1

NATIONAL RIBAT UNIVERSITY

Faculty of Graduate Studies and Scientific Research

The Effectiveness of an Educational Program about

Occupational Hazards Safety Measures on Critical

Care Nurses at Khartoum State Public hospitals

Sudan 2013-2016

Research Presented to a Ph. D in community Health Nursing

Prepared By: Yasmin Elsiddig Abdalla

Supervisor: Dr. Adil Abu Almaali Elsiddig

August 2016

2

Dedication

I dedicate this work

To my

Mother, husband, sisters and brothers for their support and encouragements

To my

Children: Mohammad, Mafaz, Yomna and Mariam

God bless you all, wish you always live in love and peace

I

3

Acknowledgement

I would like to acknowledge Dr Adil Abu Elmaali for his guidance and help,

my thanks extended to Khartoum state ministry of health personnel who

facilitated this work, and critical care nurses who worked in my study hot

areas.

II

4

Contents

III

Title Page No.

Chapter (1)

Introduction

2

Justification 4

Thesis questions 4

Objectives 5

Chapter (2)

Literature review

6

Previous study 26

Chapter (3)

Research methodology

33

Study design 34

Study population 34

Sampling technique 34

Sample size 34

Participants number 35

Interventions 35

Study tools 35

Study variables 36

Ethical consideration

37

Chapter (4)

Results

38

5

Title Page

No.

Chapter (5)

Discussion

75

Conclusion

77

Recommendations

78

References

79

Bibliography

82

Annex 1 (questionnaire)

84

Annex 2 (check-list)

87

Annex 3 (formal letters)

88

Annex 4 ( manual of the educational program)

92

6

IV

List of abbreviations and figures

Abbreviation

AACCN: American Association of critical care nursing

A/N: afternoon/night

BSI: body substance isolation

CDC: center for diseases control and prevention

CCU: cardiac or coronary care unit

CC: critical care

CCN: critical care nursing

CCNs: critical care nurses

CMV: cytomegalovirus

DB: the decibel

E.G: example gratia, (gratia is Latin word means for the sake of)

HBV: hepatitis B virus

HCV: hepatitis C virus

HAI: hospital acquired infection

ICU: intensive care unit

ILO: international labor organization

MPD: maximum permissible dose

MRSA: methicillin resistant staphylococcus aureus

NCRPM: the national council on radiation protection and managements

OH: occupational hazards

OSHA: the occupational safety and health administration

OHN: occupational health nurse

PPE: personal protective equipment

RN: registered nurse

RR: recovery room

TB: tuberculosis

7

WHO: world health organization

V

Figures & tables

Figure 1: CCNs distributions in study areas

Figure 2: CCNs distributions in CC areas types

Figure 3: CCNs age groups

Figure 4: participants’ gender

Figure 5: CCNs educational level

Figure 6: main working shift

Figure 7: length of experience

Figure 8: meaning of occupational hazard

Figure 9: tapes OHs

Table 1: CCNs knowledge about meaning of occupational hazards

Table 2 : types of OHs

Table 3: causes of OHs

Table 4: preventive measures of OHs

Table 5: component of universal precautions

Table 6: availability of PPE

Table 7: coping characteristics of CCNs

Table 8: CC units per hospitals

Table 9: types of CC units

Tables 10: assess attitude of CCNs for preventive measures

8

VI

الخالصة

األهداف

بالمستشفيات الحكومية بوالية الخرطوم وهي: مستشفى بأقسام الرعاية الحرجةأجريت هذه الدراسة

ومستشفى أ حمد قاسم للقلب أم درمان التعليمي، بحري التعليمي، الخرطوم التعليمي، الشعب التعليمي

عنوسط تقنيي التمريض لتقويم التأثير الناتج عن البرنامج التعليميهذه الدراسة تهدفو .والكلى

.(والسالمةالمخاطر المهنية )المعرفة

- المنهجية:

الى 2014 الفترة )من، أجريت في (وبعد التدخلقبل ) الدراسة التداخلية بطريقةدراسة تم إنفاذ هذه ال

وبعد قبل استخدام استبيان وقائمة تم ،)تغطية كاملة( تمريضتقني 200عينة الدراسة كانت ،)2016

أقسام تقنيي تمريض والسالمة لدىالبرنامج التعليمي في المعرفة عنالتأثير الناتج لمعرفة التدخل

أيضا وقد تم عملهم،في مكان الموجودةالمهنية طر افيما يتعلق بالمخ الرعاية الحرجة أو العناية المكثفة

.مستشفى لإجراء مقابلة مع رئيسة التمريض لك

-النتائج:

%67 وحملة البكالوريوس يمثلون %17% بينما الذكور 83تمثل نسبة اإلناث في الدراسة

مقارنة وذلك بعدلبرنامج التعليمي على المشاركين أثر إيجابي معتبر إحصائيا لاوضحت الدراسة

% 14.5هي التدخل الفيزيائية قبلفكانت نسبة معرفة المشاركين للمخاطر .وبعد البرنامجالنتائج قبل

% قبل 17، كذلك خطر اإلشعاع كانت نسبة معرفته أي الغالبية العظمى %99.5أما بعده فقد أصبحت

بعده. كل المشاركين %100والتدخل

وبعد % قبل 100الدراسة المعرفة الممتازة للمشاركين للمخاطر الحيوية حيث كانت بنسبة بينت

كالتالي: المخاطرخاطر المهنية كانت نسبة نتيجتها ممعرفة طرق السالمة أو الوقاية من ال .التدخل

% 100% قبل و81.5بعده، طرق السالمة من اإلشعاع هي % 99.5 –% قبل التدخل 93الكيميائية

%.99% قبل التدخل وبعده أصبحت 14.5نسبته نفسيالبرنامج التعليمي، وتخفيف الضغط ال بعد

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بالطريقة التي تحتمها طبيعة عمل الوسائل الواقية من العدوى المعروفة عالمياً لم يتم توفيرها

.من العدوى المتوفرة بطريقة جيدة المشاركون في العينة يستخدمون الوسائل الواقية المشاركين،

V11

-الخاتمة:

لعدد من المخاطر المهنية، حيث يمكن الوقاية االمهن التي يتعرض العاملين فيه التمريض منيعتبر

في مكان العمل كتقديم الرعاية الواجبات اليومية ويصبح أحدمن بعضها بينما البعض اآلخر ال مفر منه

.وبال تأجيلللمرضي في وضع قيام

-التوصيات:

المعرفة بالمخاطر المهنية عبر برامج تدريب دوريةتطوير -

توفير وسائل الوقاية بصورة دائمة -

تحسين بيئة العمل -

تشجيع التصنيع الداخلي لوسائل الوقاية المعروفة عالميا -

القيام ببحوث في الموضوع مستقبال -

تعيين ممرض صحة مهنية لكل مستشفى -

ى السودان بالقيام نوصي المختصين في الصحة المهنية على مستو هذه الدراسةاستنادا على -

ببرامج تدريب لهذه الفئة في كل مستشفيات الواليات األخرى.

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VIII

Abstract

Objective:

The aim of the study was to assess the effectiveness of an educational program on critical

care nurses about occupational hazards, knowledge and safety.

Methodology:

It was a pre/post interventional, hospital-based study carried during 2014-2016, The study

subjects were 200 critical care nurses working in intensive care settings, Khartoum state

public hospitals. Questionnaire and checklist were used, pre and post the educational

program to assess the effectiveness of the program on critical care nurses’ knowledge,

safety practice regarding occupational hazards; interview was carried with hospital’s

matron.

Results:

Knowledge about Physical hazards as type in pre intervention results was 14.5%, and

99.5% in posttest, Knowledge about radiation hazard was 17% in pretest, 100% in post

intervention.

Knowledge about biological hazard type was 100% in both pre and post results. Knowledge

about chemical hazard as one of hazards in pretest was 11.5% and 98.5% in posttest.

Knowledge about psychosocial hazards was 34% in pretest and 99.5% in posttest.

Regarding preventive measures of occupational hazards, participants showed 93% of pre

intervention knowledge about chemical hazards prevention and 99.5% in posttest result,

prevention of radiation by distance 81.5% in pretest and 100% post intervention test.

Stress mitigation by relaxation exercise results was 14.5% in pretest and 99% posttest.

Personal protective equipment were poorly provided. Shoes cover, face shield

unavailable.

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IX

Conclusion

The educational program for critical care nurses had efficiency results, evidenced by the

improved results of critical care nurses’ knowledge about occupational hazards types,

causes and preventive measures for each hazards in critical care settings in post educational

program results.

Recommendations:

• Based on this study, regular trainings and educational meetings to enhance

occupational safety, develop/introduce policies and guidelines or strategies in all

aspects related to occupational hazards safety measures need to be offered in all

Sudan states hospitals.

• Develop effective continuous commitment program for provision of protective

measures.

• Improvement of the physical and social environment of critical care settings.

• Occupational health Department at the level of the State should have a role in

protecting the workforce in health care settings.

• Encouragement of manufacturing the protective measures locally.

• Future research recommended for this specialty population.

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13

14

Chapter (1)

Introduction

Objectives

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Introduction

Daily patient care presents the nurses with a real risk for infectious diseases, toxic

substances, back injuries, and radiation. Nurses also are subject to hazards such as stress,

shift work, and violence in the workplace. These typically fall under the broad categories

of chemical, biological, physical, and psychosocial occupational hazards.

Nurses continue to report high levels of job-related injury and illness. Working

environment, responsibilities, and duties of nurses put them in the frontline of numerous

occupational hazards. (1, 2, 3, 4)

The Bureau of Labor Statistics reports that there are 1,859,000 registered nurses (1993)

and 659,000 licensed practitioners nurses (1992) employed in the United States. Of the

2,518,000 nurses, 882,647 35% are employed in hospitals, and the rest in other health

care settings including but not limited to nursing homes, health maintenance

organizations, physicians' offices, community health agencies, schools, and corporations.

In 1992, the rate of occupational injury and illness for nurses in health care settings was

18.6% per 100 full-time workers (18.2% accounted for injuries). This is higher than for

hazardous occupations such as heavy construction where the rate of occupational injury

and illness is 13.8% per 100 full-time workers or mining where the total is 7.5% per 100

full-time workers. (3)

Some common occupational hazards that nurses might face are:

* Communicable and contagious diseases and exposure to blood-borne pathogens (e.g.,

HIV, HCV, and HBV) due to needle-stick injuries threaten health of nurses. It is

estimated that 600000 to 800000 needle-stick injuries occur each year in all healthcare

settings. Injections (21%), suturing (17%), and drawing blood (16%) are the main causes

of exposures. Severe acute respiratory syndrome (SARS), tuberculosis, and methicillin

resistant staphylococcus infection are other infectious diseases that can afflict nurses.

(2, 5)

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* The vast majority of nurses experience persistent job-related pain, mainly

musculoskeletal pain in at least one region, it seems that work-related musculoskeletal

pain and injuries are common among nurses all over the world. Most of these pain and

injuries are due to lifting and moving patients manually. (6, 7)

* Work overload and stress are other factors that threaten the health of nurses and can

cause burnout and fatigue. Working in three shifts, in difficult settings such as oncology,

intensive care units or emergency wards, and caring of incurable patients puts a

considerable psychologic, spiritual, and physical pressures on nurses. As a result، fatigue

is a common feeling among nurses.

* Chemical materials are other hazardous sources to nurses. Disinfectants and sterility

products such as glutaraldehyde and ethylene oxide, hazardous drugs such as drugs that

are used during chemotherapy and latex exposure are among other occupational hazards

for nurses.(2)

* Nurses, continue to experience high rates of on-the-job violence, experiencing verbal

abuse and physical violence. (8)

Critical care nursing specialty, concerns with delivery of care for physiologically

unstable patients, with life- threatening condition and it is a highly interdisciplinary

specialty, this give big chance for those nurses to face more occupational hazards. RNs

who work with critically ill patients also may suffer emotional strain from observing

patient suffering and from close personal contact with patients’ families.

