nurses that sustained NSIS in 2007 and 2008, 26% (31/120) came from the AER department (Table 22). These data ar e in concordance with other works where operating room and ER are the de partments with highest incide nce of NSIS (Perry et al. 2005), but at the same time the results from this study differs from a study done in

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131 Europe where NSIS were most likely to o ccur in patient rooms and the operating room (Sulsky et al., 2005). The rates of needlestick injuries and occupied hosp ital beds were around 22, 15, 19, 24, and 16 needlestick injuries per 100 occupied hospital beds during 5 years (Table 23). This data are lower than the average suggested by the EPINet system of 26 needlestick injuries per 100 occupied beds per year for teaching hospitals, (US, EPINet, 2001). According to Jagger (2001), these rates give an idea of the institutional needlestick experience, which can then be used to follow NSIS levels over time. At the same time, it is possible to compare the rates with other institutions, however, according to the author hospital management has to be aware because the rates can be affected by a number of factors, including the level of needlestick underreporti ng and the types of patients the hospital treat. Table 24 provides the rates of NSIS in all health care workers, nursing staff from other units and nurses from the departments studied. The data were similar for 2007 and 2008, however, it is important to highlight that of the 13 NSIS in nurses by 100 hospital occupied beds, 5.7 and 5.5 NSIS respectively, almost a half of the events came from nurses from the departments participating in the study. Obviously, as was showed in the table 22, the AER department played a main role in this rate. The information provided in Table 25 s hows the rate of NSIS when was calculated using as denominator the total of beds (158) in the departments par ticipating in the study (Table 4), it is important to notice that th e results show values higher when compared with the data show in Table 24. For both years, from rates of 5.7 and 5.5, the rate of NSIS increases to 17 and 16 NSIS by 100 occupied beds. Although both rates are in the

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132 average according to EPINet values, the 3 fold increase when the denominator was changed could mean that NSIS in nurses from the departments participating in the study need to be follow across the time in or der to compare the new NSIS rates. Qualitative Findings Circumstances Related to Recapping of Used Needles and Need lestick Injuries Environmental factors. a1) Physical conditions. Regarding the results of the qualita tive section it is important to note that environmental factors were one of the aspects most commented upon by nursing staff. Several nurses expressed that the work ing conditions in the MCH were less than the minimal necessary to accomplish their duties. This situation has been reported in other works. Borges (1998), suggests that in many Venezuelan hospitals work environments (emergencies, hospitalization areas, surgical and medical wards among others), health care workers do not have handwashing facilitie s because they are inadequate (do not having running water, malfunction of faucets), or there is lack of them. At the same time there is absence of soap and paper towels to accomplish the main practice of asepsis and antisepsis in order to reduce exposure to biological hazards. This information confirms the comments of the nursing staff from the focus group sessions about the physical work conditions at the MCH specifically re lated to handwashing facilities. According to Tomasina, Bozzo, Chaves, and Pucci (2008) in a work done in the Hospital Clinicas, a surgical center in Uruguay, the most impo rtant results revealed lack of favorable working conditions in terms of heat, air conditioning, ventilation and lighting. Physical, chemical a nd biological risks determine a complex profile of burden that affects the workers, who considered it as an important risk for their health. Regarding

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133 acute lesions, accidents caused by sharp implements and traumas were the most outstanding. Marchant (2005), conducted an analysis case of organizational climate in Chile’s hospitals, found that the "space, physical environment and infrastructure," has been one of the worst variables evalua ted, showing a general dissatisfa ction with the physical and environmental work conditions (p.138). It is important to highlight, based on the comments expressed by nurses in the focus gr oup sessions, the variable of physical space and infrastructure of the hospital under study are not the most appropr iate for carrying out their activities. The conclusion is that when work space is not large enough nor properly equipped for its functionality there are not the proper environmental conditions for working. As a consequence the work performan ce is not the optimal. In other words, if the working conditions can be improved, th e workers performance will be better. In order to establish the level of job satisfaction, a study was done by Fernandez and Paravic (2003) in public and private Hospita l Centers in the Provi nce of Concepcin, Chile. The results showed that physical worki ng conditions stand out as a dissatisfaction factor in the case of hospita l nurses, especially those working for the public area. In summary, there are several studies th at establish a clear relationship between physical working conditions, job satisfaction and likelihood of needlestick injuries at hospital settings. a2) Organizational Climate Factors. The organizational climate is one of the determinants factors of the organizational processes, management change and innovation. The nursing staff in the focus group sessions re lated that not only the physical working conditions but also the organizational cl imate were important matters. Regarding

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134 organizational climate factors nurses stated th at stress, shortage of nurses, work overload, and violence among others play a very importa nt role in the unsafe workplace conditions as well as in the incidence of needlestick injuries. According to Rodriguez (1998) the organizational climate has been defined as "the perception that members of an organi zation have about the more significant characteristics that describe and differentia te from other organizations (p.1)”, which influences in the behavior of organizational nur sing staff. The term is also refers to the social atmosphere of a company or organiza tion that specifies and determines the degree of well-being and satisfaction to be found in it (Gonzalez-Roma, & Peiro, 1999). Concerning organizational climate and needle stick injuries there are several studies around the world that establish a close rela tionship between thes e two variables. The American Nurses Association (ANA) announced the findings of the 2008 Study of Nurses’ Views on Workplace Safety and Needle stick Injuries, an independent nationwide survey of more than 700 nurses. According to the latest research, (64%) of U.S. nurses say needlestick injuries and bloodborne inf ections remain major concerns, and 55% believe their workplace safety climate negati vely impacts their own personal safety. According to Clarke (2007), although indivi dual behaviors influe nce risks of sharps injuries and other occupati onal accidents, organizational factors appear to provide important context for safety by influenc ing the immediate working conditions under which potentially risky tasks are undertaken. The same author stated that mechanisms are not altogether clear, bu t work environments a nd cultures appear to affect worker safety not only in health care, but in other industrie s as well. In conclusion, nurses working in hospitals with better working environments were at lower risk of sh arps injuries. In the

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135 same direction, Stone, Yunling, and Gershon, 2007 in a study done in nurses of New York City hospitals concluded that organizatio n climate (OC) is significantly associated with the health and well-b eing of hospital nurses. As was commented by Clark, et al., (2002) in a study carri ed out in US hospitals, nurses working on hospital units with poorer work climates and lower staffing levels were substantially more likely to report th e presence of risk factors associated with needlestick injuries. The same authors suggested that remedying problems with understaffing, inadequate administrative support and poor morale in hospitals may turn out to be the most important steps in building a safer hea lth care system. In a study done by Mark, Hughes, Bely ea, Chang, Hofmann and Bacon (2007), and conducted in 281 medical surgical units in 14 3 general acute care hospitals in the United States, work engagement and work conditions were positively related to safety climate, but not directly to nurse back injuries or needlesticks. The positive work engagement and work conditions contribute to enhanced safe ty climate and can reduce nurse injuries. a.1.1) Stress. Stress was one of the most common f actors cited by nursing staff in the focus group sessions. They associated the stre ss with other workplac e factors that were present in the hospital. Nurses in this study stat ed that this problem is affecting their daily work activities. Most of the comments em phasized that stress is linked to the poor organizational climate existing in the different departments. However, the most relevant aspect was that nurses percei ved the stress as one of the circumstances related to needlestick injuries. The National Institute for Occupational Safety and Health (NIOSH, 2008) defines occupational stress as "the ha rmful physical and emotional re sponses that occur when the

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136 requirements of the job do not match the capabil ities, resources, or needs of the worker" (p.1). Nearly everyone agrees that job stress results from the interaction of the worker and the conditions of work. Views differ, however, on the importance of worker characteristics versus working conditions as the primary cause of job stress. These differing viewpoints are important because they suggest differe nt ways to prevent stress at work. Stressors common in health care settings include the following: inadequate staffing levels, long work hours, shift work, role ambiguity, and exposure to infectious and hazardous substances. In general, studies of nurses have found the following factors to be linked with stress: work overload, time pr essure, lack of social support at work (especially from supervisors, head nurses, and higher management), exposure to infectious diseases, needlestic k injuries, exposure to work-related violence or threats, sleep deprivation, role ambigu ity and conflict, understaffing, career development issues, dealing with difficult or se riously ill patients. Occupational stress has been a longstanding concern of the health care industry and some studies indicate that health care workers have higher rates of substance abus e and suicide than other professions and elevated rates of depression and anxiety lin ked to job stress (NIOSH, 2008). In addition to psychological distress, other outcomes of job stress include burnout, absenteeism, employee intent to leave, reduced patient sa tisfaction, and diagnosis and treatment errors (NIOSH, 2008). The American Nurses Association (ANA, 2008) showed that 84% of nurses of the 700 nurses who participated in the survey repor ted that workplace stress levels impact workplace safety. Higher nurses workloads are associated with burnout and job

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137 dissatisfaction, precursors to voluntary turnove r that contribute to the understaffing of nurses in hospitals and poor er patient outcomes (Vahey, Aiken, Sloane, Clarke, & Vargas, 2004). More than 41 million workers in the Eur opean Union are actually suffering stress at work (one in three in the fifteen memb er countries (Rodriguez and Vazquez, 2008). According to a study done by the European Agency for Safety and Health at Work, the economic cost of absenteeism and sick leav e generating by this s ituation is over 20,000 million euros a year (Rodriguez and Vazquez, 20 08). It is feasible to understand that the situation about stress in the European workfor ces can be extrapolated to the health care sector, as illustrated, in a study done by Mcvicar (2003), to identify nurses’ perceptions of workplace stress. In this literature search from 1985 to 2003 conducted in the UK, the most relevant findings were workload, leadership/management style, professional conflict and emotional cost of caring as the main s ources of distress for nurses for many years. Lack of reward and shift working may also now be displacing some of the other issues in order of ranking. The conclusi ons stated that stress interv ention measures should focus on stress prevention for individuals as well as tackling orga nizational issues. Gil-Montes (2002) stated that the nursing profession by their unique characteristics, shortage of staff, work overload, shift wo rk, relationships with patients and family problematic, among others) generate chronic stress, and being one of the occupations with the highest incidence of “burnout syndrome." Work overload has a special impact as a source of chronic stress in nursing. Obviously, the association between stress and needlestick injuries is one of the aspects linked to this study. But stress is also related to nurses’ health. In a l iterature review done

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138 by McNeely (2005) found that the general comp lacency or tolerance for stress in the profession and perhaps as well in society mi nimizes the importance of this issue for nurses’ health. Although several studies show that chronic st ress may result in increased morbidity and mortality and also other studie s find that nurses bear increased risk of certain diseases, the potential link between chronic stressful nursing work and lasting health consequences has not been established. a1.2) Shortage of Nurses and Work Overload. The nursing staff expressed that a shortage of nurses and work overload ar e conditions that affect not only the quantity of care but also the quality. Most of the comments in this study were associated to the hospital as an old institution that was created for a speci fic population 30 years ago. But the population has increased and the number of beds and pers onnel has remained the same as in the past. Consistently these aspects were mentioned as possible causes of needlestick injuries as well as unsafe practices. According to the PAHO publication 2007, the Region has 3,580,000 nurses, for an average of 42 per 100,000 population. Recently (2000-2004) this rate has increased at an annual pace of 0.20 for nurses. Positive grow th of health human resources is being maintained but the increase tends to be smaller. In the period 1980-1992, the annual average growth in the number of nurses th roughout the Region was 8.2% with the figures falling in 1992-2000 to 2.7%. In the period of 2000-2004, the trend became more marked, with annual average growth of 0.8% for nurses. These values indicate that the drop in the number of nurses is consider ably largest when is compared with the physicians. In the same report, it was stated that the rate of nurses was high in the United States (97.2 per 10,000 population), with nurses outnumb ering physicians in a ratio of 3 to 1 in the U.S.,

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139 Canada and some Caribbean countries. The concentration of nursi ng personnel in the Region is clear, in 2004, 83% of nurses work ed in the United States and Canada. In Venezuela there are approximately 1,200,000 health care workers and there are 7.9 nurses per 10,000 population (PAHO, 2004). Thes e data from PAHO reflect that the shortage of nurses is an international s ituation as least in the American Region. According to ANA 2008 study, the majority of nurse participants in the survey (89%) said that work loads impact workplace safety. A work done in the US by Rogers, Hwang, Scott, Aiken, and Dinges (2004) found th at working 50 hours or more per week increased the likelihood of percutaneous acci dents 2.4 times. Similar results were found for those who worked in rotati ng shifts or on night shift, wh en compared with those who worked only at the daytime shift. A study of sharps-related accidents nurses also put in evidence that the probability of experiencing this type of injury has increased in rotating shifts (Smith et al., 2006). Mu stafa et., al., (2006) in a university hospital of Turkey, studying the association between long hours of work and needlestick injuries in nurses found that working for more than 8 hours per day was significant stat istically (p < 005). The conclusion of this study was that the unw anted effects of working long shifts and subsequent fatigue may contribute to the number of needlesticks injuries in this category of personnel. Curting (2003) in a literat ure review of nurse staffing and effects on patient outcomes found data that can help to determine what is, appropriate staffing. Ratios are important. In fact, a consensus seems to be emerging s upporting a range of from 4 to 6 patients per nurse in most acute care hospital inpatient se ttings, with no more than one to two patients per nurse in areas of higher ri sk patients’ care. However, ra tios must be modified by the

