Medical sharps are needles, blades (such as scalpels) and other medical instruments used in healthcare procedures that could cause an injury by cutting or pricking the skin (Health and Safety Executive (HSE) (2023). Sharps injuries are reported by 3.5 million healthcare workers worldwide every year (Fadil et al, 2021), with each injury costing between $650 and $750 (£519 and £599) several years ago (Mannocci et al, 2016). These figures, however, do not take into account litigation or compensation so are an underestimation of the true cost. The total costs, financial and other, are difficult to estimate as they include: the emotional cost related to fear and anxiety over the possible consequences of an exposure; the direct and indirect costs related to drug toxicities; time absent from work; and the societal cost linked with an HIV, hepatitis B or hepatitis C seroconversion (Hambridge et al, 2020).
Up to 60 bloodborne pathogens are known to be transmitted through percutaneous injuries (Tarantola et al, 2006). The most common of these bloodborne pathogens are hepatitis C, hepatitis B and HIV (Public Health England (PHE), 2014). The psychological impact of sharps injuries needs to be considered, and this includes anxiety (Matsubara et al, 2020), depression (McDowell, 2012) and post-traumatic stress disorder (Naghavi et al, 2013).
Doctors, nurses and dentists are all at risk of sharps injuries (Bouya et al, 2020). In addition, ancillary healthcare staff, such as cleaners and porters, who have no direct patient contact, are injured because of incorrect sharps disposal (PHE, 2014). Much is known about the type and extent of sharps injuries sustained by medical students, with the reported incidence ranging widely from between 11% (Varsou et al, 2009) and 95% (Liyanage et al, 2012). Similarly, among nursing students, the reported incidence of sharps injuries ranges from 5.9% (n=52) Cheung et al (2012) to 100% (n=100) (Trivedi et al, 2013). Among dentistry students, reported sharps injuries range from 13% (Smith et al, 2006) to 43.1% (Fernandes et al, 2017).
It is likely that healthcare students studying paramedicine, dietetics, physiotherapy, occupational therapy, optometry, pharmacy, podiatry and radiography are also at risk of sharps injury, although there is a lack of evidence. Qualified paramedics have a high risk of sharps injury (Ganczak et al, 2020) as do radiologists (Deipolyi et al, 2017). Sharps injuries can also occur within ophthalmology practice (Ghauri et al, 2011) as well as physiotherapy (West and Gardner, 2001).
Given that sharps injuries occur in a broad range of health professionals, there is the possibility that sharps injuries are also being sustained by an equally wide variety of healthcare students.
Methods
The aim of the narrative review was to identify the extent, type and causes of sharps injuries sustained by healthcare students other than those studying nursing, medicine or dentistry.
The review was conducted by searching the following electronic databases: BMJ Journals collection, CINAHL Plus with Full Text (EBSCO), the Cochrane Library (Wiley), Medline (EBSCO), PubMed, PsycArticles, PsycINFO and UK PubMed Central.
Keywords selected to identify relevant articles were: pre-registration, allied healthcare, paramedicine, dietetics, physiotherapy, occupational therapy, optometry, pharmacy, podiatry, radiography, student, sharp, injury, needlestick, inoculation, needle prick, accidents, incidents, occupational injury, biological exposure incident, percutaneous exposure, blood borne infection, incidence and prevalence. Boolean operators and truncations were used.
The search was limited to literature in the English language published between 1980 and 2023. The process for the review followed four stages:
- Using search terms to search relevant databases
- Screening titles and abstracts of the results to identify and save relevant articles
- Retrieval, reading and data extraction of full texts of the relevant articles
- Identification of other relevant articles within bibliographies.
Articles without an abstract or full text were excluded. The extracted data were then scrutinised and grouped into categories.
The narrative review was conducted between January and March 2023.
Results
Sharps injuries involving healthcare students other than nursing, medicine and dentistry students were reported in seven studies, which were conducted in Ethiopia, Turkey, China, Pakistan and Thailand.