Nurses must observe rigid, standardized guidelines to guard against diseases and other

dangers posed by work hazards. Indeed, the cost to prevent, control, and treat

occupationally acquired illness is considerable, in terms of both money spent and lives

affected. Rather, incurring the risk for occupationally acquired illness is necessary for

daily health care delivery. The willingness of health care workers to accept this risk is, in

many ways, as important to health care as their professional skills. Every healthcare

setting should address this important issue and give priority to the safety of health care

workers. (2, 9, 10)

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Justification

As the critical care areas are the units of hospitals offering potentially life-saving

intervention during physiological crises and life threatening conditions, the nurse who

works in these units must has essential part in health workers safety programs.

Critical care nurses expose to variety of biological, physical, chemical, ergonomic,

psychosocial hazards in the work and chemical dependency. They must be aware of the

potential hazards they face, and preventive strategies that are effective for developing

appropriate occupational safety programs. (2)

The researcher master thesis was a descriptive, cross-sectional study carried in April,

May and June 2011 in Ahmed Gasim Hospital Cardiac Surgery and Renal Transplant

Center, about occupational hazards and illnesses among CCNs, the Study subjects are 66

nurses working in CC area for more than one year. Questionnaire and checklist were used

to assess occupational illness among critical care nurses and preventive measures that

actually used.

The results revealed that low backache, eye fatigue, muscles pain, irritability and upset

stomach occurred to more than 50% of the participants, 6% HBV, 1.5% HCV and 4.5%

TB. According to these values, the researcher found it was important to provide

occupational hazards safety educational program on similar areas to nurses in Khartoum

State public hospitals.

Thesis questions:

1- Would an educational program about occupational hazards safety for CCNs be

effective?

2- Would CCNs know OH they face in work, the causes and prevention of each

hazard?

3- Are personal protective equipment available in CC areas?

4- Would CCNs practice suitable safety measures in their areas?

5- Would CCNs know the coping methods that make them successful nurses,

tolerating their job hazards?

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Objectives

a) General objectives

To assess the effectiveness of an educational program for critical care nurses about

occupational hazards knowledge and safety.

b) Specific objectives

1. To assess the effectiveness of an educational program for critical care nurses about:

- Physical hazard knowledge and safety

- Radiation hazard knowledge and safety

- Biological hazard knowledge and safety

- Chemical hazard knowledge and safety

- Psychosocial hazard knowledge and safety

2. To determine changes in CCNs practice post the educational program

3. To evaluate changes in CCNs awareness about universal precaution of infection

control.

4. To test availability of personal protective equipment in critical care settings.

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Chapter (2)

Literature Review

Previous studies

20

Literature Review

Occupational health

It is defined as the prevention among workers, of departures from health caused by their

working conditions, The protection of the workers in their employment from risks resulting

from factors adverse to health, the placing and maintenance of the worker in an

occupational environment adapted to his physiological and psychological equipment, and

to summarize the adaptation of work to man and each man to his job.

Occupational health aims at the promotion and maintenance of the highest degree of

physical, mental, and social well- being of all workers in all occupations.

The joint ILO/ WHO committee on occupational health, in the course of its first session,

held in 1950, gave the fallowing definition: (Occupational health should aim at the

promotion and maintenance of the highest degree of physical, mental and social wellbeing

of workers in all occupations). (11, 12)

Occupational hazards:

OHs are an external conditions and influences, which have their effects on work

population, in their work environment.

Workers may be exposed to five types of hazards depending upon their occupation.

Occupational Hazards are:

(1) Physical

(2) Chemical

(3) Biological

(4) Mechanical

(5) Psychosocial hazards. (12)

Critical Care Settings:

Are the units offering potentially life-saving intervention during physiological

crises, with emphasis of medical needs and availability of technology, called tertiary care

areas or intensive care units (ICUs, CCU),are brightly lit, windowless units, often noticed

by infrequent visitors in fact are noisy (Hilton1985). (13, 14)

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Critical care nurse or intensive-care nurse:

A professional registered nurse who works in an intensive-care unit. Receives the patient

into the ward; gives him/her the necessary personal treatment; connects him, according to

need, to the appropriate medical system (e.g. respiratory instruments, artificial-feeding

set-up, blood and plasma transfusion system, measuring and monitoring systems, etc.);

Conducts a follow-up of his health condition and has to be aware of any change in the

health situation of the patient.

Assists the medical doctor in the treatment in extreme events of required resuscitation

and in connecting into the necessary instrument systems, highly proficient in the medical

model, had broad knowledge base in physiological and pathophysiological of the organ

systems and response quickly and intelligently to subtle alteration in critically ill patient.

Examples of occupational hazards in critical care units:

• Biological hazards [infectious hazards]

• Physical and ergonomics [noise, musculoskeletal injuries]

• Chemical hazards [cytotoxic drugs]

• Radiological hazards [portable radiography and fluoroscopy]

• Psychosocial hazards [stress, conflicts, job dissatisfaction] (2)

Infectious (biological) hazards:

There is a potentially high risk of acquiring infectious diseases in the critical care

units. Potential infection may be transmitted by blood or body fluids, by droplets in the air,

or by direct contact. Blood–borne pathogens of major concern include human

immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus. Infections

transmitted by air–borne particles include cytomegalovirus (CMV), tuberculosis (TB), and

meningococcal disease. Direct contact with secretions infected with herpes simplex virus

produces herpetic whitlow. Adherence to strict procedures involving body substance

isolation (BSI) minimizes the risk of occupational exposure to infectious agents.

The risk of acquiring infection from exposure to blood and body fluids varies, it is

estimated that 10% to 20% of health care workers are seropositive (anti-HBs) for hepatitis

22

B (Patterson et al., 1995). The risk of seroconversion following exposure to blood from

HIV – infected patients is less than 1% (Gurevich, 1989; CDC, 1988, 1989).

Methods of minimizing exposure to blood and body fluids are known as universal

precautions or BSI. Since the infection status of patients is usually unknown, all patients

should be considered potential carriers of HIV, HBV, and other blood-borne pathogens.

Recommendations from the Centers for Disease Control, (CDC, 1989) for health care

professionals who are likely to have percutaneous or mucous membrane exposure to blood

or body fluids include:

1. Proper handling and disposal of needles or other instruments.

2. Use of gloves, masks, gowns, or eyewear when direct contacts, aerosolization, or

splashing of blood and body fluids are likely.

3. Immediate washing of hands and other skin surface after contamination with blood

or body fluids.

4. Use of effective germicides for cleaning spills of blood or body fluids (1: 10

dilution of household bleach).

Special attention should be given to proper handling and disposal of needles because

the incidence of needle–stick injury remains high among nurses (Jackson et al., 1986).

Needles should never be recapped, bent, or separated from the syringe. Impervious

receptacles for needle – disposal should be conveniently placed as close to the bedside as

possible.

The hepatitis B virus is a potentially unrecognizable source of infection for critical care

nurses because asymptomatic carries remain infectious. The risk of acquiring HBV

infection following a puncture from a contaminated needle ranges from 6% to 30%. Two

types of vaccines are effective in preventing hepatitis B. One is plasma – derived, and the

other is a recombinant vaccine. Use of the plasma- derived vaccine is restricted to dialysis

patients, other immunocompromised persons, and those with a known allergy to yeast. Pre-

exposure vaccination is recommended for all health care and public safety workers due to

their risk of exposure to blood or body fluids (Centers for Disease Control, 1990). (2, 12,

16, 17, 18)

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Universal infection control precautions:

. Devised in US in the 1980’s in response to growing threat from HIV and hepatitis B

. Not confined to HIV and hepatitis B

. Treat ALL patients as a potential biohazard

. Adopt universal routine safe infection control practices to protect patients, self and

colleagues from infection

- Composed of:

1. Hand washing

- Single, most effective action to prevent HAI - resident/transient bacteria

- Correct method - ensuring all surfaces are cleaned - more important than agent

used or length of time taken

- No recommended frequency - should be determined by intended/completed actions

- Research indicates:

* poor techniques - not all surfaces cleaned

*frequency diminishes with workload/distance

*poor compliance with guidelines/training

2. Personal protective equipment [PPE]

PPE when contamination or splashing with blood or body fluids is anticipated:

Are:

*Disposable gloves

*Plastic aprons

*Face masks

*Safety glasses, goggles, visors

*Head protection

*Foot protection

*Fluid repellent gowns

3. Preventing/managing sharps injuries

Prevention by:

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Correct disposal in appropriate container

Avoid re-sheathing needle

Avoid removing needle

Discard syringes as single unit

Avoid over-filling sharps container

Management by:

Follow local policy for sharps injury

4. Aseptic technique

Sepsis – is harmful infection by bacteria

Asepsis – is prevention of sepsis

Minimize risk of introducing pathogenic micro-organisms into

susceptible sites

Prevent transfer of potential pathogens from contaminated site to other

sites, patients or staff

Follow local policy

5. Isolation

Single room or group

Source or protective

Source - isolation of infected patient

Mainly to prevent airborne transmission via respiratory droplets

respiratory MRSA, pulmonary tuberculosis

Protective - isolation of immuno-suppressed patient (May, 2000)

Significant psychological effects (Davies et al, 1999)

6. Staff health

(Risk of acquiring and transmitting infection)

- Acquiring infection

Immunization

Cover lesions with waterproof dressings

Restrict non-immune/pregnant staff

25

- Transmitting infection

Advice when suffering infection

Report accidents/untoward incidents

Follow local policy

7. Linen handling and disposal

Bed making and linen changing techniques

Gloves and apron - handling contaminated linen

Appropriate laundry bags

Avoid contamination of clean linen

Hazards of on-site ward-based laundering

Follow local policy

8. Waste disposal

Clinical waste

- high-risk red color, Potentially/actually contaminated waste including body fluids

and human tissue

Sharp objects

- Yellow plastic sack, tied prior to incineration

Household waste - low risk

- green color

Paper towels, packaging, dead flowers, other waste which is not dangerously

Contaminated

- black plastic sack, tied prior to incineration

Follow local policy

9. Spillages of body fluids

PPE - disposable gloves, apron

Soak up with paper towels, kitchen roll

Cover area with hypochlorite solution e.g., Milton, for several minutes

Clean area with warm water and detergent, and then dry

Treat waste as clinical waste - yellow plastic sack

26

Follow local policy

10. Environmental cleaning

Recent concern regarding poor hygiene in hospital environments

Some pathogens survive for long periods in dust, debris and dirt

Poor hygiene standards - hazardous to patients and staff

Report poor hygiene to Domestic Services

“Hospitals should do the sick no harm” (Nightingale, 1854)

11. Risk management/assessment

No risk of contact/splashing with blood/body fluids - PPE not required

Low or moderate risk of contact/splashing - wear gloves and plastic apron

High risk of contact/splashing - wear gloves, plastic apron, gown, eye/face

protection.

(Body fluids are Cerebrospinal fluid, peritoneal fluid, pleural fluid,

synovial fluid, amniotic fluid, semen, vaginal secretions, and

Any other fluid containing visible blood e.g., urine, faeces. (3, 17)

Musculoskeletal injuries

Fatigue and lower back pain due to the handling of heavy patients and long periods of

work in a standing posture. Back pain occurs frequently among nurses despite their

training and experience. The frustration and discomfort of back pain decreases patient

care efficiency. Determining the cause in individual cases is complex because nurses

perform many activities that lead to musculoskeletal strain. Since the continuum of

symptoms ranges from minor to severe pain, it is difficult to characterize back injury.

Most injuries involve the lumber muscle group.

In a study in Iran, on average, the nurses reported musculoskeletal pain, 89% had

musculoskeletal pain, mainly in lower back (74%), and knees (48.5%). (6)

In a study in the Netherlands, 57% of nurses had musculoskeletal pain in at least one

region. In another study in Brazil, 80.7% of nurses complained of musculoskeletal pain.

Upper extremity, shoulder, and neck injuries are also common among nurses. It seems

27

that work-related musculoskeletal pain and injuries are common among nurses all over

the world. Most of these pain and injuries are due to lifting and moving patients

manually. (6, 7)

Results from a number of back pain studies conducted during the past 15 years show

an annual prevalence rate of 400 to 500 injuries per 1000 nurses at risk ( Buckle, 1999).

Strains and sprains of the lower back account for 50% of all musculoskeletal disorders

among American workers (Williamson et al., 1988). Back injuries result in more lost time

and wages among nurses who provide bedside care than any other single injury.