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140 nurses’ level of experience, th e organization’s charac teristics, and the quality of clinical interaction between and among physicia ns, nurses, and administrators. Palucci (2003) found in hospitals in Br azil that extended work schedules of many nurses who begin their work al ready tired, inappropriate form s of work organization and extra activities to be executed were factors associated with needlestick injuries. Palucci and Carmo (2004) found in other Brazilian hosp itals that the factor s associated with needlestick injuries were: work overload, poor quality of dispos al materials, inappropriate needles devices, professional negligence, aggr ession of patients, lack of attention and recapping needles. Similarly the authors Do, Ciesielski, Metler, Hammett, Li, and Fleming (2003) and Rapparini (2006), refer ot her factors may be associated with the occurrence of percutaneous injuries associ ated to the conditions under which work is performed, such as lack of training, work overload, and lack of personal protective equipment. Additionally, there are the mechan ical factors related to the procedures performed, such as recapping used and the lack of sharps disposal containers. Havlovic, Lau and Pinfield (2002) expressed that extended work schedules per week lead to an increased likelihood of accidents which may be increased from a worker's exposure time to risk, and also by the fact that extended work schedules may promote fatigue and increase the risk of accidents. In a cross-sectional stud y of 1,500 nurses employed on 40 units in 20 hospitals, poor organizational climate and high workloads deri vate from short staffing were associated with 50% to 200% increases in the likeli hood of needlestick inju ries among hospital nurses (Clarke, et al., 2002). These results s how a relationship between short staffing and needlestick injuries. Nurses from units with low staffing and poor organizational climates

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141 reported twice as many needlestick injuries than nurses on well-staffed units. Thus, adequate staffing is not only safe r for patients and prevents me dical errors but it is also safer for nurses. Exposures to bloodborne pa thogens (including needlesticks) were found in one study to be more common at the beginning and end of shifts (Macias, Hafner, Brillman, & Tandberg, 1996). These findings corroborate with those pr esented in Table No. 12, where the group of nurses in the MCH had a mean of daily and weekly hours worked over labor regulations. The numbers of working hours in this study gr oup could be a cause of accidents in the hospital. Furthermore, there is a correlati on between the factors identified by different authors and the comments expressed by nurse s in the focus group sessions as causes of accidents by needlestick injuries in the departments studied. Regarding the results found in this study, it is not only a problem with the shortage of nurses but also a problem linked to multitasking functions. This coincides with the results of Marchant (2005), concerning the assessm ent of the "staffing" and "division of functions" which was also negative in their st udy. People believe that the current staffing levels, either in quantity, quali ty or distribution units and f unctions, are inadequate. Poor distribution of personnel creates multitasking, which prevents them from developing the technical and professional ta sks originally assigned, with consequent dissatisfaction stems from the above. a1.3) Violence. One of the problems that emerged from focus group sessions in this study was related to the violence at the hospital, ma inly during the night shifts. Nurses stated that it is common having violent episodes comi ng from patients’ family members or from external aggressors, as well as from other colleagues, and reasons why they do not feel

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142 secured. They expressed that the hospital ma nagement has to adopt additional security measures to guarantee the protection of the employees while at workplace. NIOSH (2002) defines workpl ace violence as violent acts (including physical assaults and threats of assaults) directed toward pers ons at work or on duty (p. 1, 2). Examples of violence include the following: 1) Threats: ex pressions of intent to cause harm, including verbal threats, threatening body language, and written threat s. 2) Physical assaults: attacks ranging from slapping and beating to rape, homicide, and the use of weapons such as firearms, bombs, or knive s. 3) Muggings: aggravated a ssaults, usually conducted by surprise and with intent to rob. According to the Department of Labor Statis tics (USBLS, 2002), the data indicate that hospital workers have a high risk of experien cing violence in the workplace. Nowadays more than 5 million U.S. hospital workers from many occupations perform a wide variety of duties. They are exposed to many safety and health hazards, including violence. Recent data indicate that hospital workers are at high risk for experiencing violence in the workplace. According to estimates of the Bureau of Labor Statistics (USBLS, 2002), 2,637 nonfatal assaults on hospital workers oc curred in 1999 a rate of 8.3 assaults per 10,000 workers. This rate is much higher than th e rate of nonfatal assaults for all private sector industries (2 per 10,000 workers). In order to identify the magnitude of poten tial risk factors for violence within a major occupational population, a study was conducte d by Gerberich et al., (2004). In 6300 Minnesota licensed registered (RNs) and practic al (LPNs) nurses the findings show that non-fatal physical assault and non-physical forms of violence are frequent among both RNs and LPNs; such violence is mostly perpetra ted by patients or clie nts. Hesket et al.,

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143 (2003), in a study in the Canadian provinces of Alberta and British Columbia found that the violence was associated to the emotional a buse and its sources from patients, families, coworkers and physicians. These findings illust rate how important is to understand that hospitals are not always healthy workplaces and may increasingly be stressful and hazardous ones. As was related in the previous paragr aph, the hospitals as a workplace are not invulnerable to the violence, and are of con cern for health care wo rkers including nursing staff. Hospital Policies to Prevent Needlestick Injuries For this topic, the comments from the nursing staff about the hospital management policy were very negatives. Hospital mana gement has the legal and administrative responsibility of implementing programs for occupational safety and health for healthcare workers. The Venezuelan laws establish th at both public and private sectors must accomplish Policies and Regulations in order to develop safe places for workers and designed to prevent occupational diseases or accidents related to work. Healthcare organizations can improve staff safety by i nvesting in programs with approaches to minimize risks, (needlestick injuries among others), providing protective equipment (sharp disposal containers, personal protectiv e equipments and safety needles devices) as well as promoting educational programs to en sure compliance with Standard Precautions. This situation can be exemp lified by the study done by Vaughn et al., (2004), in all nonfederal hospitals in Iowa and where results show that a visible management support for staff is extremely important for safety and health for health care workers.

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144 Perceptions of Nurses about Needlesti ck Injuries and Recapping Used Needles Several nurses explained that recapping us ed needles was a preventive measure to protect them and other coworkers. This way to think might be related to the notion that nurses have a protective instin ct towards others and always have in mind to recap the needle to prevent harm to others. It is impor tant to mention that this protective instinct goes back to very beginning of the nu rsing profession in 1860, when Florence Nightingale changed the nursi ng job to a fully professiona l level. Paradoxically the nursing staff was aware that recapping used need les is an unsafe practice (not to be done) but they explained that th ey did it to be safe. In the literature review there was not found any documents that illustrate the emotional impact of needlestick injuries by contamin ated needles, however, the author found a video of NIOSH where there are two stories of American nurses who after their needlestick accident had seroconversion to HI V and HCV. In both cases, the participants expressed details about the events of the accident and their mood state during and after the accident (IAES, CORPOSAL UD, PAHO, WHO, NIOSH, 2008). This is a powerful tool that might be employed to use as a needlestick preventive strategy in HCWs. According to Junco et al., (2003), the per ception of risk from sharp objects, a vital element is the level of knowledge about the regulations on injury prevention for these objects. Similarly they expresse d that the lack of adequate means of protection in Cuba health institutions is conditioned by the act ual economic conditions that may be a limiting factor for its reality. Regarding the previous paragraph, the scenar io for Venezuela is different because this nation has oil producers with e nough financial resources that are not invested in safety

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145 and health programs. Concha (2009) affirms that Venezuel a in the last 10 years has obtained no less than 350 billion dollars regarding to the oil business, in opinion of the former Director of the Venezuelan Central Bank. It is important to note that sharp injuries of health worker s is not just a problem with infection or disease, but car ries significant and prolonged emotional impact, when they are exposed to injuries, even in the abse nce of a serious infection. This impact is particularly severe when the injury caus es exposure to HIV, although there is now excellent treatment with retroviral drugs, h ealthcare workers as well as coworkers and family members are affected emotionally. Needlestick Injuries Prevention Strategies The different preventive measures suggest ed by the nursing staff on how to avoid needlestick injuries were in general very si milar to those found in the literature. These measures support nurses’ knowledge about the problem and the means to prevent it. According to Wilburn and Eijkemans (2004) the most effective means of preventing the transmission of bloodborne pathogens is to prevent exposure to NSIS. Primary prevention of NSIS is achieved through the elimination of unnece ssary injections and elimination of unnecessary needles. The implementation of education, Universal Precautions, elimination of needle recapping, and use of sharps containers for safe disposal have reduced NSIS by 80%, (C DC, 1997 & Jagger 1996) with additional reductions possible through the use of safer n eedle devices. Control measures to prevent NSIS following the traditional hi erarchy of controls from most effective to least effective include (ANA, 2002; Foley & Leyden, 2005): a) Elimination of hazard-substitute injections by administering medications through another route, such as tablet, inhaler, or

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146 transdermal patches, for example. Remove sharps and needles and eliminate all unnecessary injections. Jet injectors may substitute for syringes and needles. Other examples include the elimination of unnecessa ry sharps such as towel clips and using needleless intravenous (IV) system s; b) Engineering controls su ch as needles that retract, sheathe, or blunt immediately after use. These devices, after a decade of technologic advances, are widely available in North Am erica and Europe and required by law in the United States; c) Administrative controls-pol icies and training programs aimed to limit exposure to the hazard. Examples include Un iversal Precautions, allocation of resources demonstrating a commitment to HCWs safe ty, a needlestick prevention committee, an exposure control plan, and consistent trai ning; d) Work practi ce controls-examples include no recapping, placing sharps containers at eye level and at arms’ reach, checking sharps containers on a schedule and emptying th em before they’re full, and establishing the means for safe handling and disposing of sharps devices before beginning a procedure; e) Personal protective equipment (PPE) barriers and filters between the worker and the hazard. Examples include eye goggles, face shields, gloves, masks, and gowns. Experts agree that safety devices and work practices alone will not prevent all sharps injuries (Davis, & AHA, 1999). Significant dec lines in sharps injuries also require: education, a reduction in the use of invasive procedures (as much as possible), a safe work environment, and an adequate staff-to -patient ratio. These are parts of something called multi-component prevention approaches. One report detailed a program to decrease needlestick injuries that involv es simultaneous implementation of multiple interventions: formation of a needlestick prevention committee for compulsory in-service

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147 education programs; out-sourcing of replacement and disposal of sharps boxes; revision of needlestick policie s; and adoption and evaluation of a needleless IV access system, safety syringes, and a prefilled cartridge needleless system (Gershon, Pearse, Grimes, Flanagan & Vlahov, 1999). This strategy showed an immediate and sustained decrease in needlestick injuries, leading researchers to conclude that a multi-component prevention approach can reduce sharps injuries. These preventive measures are a necessary i nvestment to preserve the health of the health care worker. Health management shoul d make every effort to take preventive measures in health and safety. To illustrate the situation is what happened in the Aragua State in 2005. There were a reported and re gistered 260 cases of sharps accidents in workers in the health sector that required antiretroviral tr eatment with three drugs during one month which resulted in an inve stment total equivalent to $ 18,130.00 (CORPOSALUD, 2006). Another example that illustrates terms of cost, according to the American Hospital Association AHA, (1999) one case of severe infection caused by bloodborne pathogens can generate $ 1 million for testing and monitoring among other things. Costs for monitoring high-risk exposure are almost $ 3,000 per injury caused by needles, if the HCW does not acquire a bloodborne pathogen infection. Some brands of needles with safety devices only cost 28 ¢ more than the common ones. California hospitals expect to save more than $100 million annually after the implementation of the legislation requiring use of safety devices (ANA, 1999). It is important to state that in both examples the money spent on treatments might well be us ed to invest in preventive health and safety.

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148 The PRECEDE Component In this section the discussion is fram ed around the PRECEDE component of the PPM, including predisposing, reinforcing, enabling, and environment factors. Predisposing Factors In this study, according to the findings of the quantitative and qualitative parts, it is feasible to say that despite the nurses’ posit ives attitudes and beliefs regarding recapping as well as the favorable re sults obtained af ter the educational strategy, recapping activities continue to be a r outine procedure in some nurse s’ daily practice. There are several reasons that could expl ain this behavior; it can be ranked from individual domain (attitudes, beliefs, values, perceptions) to the environment factors (physical and organizational climate). Regarding the indivi dual domain, nurses’ perception of the risk could be influencing needle recapping. It appe ars that there is not agreement between the nurses’ knowledge about the pote ntial hazard of this procedure, the Standard Precautions recommendation and the perception of risk regarding recapping theme. In this study, most of the nurses believed th at recapping needles is an uns afe practice and so did not do so. However, paradoxically, for other nurses r ecapping used needles was a way to protect them and coworkers especially cleaning and ma intenance staff because they believe that leaving an unsheathed needle is unsaf e, therefore they would recap it. These findings are in agreement with a study done by Whitby and McLaws (2002) in an Australian Hospital where it was shown that nurses have a culture of care, part of which is to protect their peers from unsafe pr actices. Furthermore, the perceived risk of infection following a needlestick injury va ries across the population of nurses, despite them all working within the same environment.