Rate of injury
Some studies reporting sharps injuries did not specify the type of healthcare student involved in the injury. A survey by Demsiss et al (2018) in Ethiopia reported that 49.8% (n=203) of healthcare students had sustained a needlestick injury, whereas İnandi et al's (2019) survey in Turkey identified that 35.6% (n=113) of healthcare students had experienced a needlestick injury. Abdela et al (2016) conducted a survey in Ethiopia and reported that 26.8% (n=66) of health profession students had sustained a needlestick injury. The sample included physiotherapy and optometry students, although it is not known whether they sustained sharps injuries as medical and nursing students were also included in the study.
Some studies identified the type of healthcare student involved in the sharps injury.
A study in Turkey of physiotherapy students (Kayis et al, 2019) reported that 39.3% (n=11) had sustained a sharps injury in the past year. A small study in China (Zhang et al, 2008) found that 9.1% (n=9) of pharmacy students reported at least one sharps exposure during the previous year, whereas in Thailand, Santimaleeworagun (2014) reported four cases of needlestick injury among pharmacy students, equating to 17.4% of students surveyed. Finally, two trainee radiographers sustained a sharps injury over a 10-year audit in Pakistan (Sayani and Rajani, 2012).
Device involved
Within a sample of physiotherapy students who had sustained a sharps injury, Kayis et al (2019) reported the devices as being a needle (45.5%; n=5); an ampoule or shard of glass (36.4%; n=4); an intravenous needle (9.09%; n=1); and a suture needle (9.09%; n=1). Two of the needles (18.2%) were contaminated.
Location
İnandi et al (2019) reported that needlestick injury rates within healthcare students were significantly higher in emergency and anaesthesia departments (P<0.001). Meanwhile, Santimaleeworagun (2014) reported that pharmacy students sustained sharps injuries within ambulatory care (n=2) and during a community pharmacist placement (n=2).
Academic year
İnandi et al (2019) reported that sharps injuries were more frequent in the final year of training than in the first year (P<0.001). Similarly, Zhang et al (2008) found that most sharps injuries were sustained in the final year (24.6%; n=35) compared to the first year (2.8%; n=7). Within this study, 23.4% (n=36) occurred within the fourth year, 12.1% (n=30) in the second year and 7.9% (n=14) in the third year. Kayis et al (2019), meanwhile, identified that 55.4% of healthcare students who sustained a sharps injury were aged <20 years; 52.6% (n=150) were in the second year, 27% (n=77) were in the fourth year and 20.4% (n=58) were in the third year.
Reporting sharps injury
Non-reporting of the sharps injury ranged from 46.3% (n=114) in the study by Abdela et al (2016) to 46.8% (Demsiss et al, 2018) and 65.6% in Zhang et al (2008).
Procedure involved
Kayis et al (2019) reported that physiotherapy students sustained a sharps injury while providing treatment (27.3%; n=3); from a broken ampoule (27.3%; n=3); while inserting an intra catheter (9.09%; n=1); when administering an injection (9.09%; n=1); and when taking blood (9.09%; n=1). Santimaleeworagun (2014) found that pharmacy students sustained sharps injuries when monitoring blood glucose and administering insulin.
Part of the body involved
Kayis et al (2019) reported that 90.9% (n=10) of sharps injuries sustained by physiotherapy students occurred on the hand and 9.1% (n=1) injured the arm.
Cause
Zhang et al (2008) reported the cause to be a lack of knowledge of syringe handling and universal precaution guidelines.
Discussion
Abdela et al (2016) found that health profession trainees were at a very high risk of accidental exposure to blood. In one study, almost half of healthcare students had sustained a sharps injury (Demsiss et al, 2018). This has been reported within healthcare students outside nursing, medicine or dentistry, particularly in pharmacy and physiotherapy students. Many other groups of healthcare students were not identified within the evidence as having been injured with a sharp. These included those studying paramedicine, dietetics, occupational therapy, optometry, podiatry and radiography.