Nursing is unique because the occupation involves lifting and transferring human

beings rather than inanimate objects. As Harber and associates (1985) point out, the

human body is not a compact mass, and patients are unpredictable. Sudden resisting

movements are common in critical care. The proper technique for lifting or transferring a

patient may depend on patient size, available staffing, or accessible equipment.

Nurses must assess each individual patient separately to minimize the risk of back

injury, especially during patient transfers.

Conditions that predispose nurses to musculoskeletal injury can be classified into

two major categories: nurse characteristics and hospital environment (Feldman, 1986).

Nurse characteristics are divided into three subgroups: physical, emotional, and

preferential. Preferential characteristics include activities that nurses perform on their own

volition. The categories and subgroups are not mutually exclusive. Fox example, stress

caused by inadequate staffing may cause fatigue, which in turn may produce carelessness.

Physical characteristics such as length or heredity cannot be changed. However, emotional

and preferential characteristics of nurses can be modified or alleviated to reduce the risk of

back injury.

In a study, 43.4% of nurses reported excessive fatigue. Raftopoulos et al. also reported that

91.9% of Cypriot nurses had fatigue.

28

Nurse and Hospital Environment Factors that Increase the Risk of Back Injury:

Nurse Hospital Environment

Physical : Decreased staffing

Weak abdominal and lumber muscles Inaccessible lifting devices

static actions

Poor posture Stress

Unequal leg length Inadequate storage space for equipment

and furniture

Hereditary back problems Uncooperative patients

Fatigue Leg, head, and elbow Clearance

Obesity or poor nutrition

Lifestyle Workstation design

Smoking, drug use, inadequate exercise Equipment design

weight of " portable" equipment

Emotional :

Stress

Lack of motivation

Working surface height

Job dissatisfaction Presence of tubes or catheters on patient

Preferential :

Ignoring physical limitations

Not soliciting assistance from patient or

co-workers

Lack of training and experience with

lifting and transfer techniques and devices

Carelessness

Restrictive clothing

Risk- taking behavior

The height of the bed influences the working posture of the nurse; the optimal bed height

for a nurse's performance of routing procedures is usually higher than the desired height

for the patient (Pheasant, 1997). Patient comfort and safety may be compromised if a nurse

29

adjusts the bed height to provide protection from back strain. Bed height will be different

for each nurse depending on the procedure to be performed and the height of the nurse.

Maintaining ergonomically correct equipment for each nurse at any given time is

problematic, especially when more than one nurse is assigned to a patient.

Patient contact activities in critical care frequently require nurses to maintain an

awkward, stressful posture for an extended period of time. In an observational study,

Harber and colleagues (1998) found that 78% of static actions were performed in a

squatting or semi-squatting position. These actions may be particularly stressful on the

lower back because the same muscle groups are involved throughout the activity.

It is important to recognize and develop ways to minimize stressful postures a

combination of personal and environmental modifications should be implemented to be

effective. No single method will completely prevent or control low back pain.

Nurses are not selected by physical ability, and job strength requirements are rarely

addressed in critical care. Conducting pre-employment strength tests to determine whether

the nurse can perform strenuous nursing tasks is feasible (Keyserling et al, 1987). Patient

assignments could then be matched according to the physical strength of the nurse.

Methods for Minimizing Low Back Injury:

Personal:

Strengthen abdominal lumbar muscles through regular exercise

Maintain good posture

Maintain proper nutrition

Solicit assistance from co-workers and patients

Use mechanical devices for lifting

Review knowledge of proper lifting techniques

Alleviate risk–taking behaviors

Wear nonrestrictive clothing

Lift no more than 35% of your body weight or less

Raise or lower beds to facilitate good posture

Minimize stress

Environmental:

Design workplace layout using ergonomic principles

30

Provide adequate staffing

Conduct pre- employment strength testing and evaluation

Make lifting devices accessible

Conduct regular in – service training addressing static actions

Consult a nursing ergonomic specialist

Redesign storage areas

Maintain clear paths for walking and moving furniture or equipment

Install nonslippery floor surfaces

Because the number of low back injuries among nurses has not shown any

appreciable decline, researchers question the effectiveness of training programs that focus

on safe lifting procedures (Haber et al., 1995, 1997a and; Stubbs et al., 1993; Snook et al.,

1988). As Cato and colleagues (1989) point out, perhaps training programs are more

effective when used in conjunction with ergonomic job analysis and job – specific training.

Training programs should provide information on correct postures to minimize muscle

strain, exercises to strengthen the back, and proper lifting techniques. A well – trained

“nursing ergonomic consultant" who is sensitive to each nurse's physical ability could

provide services and assistance to individuals who are at risk of low back injury (Harbor

et al., 1985).

Although patient comfort and safety are the highest priorities in hospital care, nurses

should be encouraged to develop an understanding of basic ergonomic concepts and to

analyze their own safety at the bedside and work station. Personal habits are not easily

modified, but awareness and effort to maintain a safe environment in the workplace is

important. Efforts should be made to minimize back injury away from the workplace as

well. Application of these principles will reduce musculoskeletal injury, increase

productivity, improve health and safety, and provide a higher quality of patient care.( 2, 4,

19, 20)

Chemical hazards

There are varieties of chemicals, including many therapeutic agents, in the critical care

setting that may pose a hazard to nurses.

31

Danger of exposure to anesthetic gases (ethyl bromide, ethyl chloride, ethyl ether,

halothane, nitrous oxide.).

Skin defatting, irritation, and dermatoses because of frequent use of soaps, detergents,

And disinfectants.

Irritation of the eyes, nose, and throat because of exposure to airborne aerosols or contact

with droplets of washing and cleaning liquids.

Chronic poisoning because of long-term exposure to medications, sterilizing fluids (e.g.

glutaraldehyde), and anesthetic gases.

Latex allergy caused by exposure to natural latex gloves and other medical devices.

Nearly 400.000 cancer patients received therapy with cytotoxic drugs in 1986

(Williamson et al., 1988). Some of these patients required care for septic complications.

Aerosolized drugs used to treat infections in neonates and persons with HIV infection may

cause birth defects. Pregnant women should avoid ribavirin because so many unknown

factors are associated with these agents, nurses should minimize contact with all potential

chemical hazards. Antineoplastic agents may enter humans inadvertently through

inhalation, ingestion, or absorption through unprotected skin. These agents have

carcinogenic potential. All nurses should wear gloves when handling potentially hazardous

drugs. Strict adherence to body substance isolation precautions will help prevent exposure

to drugs and their metabolites in body fluids, including urine. (2, 10, 20, 21, 22)

Radiation Hazards

Portable radiography and fluoroscopy are routine bedside procedures in critical care

areas. Radiation exposure carries the potential for both short-term and long-term biologic

effects. Familiarity with the types and sources of radiation, the maximum permissible doses

for occupational exposure and ways in which the risk of exposure to ionizing radiation can

be minimized will protect nurses from harmful biologic effects.

When atoms and molecules undergo change, energy is released in the form of heat

or light. This energy is referred to as radiation. The three common forms of radiation used

in hospitals are alpha particles, beta particles, and gamma rays (x-rays). Alpha particles

travel only inches in the air and are stopped by health skin tissue. Beta particles may travel

32

several feet before they are absorbed by a thin piece of metal or wood. Gamma rays travel

hundreds of feet and have great penetrating power.

The penetrating ability of each type of radiation varies. Harmful effects to human

tissue result largely from the energy absorbed by the cells. The amount of energy absorbed

or deposited in human tissue determines the total biologic effect. The rem (roentgen

equivalent man or mammal) is the unit that represents the biologic dose used to estimate

potential damage caused by radiation.

There are three potential sources of scattered radiation in critical care environment:

portable x-ray equipment, fluoroscopic equipment, and diagnostic or therapeutic

radionuclide. Scattered or secondary radiation occurs after the primary radiation beam or

application passes through matter. All x-ray and fluoroscopic examinations generate some

scattered radiation. Alpha, beta, and gamma rays exist in the isotopes used for external and

internal radiation treatments. The amount of secondary radiation emitted by patients

receiving radionuclide therapy depends on the organ in which it is localized, the dosage,

the elapsed time after injection, patient size and the distance from the patient (Jankowski,

1984).

Critical care nurses should pay particular attention to the levels of secondary radiation

received from patients who receive radionuclide because the number of hours they spend

in individual patient contact is greater than the time needed in other unit in the hospital.

The body fluids of patients who have received injections of radioactive substances contain

significant amounts of radioactivity. Compliance with BSI procedures is crucial.

The National Council on Radiation Protection and Measurements (NCRPM)

establishes maximum permissible dose (MPD) levels of radiation for occupational

exposure. The current recommendation is 5000 mrem per year for employees who are

likely to be exposed to ionizing radiation during the course of their work (National Council

on Radiation Protection and Measurements, 1980). According to the Code of Federal

Regulations (CFR), radiation dosimetry badges are required when nurses receive doses in

excess of 1250 mrem every 3months.

Actively proliferating cells, such as the gonads, are highly sensitive to radiation.

Teratogenic or carcinogenic effects may occur when an embryo, fetus, or male germ cell

33

is irradiated. Studies show that ionizing radiation damages the gonads, alters genetic

material, reduces fertility, and induces spontaneous abortion (Hunt, 1988).

Exposure to scattered radiation can be minimized in three ways: by time, by

distance, and by shielding.

Protection from secondary radiation can be enhanced by completing procedures in the

shortest possible time without compromising good clinical practice. Penetrable radiation

rapidly decreases as the distance from the source increases. For example, a single film

taken by a portable x-ray machine at 1 meter will produce approximately 0.06 merm of

scattered radiation. At 2 meters the amount is indistinguishable from background radiation

existing in the natural environment.

The third method of minimizing exposure to secondary radiation is the use of

protective shielding lead screens or aprons 5 mm in lead – equivalent thickness should be

used during x-ray and fluoroscopy to protect the gonads. Protective shielding is particularly

important when working with patients who have received radiopharmaceuticals. Leaded

glasses and a thyroid shield are recommended during procedures involving elevated levels

of radiation such as angioplasty (Patterson et al., 1985).

Further epidemiologic studies on the effects of long-term occupational exposure to

ionizing radiation are needed. Until more data are available, pocket dosimeters and film

badges for monitoring exposure to radiation should be used by nurses who are likely to

receive more than 1250 mrem in a 3-month period. Radiation safety committees should

periodically monitor nurses for proper radiation safety techniques. Radiation safety should

be included in hospital orientation programs for new staff and should be reviewed annually

for all employees. Finally, hospital policies regarding the use of radioactive substances and

equipment should be reviewed and revised to include methods for minimizing radiological

hazards to staff. (2, 21, 23)

Noise

Prolonged exposure to noise can be distracting and can prohibit mental

concentration. Psychological responses to noise include increased annoyance and

irritability, impaired judgment, and altered perception (Hilton, 1997). Controlling noise in

the critical care environment will help to minimize fatigue and reduce errors. Factors that

34

influence the impact of noise on nurses include the intensity or loudness of the sound, type

of sound, distance from the source, frequency and duration of exposure, individual

perception of sound, stress level, and age.

The decibel (dB) is used to express the sound level associated with noise

measurement. The Occupational Safety and Health Administration (OSHA) standard for

permissible exposure to noise is 90 dB during an 8- hour shift (Code of Federal

Regulations, 1990). The International Noise Council recommends that sound levels in

patient care areas not exceed 45 dB during the day and 20 dB at night (Hansell, 1994).

Background noise occurs in most work environments. Critical care areas, however,

are remarkably loud. One study reported that sound levels in four critical care units were

as high as 77 dB, which is comparable to hospital cafeteria at noon (Redding et al., 1987).

Other studies have reported sound levels greater that 50 dB over a 24-hour period, with a

number of noises exceeding 70 dB (Hilton,1997; Hansell, 1994). Noise levels of this

magnitude increase the tendency for nurses to become desensitized to noise levels in the

critical care environment.

Elimination or reduction of unnecessary sources of noise is essential. Increasing

nurses' sensitivity to the level of noise on the unit will help to develop appropriate

interventions to decrease or control unwanted sound. Everyone should be encouraged to

speak softly. Patients report that staff conversations and activity are the most disturbing

noise (Hansell, 1984). Discussions among nurses and other hospital staff can generate

sound levels as high as 90 dB (Hilton, 1997). Normal conversational tones measure

between 56 and 60 dB. As Hilton (1997) points out, whispering may be appropriate at

night. Conversations between staff should be limited to patient care concerns, especially at

the bedside. A system of concentrated noise may be helpful (Lindenmuth et al., 1990).