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149 Another study done in a hospital of Nigeria (2006) by Sadoh, Fawole, Sadoh, Oladimeji, and Sotiloye, showed that the compliance with UP recommendation about recapping also varied between health care wo rkers, for example, trained nurses were more compliant than doctors. They are more likely to admit that they resheath used needles manually than nurses. For above exampl es, risk perception can act as a facilitator of safe practices in some situati ons and as an obst acle in others. According to the nursing staff, it appeared that knowledge of self or other's experience serves as a predisposing factor toward the goal behavior of safe practices. In a study comparing medical students who had and had not been stuck by a used needle, Shalom, Riback, & Froom (1995), argued "those who experienced a needlestick while recapping were more likely to believe that recapping is more dangerous than the risk of downstream injuries" (as cited in Haiduven 2000b p. 847). Ippolito et al., (1997) found that within the factors associated with the occurrence of accidents with sharp material between the nursing staff were mainly the recapping used needles, which are considered inappropr iate and opposes Universal Precautions. It is important to emphasize that predispos ing factors might need to be reevaluated periodically to determinate cha nges in attitudes, beliefs or perceptions that need to be corrected to maintain the level of commitmen t required to achieve the goal behavior. One way to change behavior is thr ough education, but in order for e ducation to be effective, as was mentioned by Bastable that the three domai ns of learning, cogni tive, affective, and psychomotor, must be addressed (as cite d in Haiduven, 2000b, p. 220). Knowledge is the target for the cognitive domain, skills in the psychomotor domain, and attitudes and beliefs in the affective domain (Haiduven, 2000b).

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150 Reinforcing Factors Positive reinforced behavior tends to be repeated while negative reinforced behaviors tend to be inhibited (Borkoswki, 2005). Employe es learn to do the right thing by avoiding unpleasant situations. Peters argued that the positive a nd negative reinforcement, rewards, and punishments and their effect on h ealth care worker safety behaviors, have been reported in other occupational setti ngs (as cited in Haiduven, 2000b, p. 221). Peters reports that incentives have been demonstrated to positively influence safety compliance, while disciplinary action has not been found to increase compliance. The positive influence of a positive event, nurses not having a needlestick injury, is a reward to keep doing safe procedures. Altern atively, the positive influence of a negative event on future safe practice of hospital nurs es, not recapping after sustaining an injury, was demonstrated in this study. On the othe r hand, hospital management’s attitude was an example of negative reinforcing factor th at influences the act ual behavior or the undesired behavior. The lack of education and training on safe issues was one of the most frequently reported aspects by nursing staff as a need to en sure that safe practi ces would be used in order to prevent needlestick injuries. Howe ver, the hospital management does not have regulations about the frequency and topics to be discussed. The influence of this matter could be affecting the attitudes as well the ability to perform routine procedures (see Figure 1). There are several ways to prevent ne edlesticks injuries such as adherence to Universal Precautions, safer disposal of clinical waste such as needle s, and the raising of awareness among healthcare workers of th e risks of needlestick injuries.

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151 According to CDC Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program (CDC, 2004) educatio n and training of healthcare personnel is another important element of a sharps inju ry prevention program. However, CDC stated that healthcare workers are “adult learners” a nd then the process to learn is different from children because adults have existing knowledge, beliefs, a nd attitudes that influence what they take from or contribute to a le arning opportunity. Unfortunately, much of the education and training of hea lthcare personnel is more typica l of traditional schooling and is provided in the context of meeting re gulatory requirements (C DC, 2004). As such, there is often a resistance or lack of personal motivation to attend lectures or view videotapes or other self-dir ected teaching tools. In the end, a requirement is met but learning may not have taken place (CDC, 2004). It is possible that for this reason, the effect of training on needle stick injuries prevention or compliance with Standard Precaution (formerly Universal Precautions) has varied. In several studies the effectiveness of educational intervention has been positive to increase safety knowledge and performan ce (Burke, Sarpy, Smith-Crowe, Salvador, & Islam, 2006). Krishnan and Murphy (2006) found greater knowledge regarding management of exposures to blood and body fl uids following face to face training than other educational interventions in a group of healthcare wo rkers (medical and dental practices). In a work done by Trape-Cardos o and Schenck (2004), the authors found that after administrative interventi ons, engineering controls, a nd educational modules, there was a significant decrease in percutaneous injuries among medical and dental students and to nursing staff over the 5-year period.

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152 According to Elliott, Keeton, and Holt (2005), findings on a study done in medical students show that with intensive teaching a nd self-learning programs, it is possible to improve the knowledge and therefore reduce th e number of needlestick injuries. The work of Suchitra and Devi (2007) found that education has a positive impact on retention of knowledge, attitudes and practi ces in all categories of staff. There is a need to develop a system of continuous educa tion for all types of staff. Searching in the literature, there are some studies that used recapping needle rates as an outcome measure. One example is the study done by Ribner in 1990 where he developed an educational program that report ed the rate of needle recapping in health care workers, in conjunction with emphasis on appropriate di sposal procedures. Over 12 months, the rate of recapping needles used for venipuncture and for percutaneous medication injections fell from 61% to 16%. Reevaluation of the rate of recapping eight months later showed a conti nuation of these lowered rates. He also affirms that needlestick injuries were too few in numbers during the study period to detect any change accompanying the decreased recapping rate. It is important to highlight that in the studies where education was effective, it was combined with other interventions as wa s mentioned by Haiduven (2000b). For instance, convenient placement of sharps containers, co mmunication of needlest ick injury data to employees among others, as was found in the study of Haiduven et al., (1992, and 1995). This educational process has to be repeated at regular intervals to produce a booster effect (Haiduven et al., 1995).

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153 Enabling Factors Lack of availability and acces sibility of sharp containers, needle safety devices, personal protective equipment, and safety s upport from the hospital were reported to be negative enabling factors by nurses in the study. It is obvious that this factor is one of the most relevant in this investigation because if the institution does not have a positive attitude to purchase equipment for prev ention, the nursing staff and other healthcare workers are at risk to acquire bloodborne diseases as well as to not comply with Standards Precautions. These findings are in opposition to other studies where positive safety climate and institutional support significantly influenced compliance with safe procedures and Universal Precautions in the h ealth care work environment (Clark et. al., 2002, Gershon et al., 1999). According to Gershon, et al., (2000), orga nizations with strong safety cultures consistently report fewer injuri es than organizations with weak safety cultures. This happens not only because the workplace ha s well-developed and effective safety programs, but also because management, through these programs, sends cues to employees about the organization's commitme nt to safety. In a study done in one healthcare organization linked measures of sa fety culture with both employee compliance with safe work practices and reduced expos ure to blood and other body fluids, including reductions in sharps related injuries (Gershon, 1996). These investigations corroborate the concep t that strong management commitment to safety issues are characteristics of successful safety programs in occupational settings.

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154 Environmental Factors These factors were widely explained in the discussion of circumstances related to needlestick injuries and reca pping used needles. The worki ng environment of the nurses’ hospital emphasizes the importa nce of the effect of the environment on the actual and goal behavior. Hospital management has to understand that there are environmental factors affecting the safety of nursing staff and other health care workers in order to design interventions to modify and improve it, removing obstacles or reinforcing facilitators to safe practice in any occupational setting. Stone, Clarke, Cimiotti, and Correa (2004), in a literature re view, reported that monitoring and improving the working condition s of nurses are likely to improve the quality of health care by decreasing the incidence of many infectious diseases. Limitations and Strengths of the Study Regarding Aims An aim of this study was to obtain estimates of the incidence of needlestick injuries in nurses from the selected departments, but the author could not achieve this objective because the data were too few. Additiona lly, the data from 2004 to 2006 from the Maracay Central Hospital did not allow to the researcher to obtain the number of nurses with NSIS discriminated by the department s studied. For the year 2007 and 2008 the data used was from CORPOSALUD Occupational Safety and Health Department. Another aim related to report the resu lts of the study to nurses and hospital management, was partially achieved. The results were analyzed and discussed with th e authorities but is still in the process to be presented to nurses. The authorities were very interested in the results, but at the same time, very concer ned because they do not manage their own

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155 budget. This comes from the Ministry of Hea lth and they might not be able to buy the sharps disposal containers and other safety devices. Study Design The study design did not include use of c ontrol groups. This may have strengthened the design of the study and should be considered for future studies. As was commented in the methodology sect ion, the study was based on a before and after design. The number of needles was count ed before the focus group sessions started (November 2006-February 2007) and were counted after the educationa l strategy finished (October 2007). The time invested during th e after phase (November 2007-February 2008) could have influenced the increase in the number of no recapped needles found in the last weeks of the recollection part (Table 6). It is possible that during that time the information provided in the education strategy had been forgotten and so the nursing staff began to recap used needles again. This situation is possible to find because the learning/training process have to be reinforced periodicall y in order to keep the goal behavior. The frequency of educational/tr aining program implemented by the hospital management has to be periodic to avoid the extinction process. Focus Group Sample Selection As was mentioned in the methodology chapter, a conve nience sample (purposeful sampling) of nurses was used from each de partment involved in the study. The focus group technique is characterized by homogene ity; participants have something in common, in this case experience on Maracay Cent ral Hospital tasks. In this aspect, the representativeness of the sample was enhan ced because the characteristics of nursing

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156 staff who were in the focus group did not diffe r from other hospital’s nurses. In fact, the sample's demographic characteristics results were similar to other studies done in the same hospital and for the information obtai ned from the MCH nurses’ office (Table 8) that illustrates the representative nature of da ta. The selection of the nurses to participate in the focus group was made by the person who was designated in each department by the author, thus the major limitation of the samp ling plan could be the lack of moderator control in selecti on of the subjects. Methodological Issues The potential bias of the i nvestigator as moderator in in fluencing the responses of the participants is a potential limitation in any type of qualitative study. However, in this study, this threat was minimized by adhering to the original questions in the twelve focus group (Appendix H); not making judgmental co mments; not correcting the participants' responses; and attempting to minimize persona l movements, particularly head nodding (Krueger, 2000). The same introduction (Appe ndix F) was read in all focus group sessions. Operative Issues According to focus group experts, these sessi ons had to be performed in a comfortable and permissive environment in order to enha nce the discussion. However, in this study, the focus group sessions and educational stra tegies were developed in the same place within the working hours of nurses. The dynamics of work of the nursing staff did not allow focus group to be held away from the daily activities or work environment to avoid distractions or interruptions as well work pr essure that prevent th e performance of the discussions. However, it was not possible a nd hence the duration of each focus group and

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157 educational sessions had a maximum of two hour s. Therefore, despite this limitation, the objectives of the discussion were achieve d and the participants relayed personal experiences. Limited Previous Qualitative Studies There are few studies in the literature that have used qualitative methodology of focus group to establish the factors associated w ith needlestick injuri es and recapping used needles. In this sense, it was difficult to find studies to compare with this study. The only study found was the doctoral dissertation of Haiduven (2000b) where she studied the circumstances surrounding blood exposures and n eedle safety practices in home health care nurses. The author consider s that more studies in the h ealth field can be done using this methodology but not only to be used in th e diagnosis or descriptive section but as well as in the development of intervention strategies. However, for the author, the experience was invaluable because it was possibl e to investigate in depth aspects of the everyday life of a group of health care workers with many needs.

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158 CHAPTER EIGHT: CONCLUSI ONS AND IMPLICATIONS In this section, the major conclusions of this study are summarized, recommendations and implications for clinical practice articulated and areas for future studies suggested. The major findings in this study were: 1. The participation of nursing personnel in the focus group sessions was fundamental to corroborate that need lestick injuries in the MCH are not associated exclusively with individual ri sk behaviors or personal protection. It was evident that these accidents ar e strongly influenced by the physical environment in which nurses are forced to work and perform their work, as well as the organizational climate of the hospital. The needle recapping activities continue to be a routine pr ocedure in the some nurses’ daily practice. Therefore, the hospital management can not underestimate the importance of evaluating the work environment (physical ly and organizationally). 2. The educational strategy implemented after the focus group sessions was successful, according to the finding showed in Tables (13, 14, and 16), where the numbers of recapped needles were lo wer after the educational strategy. 3. The odd ratios obtained in the four departme nts could indicate th at the educational strategy was an excellent intervention for reducing the recap ping practices. The 53% of decrease of no recapped needles s howed that this type of intervention should be developed periodically for the pr evention of needlestic k injuries. It is important to emphasize the fact that only one meeting of two hours of

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159 length/duration could achieve positive changes, showing that nursing staff is motivated to change in order to impr ove safe practices despite the working conditions. 4. The positive response of nursing staff in the focus group sessions allowed not only obtaining information important for the study but at the same time it was an important space for nurses’ communication to share work and personal experiences about recapping us ed needles and needlestic k injuries. In all focus group sessions nursing staff stated the need to have other opp ortunities like these to share experiences and knowledge. For these reasons, the focus groups should also be considered as an intervention. These groups allowed to nurses to raise awareness about the recapping used needles and needlestick injuries as important problems that need to be faced by health authorities and health care workers from the Maracay Central Hospital. 5. The PRECEDE component of PPM allowed the investigator to obtain useful information about hospital nurses’ actual behavior (unsafe practices) and the goal behavior (safe practices). Concerning the findings regarding predisposing, reinforcing, enabling and environmental f actors, it appeared that these factors could have positively or negatively influenced the hospital nurses attitudes and beliefs regarding recapping activities (Figure 3). Implications/Recommendations for Clinical Practice It is possible that findings from this st udy may be used to design interventions to change not only the nurses’ safe practices but also the environmen tal conditions at the

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160 Maracay Central Hospital. The following r ecommendations for improving work practice were developed based on the information obtained from the nurses' comments: Organizational/Administrative 1. Engage hospital management in crea ting a positive safety climate: a) Improving physical conditions (handw ashing facilities, poor lighting, and unsanitary conditions). b) Improving organizational climate (str ess, shortage of nurses, work overload, violence). c) Acquiring safe products (e.g. sharps disposal containers, and personal protective equipment). d) Incorporating new devices such as n eedles that retract, sheathe or blunt after use. 2. Involve nurses and hospital management in development of policies, procedures, and guidelines regarding needlestick injuri es and other occupational safety issues. 3. Include nurses and other health care workers from the hospital in the creation, development and implementation of a need lestick injuries prevention committee. This committee would require active participation from all members. The committee’s charge would be the responsibil ity of evaluating the circumstances of all blood exposures in each hospital depa rtment for purposes of complying with the regulations about bloodborne pathogens as well as for designing interventions for prevention of future injuries.