The rates identified in this review were low compared with the reported 95% of medical students (Liyanage et al, 2012) and up to 100% of nursing students having sustained a sharps injury (Trivedi et al, 2013). They are comparable with those reported within dentistry, where up to 43.1% (Fernandes et al, 2017) of students have sustained a sharps injury. The rates may be lower because of factors such as close supervision and less sharps contact in these student groups; nonetheless, continued education about sharps is essential.
Needles were the most commonly mentioned device involved in sharps injury among healthcare students, although glass was also reported. On a few occasions, the sharp had been used. These are similar to the devices involved when medical, nursing and dental students sustain sharps injuries. Intravenous needles (Tarantola et al, 2003), needles and glass (Cheung et al, 2010) have been highlighted as common devices involved with sharps injuries sustained by nursing students. Ghasemzadeh et al (2015) identified needles as the most common device involved in sharps injuries in medical students. Meanwhile, Musekene et al (2020) identified needles were the commonest device causing sharps injuries in dental students. It seems that, despite the implementation of legislation such as the 2010 EU directive (European Agency for Health and Safety at Work, 2010) and the 2013 UK regulations (HM Government, 2013) to prevent sharp injuries, healthcare workers continue to sustain them (HSE, 2016).
Sharps injuries have been reported in trainee healthcare practitioners working in acute areas such as emergency departments and anaesthetics, as well as non-acute areas such as ambulatory care and in the community. Student nurses most commonly sustain sharps injuries in medical and surgical environments (Cheung et al, 2012). Al-Dabbas and Abu-Rmeileh (2012) identified that medical students sustained sharps injuries in the emergency room, in obstetrics and in surgical environments.
Although they occur in each year of training, sharps injuries are more commonly sustained in the final year of a programme than the first year. Similarly, Rossouw et al (2017) reported that more senior medical students (85.7%) sustained sharps injuries than junior students (14.3%).
Up to 65.6% of sharps injuries involving healthcare students are not reported. Similar high figures on non-reporting have been noted within populations of nursing and medical students. Zhang et al (2018) found that 86.9% of sharps injuries sustained by nursing students were not reported. In a study of medical students, Saleem et al (2010) found that 70.3% of sharps injuries were not reported. Reasons given for this by nursing students include that the device had not been used on a patient, the patient was not viewed as infectious and the student was unaware of how to report the incident (Zhang et al, 2018). The reasons for non-reporting in other healthcare students is unknown.
As expected, healthcare students sustained sharps injuries when doing procedures involving such an item. These included giving injections, taking blood and using a glass ampoule. Similarly, glass (Ozer and Bektas, 2012) and needles (Trivedi et al, 2013) are regularly reported as the devices involved with sharps injuries involving nursing students. One unexpected finding was that there were no reports within the literature of indirect sharps injuries involving healthcare students, indicating that healthcare students had not been injured accidently by sharps used by others.
The most common part of the body affected was the hand followed by the arm. This is consistent with sharps injuries sustained by dental students (Gaballah et al, 2012), medical students (Marnejon et al, 2016), nursing students (Talas, 2009) and healthcare workers in general (Saadeh et al, 2020).
This review identified that the only cause reported was a lack of knowledge (Zhang et al, 2008). This cause has also been found in relation to sharps injuries within medical students (Ghasemzadeh et al, 2015) and nursing students (Vandijck et al, 2008). Students have limited clinical experience and knowledge of infection control procedures, which puts them potentially at a high risk of injury (Tavolacci et al, 2008). Many causes of sharps injuries involving medical students have been proposed, including distraction, busyness, forgetting, patient restlessness, excessive fatigue (Ghasemzadeh et al, 2015), being rushed and a lack of skill (Sharma et al, 2009), which may be relevant to other healthcare students. It is thus recommended that healthcare students receive adequate training on precautions and use of sharps before they are exposed to clinical settings (Zhang et al, 2008; Santimaleeworagun, 2014; İnandi et al, 2019; Kayis et al, 2019).