Noise can also be reduced by introducing sound absorbing materials into the architectural

design of the unit. Carpeted walls and floors in the nursing station and patient care areas

will have a dramatic effect on reducing noise. Each unit should have a soundproof section

in which nurses and physicians can confer or spend break periods without disturbing

patients (Dracup, 1998). Utility rooms with sinks, refrigerators, and ice machines should

be partitioned separately from patient care areas. Alarm parameters should be set

appropriately to avoid false alarms. Nurses must take an active role in developing effective

35

strategies to reduce noise. Strict compliance with the standards of occupational exposure

to noise will enhance awareness of noise reduction among the staff. Nurses should be

responsible for evaluating and purchasing equipment such as ventilators, monitors, and

balloon pumps. Equipment that produces excess noise can be modified by the manufacture

to meet noise reduction standards. Nursing consultants should assist in the development of

plans for construction or remodeling of critical care units (Dracup, 1998).

Suppression of noise is an important element of occupational safety and health in

the critical care environment. Nurses and other hospital staff must develop an appreciation

for a quiet working environment. Keeping the noise level as low as reasonably possible is

advantageous to nurses and beneficial to patients. (2, 12)

Stress among critical care nurses

Stress is an imbalance between demand and the ability to cope with it. Stress response

results when the individual fails to cope with a stimulus. Shouk Smith defined it as the

body state of tension, which result from external or internal stressors. External or internal

stressors trigger a stress response. External stressor is an environmental event such as

disasters or being taken seriously ill very suddenly. Internal stressors are our own responses

to wide range of events and situations.

Nurses in critical care units face great amount of stress, which is recognized by all health

professionals. Nursing has been identified as a stressful occupation. Health authorities 1988

report in the public sector included nursing as one of the four high stress occupations

together with police, social works and teaching (Roger D. Poppy N.1999).

Critical care nursing involves excessive physical and emotional stress due to the

nature of the environment which is a closed one, isolated from the rest of the hospital. In a

critical care unit there is constant use of sophisticated machines and equipment amidst

which a nurse is expected to work calmly and efficiently at all times. Nurses encounter

stress while facing death of patients in the critical care units when they have nursed

carefully which perceived as a failure of their work. A sense of inadequacy prevails among

nurse as they lack confidence in handling the patients and equipment's.

Death and dying are the major stressors in critical care, the unpredictability of critical

care environment is another leading stressor other factors of stress also every step must be

36

charted. frequent situation of acute crisis, physical dangers ( inadequate protection from x-

rays, needles, isolation patients, and those who are delirious), lifting heavy unresponsive

patients, constant sounds of moaning, crying, screaming, buzzing, and beeping monitors,

gurgling suction pumps, and whooshing respirators.

Poor communication causes stress leading to a spiral of conflict that leaves everyone

dissatisfied. Furthermore, communications is the medium through which stress is

expressed.

The accumulation of stressors from this intense environment can result in individual’s

developing physical or psychological symptoms. Each person’s response to stress is unique

and individualized. (20, 24, 25)

Effects of stress

Behavioral

Short term irritability, forgetfulness, disorganization thinking, overindulge in drugs,

alcohol, smoking, accidents, impulsive behavior, poor relationship with others, poor work

performance.

Long term: difficulty concentrating on tasks, decreased interest in relationship, Marginal

family breakdown, social isolation.

Physical

Short term: Headaches, backache, insomnia, indigestion and gastrointestinal upset,

tightness in chest, nausea, dizziness, excessive sweating and unexplained shortness of

breath.

Long term: Heart diseases, hypertension, ulcer, poor general health.

Emotional

Short term: Tiredness, anxiety, boredom, irritability, and depression, lack of concentration

low self-esteem, apathy.

Long terms: Depression, neurosis break down, suicide.

CCNs need to listen to their bodies and thoughtfully consider their sense of well-being.

Frequent personal assessment for signs of stress is important to longevity and satisfaction

in critical care nursing. Awareness of the early warning signs of stress can facilitate rapid

identification and swift intervention to enhance individual coping.

37

CCNs are vulnerable to burnout, which is the response to chronic emotional strain

extensively with other human beings, particularly when they are troubled, ill, or having

personal problems.

The condition of burnout renders the individual feeling resigned, ineffective, and hopeless

about working in such an environment. The behavior common in burnout include

absenteeism, anger, frustration, anxiety, and loss of commitment. The result of burnout is

that the employee either leaves the job or remains in the position functioning ineffectively.

(2, 13, 14, 25, 26)

Chemical dependency

Chemical dependency occurs among workers in every occupation. Nurses are

exposed to constant stress and human suffering. They also have easy access to narcotics

and other drugs. Although there are no reliable estimates of the number of nurses who

suffer from chemical dependency, the problem of chemical dependency is surfacing more

frequently. The costs to society of chemical dependency include increased use of health

insurance benefits, decreased productivity, increased absenteeism, poor patient relations,

reduced staff morale, poor judgment and increased mistakes or accidents. Mistakes or

accidents often lead to litigation and damage to the reputations of both the organization

and the nurse. Drugs that may be abused include cocaine, marijuana, alcohol, narcotics,

amphetamines, and tranquilizers. Nurses should be observant of colleagues who may

display signs of chemical dependency or impairment and should refer them to the peer

counseling program run by the nurses' association or employee assistance program at the

hospital.(2, 25)

Personality and coping characteristics of successful CCNs:

- Adventurous

- Detached ( based on defense mechanisms), which reduces anxiety level

- Strong capacity for coping and adaptation

- Hardiness: control, commitment, challenge, companionship

- Resiliency (bounces back): insight, independence, social support, and initiative.

(13, 27)

38

CONCLUSION

It has been established that those in the nursing profession are susceptible to a number of

Occupational hazards, many of which are avoidable and preventable while others are

inevitable, being parts of the everyday nursing duties. Nurses must pay attention for the

potential hazards they face and preventive strategies that are effective.

CCNs must examine the hazards in the critical care work environment. An awareness of

hazards and nurses perceptions of their causes and solutions set the stage for developing

appropriate occupational safety programs. Nurse with research skills and a familiarity with

the tasks, procedures, and physical environment of the critical care unit have an opportunity

to study and contribute to the understanding of occupational hazards and ways to prevent

them.

39

Previous studies

1. Chen-Yin Tung, Department of Health Promotion and Health Education, College of

Education, National Taiwan University, carried study on Occupational Hazards

Education for Nursing Staff through Web-Based Learning, Published: in 2014.

The study was a pre/post-test control group design. The subjects were nursing staff from

two hospitals in Taipei City, Taiwan. One hospital was the experimental group and the

other one was the control group. The study aimed to explore the efficiency of using

online education as an intervention measure to prevent occupational hazards in a clinical

nursing setting as well as to understand nursing staff’s experiences of occupational

injuries. The subjects were 320 female nursing staff from two hospitals in Taiwan.

The questionnaire results indicated that the subjects primarily experienced human factor

occupational hazards, as well as psychological and social hazards. Specifically, 73.1%

and 69.8% of the subjects suffered from poor sleep quality and low back pain. the

experimental group had higher post-test scores than the control group in knowledge.

The subjects of the experimental group and the control group did not show significant

differences in their attitudes and practices toward the prevention of occupational hazards.

A possible explanation for this result may be that the education website lacked an online

discussion forum, which could offer solutions to the problems encountered by the nursing

staff in the prevention of occupational hazards. (28)

2. Amosu.M. Department of Nursing, Igbinedion University, Okada, Nigeria 2011

Studied the Level of Knowledge Regarding Occupational Hazards among Nurses in

Abeokuta, Ogun State, Nigeria.

Descriptive survey was carried out to investigate the level of knowledge on the

predisposing factors to occupational hazards, among nurses in health facilities in Abeokuta,

Ogun state, Nigeria. The study population consisted of nurses of varying categories

working in ten public and two privately owned health facilities in five local government

areas of the state. The simple random sampling technique employed in selecting 1,200

respondents across the health facilities. A validated structured questionnaire developed.

The results revealed that 5.7% of the respondents were males, 94.3% were females,

40

four hundred and sixty-nine (39.1%) respondents have 1-10 years working experience

while 60.9% have spent 11 years and above in the nursing profession.

96.2% of the respondents knew that, the profession is prone to occupational hazards, and

as expressed by 88.6% of the respondents, back injury is the commonest hazard, followed

by neck and back pain as attested to by 84.8% of the nurses. The most prominent

predisposing factor was prolonged standing as viewed by 84.5% of the sample. (29)

3. Occupational Health and Safety issue Among Nurses in the Philippines:

Castro - A. B.2009. Studied the health and safety issues among nurses in Philippine. The

study was designed to gain preliminary insights into some of the occupational health and

safety problems faced by nurses in the Philippines.

He found that 38% of nurses reported being inadequately informed by employers about

workplace hazards. When asked to rank their top concerns, respondents reported acute

and chronic effects of stress and being overworked; a disabling back injury; and being

infected with a blood borne pathogen from a needle stick. These injuries and illnesses

appeared to be consequential not only for the nurse, but also for the workplace. About

23% reported missing 2 or more days in the past year due to a work-related injury or

illness, and 76% reported that unsafe working conditions interfered with the delivery of

quality nursing care.

Nurses in developed countries such as the United States may have safer working conditions

lesser than nurses in developing countries. This advantage may result from greater

economic resources and regulatory oversight that support quality occupational health and

safety protections. For example, in 1991, the U.S. Occupational Safety and Health

Administration (OSHA) promulgated the Blood borne Pathogen Standard to protect all

workers at risk for exposure to blood borne pathogens through sharps injuries or contact

with skin or mucous membranes (OSHA, 1991). In contrast, the Philippines has no

equivalent policy, even though the nursing profession is regulated by the Department of

Labor and Employment and the Department of Health. (30)

41

4. Study published in 2010 by Ticiani D. et al, Department of Nursing, University

of Brasilia

Studied occupational health hazards in ICU nursing staff Hospital de Base of the

Federal District, Was a descriptive cross-sectional study which was carried out with

nurses and nursing technicians at the ICU at the Hospital de Base, a public

institution located in Brasilia, Brazil. The study analyzed occupational health

hazards for Intensive Care Unit (ICU) nurses and nursing technicians, comparing

differences in the number and types of hazards which occur at the beginning and

end of their careers. The study population were 26 nurses and 96 nursing

technicians.

Results: The study found that the psychological and social hazard levels were

tolerable. Leg pains and sleep disturbance symptoms were at critical levels among

nurses; among nursing technicians, critical levels were detected for leg and back

pains. Concerning psychological hazards it may be verified that for both categories,

levels were satisfactory with regard to negative feelings (loss of self-confidence,

loss of self-control, feeling of emptiness, bitterness, feeling of defeat, crying for no

apparent reason, willingness to give everything up, long-lasting feeling of despair,

and negative image of oneself). A moderate level of sadness was identified among

nurses, being considered satisfactory for nursing technicians. The study concluded

that most of these professionals held more than one job to maintain family income

levels, as a consequence of working two shifts possibly provoking certain psycho-

emotional illnesses. (31)

5. Prevalence and risk factors of low back pain among nurses in a typical Nigerian

hospital

Sikuru Land Hanifa S, 2010 studied LBP among nurses, the objective of this study was to

determine the prevalence and risk factors of LBP among nurses in a typical Nigerian

Specialist Hospital. A cross-sectional study was designed to determine the prevalence and

risk factors for LBP among nurses in a typical Nigerian Hospital. A department-to-

department enquiry was conducted using a self-structured valid and reliable questionnaire.