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161 Educational/Training 1. Advocate/suggest that hosp ital management periodically update the departments’ nurses on the risks of acquiri ng a bloodborne infection fr om a needlestick injury. The information available from the CDC, NIOSH, OSHA and the National Institute of Prevention, Health and Safety of Work (INPSASEL) can be used for this purpose. 2. Promote continuing educati on within different hospita l departments about safe practices, and aspects about Venezuel an Occupational Safety and Health legislation among others. In this aspect, nursing staff from each department can suggest additional topics th at would be of interest for those personnel. 3. Develop practice scenarios simulating the environmental conditions of the hospital as well as needle stick accidents. Conduct se ssions to troubleshoot potentially hazardous situations and to develop strategies for manipulating the environment as well as needlestick injuri es. For these activities videos, lectures, poster, health care workers’ persona l experiences etc. can be used. 4. Include health care worker s in research in the health and safety field. Future Research Results of this study have numerous implica tions for future research in safe practice for health care workers in Venezuelan public hospitals. The descrip tive nature of this study provided valuable information regardi ng circumstances surrounding recapping as a cause of needlestick injuries in Maracay Central Hospital nurs es. Future research must be conducted to add to this preliminary informa tion, replicate in other hospital departments, and extend the findings to other settings in Maracay and Aragua health care centers

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162 where safe practice is the goal health behavior. Hospital management and CORPOSALUD as main health au thorities in Aragua State can/may participate actively in these future research. According to the results of this study, the nursing staff’ s attitudes about recapping are linked mainly to the lack of sharps disposal co ntainers. It could be in teresting to be study what would be the effect in the attitude of nursing staff about recapping after the sharps disposal containers are available at hospital departments. The rationalization for this topic is related to healthcare personnel who have difficulties changing l ong-standing practices. Another aspect to be investigated is th e method of disposal of sharps disposal containers, and what it’s the impact on the outdoor environment will be. The MCH has two incinerators but according with the information obtained from the chief of cleaning and maintenance department, they are actually not working appropriately. The increasing number of needlestick injuri es in the nursing students as well as in the medical students is a very concerning issu e based on the implication of these findings. The students are working at the hospital, where there are several factor s that influence the needlestick accidents, but the legal responsibil ity about any consequence of a needlestick and sharp exposure (bloodborne disease) is di rectly linked to the University of Carabobo as the teaching institution. Therefore, it is ve ry important to invest igate the factors or circumstances related to needles tick injuries in these groups. The PROCEED component of the PPM was not used in this study. However, from the PRECEDE component (predisposing, reinforc ing enabling and environmental factors) emerged valuable information from the nursing st aff’s comments, that can be utilized as a base for future research. PROCEED component should be used to assess/identify the

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163 policies, regulations and organizational factor s that may influence safe practices in nursing staff and other health care workers (Figure 4). The figure 4 shows the possible relationship between the different phases of the PROCEED component and how theses constructs would influence in the PRECEDE factors as well as in the nurses’ behaviors (use of safe practices). For example, it woul d be important to assess/identify if the MCH management has policies, procedures and regulations about occupational safety and health issues and how these aspects would influence the PR ECEDE component as well as in the nurses’ behavior regarding the use of safe practices. Additionally, from this study several aspects of organizationa l factors were identified by pa rticipants in the focus group sessions such as shortage of nurses and work overload, stress, and viol ence. Therefore, in future research the model will need to include other organizational factors that might influence the behavior of nurses in terms of safe practice. Other research should be related to study in depth the factors that were mentioned in this study. Maracay Central Hospital nurses work in a very complex environment. The findings showed that there are several negative fact ors regarding recapping used needles. This practice can generate needlestic k injuries that are a serious risk of potential transmission of bloodborne pathogens (Hepatit is B, C and HIV) after a ne edle accident in nurses and other health care workers. For this reason, it is esse ntial that those negative factors have to be removed in order to prevent future e xposure incidents. In th is aspect, nurses and hospital management have to engage in the commitment to work together in the occupational and health field to ensure compliance with safe work practices.

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174 Ribner, B.S. (1990). An effective educational program to reduce the frequency of needles recapping. Infection Control and Hospital Epidemiology, 11, 635-638. Rodrguez, D. (1998) “Diagnstico Organizacional.” Ediciones Universidad Catlica de Chile. Rodrguez, C., Vzquez, C. (2009) Se quema la Sanidad espaola? Revista Economa y Salud. Retrieved March 18, 2009 from: www.economiadelasalud.com Rogers, A.E., Hwang, W.T., Scott L.D., Aiken, L.H., & Dinges, D.F. (2004). The working hours of hospital staff nurses and patien t safety both errors and near errors are more likely to occur when hospital staff nurses work twelve or more hours at a stretch. Health Affairs, 23, 202-212. Rong, L., Lipscomb, J., Trinkoff, A., & Geiger-B rown, J. Work schedule, needle use, and needlestick injuries among registered nurses. Infection Control and Hospital Epidemiology 28, 2, 156-164. Sadoh, W.E., Fawole A.O., Sadoh, A.E., Oladime ji, A.O.,& Sotiloye OS. (2006). Practice of universal precautions among healthcare workers. J Natl Med Assoc. 98, 722-726. Saulat, J. (2005). Epidemiology of needlestick injuries among health care workers in a secondary care hospital in Saudi Arabia Ann Saudi Med, 25, 233-238. Shalom, A., Ribak, J., & Froom, P. (1995) Needlestick in medical students in universities hospitals. Journal of Occupational an d Environmental Medicine 37, 845849. Shapiro, C. (1995). Occupational risk of infec tion with Hepatitis B and Hepatitis C virus. Surg Clin North Am, 75, 1047-1056. Shelton, P., & Rosenthal, K. (2004) Explore the clinical benefits of passive safety needles, including reduced exposure risk, easy to use, and minimal training requirements. Nurs Manag, 35, 25-32. Smith, D.R., Mihashi, M., Adachi, Y., Na kashima, Y., & Ishitake, T. (2006). Epidemiology of needlestick and sharps in juries among nurses in a Japanese teaching hospital. J Hosp Infect 64, 44-49. Simpkins, S., Haiduven D., & Stevens D. (1995) Safety product evaluation: six years of experience. Am J Infect Control, 23, 317-322. Stewart, D., & Shamdasani, P. (1990). Focus group: Theory and practice Applied Social Research Methods Series, Vol. 20. Ne wbury Park, CA: Sage Publications

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175 Stone, P., Clarke, S., Cimiotti, J., & Corr ea, R. (2004). Nurses’ working conditions: Implications for in fectious disease. Emerging Infectious Diseases, 10, 1984-1989. Stone, P., Yunling, D., & Gershon, R. (2007) Organizational climate and occupational health outcomes in hospital nurses. Journal of Occupational and Environmental Medicine, 49, 50-58. Strickland G. (2000). Hunter’s Tropical Medicine and Emerging Infectious Diseases Eighth Edition. W.B. Saunder Compa ny. Philadelphia, Pennsylvania. Suchitra J, B., & Lakshmis Devi (2007). Im pact of education on knowledge, attitudes, and practices among various categories of health care workers on nosocomial infections. Indian Journal of Medicine Microbiology 25, 181-187. Sulsky, S., Birk, T., Cohen, L., Luippold, R ., Heidenreich, M., & Nunes, A. (2005). Effectiveness of measures to prevent needle stick injuries among employees in health professionals. Published by: Hauptverband der gewerblichen Berufsgenossenschaften (HVBG). Sulkowski, M., Ray., S., Thomas, D. (2002) Needlestick transmission of Hepatitis C. JAMA, 287, 2406-2413. Tomasina, F., Bozzo, E., Chaves, E., & Pu cci, F. (2008). Impacto de las condiciones laborales en la salud de trab ajadores de un centro quirrgico. Revista Cubana de Salud Publica Retrieved January 15, 2009 from http://bvs.sld.cu/revistas/spu/vol 34, 2, 08. Trape-Cardoso, M., & Schenck, P. (2004). Re ducing percutaneous injuries at an academic health center: A 5-year review. AJIC 32, 301-305. U.S. EPINeT. (2001). “Uniform Needlestick an d Sharp Object Injury Report. Advances in Exposure Prevention. 6, 33. U.S. Department of Labor, Bureau of La bor Statistics. (1999). Occupational outlook handbook, 2002–2003 edition. Washington: U.S. USF, University of South of Florida (2003). Social and Behavioral Sciences Applied to Health Lectures. United Nations Programme on HIV/AIDS (2004). Epidemiology of HIV/AIDS. Retrieved from www.unaids.org/Un aids/En?resources/epidemiology.asp. United States General Accounting Office (2000) Occupational safety: selected cost and benefit implications of needlestick pr evention devices for hospitals. GAO-01-60R. Vahey, D.C., Aiken, L.H., Sloane, D.M., Cl arke, S.P., & Vargas, D. (2004). Nurse burnout and patient satisfaction. Medical Care, 42, 57-66.

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176 Vaughn, T.E., McCoy, K.D., Beekmann, S.E ., Woolson, R.F., Torner, J.C., & Doebbeling, B.N. (2004) Factors promoting consistent adherence to safe needle precautions among hospital workers. Infection Control and Hospital Epidemiology, 25, 548-555. Yassi, A., McGill, M., & Khokhar, J. (1995) Efficacy and cost effectiveness of a needleless intravenous system. American Journal of Infection Control, 23, 57-64. Wilburn, S. (2004). Needlestick and sharps injury prevention. Online Journal in Nursing 9, .3. Retrieved May 23, 2006 from http//www.nursingworld.org. Wilburn, S., & Eijkemans, G. (2004). Preven ting Needlestick injury among healthcare workers. Int J Occup Environ Health, 10, 451-456. Whitby R., M., & McLaws M.L. (2002. Hollow-bor e needlestick injuri es in a tertiary teaching hospital: epidemiology, education and engineering. Med J Aust, 177, 418-422. Wolcott, H. (1994). Transforming Qualitative Data. Description, Analysis, and Interpretation. Sage Foundation. World Health Organization. (2003). Aide-Memoire for a Strategy to Protect Health Care Workers from Infection with Bloodborne Viruses. Geneva, Sw itzerland: WHO World Health Organization. (2002a).The wo rld health report 2002: Reducing risks, promoting healthy life. Geneva: WHO. World Health Organization. (2002b). Hepatit is B. Retrieved, October 17, 2004, from http://www.who.int/mediacen tre/factsheets/fs204/en/. World Health Organization. (2000). Hepatit is C. Retrieved October 17, 2004 from http://www.who.int/mediacentre/factsheets/fs164/en/

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177 APPENDICES

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178 APPENDIX A: Recommended Post Exposur e Prophylaxis for Exposure to Hepatitis B Reference: Centers for Disease Control and Prevention. (2001). Updated U.S. Public Health Service guidelines for the management of occupational exposure to HBV, HCV, and HIV and recommendations for post-exposure prophylaxis.

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179APPENDIX B: Recommended HIV Percutaneous and Mucous Membrane Post Exposure Prophylaxis Reference: Centers for Disease Control and Prevention. (2001). Updated U.S. Public Health Service guidelines for the management of occupational exposure to HBV, HCV, and HIV and recommendations for post-exposure prophylaxis.

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180APPENDIX B: Continued Reference: Centers for Disease Control and Prevention. (2001). Updated U.S. Public Health Service guidelines for the management of occupational exposure to HBV, HCV, HIV and recommendations for post-exposure prophylaxis.