A little-reported consequence of exposure to blood through a sharps injury in the studies is psychological and emotional harm. Anxiety and stress (Hambridge et al, 2016), depression (Hambridge et al, 2016) and post-traumatic stress disorder (Naghavi et al, 2013; Hambridge et al, 2021) have all been identified within nursing and medical students following a sharps injury. This issue could be an unreported issue for other healthcare students.
Recommendations
Education regarding the use, management and disposal of sharps is paramount. Incorporating sharps injury prevention into the curriculum and introducing it early into the programme have been suggested to improve the sharps safety of healthcare students (Datar et al, 2022). This would update previous experience and education. This should be within modules, through simulation (Silva et al, 2018), posters and websites (HM Government, 2013). This education should be mandatory, repeated during the student's programme and reviewed at intervals to ensure it is current. This education should continue at regular intervals within organisations throughout the practitioner's healthcare career as the risk of sharps injury does not stop on qualification. Skills in managing sharps injuries are essential, including for non-clinical personnel such as cleaners and porters. Keeping training records is paramount.
Healthcare students should, like all practitioners, be made aware of and comply with laws and regulations regarding sharps use. They need to be instructed in and work within the Health and Safety etc. Act 1974. This is to ensure that they can use and dispose of sharps safely so as not to injure colleagues such as cleaners and porters.
Linked to this is the importance of senior staff holding responsibility within healthcare organisations of training the supervisors, educators and employees as required by the law. The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 (HM Government, 2013) are clear that employers should ensure that the risks of sharps injuries are adequately controlled. This is important as healthcare students spend a proportion of their learning in clinical placements.
The primary points to consider for students are that: sharps should not be used unless needed; safer sharps should be made available for practitioners; recapping should not be done; and disposal containers for medical sharps should be used safely. The reporting of sharps injuries is also an essential component of laws and regulations; this should aid the identification of learning points and gaps in training that would need to be addressed.
Conclusion
This review has highlighted that healthcare students other than those in nursing, medical and dentistry sustain sharps injuries. The available literature mentions only a few health profession students – in physiotherapy, optometry, pharmacy and radiography.
Devices causing injury that were highlighted in the literature are similar to those reported by medical, nursing and dentistry students. The injuries occurred in a range of healthcare environments in both hospitals and the community.
Many sharps injuries are not reported by healthcare students, which is concerning considering that some of the sharps causing the injury had been used and were not clean. There is the potential for healthcare students to experience a range of psychological effects following a sharps injury and nurses should be aware of this possible issue within the clinical setting so they can help support students. Healthcare organisations should ensure that there are psychological support systems in place to support students who have sustained a sharps injury.
The main cause of sharps injuries identified within the limited literature involving healthcare students was a lack of knowledge. Additional research, especially within Europe and the UK, would help to identify the extent, type and impact of sharps injuries occurring in healthcare students, which would aid the planning of education, the promotion of the assessment and management of risks, and the prevention of sharps injuries in them.
KEY POINTS
- Sharps injuries occur in a wide range of clinical practitioners and healthcare students
- Many sharps injuries are not reported
- A lack of knowledge and inexperience are the major causes of sharps injuries in healthcare students
- Needles and glass ampoules are the most common devices involved in sharps injuries sustained by healthcare students
- Continuous education about sharps safety throughout healthcare students' and practitioners' careers is paramount
CPD reflective questions
- Reflect on your practice of using sharps and contemplate how your clinical practice could be improved
- What psychological and emotional support is available to healthcare students following a sharps injury?
- Consider what actions you can take to use safer sharps to decrease the risk of sharps injuries to yourself and others