42

The main results of that study: Four hundred and eight respondents (148 [36.27%] males

and 260 [63.73%] females) participated in the study. The 12-month prevalence of LBP

was 300 (73.53%). LBP was more prevalent among female nurses (68%) than the male

nurses (32%). It was also associated with occupational hazard and poor knowledge of

back care ergonomics. in the study LBP did not feature as a major cause of sickness

absence in the work place. The study concluded that poor back care ergonomics is the

major predisposing factor of LBP. (32)

6. Stress in nurses working in intensive care unit, Antonio Carlos, RN, Hospital

Israelita Albert Einstein, Doctoral student at São Paulo Federal University,

Brazil.

study aimed to identify the presence of stress in nurses working in intensive care units,

the stressing agents and symptoms associated to the nurses' perceptions of stress, and to

assess the correlation between the occurrence of stress, sources of stress, and symptoms

shown by the nurses. Seventy-five nurses took part in the study. The data were collected

from questionnaires. The study showed the presence of stress related to work

dissatisfaction, activities regarded as critical situations in intensive care units, symptoms

related to cardiovascular, digestive and musculoskeletal disorders. The study indicated

that there was a relation between the stress sources identified by the questionnaire of

critical situations with the levels of stress and general dissatisfaction with work.

The conclusion was that stress presents in nurses' activities in intensive care units,

related to characteristics of the health area itself, causing dissatisfaction and stress-related

symptoms. (33)

7. Occupational Health Hazards among Healthcare Workers in Kampala, Uganda

Rawlance Ndejjo et al. Department of Disease Control and Environmental Health, School

of Public Health, Makerere University, Kampala, Uganda.

Study published in 2015, assessed the occupational health hazards faced by healthcare

workers and the mitigation measures. A cross-sectional study conducted utilizing

43

quantitative data collection methods among 200 respondents who worked in eight major

health facilities in Kampala.

Results. Overall, 50.0% of respondents reported experiencing an occupational health

hazard. Among these, 39.5% experienced biological hazards while 31.5% experienced

nonbiological hazards. Predictors for experiencing hazards included not wearing the

necessary personal protective equipment (PPE), working overtime, job related pressures,

and working in multiple health facilities.

Among those that experienced nonbiological hazards, the majority experienced stress

(21.5%), physical, psychological, sexual, and/or verbal abuse (10.5%), and

musculoskeletal injuries (10.5%). The proportions of nonbiological hazards were higher

among females (male (26.3%) versus female (33.6%)), those older than 30 years (≤30 years

(23.3%) versus >30 years (38.2%)).

Thhe study concluded that interventions should be instituted to mitigate the hazards,

specifically PPE supply gaps, job related pressures, and complacence in adhering to

mitigation measures should be addressed. (34)

8. Knowledge and practices among registered nurses on occupational hazards in

Onandjokwe health district: Oshikoto region, Namibia 2015

By Julia Tuvadimbwa, MSC, public health, University of Namibia

The aim of the study was to determine the existing knowledge and practices of the

registered nurses and strategies that were in place to guide practice on occupational hazard

and safety in the Onandjokwe health district.

A quantitative research design utilizing a survey by means of questionnaires is used. The

population of the study were registered nurses in direct contact with patients (50 nurses).

The results indicated that a significant number of registered nurses have knowledge on

occupational hazards, although there were a few numbers which have insufficient

knowledge on occupational hazards. Population also were trying to practice occupational

safety but the restrictions such as non-availability of facilities prevented them from the

safety practices.

44

It seems that the majority of the respondents, that is 39 (76%) of the sample understood

occupational hazards as it was indicated in their responses. Six (6) 12% respondents have

only mentioned the types of occupational hazards instead of explaining the meaning.

Thirty seven (37) 74% respondents have indicated that they are exposed either through

handling of sharp instruments or equipment, lifting of patients, exposure to aggressive patients,

exposure to airborne diseases.

Nineteen 19 (38%) respondents indicated that they are aware of the content of the guidelines

on body mechanics. Twenty-eight 28 (56%) respondents were not aware of the content of the

body mechanics guideline.

All the respondents that were 50 (100%) indicated that they wash their hands on duty to prevent

or reduce cross infections.

Non-availability of facilities may also contribute to protective measures not to be used.

Sixteen (16) 32% responded that they do not use spectacles/goggles on duty

The researcher strongly recommended that the knowledge on occupational hazard and

safety among nurses should be improved through the following means:

- Registered nurses on a regular basis should attend training on occupational

hazards and safety.

- A well-trained occupational nurse should be appointed to educate health workers

on the prevention and management of occupational hazards. (35)

9. Anwar Abbas Ahmed studied occupational hazards affecting dental manpower in

Khartoum state, 2004.

The data of his study collected through two methods, interviews and observation, analysis

of the results revealed the high knowledge of the respondents about biological hazards

(95.9%), ( 94.1%) about physical hazards, (77.7% ) about chemical hazards and( 66.7%)

psychological hazards. The acceptance of protective tools and sterilization is poor (61.9%

& 55.6% respectively).

The results may indicate that, the knowledge of the dental manpower included in the study

about professional hazards is not reflected as behavior. The following recommendation is

suggested:

1- Dental manpower including dentists, assistants and nurses should be informed and

reminded about occupational hazards and mean of avoiding them.

45

2- Continuous surveillance and the inception of proper protective measures against

occupational hazards need to be arranged, through frequent check visits by

organizing licensing periodic.

3- Education of professional and generate public awareness. (36 )

10. Study done by (the researcher), for a complementary program of MSc in nursing

It was a descriptive, cross-sectional study carried during April, May and June 2011,

aimed to investigate occupational hazards that facing nurses in critical care areas, the Study

subjects were 66 nurses working in Ahmed Gasim Hospital Cardiac Surgery and Renal

Transplant Center areas for more than one year. Questionnaire and checklist were used to

assess occupational hazards among critical care nurses and preventive measures that

actually used. Respondents mentioned high level of knowledge (90%) about infectious,

stress and musculoskeletal disorders.

The results revealed that low backache, eye fatigue, muscles pain, irritability and upset

stomach occurred to more than 50% of the participants, 6% HBV, 1.5% HCV and 4.5%

TB. International measures are poorly applied. Shoes, covering, face shield and plastic

gown are not available. Participants appropriately use available protective measures.

46

Chapter (3)

Research Methodology

Research Methodology

Study design:

This study was pre - post-intervention, one group, hospital-based study carried out during

2013-2016.

Study area:

47

This study was carried out at critical care settings (Intensive care units), in Khartoum

state governmental hospitals.

In the following five hospitals:

• Khartoum teaching hospital ( one postoperative ICU)

• Omdurman teaching hospital (CCU, medical ICU, surgical ICU)

• Khartoum North teaching hospital (Bahari) (ICU A, ICU B)

• Elshaab teaching hospital (ICCU, ICU, Asthma ICU)

• Ahmed Gasim hospital - cardiac and renal center (CCU, ICU, RR)

The study population:

All nurses working in CCU, ICU and RR, in Khartoum state (governmental hospitals).

Sample size and sampling technique:

Sampling technique:

Total coverage of all population

The sample size:

Two hundred and fifty (250) nurses.

The participants’ number (who agreed to participate):

Two hundred (200) nurses

The rest of the population 50 CCNs dropped because of an individual and institutional

causes.

Number of staff in all study areas is greater than this study sample, because about hundred

jobs were covered with same CCNs, in mean of double shift work.

Hospitals CCNs total

number

Participants

number

CCNs Jobs/

hospital

Khartoum hospital 40 30 40

Omdurman hospital 50 45 55

Khartoum north hospital 45 30 52

Elshaab hospital 55 40 108

Ahmed Gasim hospital 60 55 102

48

Total 250 200 357

Interventions:

After the first questionnaire administered with participants, an educational program was

conducted by:

1. Lectures in hospital conference hall contain:

- Purposes of occupational health – occupational hazards types, causes, and preventive

methods. – Infection control universal precautions. – Stress and its effects – training on

relaxation exercises technique – health education session about personality, and coping

methods to gain success in life despite this stressful job.

(same contents of lecture taught in other educational types)

2. Discussions in the prescribed units as sitting group’s discussion

3. Direct individual educational session.

(Manual of the educational program hard copy and International datasheets on OHs for

ICU nurse of ILO, distributed to all nurses in critical care areas)

The study tools:

1. An interviewing structured closed ended questionnaire was used, developed by

the researcher to identify nurses’ knowledge about possible occupational hazard,

causes, and prevention measures in intensive care units. The questionnaire composed of

seven sessions:

a. background data about participants

b. knowledge of meaning and types of OHs. c. knowledge of OHs causes

d. knowledge of OHs preventive methods. e. knowledge of universal precaution

f. provision of PPE g. coping characteristics of CCNs to gain success.

2. Observational Checklist (Adapted from CDC & AACCN procedure book)

Prepared to evaluate nurses' practice regarding the suitable uses of universal preventive

measures of occupational hazards.

3. Interview with key persons (I.K.P), structured and guided by researcher with

Hospital matron for discussion of:

49

- Causes behind unavailability of personal protective equipment and causes of gaps

in supply of that equipment.

- Availability of hand washing sinks, soaps and germicides

- Pre-employment education about safety measures.

- Assigned OHN in hospital.

Study variables:

Dependent variable

Occupational hazards in critical care areas.

Independent variables

- Efficiency of educational program on CCNs knowledge about OHs

- Knowledge about occupational hazards types, and causes.

- Knowledge about prevention and mitigation of OHs.

- Availability of PPE in CC areas

The data analysis Data were assessed, coded, managed, and analyzed by Statistical Package of Social

studies (SPSS), were presented in forms of frequency figures and table for cross

tabulation. Significance differences of results were tested by Pearson’s chi squire, the p

value was accepted below 0.05.

Ethical Considerations

Many formalities were done before starting data collection, ethical approvals to carry out

the study was obtained from Ribaat National University, to curative medicine

administration, Khartoum state ministry of health, formal letter was sent to each hospital

general director, which was directed to hospital’s research director and hospital’s

50

matron, followed by letter to critical area nursing director then each CCN informed

verbally by researcher with mentioning of information confidentiality.

Study Limitations

The limitations of this study were:

- One hospital was not included because there were obstacles from hospital

managers’ side to carry the study in their area (Ibrahim Malik Hospital).

- In (CCU, Elshaab hospital), the head of nursing staff refused to do this study in

her unit; she told this time consuming program.

51

The Results

Chapter (4)

Results

52

n =200

Figure 1. Reflects respondents distribution in study areas

Figure 2. Reflects respondents distribution in critical care settings types

27.5%

22.5%

20%

15%15%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

0

10

20

30

40

50

60HOSPITALS

ICU CCU RR

84.0%

12.5% 3.0%

CC AREAS

53

Figure 3. Respondents’ age groups

Figure 4. Respondents’ gender

Figure 5. Respondents’ graduation level

20-30 31-40 > 40

73.5%

24.5%2.0%

AGE GROUPS IN YEARS

FEMALE83%

MALE17%

GENDER

FEMALE

MALE

DIPLOMA BACHELOR MASTER

23.0%

67.0%

9.5%

GRADUATION LEVEL OF NURSING

54

Figure 6. CCNs in morning shift were more than afternoon/night shift

Figure 7. Shows participants’ experience length in years

MORNING

54%

A/N46%

MAIN WORKING SHIFT

MORNING A/N

< 1 YR 1-5 YRS > 5 YRS

24.0%

43.5%

32.0%

THE LENGTH OF EXPERIENCE IN YEARS

55

Table 1. Knowledge of critical care nurses about the meaning of occupational

hazards in Khartoum state 5 public hospitals (2013-2016)

((Note: p value = < 0.05))

P value .000

Respondents showed improvement in posttest result

Tables 2. Knowledge of critical care nurses about occupational hazards types in

work area in Khartoum state 5 public hospitals (2013-2016)

Table 2-1. Knowledge of critical care nurses about biological hazard as a type of

occupational hazards in work area in Khartoum state 5 public hospitals (2013-2016)

P value 1.0

Respondents’ knowledge about biological hazards in work place was high in pretest

result.

Meaning of occupational hazards Pretest

%

Posttest

%

Total

Right answer 149

(74.5%)

200

(100.0%)

349

Wrong answer 51

(25.5%)

0

(0%)

51

Total 200

200 400

Biological (infectious) hazard Pretest

%

Posttest

%

Total

Right answer 199

(99.5%)

200

(100.0%)

399

Wrong answer 1

(0.5%)

0

(0%)

1

Total 200

200 400

56

Table2- 2. Knowledge of critical care nurses about physical hazard as a type of

occupational hazards in work area in Khartoum state 5 public hospitals (2013-2016)

P value .000

Respondents in pretest knew the physical hazards in term of backache.