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181 APPENDIX C: PRECEDE-PROCEED MODEL [ Source: Green, L., & Kreuter, M. ( 1999). Health Promot ion Planning: An Educational and Environmental Approach. 3rd edition. Mountain View, CA: Mayfield Publishing Co.]

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182 APPENDIX D: Moderator Introduction fo r Focus Group Sessions in English and Spanish MODERATOR INTRODUCTION FOR FOCUS GROUP Recapping needles at the Maracay Central Hospital Project Good afternoon and welcome to the session today. Thank you for taking the time to discuss about recapping needles. My name is Luis Galindez and I am the researcher who is conducting the focus group for this project. I am a Ph.D. student at the University of South Florida (USF) at Tampa. I am interested in hearing your viewpoints and opinions on issues relating recapping needles at the Maracay Central Hospital. I will be asking a variety of questions for the group to discuss. I will be reading this introduction and the discussi on questions. I plan to meet with two other groups, and I want to be sure to say the same thing to each group. The purpose of these focus group is to get input on what factors are associated with recapping needles and how do you think that this situation can be modified to protect nurses and other health care workers in the hospital. This research is being conducted jointly with the University of Carabobo. I am not employed by your hospital and I do not receive funding from it or any other health institution from Aragua or Venezuela. This is a study that is serving as my doctoral dissertation from the University of South Florida, Tampa, and is funded partially by the CODECIH of the University of Carabobo. There are no rights or wrong answers to any of th e questions I will ask today. However, people may have different points of view. Please feel free to share your point of view, even if it differs from what others have said. Please feel free to expand on what others have said. My role in this focus group is to serve as a fac ilitator. I will ask questions for the group to discuss. I will be accompanied by Victor Loreto who is a researcher from the University of Carabobo Victor will help clarify any issues they think are unclear. Before we begin, let me remind you of some gr ound rules. Because this is a research project, we will be tape recording this session. Therefore, you will need to speak up, and only one person should speak at a time. I don't want to miss any of your comments. Please do not disclose anything during the discussion th at is personal and/ or confidential. Please don't discuss what was said during the discussion outside of the focus group. During the discussion, please don't refer to anyone's name. My goal is to preserve your confidentiality. As stated in the consent form that you signed, the tapes will be held by the researchers in a locked cabinet. This session will last approximately 2 hours, and we will not take a formal break. Feel free to get up at any time if you need to, but please do so quietly. We will start by going around the table and havi ng you introduce yourselves. The tape will not be started until after these introductions.

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183 APPENDIX D: Continued Modelo de introduccin para la reunin del grupo focal Estudio del reencapuchado en agujas usadas y heridas por pinchazos en el Hospital Central de Maracay, (HCM) Aragua Venezuela Introduccin del moderador Buenos das y bienvenidos a la sesin de hoy. Gr acias por tomar parte de su tiempo para asistir a esta reunin. Mi nombre es Luis Galndez y soy el investigador quien conducir las reuniones con los grupos focales en este estudio. Soy estudiante de doctorado en la Universidad del Sur de la Florida (USF) en Tampa. Estoy interesado en or sus opiniones y puntos de vista en aspectos relacionados con la reinsercin de la tapa plstica en agujas usadas y heridas por pinchazos en el HCM. Leer esta introduccin as como las preguntas para la discusin. Mi plan es reunirme con otros grupos y deseo estar seguro de decir lo mismo en cada grupo. El propsito de estos grupos focales es obtener informacin sobre cuales son los factores asociados con el reencapuchado en agujas usadas y heridas por pinchazos y como ustedes piensan que esta situacin pueda ser modificada para proteger la salud de los trabajadores en este hospital. Yo no trabajo para este hospital y no recibo financiamiento ni de esta ni de otra institucin de salud del estado Aragua o de Venezuela. Este es un es tudio que sirve para mi tesis doctoral en la (USF) y es financiada parcialmente por la Universidad de Carabobo (UC). No existen respuestas correctas o incorrectas en ninguna de las preguntas que se harn hoy. Sin embargo, ustedes pueden diferir en puntos de vista. Por favor, comprtanlos con nosotros an cuando sean diferentes. A la vez profundice en co mentarios hechos por otros compaeros (as). Mi rol en esta reunin es servir de facilitador. Ha r las preguntas al grupo para establecer la discusin. Estar acompaado el Licenciado Vctor Loreto es investigador de la UC. Vctor ayudar a clarificar cualquier aspecto que usted es consideren no lo esta debidamente. Vctor tambin tomar apuntes de la discusin. Ante de comenzar, permtanme recordarles algunas reglas bsicas para la reunin. Debido a que esto es una investigacin, esta sesin ser grabada. Por lo tanto, ustedes debern hablar en voz alta y solamente una persona podr hablar a la vez. Yo no quiero perderme ninguno de sus valiosos comentarios. Por favor, no revele nada durante la discusi n que sea personal o confidencial. Por favor, no comente afuera del grupo focal lo que se dijo dur ante la discusin. Durante la discusin, por favor, no mencione nombres de ninguna persona. Mi objetivo es prevenir y preservar su confidencialidad. Como esta escrito en el doc umento de consentimient o que usted firm, las cintas de grabacin sern guardadas por el i nvestigador en un gabinete con cerradura. Esta sesin durar aproximadamente 2 horas, no habr un receso formal. Puede levantarse en cualquier momento pero por favor hgalo en silencio. Empezaremos con una ronda alrededor de la mesa y cada quien se presentar. La grabacin no comenzar hasta que se terminen las presentaciones individuales. Alguna pregunta? Comencemos!

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184 APPENDIX E: Field Notes Form Used in Focus Group Sessions in English and Spanish FIELD NOTES FORM USED IN FOCUS GROUP Information about the Focus Group Date of Focus Group: ____________ Location: _____________________ Number of Participants: ____ Moderator Name: _______________________________ Assistant Name: _______________________________ Time started: ________ Time ended: ___________ Responses to Questions 1) "Before we get into specific questions about recapping needles and needlesticks injuries in the hospital, we would like to get a better understanding of the conditions under which you work every day. Please describe conditions or circumstances that are present in the hospital work environment.” Potential follow-ups: Describe the physical setup (e.g. lighting, beds, electr ical outlets, hand washing facilities). Describe organization fact ors (safety climate, policies and procedures, work assignments, planning time, education) Brief Summary/ Key Points: Notable Quotes: Comments/Observations 2) Please describe your current system for disp osing of used needles in this hospital Brief Summary/Key Points: Notable Quotes: Comments/Observations

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185 APPENDIX E: Continued 3) What circumstances or procedures do you think can contribute to needlestick injuries in this hospital? Brief Summary/Key Points: Notable Quotes: Comments/Observations 4) Describe any recent exposure incidents involving bloodborne pathogens that could have been prevented in this hospital. Brief Summary/Key Points: Notable Quotes: Comments/Observations 5) Do you recap used needles? What influen ces a health care worker’s decision to recap needles in this hospital? Brief Summary/Key Points: Notable Quotes: Comments/Observations 6) Think back to a time when you may have had to recap a needle or place a used needle in something other than a sharp container. Tell us what happened? What particular circumstances do you th ink influenced this action? Brief Summary/Key Points: Notable Quotes: Comments/Observations 7) How do you think that recapping needles ca n be eliminate or controlled in this hospital? Brief Summary/Key Points: Notable Quotes: Comments/Observations 8) Please describe polices and procedures used by this hospital to avoid needlesticks injuries. Brief Summary/Key Points: Notable Quotes: Comments/Observations

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186 APPENDIX E: Continued 9) What is the most important thing you would do to assure that work is done safety? Brief Summary/Key Points: Notable Quotes: Comments/Observations 10) Any other comments? Brief Summary/Key Points: Notable Quotes: Comments/Observations

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187 APPENDIX E: Continued ESQUEMA USADO PARA LA TOMA DE NOTAS EN LA SESIONES DE LOS GRUPOS FOCALES Informacin acerca del grupo focal Fecha del grupo focal: ____________ Departamento: _____________________ Nmero de participantes: ____ Nombre del Moderador: _______________________________ Nombre del Asistente: _______________________________ Tiempo de inicio: ________ Ti empo de finalizacin: ___________ Respuestas a las preguntas: 1. Antes de introducirnos en las preguntas especi ficas acerca del reencapuchado de agujas usadas y heridas por pinchazos en el hospital, nos gustara obtener un mejor conocimiento de las condiciones bajo las cuales ustedes trabajan todos los das. Por favor describa condiciones o circunstancias que estn presentes en el ambiente laboral hospitalario. Por ejemplo: describa aspectos fsicos (iluminacin, nmero de camas asignadas, lavamanos cercanos etc.) Describa factores organizacionales tales como (clima de seguridad, polticas y procedimientos, asignacin de tareas, duplicid ad de tareas, planificacin del tiempo de trabajo, entrenamiento o cursos de actualizacin, etc.) Resumen/ Palabras claves: Notables Acotaciones: Comentarios/Observaciones: 2. Por favor describa el procedimiento actualmente utilizado en el hospital para desechar las agujas usadas. Resumen/ Palabras claves: Notables Acotaciones: Comentarios/Observaciones:

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188 APPENDIX E: Continued 3. Que circunstancias o procedimientos pien sa usted puedan contribuir a pinchazos por agujas en el hospital? Resumen/ Palabras claves: Notables Acotaciones: Comentarios/Observaciones: 4. Describa algn incidente reciente en un personal de enfermera que involucre a microorganismos (patgenos) transmitidos por sangre que haya podido ser prevenido en el hospital Resumen/ Palabras claves: Notables Acotaciones: Comentarios/Observaciones: 5. Usted reinserta la tapa plstica en agu jas usadas? Que factor o factores pudieran influenciar a una enfermera (o) la decisin de reinserta la tapa plstica en el hospital? Resumen/ Palabras claves: Notables Acotaciones: Comentarios/Observaciones: 6. Piense retrospectivamente si usted ha tenido un accidente por pinchazo al reinsertar la tapa plstica en agujas usadas. Que pens en el momento del accidente? Cual fue su reaccin inmediata? Como manejo la situacin? Que circunstancia en particular piensa usted pudiera haber influido en ese accidente? Resumen/ Palabras claves: Notables Acotaciones: Comentarios/Observaciones: 7. Como piensa usted que la reinsercin de la tapa plstica en agujas usadas pueda ser eliminada o controlada en el hospital? Resumen/ Palabras claves: Notables Acotaciones: Comentarios/Observaciones:

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189 APPENDIX E: Continued 8. Por favor describa polticas o procedimientos usados por el hospital para evitar heridas por pinchazos. Resumen/ Palabras claves: Notables Acotaciones: Comentarios/Observaciones: 9. De acuerdo a su criterio cual seria lo ms importante para asegurar que el trabajo que usted realiza se haga con seguridad? Resumen/ Palabras claves: Notables Acotaciones: Comentarios/Observaciones: 10. Algn comentario adicional que desean hacer? Resumen/ Palabras claves: Notables Acotaciones: Comentarios/Observaciones:

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190 APPENDIX F: Sample Cover Letter Used for Member Checks in English and Spanish and Sample of Materials Used for Member Checks in Spanish SAMPLE COVER LETTER USED FOR MEMBER CHECKS Date: Dear participant, As a result of your participation in the origin al set of focus group sessions for this study, you are being requested to give your opinions on the study’s preliminary findings. This will be done in a one-hour discussion between you and Luis Galindez. You will be asked to give written and verbal feedback to some written materials from the study. This procedure is called “member chec king” and its purpose is to measure the trustworthiness of the findings from focus group sessions. The purpose of this discussion is to review the findings for f actual and interpretative accuracy. Thank you very much for agreei ng to participate in this member check. Should you have any questions, please call Luis Galindez at 0412-3450609. Luis Galindez, MD, MPH Principal Investigator

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191 APPENDIX F: Continued CARTA DE PRESENTACION P ARA LOS MIEMBROS REVISORES Fecha: Estimada (o) participante, Como resultado de su participacin en la di scusin de los grupos fo cales en el presente estudio, usted ha sido seleccionada (o) para emitir su opinin acerca de los resultados preliminares. Esto se realizar con una reun in de una hora de durac in entre usted y mi persona. Se le solicitar que aporte informacin tanto escrita como verbal de algunos de los materiales escritos del estudio. Este procedimiento se denomina “miembros revisores” y su propsito es medir la veracidad de los hallazgos aportados por uste des en la reunin de los grupos focales. El propsito de esta discusin es revisar los re sultados para su prec isin interpretativa. Muchas gracias por aceptar participar como miembro revisor. Si usted tiene alguna pregunta, por favor contcteme al telfono 0412-345-0609. Luis Galindez MD, MPH Principal Investigator

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192 APPENDIX F: Continued SAMPLE OF MATERIALS USED FOR MEMBER CHECKS Instructions for Review of Findings 1. After reading this summary of findings, pl ease give your judgment of the overall credibility of these findings. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 2. Is there anything you think was missed? If so, please add here: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 3. Is there anything you would like to add? If so, please do so here. _______________________________________________________________________ _______________________________________________________________________