Table 2-3. Knowledge of critical care nurses about radiological hazard as a type of

occupational hazards in work area in Khartoum state 5 public hospitals (2013-2016)

P value .000

Respondents’ knowledge about radiological hazard improved in posttest result.

physical and ergonomics hazard

(musculoskeletal injuries)

Pretest

%

Posttest

%

Total

Right answer 29

(14.5%)

199

(99.5%)

228

Wrong answer 171

(84.5%)

1

(0.5%)

172

Total 200

200 400

Radiological hazard

(portable radiography)

Pretest

%

Posttest

%

Total

Right answer 34

(17%)

200

(100.0%)

234

Wrong answer 166

(83%)

0

(0%)

166

Total 200

200 400

57

Table 2-4. Knowledge of critical care nurses about chemical hazard as a type of

occupational hazards in work area in Khartoum state 5 public hospitals (2013-2016)

P value .000

The result of respondents’ knowledge improved in posttest.

Table 2-5. Knowledge of critical care nurses about psychosocial hazard as a type of

occupational hazards in work area in Khartoum state 5 public hospitals (2013-2016)

P value .000

Less than half of participants mentioned psychosocial hazard in pretest while most of

them mentioned psychosocial hazard in posttest.

chemical hazards (cytotoxic drugs)

Pretest

%

Posttest

%

Total

Right answer 23

(11.5%)

197

(98.5%)

220

Wrong answer 177

(88.5%)

3

(1.5%)

180

Total 200

200 400

psychosocial hazard

(stress, conflicts,

job dissatisfaction)

Pretest

%

Posttest

%

Total

Right answer 68

(34%)

199

(99.5%)

267

Wrong answer 132

(66%)

1

(0.5%)

133

Total 200

200 400

58

Tables 3. Knowledge of critical care nurses about causes each hazard in work area

in Khartoum state 5 public hospitals (2013-2016)

Table 3-1. Knowledge of critical care nurses about causes of biological hazard in work

area in Khartoum state 5 public hospitals (2013-2016)

All respondents knew the causes of biological hazard in pretest & posttest result.

Table 3-2-1. Knowledge of critical care nurses about causes of physical hazard in work

area in Khartoum state 5 public hospitals (2013-2016)

P value .000

Posttest results improved.

biological: blood, body fluids,

droplets in the air or direct contact

Pretest

%

Posttest

%

Total

Right answer 200

(100.0%)

200

(100.0%)

400

Wrong answer 0

(.0%)

0

(.0%)

0

Total 200

200 400

Physical and ergonomic: handling of

heavy patient

Pretest

%

Posttest

%

Total

Right answer 168

(84.0%)

198

(199.0%)

366

Wrong answer 32

(16.0%)

2

(1.0%)

34

Total 200

200 400

59

Table 3-2-2. Knowledge of critical care nurses about causes of physical hazard in work

area in Khartoum state 5 public hospitals (2013-2016)

P value .000

All respondents knew that working in standing posture caused physical hazard in result of

posttest assessment.

Table 3-3. Knowledge of critical care nurses about causes of chemical hazard in work

area in Khartoum state 5 public hospitals (2013-2016)

P value .000

In posttest assessment total number of participants mentioned causes of chemical hazard.

Physical by long period of work in

standing posture

Pretest

%

Posttest

%

Total

Right answer 173

(86.5%)

200

(100.0%)

373

Wrong answer 27

(13.5%)

0

(.0%)

27

Total 200

200 400

Chemical by exposure to anesthetic

gases, disinfectant and frequent use

of soap.

Pretest

%

Posttest

%

Total

Right answer 185

(92.5%)

200

(100.0%)

385

Wrong answer 15

(7.5%)

0

(.0%)

15

Total 200

200 400

60

Table 3-4. Knowledge of critical care nurses about causes of radiological hazard in work

area in Khartoum state 5 public hospitals (2013-2016)

P value .000

Vast majority of respondents answered rightly in posttest assessment.

Table 3-5. Knowledge of critical care nurses about causes of psychosocial hazard in

work area in Khartoum state 5 public hospitals (2013-2016)

P value .030

Causes of this hazard known by most participants in first assessment.

Radiological by portable radiography

Pretest

%

Posttest

%

Total

Right answer 179

(89.5%)

199

(99.5%)

378

Wrong answer 21

(10.5%)

1

(0.5%)

22

Total 200

200 400

Psychosocial by stress, conflict and

job dissatisfaction

Pretest

%

Posttest

%

Total

Right answer 194

(97.0%)

200

(100.0%)

394

Wrong answer 6

(3.0%)

0

(.0%)

6

Total 200

200 400

61

Table 4. Knowledge of critical care nurses about preventive measures that mitigate

occupational hazards in Khartoum state, 5 public hospitals (2013-2016)

Table 4-1-1. Knowledge of critical care nurses about preventive measures that mitigate

biological hazard in Khartoum state, 5 public hospitals (2013-2016)

P value 0.499

High knowledge of participants about prevention by using of personal protective

equipment in the two parts of assessment.

Table 4-1-2. Knowledge of critical care nurses about preventive measures that mitigate

biological hazard in Khartoum state, 5 public hospitals (2013-2016)

P value .000

In pretest, about half of participants mentioned prevention by hand washing while vast

majority mentioned it in posttest.

Prevention of biological hazards by

uses of PPE Pretest

%

Posttest

%

Total

Right answer 198

(99%)

200

(100.0%)

398

Wrong answer 2

(1%)

0

(.0%)

2

Total 200

200 400

Prevention of biological hazards by

hand washing

Pretest

%

Posttest

%

Total

Right answer 99

(49.5%)

199

(99.5%)

298

Wrong answer 101

(50.5%)

1

(0.5%)

102

Total 200

200 400

62

Table 4-1-3. Knowledge of critical care nurses about preventive measures that mitigate

biological hazard in Khartoum state, 5 public hospitals (2013-2016)

P value .000

Improvement in posttest results about prevention of biological hazard by uses of

germicide.

Table 4-1-4. Knowledge of critical care nurses about preventive measures that mitigate

biological hazard in Khartoum state, 5 public hospitals (2013-2016)

P value .000

Less than quarter of respondents mentioned the right answer in pretest while most of

them mentioned the right answer in posttest.

Prevention of biological hazards by

uses of effective germicide

Pretest

%

Posttest

%

Total

Right answer 13

(6.5%)

183

(91.5%)

196

Wrong answer 187

(93.5%)

17

(8.5%)

204

Total 200

200 400

Prevention of biological hazards by

proper handling and disposal of sharp

objects

Pretest

%

Posttest

%

Total

Right answer 32

(16%)

196

(98%)

228

Wrong answer 168

(84%)

4

(2%)

172

Total 200

200 400

63

Table 4-2-1. Knowledge of critical care nurses about preventive measures that mitigate

physical hazards in Khartoum state, 5 public hospitals (2013-2016)

P value .000

Posttest result improvement was noticed.

Table 4-2-2. Knowledge of critical care nurses about preventive measures that mitigate

physical hazards in Khartoum state, 5 public hospitals (2013-2016)

P value .000

Respondents’ knowledge was improved in posttest results.

Prevention of physical hazards by

maintain good posture

Pretest

%

Posttest

%

Total

Right answer 162

(81%)

199

(99.5%)

361

Wrong answer 38

(19%)

1

(.5%)

39

Total 200

200 400

Prevention of physical hazards by use

of mechanical device for lifting

Pretest

%

Posttest

%

Total

Right answer 15

(7.5%)

179

(98%)

194

Wrong answer 185

(92.5%)

21

(10.5%)

206

Total 200

200 400

64

Table 4-2-3. Knowledge of critical care nurses about preventive measures that mitigate

physical hazards in Khartoum state, 5 public hospitals (2013-2016)

P value .000

Less than one quarter of respondents were mentioned the right answer in pretest and more

than three quarters were mentioned the right answer in posttest.

Table 4-2-4. Knowledge of critical care nurses about preventive measures that mitigate

physical hazards in Khartoum state, 5 public hospitals (2013-2016)

P value .000

Very low participants’ number knew the answer in pretest results.

Prevention of physical hazards by

proper lifting technique

Pretest

%

Posttest

%

Total

Right answer 29

(14.5%)

184

(92%)

213

Wrong answer 171

(85.5%)

16

(8%)

187

Total 200

200 400

Prevention of physical hazards by

using ergonomics principles for

workplace designing

Pretest

%

Posttest

%

Total

Right answer 5

(2.5%)

139

(69.5%)

144

Wrong answer 195

(97.5%)

61

(30.5%)

256

Total 200

200 400

65

Table 4-2-5. Knowledge of critical care nurses about preventive measures that mitigate

physical hazards in Khartoum state, 5 public hospitals (2013-2016)

P value .000

The respondents’ posttest results were improved.

Table 5-2-6. Knowledge of critical care nurses about preventive measures that mitigate

physical hazards in Khartoum state, 5 public hospitals (2013-2016)

P value .000

Posttest results were showed noticeable improvement.

Prevention of physical hazards by

adequate staffing

Pretest

%

Posttest

%

Total

Right answer 55

(27.5%)

181

(90.5%)

236

Wrong answer 145

(72.5%)

19

(9.5%)

164

Total 200

200 400

Prevention of physical hazards by

exercise

Pretest

%

Posttest

%

Total

Right answer 6

(3%)

186

(93%)

192

Wrong answer 194

(97%)

14

(7%)

208

Total 200

200 400

66

Table 4-3. Knowledge of critical care nurses about preventive measures that mitigate

chemical hazards in Khartoum state, 5 public hospitals (2013-2016)

P value .000

Most of participants knew how they could prevent chemical hazards in first assessment

results. `

Table 4-4-1. Knowledge of critical care nurses about preventive measures that mitigate

radiological hazards in Khartoum state, 5 public hospitals (2013-2016)

P value .000

Noticeable elevation in posttest values.

Prevention of chemical hazards by

adherence to body substance isolation

Pretest

%

Posttest

%

Total

Right answer 186

(93%)

199

(99.5%)

385

Wrong answer 14

(7%)

1

(.5%)

15

Total 200

200 400

Prevention of radiological hazards by

time

Pretest

%

Posttest

%

Total

Right answer 6

(3%)

192

(96%)

198

Wrong answer 194

(97%)

8

(4%)

202

Total 200

200 400

67

Table 4-4-2. Knowledge of critical care nurses about preventive measures that mitigate

radiological hazards in Khartoum state, 5 public hospitals (2013-2016)

P value .000

All respondents mentioned the right answer in posttest

Table 4-4-3. Knowledge of critical care nurses about preventive measures that mitigate

radiological hazards in Khartoum state, 5 public hospitals (2013-2016)

P value .000

Vast majority of respondents gained the knowledge of radiation prevention by shielding

in posttest results.

Prevention of radiological hazards by

distance

Pretest

%

Posttest

%

Total

Right answer 163

(81.5%)

200

(100.0%)

363

Wrong answer 37

(18.5%)

0

(.0%)

37

Total 200

200 400

Prevention of radiation hazards by

shielding

Pretest

%

Posttest

%

Total

Right answer 68

(34%)

199

(99.5%)

267

Wrong answer 132

(66%)

1

(.5%)

133

Total 200

200 400

68

Table 4-5. Knowledge of critical care nurses about preventive measures that mitigate

chemical dependency hazards in Khartoum state, 5 public hospitals (2013-2016)

P value .006

Vast majority of respondents knew the prevention methods of chemical dependency.

Table 4-6-1. Knowledge of critical care nurses about preventive measures that mitigate

stress hazards in Khartoum state, 5 public hospitals (2013-2016)

P value .000

Posttest results were improved.

Prevention of chemical dependency

by reduction of stress and suffering

Pretest

%

Posttest

%

Total

Right answer 189

(94.5%)

199

(99.5%)

388

Wrong answer 11

(5.5%)

1

(.5%)

12

Total 200

200 400

Prevention of stress hazard by

relaxation exercise

Pretest

%

Posttest

%

Total

Right answer 29

(14.5%)

198

(99%)

227

Wrong answer 171

(85.5%)

2

(1%)

173

Total 200

200 400

69

Table 4-6-2. Knowledge of critical care nurses about preventive measures that mitigate

stress hazards in Khartoum state, 5 public hospitals (2013-2016)

P value .000

Respondents gained a noticeable knowledge evidenced by elevation in posttest results.