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193 APPENDIX F: Continued MUESTRA DEL MATERIAL USADO PO R LAS PERSONAS REVISORAS DEL RESUMEN DE LOS GRUPOS FOCALES Instrucciones para revisin de los resultados 1. Despus de leer el resumen de los result ados, por favor, emita su opinin acerca de la representatividad de estos hallazgos. Usted como participante en el grupo focal considera que estos resultados son cnsonos y reales con lo expresado y discutido por el grupo en la sesin respectiva. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 2. Hay algo que se haya omitido de la discusi n? Si es as, por favor agrguelo aqu: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 3. Le gustara agregar algo? Si es as, por favor adalo aqu: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________

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194 APPENDIX F: Continued Resumen Preliminar de los hallazgos obtenidos en la reunin con los grupos focales Los factores asociados al reencapuchado y a lo s accidentes por pinchazos en el Hospital Central de Maracay fueron orga nizados en tres principales reas y en cada una de ellas est el resumen de los temas comentados por ustedes. Ambiente de Trabajo. Condiciones fsicas: Deficiencia de iluminacin, problema de dficit de lavamos, lavamanos daados, problem a de aseo del hospital, problemas con la luz elctrica. Condiciones organizacionales: Exceso de pacientes con respecto al nmero de camas existentes dficit de personal de enfermera Exceso de trabajo, stress, ausencia de vigilancia, violencia. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Polticas hospitalarias para la prevencin de los pinchazos: ausencia de poltica en materia de prevencin, ausencia de equipos para desechar agujas usad as, falta de equipos de proteccin personal, falta de motivacin por parte de la directiva hospitalaria para la prevencin de accidentes por pinchazos _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Percepcin del personal de enfermera ante los accidentes por pinchazos: relatos de experiencias personales de acc identes por pinchazos por reen capuchado de agujas u otras causas, relatos de otras experiencias de comp aeras o compaeros de trabajo, relatos de otras u otros compaeros de enfermedades infecciosas asociadas a pinchazos. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________

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195 APPENDIX F: Continued Medidas preventivas para evitar el reenca puchado y los accidentes por pinchazos: tcnicas y de formacin: adquisicin de equipos para el de scarte de las agujas usadas, dotacin adecuada y oportuna de los equipos de proteccin personal, incorporacin de nuevas tecnologas como las agujas retractiles, realizacin de taller es de capacitacin y de adiestramiento en forma peridica sobre bioseguridad, identificacin de factores de riesgos laborales y condicione s peligrosas, entrenamient o en equipos con nuevas tecnologas de seguridad, tall eres con aspectos relacionado s con leyes, reglamentos y normas tcnicas sobre la materia de Salud y Seguridad Laboral. Organizativas administrativas : incorporacin de pers onal, mejoramiento del ambiente de trabajo, polticas para el seguimiento de accidentes por pinchazos. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ MUCHAS GRACIAS POR SU VALIOSA COLABORACION

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196 APPENDIX G: Study Phases Phases of the study about recapping used needles and needlestick injuries in the Maracay Central Hospital Study Phases Duration Activities First Diagnosis period To gain understanding about predisposing factors of knowledge, attitudes, beliefs, values, & perceptions of nurses that influence motivation for a behavior (recapping) To collect data that can be used as baseline for evaluation purpose: demographic & work data # of recapping used needles # of needlestick injuries in each of the department selected 6 months (November 2006-April 2007) Focus group sessions Demographic questionnaire Discussion of the questions Visits: The departments to collect the containers with the used needles Second Implementation/Intervention period To develop an educational intervention program at the selected departments 5 months (Jun-October 2007) Educational strategy sessions Discussion of the material Application of test (pre & post) Third Follow up/Evaluation period To evaluate the educational strategy 4 months (November 2007 – February 2008) Visits: The departments to collect the containers with the used needles

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197 APPENDIX H: Focus Group Questions in English and Spanish Focus Group Questions 1. "Before we get into specific questions about recapping needles and needlesticks injuries in the hospital, we would like to get a better understanding of the conditions under which you work every day. Please descri be conditions or circ umstances that are present in the hospital work environment.” Potential follow-ups: Describe the physical set-up (e.g. lighti ng, beds, electrical outlets, hand washing facilities). Describe organization factors (safety cl imate, policies and procedures, work assignments, planning time, education) 2. Please describe your current system for dis posing of used needles in this hospital 3. What circumstances or procedures do you thin k can contribute to n eedlestick injuries in this hospital? 4. Describe any recent exposure incidents involving bloodborne pathogens that could have been prevented in this hospital. 5. Do you recap used needles? What influences a health care worker ’s decision to recap needles in this hospital? 6. Think back to a time when you may have had to recap a needle or place a used needle in something other than a sharp container. Tell us what happened? What particular circumstances do you think infl uenced this action? 7. How do you think that recapping needles can be eliminate or controlled in this hospital? 8. Please describe polices and procedures used by this hospital to avoid needlesticks injuries. 9. What is the most important thing you would do to assure that work is done safety? 10. Any other comments?

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198 APPENDIX H: Continued Preguntas a los Grupos Focales 1. Antes de introducirnos en las preguntas especi ficas acerca del reencapuchado de agujas usadas y heridas por pinchazos en el hospital, nos gustara obtener un mejor conocimiento de las condiciones bajo las cuales ustedes trabajan todos los das. Por favor describa condiciones o circunstancias que estn presentes en el ambiente laboral hospitalario. Por ejemplo: describa aspectos fsicos (iluminacin, nmero de camas asignadas, lavamanos cercanos etc.) Describa factores organizacionales tales como (clima de seguridad, polticas y procedimientos, asignacin de tareas, duplicid ad de tareas, planificacin del tiempo de trabajo, entrenamiento o cursos de actualizacin, etc.) 2. Por favor describa el procedimiento actualmente utilizado en el hospital para desechar las agujas usadas. 3. Que circunstancias o procedimientos piensa uste d puedan contribuir a pinchazos por agujas en el hospital? 4. Describa algn incidente reciente en un pe rsonal de enfermera que involucre a microorganismos (patgenos) transmitidos por san gre que haya podido ser prevenido en el hospital. 5. Usted reinserta la tapa plstica en agujas usad as? Que factor o factores pudieran influenciar a una enfermera (o) la decisin de reinserta la tapa plstica en el hospital? 6. Piense retrospectivamente si usted ha tenido un accidente por pinchazo al reinsertar la tapa plstica en agujas usadas. Que pens en el momento del accidente? Cual fue su reaccin inmediata? Como manejo la situacin? Que ci rcunstancia en particular piensa usted pudiera haber influido en ese accidente? 7. Como piensa usted que la reinser cin de la tapa plstica en agujas usadas pueda ser eliminada o controlada en el hospital? 8. Por favor describa polticas o procedimientos usa dos por el hospital para evitar heridas por pinchazos. 9. De acuerdo a su criterio cual seria lo ms importante para asegurar que el trabajo que usted realiza se haga con seguridad? 10. Algn comentario adicional que quieran hacer?

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199 APPENDIX I: Data Sheet about Demogra phic Information in English and Spanish Focus group Questions Demographic and Exposure Information Dear Participant: We are interested in the demographic characteristics of participants and would greatly appreciate a few moments of your time to complete this brief survey. For each question you answer, please check all choices that apply, when applicable. NOTE: As with all portions of this study, this information will not be used to identify particular participants and identities will kept anonymous. You may fill in all, part or none of these questions, as you see fit. 1. Age in years at next birthday: ___________ 2. Sex: ____ Female _____ Male 3. Education received: _________________ __________________ ______________ 4. What is your job position: ___Professional nurse ___Licensed Nurse __ Nurse aid ___Student nurse 5. What unit or department do you work in? __________________________ 6. Number of years of experience (specialty) _______________ 7. Number of years of experience in this hospital (organization) _____________ 8. Number of years in position _____________ 9. During an average day, in the past 6 months, how many hours do you work? ________________________ 10. What is your schedule of duty? _____ 7-1 (mor ning) ____ 1-7 (evening) ____ 7-7 (night) 11. During an average week, in the past 6 months, how many hours do you work? ___________________ 12. Are you currently working in any other hea lthcare settings in addition to the hospital? ____ Yes ____No if yes, pl ease specify_________ ________________ Exposure questions: 13. In the past 12 months have you been injured by sharp obj ect, such as a needle or scalped that was previously used in a patient? ____ Yes ____No If yes, how many blood/body fluid exposures did you sustain during this time period? _______ For how many of these exposures did you comple te/submit a blood/body fluid exposure reports? ____

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200 APPENDIX I: Continued Preguntas a los participantes de los Grupos Focales Informacin Demogrfica y de Exposicin Estimado Participante: Nosotros estamos interesados en algunos datos personales de los participantes y apreciaramos que usted se tomara algunos minutos de su tiempo para responder este breve cuestionario. Para cada pregunta que usted responda, por favor revise todas las opciones que aplican en caso de ser necesario. Usted puede responder todas o ninguna de las preguntas de acuerdo con su criterio. l. Edad: ___________ 2. Sexo: _________Femenino _________Masculino 3. Nivel educativo: ___________________________________________________ 4. Cual es su posicin de trab ajo?:____ Enfermer a profesional. __Estudiante de Enfermera. ___ Auxiliar de Enfermera 5. En que departamento o unidad trabaja actualmente?_______________________ 6. Aos de trabajo en el rea de la enfermera?_____________________________ 7. Aos de trabajo en el hospital?_______________________________________ 8. Aos de trabajo en el cargo actual____________________________________ 9. Durante un da promedio, en los ltimos 6 meses Cuantas horas ha trabajado usted?______ 10. Durante una semana promedio, en los ltimos 6 meses Cuantas horas ha trabajado usted? _______ 11. Cual es actualmente su turno de trabaj o? _7-1 (maana) __1-7 (tarde) __7-7 (noche) 12. Trabaja usted en otro hospital o c lnica? ____Si ___No. Especifique___________ Preguntas de exposicin 13. En los ltimos 12 meses ha tenido usted heridas por pinchazos con objetos punzantes como agujas o scal ps que hayan sido previament e usados en un paciente? _____ Si ____ No. Si su respuesta es afirma tiva cuantos eventos tuvo usted durante ese periodo_________ Reporto usted el accidente? _____ Si ______ No NOT A: Como todas las partes de este es tudio esta informacin no ser usada para averiguar su identificacin y por lo tanto se mantendr el anonimato. ¡Muchas gracias!

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201 APPENDIX J: CORPOSALUD Needlestick Injuries Surveillance Report Data Sheet 1 2 3 4 5 6 7 8 9 10 11 12 1. Center 2. I.D 3. Age 4. Sex 5. Date of accident 6. Hour of Accident 7. Profession 8. Unit 9. Object 10. Exposure 11. Procedure 12. Source

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202 APPENDIX K: Data Sheet of Used Needles at the Departments Studied Before educational strategy After educational strategy Rn Nrn Tn % Nrn Rn Nrn Tn % Nrn Nov Nov 1w 1w 2w 2w 3w 3w 4w 4w Total Total Rn Nrn Tn % Nrn Rn Nrn Tn % Nrn Dec. Dec. 1w 1w 2w 2w Total Total Rn Nrn Tn % Nrn Rn Nrn Tn % Nrn Jan. Jan. 1w 1w 2w 2w 3w 3w 4w 4w Total Total Rn Nrn Tn % Nrn Rn Nrn Tn % Nrn Feb. Feb. 1w 1w 2w 2w Total Total Rn= recapped needles Rn= recapped needles Nrn= no recapped needles Nrn= no recapped needles Tn= total needles Tn= total needles % Nrn= percentage of no recapped needles % Nrn= percentage of no recapped needles

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203 APPENDIX L: Pamphlet Used in the Educational Strategy

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204 APPENDIX L: Continued

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205 APPENDIX M: Venezuelan Organic Act and the Regulation of Organic Act

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206 APPENDIX N: Organic Law Articles Di scuss in the Educational Strategy Artculos discutidos en la estrategia educ ativa en el Hospital Central de Maracay Ley Orgnica de Prevencin, Condicion es y Medio Ambiente de Trabajo (LOPCYMAT) 1. Objeto de la Ley (art. 1) 2. Instituto Nacional de Prevencin, Salud y Seguridad laborales (INPSASEL, art. 18) 3. Competencias del INPSASEL (art. 18) 4. Delegados o delegadas de prevencin (art. 41) 5. Comit de Seguridad y Salud Laboral (art. 46) 6. Derechos de los trabajadores y las trabajadoras (art. 53) 7. Deberes de los trabajadores y las trabajador as (art. 54) 8. Derechos de los empleadores y empleadoras (art. 55) 9. Deberes de los empleadores y empleadoras (art. 56)

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207 APPENDIX O: American Nurses Associa tion (ANA) Recommendation about NSIS in English and Spanish

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208 APPENDIX O: Continued Agujas seguras salvan vidas* La prevencin es la mejor v a para evitar infecciones. Si usted presenta un accidente por pinchazo : En forma inmediata: Lavar la herida con agua y jabn. Reportar rpidamente ante su superv isor el accidente por pinchazo. Asistir a la Emergencia de Adultos o al Servicio de Epidemiologa para evaluacin y tratamiento. Identificar la fuente (paciente) a quien deber extraerle sangre para exmenes de Hepatitis B, Hepatitis C y VIH. Practicarte en forma inmediata los exmenes de VIH, Hepatitis B, y Hepatitis C Si la fuente (paciente) es desconocida o si resulta positivo: Hepatitis B: si estas vacunada (o) no requiere tratamiento, pero si no estas vacunada (o) colocar Inmunoglobulina es pecifica (IGHB) e iniciar esquema de vacunacin contra HB. VIH: cumplir tratamiento post exposicin dentro de las dos horas de exposicin. Hepatitis C: no hay tratamiento, pero consul ta con especialistas sobre la profilaxis post exposicin de tipo experimental. Seguimiento: Pruebas de sangre a las 5 semanas, 3, 6 meses y dependiendo del riesgo al ao. Recibir monitoreo y seguimiento de t oxicidad del tratamiento profilctico. Recibir asesora y educacin del Servic io de Salud Ocupacional del empleador. Tomar precauciones para prevenir la exposicin de otros (sexo seguro). Para prevenir accidentes: Implementar o utilizar las Precauciones Universales: o Lavarse las manos. o Evitar la reinsercin de la ta pa plstica en agujas usadas. o Recoleccin y disposicin segur a de objetos corto punzantes. o Cumplir con el esquema de vacunas c ontra el virus de la Hepatitis B. Utilizacin adecuada de los equipos de proteccin personal. Trabajar con el comit de seguridad y sa lud del Hospital Centra l de Maracay para proponer soluciones que mejoren las condiciones de trabajo y las pr cticas seguras de trabajo y as disminuir o elimin ar los accidentes por pinchazos. Traduccin realizada por el Dr. Luis Galndez del material de la Asociacin Americana de Enfermera. www.needlestick.org

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209 APPENDIX P: INPSASEL and CATDIS Pamphlet

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210 APPENDIX Q: Pretest and Post-test Applied in the Edu cational Strategy Proyecto “Factores relacionados con la reinsercin de la tapa plstica en agujas usadas y con heridas por pinchazos en el personal de enfermera del Hospital Central de Maracay 2006-2008” PRETEST Esta prueba constituye parte de la actividad de l proyecto de investigacin y tiene como objetivo obtener informacin acerca de su conocimiento s obre los accidentes laborales por pinchazos, la reinsercin de la tapa plstica en agujas usadas, inmunizaciones y aspectos legales vigentes en Venezuela. Esta prueba es completamente ANONIMA para garantizar la confidencialidad. Consta de dos tipos de preguntas, las cerradas con opcin de seleccin mltiple y las de respuesta afirmativa o negativa segn corresponda. Le ag radecemos su colaboracin y muchas gracias. 1. Los accidentes por pinchazos son ri esgos importantes por cuanto sus consecuencias pudieran ser muy grav es para la salud del trabajador a. Cierto b. Falso c. No sabe d. No contesta 2. Cual de estos virus tiene ms facilidad de transmisin despus de una exposicin a sangre contaminada: a. Virus de inmunodeficiencia humana (VIH) b. Virus de la Hepatitis C c. Virus de la Hepatitis B d. Todos tienen la misma probabilidad 3. Cual considera usted es el porcentaje a ni vel mundial del subregistro de accidentes por pinchazos: a. 10-20% b. Menos del 10% c. Entre un 30 al 80% d. Es incalculable 4. La Hepatitis B puede ser adquirida a travs de contacto casuales tales como abrazos o darse la mano: a. Siempre b. Usualmente c. Nunca d. No estoy segura (o) 5. El virus de la Hepatitis B puede causar cncer de hgado: a. Siempre b. Usualmente c. Algunas veces d. Nunca

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211 APPENDIX Q: Continued 6. La efectividad de la vacuna de la Hepatiti s B en la prevencin de la enfermedad en personal a riesgo es: 1. Siempre efectiva 2. Usualmente efectiva 3. Nunca es efectiva 4. No estoy segura (o) 7. La reinsercin de la tapa plstica en agujas usadas es un procedimiento: a. a. Que se puede utilizar de rutina ya que no representa riesgo alguno b. Es una causa importante de pinchazos c. Inseguro para el personal d. Las opciones b y c son ciertas 8. Dentro de las causas del subregistro de los accidentes por pinchazos tenemos: a. Miedo a ser despedida (o) b. Falta de conciencia sobr e el riesgo de infecciones c. Falta de entrenamiento sobre lo s procedimientos para reportar d. Todas son razones validas para no reportar 9. Antes de las sesiones de los grupos focales con el Dr. Galndez, conoca usted la existencia de equipos de seguridad para desechar material cortopuzante?: Si________ No_______ No estuve en el grupo focal________ 10. Conoce usted la Ley Orgnica de Prevencin, Condiciones y Medio Ambiente de Trabajo (LOPCYMAT). Si_______ No______ 11. Conoce usted acerca del Instituto Nacion al de Prevencin, Salud y Seguridad Laborales (INPSSL): Si_______ No______ 12. Existe en este hospital comit de seguridad y salud laboral: a. Si b. Existe pero no esta funcionando actualmente c. No d. No se 13. Por favor indique si usted ha recibido la vacuna contra la Hepatitis B: Si _____ No______ 14. Si su respuesta fue afirmativa a la pregunta anterior, por favor especifique cuantas dosis recibi? a. Solo la primera dosis b. Primera y segunda dosis c. Las tres dosis

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212 APPENDIX Q: Continued Proyecto “Factores relacionados con la reinsercin de la tapa plstica en agujas usadas y con heridas por pinchazos en el personal de enfermer a del Hospital Central de Maracay 2007” POST TEST 1. Los accidentes por pinchazos son riesgos impo rtantes por cuanto sus consecuencias pudieran ser muy graves para la salud del trabajador a. Cierto b. Falso c. No sabe d. No contesta 2. Cual de estos virus tiene ms facilidad de tr ansmisin despus de una exposicin a sangre contaminada: a. Virus de inmunodeficiencia humana (VIH) b. Virus de la Hepatitis C c. Virus de la Hepatitis B d. Todos tienen la misma probabilidad 3. Cual considera usted es el porcentaje a nivel mundial del subregistro de accidentes por pinchazos: a. 10-20% b. Menos del 10% c. Entre un 30 al 80% d. Es incalculable 4. La Hepatitis B puede ser adquirida a travs de contacto casuales tales como abrazos o darse la mano: a. Siempre b. Usualmente c. Nunca d. No estoy segura (o) 5. El virus de la Hepatiti s B puede causar cncer de hgado: a. Siempre b. Usualmente c. Algunas veces d. Nunca 6. La efectividad de la vacuna de la Hepatitis B en la prevencin de la enfermedad en personal a riesgo es: a. Siempre efectiva b. Usualmente efectiva c. Nunca es efectiva d. No estoy segura (o) 7. La reinsercin de la tapa plstica en ag ujas usadas es un procedimiento: a. Que se puede utilizar de rutina ya que no representa riesgo alguno b. Es una causa importante de pinchazos c. Inseguro para el personal d. Las opciones b y c son ciertas 8. Dentro de las causas del subregistr o de los accidentes por pinchazos tenemos: a. Miedo a ser despedida (o) b. Falta de conciencia sobre el riesgo de infecciones c. Falta de entrenamiento sobre los procedimientos para reportar d. Todas son razones validas para no reportar

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213 APPENDIX R: IRB Approval Application

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214 APPENDIX S: Consent Form in English and Spanish Proposed Consent Form University of South Florida Consent to Participate in a Research Study Research Subject Information and Informed Consent Form The following information is being presented to help you decide whether or not you want to take part in a minimal risk research st udy. Please read this carefully. If you do not understand anything, ask the pers on in charge of the study. Title of Study: Factors associated with recapping needles and needlestick injuries in nurses at the Maracay Central Hospital Aragua, Venezuela, 2006. Principal Investigator: Luis Galindez is a candidate fo r a Ph.D. degree at the Univers ity of South Florida (USF), College of Public Health, and Department of Global Health. Dr Donna Haiduven is his advisor. In partial fulfillment of the degree requirements, he is conducting a study between recapping needles and needlestick injuri es in health care workers at the Maracay Central Hospital, a Vene zuelan public hospital. Study Location(s): You are being asked to participate because you are a nurse who works at the Maracay Central Hospital, a Venezuel an public hospital. General Information about the Research Study: The purpose of this research st udy is to gain an understand ing of the factors surrounding with recapping needles and need lestick injuries. This resear ch is partially funded by the University of Carabobo (Venezuela). The info rmation gained in this study may help others in developing safer work practices. Plan of Study: If you agree to participate, the following will occur: You will participate in a two hour discussion (focus group session) regarding recapping needles and needlestick inju ries. The focus group to which you are being invited will be conducted at hospita l outside of regular working hours and will last for approximately two hours. A seri es of open-ended questions relating to

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215 APPENDIX S: Continued experiences in needlestick hospital injuries will be directed to the group. An interviewer will moderate, listen, and obser ve the discussion. One or two research assistants will observe the discussion, ta ke notes, and ask questions to clarify certain issues. You will receive a letter from Luis Ga lindez notifying you of the time and place of the focus group session. During the focus group session, an audio tape will be made of the discussion. Before the session starts, you will be asked to comp lete a short questionnaire about your education and work experience. Payment for Participation: You will not be paid for your participation in this study. Benefits of Being a Part of this Research Study: Although you may not receive any direct benefit from this research, the information that is obtained from the focus group may be used to help health care workers perform their jobs in a safer way. These potential be nefits to you cannot be guaranteed. Risks of Being a Part of this Research Study: Some of the focus group questions may touch on personal or sensitive experiences, such as a blood exposure in yourself or a co-worker. You may choose not to discuss anything that you do not want to talk about. If you choose, you can leave the focus group session at any time. The session will be tape recorded, but no individual names will be mentioned on the tapes. All of the information obtained from you during the session will be kept confidential. The tapes and discussion notes will be stor ed in a locked cabinet. Only the study investigators will have access to them. After the focus group, the tapes will be tran scribed into written form. In addition, the researchers will listen to the tapes and extract common themes and attitudes expressed. Confidentiality of Your Records: Participation in research may mean a loss of privacy. Therefore, a potential risk to you is some loss of privacy by participati ng in a group discussi on of your attitudes

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216 APPENDIX S: Continued and opinions. All participants will be asked, in a group setting, about their personal work experience and opinions. The researchers will ask you and the other people in the group to use only first names during the session. Your individual responses will be heard by ot hers who are present in the group. This might pose some risk to you if your responses are shared by othe rs outside of the focus group. Therefore, please do not di sclose anything during the focus group discussion that is personal and/ or conf idential. Please don't discuss what was said during the discussion outside of the focus group. The goal is to preserve everyone's confidentiality. However, the researchers can not guarantee that everyone will keep the discussions private. Your privacy and research records will be kept confidential to the extent of the law. Authorized research personnel, empl oyees of the Department of Health and Human Services, and the USF Institutional Review Board may inspect the records from this research project. Your responses will remain confidential. There will be no identifying information retained on the written transcripts of the focus group session. No attempts will be made to link information on the transcript s to individual subject s. The results of the focus group will be reported in summ ary form, not individual responses. Your employer will only see a summary re port and will not be able to identify individuals involved in the focus group. No information by which you can be identified will be released or published. The results of this study may be published. However, the data obtained from you will be combined with data from others in the publication. The published results will not include your name or any othe r information that would personally identify you in any way. Volunteering to Be Part of this Research Study: Your decision to participate in this rese arch study is completely voluntary. You are free to participate in this research st udy or to withdraw at any time. There will be no penalty or loss of benefits you are en titled to receive, if you stop taking part in the study. Questions and Contacts: If you have any questions about this re search study, contact Luis Galindez at 0412-3450609.