Table 4-6-3. Knowledge of critical care nurses about preventive measures that mitigate

stress hazards in Khartoum state, 5 public hospitals (2013-2016)

P value .000

Social support as prevention method of stress in pretest was known by less than one

quarter of respondents.

Prevention of stress hazards by

coping and adaptation

Pretest

%

Posttest

%

Total

Right answer 89

(44.5 %)

199

(99.5%)

288

Wrong answer 111

(55.5%)

1

(.5%)

112

Total 200

200 400

Prevention of stress hazards by social

support

Pretest

%

Posttest

%

Total

Right answer 34

(17%)

195

(97.5%)

229

Wrong answer 166

(83%)

5

(2.5%)

171

Total 200

200 400

70

Tables 5. Knowledge of critical care nurses about the component of universal

precautions that prevent infectious hazards in Khartoum state, 5 public hospitals

(2013-2016)

Tables 5-1. Knowledge of critical care nurses about hand washing as one of the

component of universal precautions that prevent infectious hazards in Khartoum state, 5

public hospitals (2013-2016)

P value .000

In Posttest evaluation, all respondents mentioned the right answer.

Table 5-2. Knowledge of critical care nurses about PPE as a component of universal

precautions that prevent infectious hazards in Khartoum state, 5 public hospitals (2013-

2016)

P value .000

Noticeable improvement was seen in posttest result.

Hand washing as one of universal

precautions

Pretest

%

Posttest

%

Total

Right answer 69

(34.5%)

200

(100.0%)

269

Wrong answer 131

(65.5%)

0

(.0%)

131

Total 200

200 400

Personal protective equipment as one

of universal precautions Pretest

%

Posttest

%

Total

Right answer 86

(43%)

200

(100.0%)

286

Wrong answer 114

(57%)

0

(.0%)

114

Total 200

200 400

71

Table 5-3. Knowledge of critical care nurses about preventing sharp injuries as a

component of universal precautions that prevent infectious hazards in Khartoum state, 5

public hospitals (2013-2016)

P value .000

Less than one quarter from the participants in the first assessment knew the right answer

while vast majority of them in posttest answered correctly.

Table 5-4. Knowledge of critical care nurses about aseptic technique as a component of

universal precautions that prevent infectious hazards in Khartoum state, 5 public hospitals

(2013-2016)

P value .000

The different between two assessments values was clear.

Preventing and managing sharp

injuries as one of universal

precautions

Pretest

%

Posttest

%

Total

Right answer 16

(8%)

198

(99%)

214

Wrong answer 184

(92%)

2

(1.0%)

186

Total 200

200 400

Aseptic technique as one of

universal precautions

Pretest

%

Posttest

%

Total

Right answer 6

(3%)

196

(98.0%)

202

Wrong answer 194

(97%)

4

(4%)

198

Total 200

200 400

72

Table 5-5. Knowledge of critical care nurses about isolation as a component of universal

precautions that prevent infectious hazards in Khartoum state, 5 public hospitals (2013-

2016)

P value .000

Knowledge status of participants elevated in posttest evaluation.

Table 5- 6. Knowledge of critical care nurses about staff health as a component of

universal precautions that prevent infectious hazards in Khartoum state, 5 public hospitals

(2013-2016)

P value .000

Pretest value was very low and posttest value increased.

Isolation as one of universal

precautions

Pretest

%

Posttest

%

Total

Right answer 11

(5.5%)

195

(97.5%)

206

Wrong answer 189

(94.5%)

5

(2.5%)

194

Total 200

200 400

Staff health as one of universal

precautions

Pretest

%

Posttest

%

Total

Right answer 3

(1.5%)

190

(95.5%)

193

Wrong answer 197

(98.5%)

10

(5.0%)

207

Total 200

200 400

73

Table 5-7. Knowledge of critical care nurses about linen handling as a component of

universal precautions that prevent infectious hazards in Khartoum state, 5 public hospitals

(2013-2016)

P value .000

Pretest value was very low and posttest value was improved.

Table 5-8. Knowledge of critical care nurses about waste disposal as a component of

universal precautions that prevent infectious hazards in Khartoum state, 5 public hospitals

(2013-2016)

P value .000

Small number of participants had the knowledge in pretest while in posttest participants’

number became bigger.

Linen handling and disposal as one

of universal precautions

Pretest

%

Posttest

%

Total

Right answer 2

(1%)

191

(95.5%)

193

Wrong answer 198

(99%)

9

(4.5%)

207

Total 200

200 400

Waste disposal as one of universal

precautions

Pretest

%

Posttest

%

Total

Right answer 6

(3%)

188

(94%)

194

Wrong answer 194

(97%)

12

(6%)

206

Total 200

200 400

74

Table 5-9. Knowledge of critical care nurses about spillage of body fluid care as a

component of universal precautions that prevent infectious hazards in Khartoum state, 5

public hospitals (2013-2016)

P value .000

Improvement in posttest evaluation was clearly seen.

Table 5-10. Knowledge of critical care nurses about environmental cleaning as a

component of universal precautions that prevent infectious hazards in Khartoum state, 5

public hospitals (2013-2016)

P value .000

More than three quarters of participants knew the right answer in second test.

Spillage of body fluid care as one of

universal precautions

Pretest

%

Posttest

%

Total

Right answer 2

(1%)

182

(91%)

184

Wrong answer 198

(99%)

18

(9%)

216

Total 200

200 400

Environmental cleaning as one of

universal precautions

Pretest

%

Posttest

%

Total

Right answer 15

(7.5%)

186

(93%)

201

Wrong answer 185

(92.5%)

14

(7.0%)

199

Total 200

200 400

75

Table 5-11. Knowledge of critical care nurses about risk management as a component of

universal precautions that prevent infectious hazards in Khartoum state, 5 public hospitals

(2013-2016)

P value .000

Improvement in participants’ posttest evaluation was clearly seen.

Table 6. Personal protective equipment availability in critical care areas in

Khartoum state, 5 public hospitals (2013-2016)

Table 6-1. Face mask availability in critical care areas in Khartoum state, 5 public

hospitals (2013-2016)

P value .889

Participants’ answers about availability of facemasks showed small changes in the second

assessment results.

Risk management and assessment

as one of universal precautions

Pretest

%

Posttest

%

Total

Right answer 2

(1%)

174

(87%)

176

Wrong answer 198

(99%)

26

(13%)

224

Total 200

200 400

Face mask availability Pretest

%

Posttest

%

Total

available 169

(84.5%)

171

(85.5%)

340

Not available 31

(15.5%)

29

(14.5%)

60

Total 200

200 400

76

Table 6-2. Disposable gloves availability in critical care areas in Khartoum state, 5

public hospitals (2013-2016)

Table 6-3. Plastic gown availability in critical care areas in Khartoum state, 5 public

hospitals (2013-2016)

P value 1.000

Plastic gowns available in one unit from the study areas.

Table6-4. Safety glasses availability in critical care areas in Khartoum state, 5 public

hospitals (2013-2016)

Disposable gloves availability Pretest

%

Posttest

%

Total

available 200

(100.0%)

200

(100.0%)

400

Not available 0

(.0%)

0

(.0%)

0

Total 200

200 400

Plastic gown availability Pretest

%

Posttest

%

Total

available 14

(7%)

13

(6.5%)

27

Not available 186

(93.0%)

187

(93.5%)

373

Total 200

200 400

Safety glasses availability Pretest

%

Posttest

%

Total

available 0

(.0%)

0

(.0%)

0

Not available 200

(100.0%)

200

(100.0%)

400

Total 200

200 400

77

Table 6-5. Shoes covering availability in critical care areas in Khartoum state, 5 public

hospitals (2013-2016)

P value 1.000

Shoes covers was available in one unit from study areas.

Table 6-6. Face shield availability in critical care areas in Khartoum state, 5 public

hospitals (2013-2016)

No study area had face shield available before.

Shoes covering availability Pretest

%

Posttest

%

Total

available 8

(4%)

7

(3.5%)

15

Not available 192

(96%)

193

(96.5%)

385

Total 200

200 400

Face shield availability Pretest

%

Posttest

%

Total

Available 0

(.0%)

0

(.0%)

0

Not available 200

(100.0%)

200

(100.0%)

400

Total 200

200 400

78

Table 6-7. Plastic caps availability in critical care areas in Khartoum state, 5 public

hospitals (2013-2016)

P value .850

Participants showed little negative changes in availability of plastic caps in the second

assessment results.

Table 7. Assessment of critical care nurses knowledge about personality and coping

characteristics to gain success in life in Khartoum state, 5 public hospitals (2013-

2016)

Table 7-1. Assessment of critical care nurses knowledge about personality and coping

characteristics to gain success in life by being adventurous, in Khartoum state, 5 public

hospitals (2013-2016)

P value .000

Changes between the two assessments answers were appeared.

Plastic caps availability Pretest

%

Posttest

%

Total

Available 16

(8%)

14

(7%)

30

Not available 184

(92%)

186

(93%)

370

Total 200

200 400

Adventurous Pretest

%

Posttest

%

Total

Right answer 13

(6.5%)

160

(80.0%)

173

Wrong answer 187

(93.5%)

40

(20%)

227

Total 200

200 400

79

Table 7-2. Assessment of critical care nurses knowledge about personality and coping

characteristics to gain success in life by detaching in Khartoum state, 5 public hospitals

(2013-2016)

P value .000

Changes between the two assessments right answers were clearly notified.

Table 7-3. Assessment of critical care nurses knowledge about personality and coping

characteristics to gain success in life by adaptation in Khartoum state, 5 public hospitals

(2013-2016)

P value .000

Most of participants answered correctly in the second assessment results.

Detached based on defense

mechanism

Pretest

%

Posttest

%

Total

Right answer 15

(7.5%)

171

(85.5%)

186

Wrong answer 185

(92.5%)

29

(14.5%)

214

Total 200

200 400

Strong capacity for coping and

adaptation

Pretest

%

Posttest

%

Total

Right answer 77

(38.5%)

193

(96.5%)

270

Wrong answer 123

(61.5%)

7

(3.5%)

130

Total 200

200 400

80

Table 7-4. Assessment of critical care nurses knowledge about personality and coping

characteristics to gain success in life by hardiness in Khartoum state, 5 public hospitals

(2013-2016)

P value .000

About one quarter of respondents replied in correct manor during the first assessment.

Table 7-5. Assessment of critical care nurses knowledge about personality and coping

characteristics to gain success in life by resiliency in Khartoum state, 5 public hospitals

(2013-2016)

P value .000

Changes between the two assessments right answers were clearly notified regarding

resiliency.

Hardiness: control, commitment,

challenge and companionship

Pretest

%

Posttest

%

Total

Right answer 41

(20.5%)

169

(84.5%)

210

Wrong answer 159

(79.5%)

31

(15.5%)

190

Total 200

200 400

Resiliency (bounces back): insight,

independence, social support and

initiative

Pretest

%

Posttest

%

Total

Right answer 13

(6.5%)

174

(87.0%)

187

Wrong answer 187

(93.5%)

26

(13%)

213

Total 200

200 400

81

Checklist

(Adapted from CDC & AACCN)

Table 8. The number of critical care areas in each hospital

Frequencies represented numbers of critical areas in each hospital.

Table 9. The critical care units

Critical areas Frequency Percent

ICU 8 61.5

CCU 4 30.8

R R 1 7.7

Total 13 100.0

Frequencies represented types of critical care units.

Hospitals Frequency Percent

Khartoum

north 2 15.4

Omdurman 3 23.1

Alshaab 4 30.8

Khartoum 1 7.7

Ahmed

Gasim 3 23.1

Total 13 100.0

82

Table 10. Assesses critical care nurses practice regarding right using of preventive

measures of occupational hazards in CC areas, Khartoum state 5 governmental

hospitals (2013-2016)

Prevention measures

pre

post

frequency percent frequency percent

1. hand washing

in suitable

time

done perfectly

8

61.5

8

61.5

not done

5

38.5

5

38.5

total

13 100.0 13 100.0

2. wearing gloves

when needed

done perfectly

13

100.0

13

100.0

Hand washing not done in needed time, when there was no hand-washing sink available

or so far form the unit, no change noticed in pre/post observation.