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217 APPENDIX S: Continued If you have questions about your rights as a person who is taking part in a research study, you may contact the Divi sion of Research Compliance of the University of South Florida at (813) 974-5638. Consent to Take Part in This Research Study: By signing this form I agree that: I have fully read or have had read and e xplained to me this informed consent form describing this research project. I have had the opportunity to question one of the persons in charge of this research and have received satisfactory answers. I understand that I am being asked to part icipate in research. I understand the risks and benefits, and I freely give my consent to participate in the research project outlined in this form, under th e conditions indicated in it. I have been given a signed copy of this informed consent form, which is mine to keep. _________________________ _________________________ __________ Signature of Participant Printed Name of Participant Date

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218 APPENDIX S: Continued Consent to Take Part in this Research Study It’s up to you. You can decide if you want to take part in this study. I freely give my consent to take part in this study. I understand that this is research. I have received a copy of this consent form. ________________________ ________________________ ___________ Signature Printed Name Date of Person taking part in study of Person taking part in study ________________________ ________________________ ___________ Signature of Witness Printed Name of Witness Date Statement of Person Obtaining Informed Consent I have carefully explained to the person taki ng part in the study what he or she can expect. The person who is giving consent to take part in this study Understands the langu age that is used. Reads well enough to understand this form. Or is able to hear and understand when the form is read to him or her. Does not have any problems that could ma ke it hard to understand what it means to take part in this study. Is not taking drugs that make it hard to understand what is being explained. To the best of my knowledge, when this pe rson signs this form, he or she understands: What the study is about. What needs to be done. What the potential benefits might be. What the known risks might be. That taking part in the study is voluntary. ________________________ _______________________________________ Signature of Investigator Printe d Name of Investigator Date or authorized research investigator designated by the Principal Investigator

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219 APPENDIX S: Continued Propuesta de Forma de Consentimiento Universidad del Sur de la Florida Consentimiento de Participar en una investigacin La siguiente informacin le esta siendo presen tada para ayudarle a decidir si desea o no participar en una investigacin con riesgo mnimo. Por favor lea cuidadosamente. Si usted no entiende algo, pregntele a la persona encargada del estudio. Titulo del estudio: Factores asociados con la reinsercin de la tapa plstica en agujas usadas y heridas por pinchazos en el personal de enfermera del Hospital Central de Maracay, Aragua, Venezuela 2006. Principal Investigador: Luis Galndez es un estudiante de Ph.D. en la Universidad del Sur de la Florida (USF) en la ciudad de Tampa, en el Departamento de Salud Global del Colegio de Salud Publica. La Dra. Donna Haiduven es su tutora. Como act ividad parcial de sus requerimientos para la obtencin de su titulo, l esta conduciendo un estudio so bre los factores que conllevan a la reinsercin de la tapa plstica en a gujas usadas y heridas por pinchazos entre los trabajadores de la salud de l Hospital Central de Maraca y un hospital publico venezolano. Sitio del estudio: Usted esta siendo solicitado para participar por cuanto usted es enfermera (o) del Hospital Central de Maracay. Informacin General acerca de la investigacin: El propsito de esta investigacin es obten er una mejor comprensin de los factores relacionados con la reinsercin de la tapa plstica en las agujas usadas y heridas por pinchazos. Esta investigacin es parcialmen te financiada por la Universidad de Carabobo, Venezuela. La informacin obtenida en este es tudio pudiera servir a ot ros trabajadores de la salud a desarrollar prcticas seguras en el trabajo. Plan de estudio: Si usted est de acuerdo en particip ar, la metodologa ser la siguiente:

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220 APPENDIX S: Continued Usted participar en una discusin de un m ximo de dos horas de duracin (sesin del grupo principal). El grupo principal al cual se le est invitando ser conducido en el hospital fuera de las horas regulares de trabajo. Una serie de preguntas abiertascerradas referentes a experiencias con respecto a la reinsercin de la tapa plstica en las agujas usadas y heridas por pinchazos en el hospital ser dirigida al grupo. Un entrevistador moderar, escuchar, y observa r la discusin. Uno o dos asistentes de investigacin observarn la di scusin, tomarn notas y harn preguntas para clarificar ciertos aspectos. con respecto a la reinsercin de la tapa plstica en las agujas usadas y heridas por pinchazos. Usted recibir una carta de Luis Galndez qui en le notificar la fecha y el lugar de la sesin del grupo principal. Durante la sesin del grupo principal, se re alizar una grabacin s obre la discusin. Antes de comenzar la sesin se le pedir completar un cuestiona rio corto sobre su nivel de educacin y experiencia profesional. Remuneracin por su participacin: Usted no recibir pago alguno por su participacin en este estudio. Beneficios por ser parte de este estudio Aunque usted pueda no recibir algn benefici o directo de esta investigacin, la informacin que es obtenida de los grupos prin cipales pudiera ser usada para ayudar a otros trabajadores de la salud a realizar su trabajo en una manera ms segura. Estos potenciales beneficios no puede n ser garantizados a usted. Riesgos por ser parte de esta investigacin: Algunas de las preguntas del grupo principal pueden tocar experiencias personales o aspectos muy sensibles sobre antecedente s de accidentes laborales por pinchazos referentes a usted como a un compaero (a) de trabajo. Usted puede elegir no discutir cualquier aspecto sobre el cual no desee hablar. Si usted desea puede retirarse de la sesi n del grupo principal en cualquier momento. La sesin ser grabada, pero no se menc ionar ninguno de los nombres individuales en las cintas. Toda la informacin obten ida sobre usted duran te la sesin ser mantenida en forma confidencial. Las cint as y las notas de la discusin sern almacenadas en un gabinete con cerradura. Solamente los investigadores del estudio tendrn acceso a dicho material.

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221 APPENDIX S: Continued Despus que las sesiones de los grupos principales finalice n, las cintas sern transcritas en forma escrita. Adems, los investigadores escucharn las cintas y extraern temas comunes y las actitudes expresadas por cada uno de los miembros del grupo principal. Confidencialidad de sus registros : La participacin en la inve stigacin puede sign ificar una prdida de su privacidad. Por lo tanto, un riesgo potencial participa ndo en una discusin de l grupo, es una cierta prdida de la privacidad de sus actitudes y opiniones. A todos los participantes se les preguntar en forma grupal acerca de su experiencia profes ional y opiniones personales. Los investigadores invitarn a que los participantes se presenten solo con su nombre durante la sesin. Sus respuest as individuales ser n odas por otras personas que estarn presentes en el grupo. Esto le puede plantear cierto riesgo si sus respuestas son compartidas por otras personas ajenas al grupo de trabajo. Por lo tanto, por favor no divulgue nada que sea personal o confidencial durante la discusin del grupo principal. De igual forma no divulgue lo comentado durante la discusin fuera del grupo principal. El objetivo es preser var la privacidad de las opiniones de cada uno de los participantes. Sin embargo, los investigadores no pueden garantizar que cada una de las personas presentes en el gr upo mantenga las discusiones en privado. Su privacidad y los registros de la i nvestigacin sern mantenidos en forma confidencial de acuerdo a lo establec ido por ley. Personal autorizado de la investigacin, empleados del Departamento de Salud y Servicios Humanos y el Comit Institucional para la revisin de investigaciones de la Universidad del Sur de la Florida (USF) pueden inspeccionar lo s registros de este proyecto. Sus respuestas seguir n siendo confidenciales. No ha br informacin que identifique a una persona del grupo principal. La c onfidencialidad ser mantenida en las transcripciones escritas de la sesin del grupo principal. No se har ningn intento de vincular la informacin sobre las transc ripciones a los temas individuales. Los resultados de los grupos principales sern divulgados en forma de resumen, respuestas no individuales. Su empleador tendr solamente un resu men del informe y no podr identificar a individuos participantes en lo s grupos principales. No se divulgar ni ser publicada ninguna informacin por la cual us ted pueda ser identificado(a). Los resultados de este estudio pueden se r publicados. Sin embargo, sus datos podran ser combinados con los datos de otras personas en la publicacin. Los datos publicados no incluirn su nombre o ninguna otra informacin que pudiera identificarlo a usted bajo ninguna manera.

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222 APPENDIX S: Continued Voluntariedad para ser parte de esta investigacin: Su decisin de participar en esta investig acin es completamente voluntaria. Usted es libre de participar en esta investigacin o retirarse en cualquier momento. No habr penalidad o perdida de beneficios que uste d tiene derecho a reci bir, si dejase de formar parte del estudio. Preguntas y contactos: Si usted tiene alguna pregunta acerca de la investigacin, contacte a Luis Galndez al telfono 0412-345-0609. Si usted tiene preguntas acerca de sus der echos como persona quien esta participando en una investigacin, usted puede contac tar a la Divisin de Cumplimiento de Investigacin de la Univer sidad de la Florida (USF) al telfono (813) 974-5638. Consentimiento para tomar pa rte en esta investigacin: Firmando este documento, yo estoy de acuerdo que: He ledo ampliamente o se me ha ledo y explicado este documento describiendo los aspectos principales de esta investigacin. He tenido la oportunidad de hacer preguntas a las person as encargadas de esta investigacin y he recibido re spuestas satisfactorias. Entiendo que estoy siendo solicitado para pa rticipar en la in vestigacin. Entiendo los riesgos y beneficios, y libremente doy mi consentimiento para participar en la investigacin antes mencionada en este doc umento, bajo las condiciones indicadas en el mismo. He recibido una copia firmada de este doc umento, la cual es mi propiedad y podr conservarla Fecha___________ Firma del participante del estudio_________________

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223 APPENDIX S: Continued Declaracin del Investigador Yo le he explicado cuidadosamente a la person a la naturaleza de es ta investigacin. Yo por este medio certifico que para mi ente nder la persona firmante este documento comprende la naturaleza, demanda riesgos y be neficios envueltos en la participacin en est investigacin. _______________________ _____________________________ __________ Firma del Investigador Nombre del Investigador Fecha o investigador autorizado designado por el Investigador Principal Consentimiento a participar en este estudio de la investigacin Esta es su eleccin. Usted puede decidir si desea participar en este estudio. Doy libremente mi consentimiento para participar en este estudio. Entiendo que sta es una investigacin He recibido una copia de esta forma de consentimiento. ________________________ ________________________ ___________ Firma de la persona quien Nombre completo Fecha participar en el estudio ________________________ ________________________ ___________ Firma del testigo Nombre completo del testigo Fecha

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224 APPENDIX S: Continued Declaracin de la persona que obtiene el consentimiento He explicado cuidadosamente a la persona que participar en el estudio lo que l o ella pueden esperar del mismo. La persona quin est dando consentimient o para participar en este estudio Entiende el lenguaje utilizado Lee bastante bien para entender este documento. O puede or y entender cuando se le lee el documento. No tiene ningn problema algo que se le dificulte entender lo que significa participar en este estudio. No est tomando medicamentos que pudieran hacer difcil entender lo que se est explicando. De acuerdo a mi entender, cuando esta persona firma esta forma de consentimiento, l o ella comprende: Sobre que trata el estudio Qu se necesita hacer Cuales podran ser los benefici os potenciales del estudio Cuales podran ser los riesgos Su participacin en este estudio es voluntaria ________________________ ____________________________ ___________ Firma del Investigador Nombre co mpleto del Investigador Fecha ________________________ ____________________________ ___________ Firma del testigo Nombre completo del testigo Fecha

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About the Author Luis J. Galindez A. received a medical degree from the University of Carabobo, Venezuela in 1980 and a Master of Science (MS) in Occupational Health from the Institute of Occupational Health in Cuba. In 2004, he entered in the Ph.D. program at the University of South Florida after culmin ation of a M.S. in Public Health. He has been a full professor in the Public Health Department at the University of Carabobo since 1986. Since 2007, he has been the Di rector of the Center for the Study of Worker’s Health at the University of Carabobo. In Jun 2006, Dr. Galindez and Dr. Haiduven presented a poster in the 33rd Annual Education Confer ence and International Meeting of the Association for Professional in Infection Control (APIC) in Tampa, Florida entitled “Circumstances Surr ounding Needlestick/ Sharp Injuries among Healthcare Workers in a Venezuelan Public Hospital.”, which was the basis for his dissertation.


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Factors surrounding and strategies to reduce recapping used needles by nurses at a Venezuelan public hospital
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by Luis J. Galindez Araujo.
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[Tampa, Fla] :
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2009.
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Dissertation (Ph.D.)--University of South Florida, 2009.
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ABSTRACT: Nurses as health care workers are at risk of biological agents such as bacteria, viruses and others. At health care settings exposure to bloodborne pathogens can cause infections through needlestick injuries. The objectives of this research were to determine factors surrounding recapping needles in hospital nurses and to implement an educational strategy to reduce the recapping practices. It was a descriptive and exploratory approach where the PRECEDE component of the PRECEDE/PROCEDE Model was used as the framework to systematize and analyze the information obtained from the focus group sessions. A total of 120 nurses participated from four different departments. The study was conducted in three phases: diagnosis, implementation and evaluation of the educational strategy. The results obtained from the focus group sessions revealed that predisposing, reinforcing, enabling and environment factors were related to the practice of recapping and needlestick injuries.Most of this information represented the essential basis for the implementation of the educational strategy. During the diagnostic phase, the percentage of needles without recapping was 24% contrasting with 40% found after the educational strategy. The percentage difference (16%) was statistically significant (p<0.001). The odds ratios calculation in the departments studied showed that the educational strategy was a protective factor to avoid the recapping of used needles. An important conclusion is that the educational strategy, which focused on the practice and habit of what should be done (e.g., NOT recapping used needles), contributed to the decrease in recapping practice. However, nurses perceived did it not provide a safe working environment. The implications are focused on: nurses and hospital management have to engage in an active role to promote a safety work environment where nurses and other health care workers can be protected.The incorporation of educational strategies, continuous and updated training, as well as the evaluation and monitoring process can play a determinant role in the control of hazard exposures. It is imperative that a safe and healthy workplace for the personnel be provided; not less important is the acquisition of equipment and devices for sharp handling and disposal, to complement the prevention of accidents related to needlestick injuries.
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Co-advisor: Boo Kwa, Ph.D.
Co-advisor: Donna Haiduven, Ph.D.
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Accidents, Occupational
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Needlestick Injuries
prevention & control.
Nursing Staff
education.
Safety Management
organization & administration.
Health Knowledge, Attitudes, Practice.
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Focus groups
Intervention
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Global Health
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