83

Table 11. Assesses critical care nurses practice regarding right using of preventive

measures of occupational hazards in CC areas, Khartoum state 5 governmental

hospitals (2013-2016)

Prevention measures Pre

Post

frequency percent frequency percent

3. wearing plastic

apron

done but not perfectly

1

7.7

1

7.7

not done

12

92.3

12

92.3

total 13

100.0 13

100.0

4. use face shield

not done

13

100.0

13

100.0

5. don face mask

done perfectly

11

84.6

12

92.3

not done

2

15.4

1

7.7

total

13 100.0 13 100.0

6. use foot cover

done

1

7.7

1

7.7

not done

12

92.3

12

92.3

total 13

100.0 13

100.0

7. use eye cover

not done

13

100.0

13

100.0

Plastic apron not wearied perfectly because not changed between different patients care,

not done when not available. One area got shoes covers but really were head caps.

During second observation, one area was supplied by facemasks.

84

Table 12. Assesses critical care nurses practice regarding right using of preventive

measures of occupational hazards in CC areas, Khartoum state 5 governmental

hospitals (2013-2016)

Preventive measures Pre Post

frequency percent Frequency Percent

8. use head cover

done perfectly

1

7.7

1

7.7

not done

12

92.3

12

92.3

total

13

100.0 13

100.0

9. disposal of sharp

objects

done perfectly

13

100.0

13

100.0

10. linen handling &

disposal

done perfectly

1

7.7

1

7.7

done but not perfectly 8 61.5

8 61.5

not done

4

30.8

4

30.8

total

13

100.0 13

100.0

11. protect self from

radiation

done perfectly

13

100.0

13

100.0

Sharp objects well treated, dirty linens not collected properly, and poor transference to

laundries in eight areas, four areas not did linens care where offered by patient’s family.

85

Interview with hospital’s matron results

During august 2015 five hospitals matrons interviewed, the points discussed were:

1. availability of PPE and causes of gaps in supply

2. Availability of sinks, soaps and germicides.

3. Pre-employment education about safety measures

4. Assigned OHN in hospital

There was similarity in all matrons’ talks, especially in PPE provision and recruited

OHN, they sent their thanks to ministry of health because disposable gloves available in

all hospital wards. Face masks, plastic apron and head covers not regularly provided, the

rest of PPE not provided. They shortage of PPE due to low hospital income and credit in

ministry of health, the set of PPE is very expensive.

Area without hand washing sink, matron said because the building not designed for ICU

from the beginning. Soap available but germicides not regularly found.

No hospital offered new nurses planned pre-employment educational program concerning

OHs, Matrons told that, they made orientation talk about hospital and sometimes,

occupational health mentioned in term of safety practice.

No hospital recruited occupational health nurse.

86

Chapter (5)

Discussion

Conclusion

Recommendations

87

Discussion

The study highlights the clear effectiveness of study interventions evidenced by the

improved results of CCNs knowledge about occupational hazards types and preventive

measures for each hazards in CC settings. In post education results, as examples,

knowledge about Physical and ergonomics hazards in pre intervention results was

mentioned by 14.5% of respondents while 99.5% of respondents in post questionnaire

knew that hazards, for radiation hazard 17% in pretest while 100% in post intervention

result. For preventive measures, participants showed 93% of pre intervention knowledge

about chemical hazards prevention and 99.5% in posttest result, stress mitigation by

relaxation exercise results were 14.5% in pretest and 99% after the intervention and

training in relaxation techniques.

These findings supported study conducted by Chen-Yin Tung, in Occupational Hazards

Education for Nursing Staff through Web-Based Learning, Taiwan, (28)

After web-based learning, post-test scores of the experimental group were higher than the

control group in terms of knowledge, attitudes, and in their knowledge about the

prevention of occupational hazards.

Participants showed good knowledge about their work biological hazards and ways to

prevent them (100%). This may be similar to the results found in other studies, (the

results from Philippine revealed that the high knowledge of the respondents about

biological hazards 95.9%), Nigeria, Uganda and Sudan also showed high nurses

knowledge of nurses about biological hazards. (29, 30, 37)

the using of the necessary personal protective equipment was associated with reduced

exposure to both biological and chemical hazards, following recommendations from the

Centers for Disease Control, (CDC, 1989) for health care professionals’ to use PPE for

infection control. ( 2 )

Indeed, use and compliance with utilization of PPE has been recognized as important

infection control measure in the healthcare industry, which should be emphasized to

minimize exposure to occupational hazards. Despite these recommendations, PPE

provision contracting with that mention above is not proper in our study areas, gaps appear

88

in plastic aprons and face masks supplies, face shield, and shoes covers never been

provided to that areas. Prevention of biological hazards by adherence to PPE, took place in

many previous studies, no study mentioned gaps in PPE provision except this study and

other two studies carried out in Uganda and Namibia, which represented similar situations

in African developing countries.

A considerable portion of the respondents reported increased level in knowledge about

causes of occupational hazards faces them in work place even though the hazards name not

mentioned by them. The possible answers for these results might reveal the actual presence

of the hazards in their areas, also might reflect that when hazard mentioned for respondents

become easier for them to find out its causes, they were not familiar with such terms. E.g.

physical and ergonomic hazards known by 14.5% in pretest while 84% enumerated causes

of physical and ergonomic hazards in pretest.

Based on the descriptions of American Board for Occupational Health Nurses (ABOHN),

(38) The Roles and Responsibilities of Occupational Health Nurses are clinical activities,

manager or administrator, educator/advisory roles, advocator, nurse practitioner,

occupational health service coordinator, and health promotion specialist. These great

roles of OHNs are absent in our study areas because there is no recruited or assigned

nurse for this job, so many CCNs don’t have enough knowledge about many aspects of

OH, e.g. knowledge about coping methods with this stressful work to gain success in life.

The importance for the advisory and OH services coordinator roles of OHN in health care

team arise to mitigate the negative effects and motivate CCNs.

Occupational health nurses advocate for occupational health and safety policies, they can

be particularly effective at this level by directly monitoring workplace exposures and

advocating to management for actions that protect workers, the study found that no any

study area assigned occupation health nurse to performe these roles, which was

supporting Amosu, A. M study about occupational hazards in Nigeria. (29)

89

Conclusion

The above study can be concluded as:

Those in the nursing profession are susceptible to a number of occupational hazards, to

work in a hazardous job nurses need to follow universal safety practice measures e.g.

recommendation from CDC.

Unavailability of personal protective measures, working overtime, experiencing work

related pressures, overload of work, low income and the inefficient role of the occupation

health department, are the main points reported by participants.

90

Recommendations

According to the results the study found that the following points are recommended:

• Teaching about international datasheets on occupational hazards for ICU nurse

before employment needs to be practiced in critical care areas.

• Improvement of the physical and social environment of critical care settings.

• Occupational health Department at the level of the State should have a role in

protecting the workforce in hospitals.

• Reporting of occupational injuries and illnesses suggest a surveillance program.

It would be useful in identifying problems.

• Based on this study regular trainings and educational meetings to enhance

occupational safety, develop/introduce policies and guidelines or strategies on all

aspects related to occupational hazards/safety need to be offered in all Sudan

states hospitals.

• A well-trained occupational health nurse should be assigned to educate health

workers on the prevention and management of occupational hazards.

• Additionally an occupational psychologist should be introduced to teach health

workers on how to cope with stress and emotional disturbances within the

working environment.

• The knowledge on occupational hazard and safety among CCNS can be

improved through Workshops, in-service training, mass meetings and refresh

courses providing information on occupational hazards safety attended by

registered nurses on a regular basis.

• Develop effective continuous commitment program for provision of protective

measures.

91

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95

Annexes

Annex 1. Questionnaire

Annex 2. Checklist

Annex 3. Formal letters

Annex 4. Manual of the program

96

Annex 1.

RIBAAT NATIONAL UNIVERSITY - FACULTY OF POST GRADUATE

QUESTINARE ABOUT OCCUPATIONAL HAZARD IN CRITICAL CARE SETTINGS

Session one

1. Age:

20—30 ( ) 31---40 ( ) More than 40 ( )

2. Sex :

Female ( ) Male ( )

3. Graduation level of nursing:

Diploma ( ) Bachelor ( ) Master ( ) Doctorate ( )

4. What is the length of your experience in years?

Less than one year ( ) Less than five years ( ) More than five years (

)

5. What is your main working shift?

Session two

6. What is the meaning of occupational hazards?

External conditions and influences affect work population in their work area ( )

7. Enumerate types of occupational hazards in your work with an example of each

hazard?

• Biological hazards [infectious hazards] ( )

• Physical and ergonomics [noise, musculoskeletal injuries] ( )

• Chemical hazards [cytotoxic drugs] ( )

• Radiological hazards [portable radiography and fluoroscopy] ( )

• Psychosocial hazards [stress, conflicts, job dissatisfaction] ( )

Session three:

8. What are the causes of each hazard in your work?

*Biological hazards [infectious hazards]:

Blood or body fluids, by droplets in the air, or by direct contact. ( )

*Physical and ergonomics

97

Handling of heavy patients ( )

Long periods of work in a standing posture ( )

*Chemical hazards

Exposure to anesthetic gases (ethyl bromide, ethyl chloride, ethyl ether, nitrous

oxide), frequent use of soaps, disinfectants. ( )

*Radiological hazards

Portable radiography and fluoroscopy ( )

*Psychosocial hazards

Stress, conflicts, job dissatisfaction ( )

Session four

9. What are the preventive measures that used to protect CCNs from work hazards?

5. *Infectious hazards:

- Use of gloves, masks, gowns, or eyewear when direct contacts, ( )

- Washing of hands and other skin surface after contamination ( )

- Use of effective germicides for cleaning spills of blood or body fluids ( )

- Proper handling and disposal of needles or other instruments. ( )

2. *Musculoskeletal hazards (back pain):

- Maintain good posture ( )

- Use mechanical devices for lifting ( )

- Review knowledge of proper lifting techniques ( )

- Design workplace layout using ergonomic principles ( )

- Provide adequate staffing ( )

- Exercise ( )

3. *Chemical hazards:

- Strict adherence to body substance isolation precautions e.g. gloves ( )

4. *Radiation Hazards:

- By time, ( )

- By distance, ( )

- And by shielding. ( )

5. *Chemical dependency:

- Reduction of stress and suffering ( )

6. *stress:

- Relaxation exercise ( )

- Coping and adaptation ( )

98

- Social support ( )

Session five

10. What are the components of universal precautions?

12. Hand washing ( )

13. Personal protective equipment [PPE] ( )

14. Preventing/managing sharps injuries ( )

15. Aseptic technique ( )

16. Isolation ( )

17. Staff health ( )

18. Linen handling and disposal ( )

19. Waste disposal ( )

20. Spillages of body fluids ( )

21. Environmental cleaning ( ) 11. Risk management/assessment ( )

Session six

22. Do you have this personal protective equipment in your units?

Available Not available Other

1. Face mask

2. Disposable gloves

3. Plastic gowns

4. Safety glasses

5. Shoes covering

6. Face shield

7. Plastic caps

Session seven

23. What are the personality and coping characteristics of successful CCNs?

- Adventurous ( )

- Detached ( based on defense mechanisms) reduces anxiety level ( )

- Strong capacity for coping and adaptation ( )

- Hardiness: control, commitment, challenge, companionship ( )

- Resiliency (bounces back): insight, independence, social support, ( )

and initiative.

24. What are your suggestions to improve your work environment?

------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------

99

Annex 2.

Check list to assess CCNs attitude regarding hazards prevention

Protective measures Done perfectly Done but not perfectly Not done

1. Hand washing

2. Wearing d. gloves

3. Wearing plastic apron

4. Put face shield

5. Put face mask

6. Use foot cover

7. Use head cover

8. Use eye cover

9. Disposal of sharp

objects

10. Linen handling &

disposal

11. Protect self from

radiation

Adapted from C D C & AACC

100

Annex three. Formal Letters

101

Annex four.

The manual of educational program