Select a peer-reviewed journal that has a research study [not provided in the course readings] related to quality monitoring (needle stick, falls, etc…) in health care delivery. In the discussion post provide:
- a brief overview of the article
- the process indicator or outcome indicator that is used to measure quality
- whether the indicator effectively measures the problem – why or why not
- report economic, legal, and regulatory processes that affect the quality initiative
- a way to monitor and measure one aspect of your current practice (turning patients, time spent collaborating with other health care workers, medication delivery, etc…)
- APA STYLE 7TH EDITION
- THE ARTICLE IS ATTACHED ( YOU MUST USE THE ARTICLE ATTACH AND TALK ABOUT EACH TOPIC.
- 1 AND HALF PAGE MINIMUN
ccidental needlestick injuries (NSIs) are
the predominant sharps-related problem in
industrialised countries (Prüss‐Üstün et al,
2005). NHS Employers estimates that there are
approximately 40 000 NSIs a year and recognises
that the true figure may be twice this, as many go unreported
(NHS Employers, 2015). Measures to prevent sharps injuries can
best be implemented using initiatives identified in the European
Directive (European Council, 2010). The directive announced the
modification of work practices that pose a risk of sharps injury
in order to make them safer and introduced a complete end to
the recapping of needles. It promoted a range of initiatives to
prevent NSIs, such as training, use of needle-safety devices (NSDs),
using sharps containers and improved treatment and care after an
NSI has occurred. The author will focus on training and safety
devices as these have been recognised as making the most impact
in reducing NSIs (Beswick et al, 2012; Cheetham et al, 2016).
Do training and needle-safety devices
prevent needlestick injuries?
A systematised review of the literature
This systematised review was undertaken to appraise research on the effects
of training and the use of needle-safety devices (NSDs) on the prevention of
needlestick injuries (NSIs) among health workers, focusing on a European
perspective. A literature search from 2007 to 2017 was performed, which
identified six studies that investigated the introduction of training and NSDs
and their affect on NSIs. The six chosen studies identified that training, as
well as the adoption of NSDs, has an impact on preventing NSIs. However,
further information is required on the content and mode of delivery of training
and on which types of NSDs are most effective at preventing injuries. This
will help healthcare workers to understand and implement the most effective
strategies to prevent injuries. This article provides a critique of the research
approaches used in the six studies.
Key words: Needlestick injuries ■ Needle safety devices ■ Needlestick
Ann-Marie Aziz, Clinical Lead: Infection Control and Prevention,
Pennine Care NHS Foundation Trust, Manchester,
Accepted for publication: July 2018
This systematised review focused on research from a European
perspective, gathering information on studies that have been
undertaken in European countries, highlighting measures that
have helped to reduce NSIs prior to and after the introduction
of European legislation (European Council, 2010). A search of
the literature from 2007 to 2017 was performed, stipulating
those studies that were available in English.
To achieve evidence-based healthcare, it is recommended that
clinicians formulate clinical questions in terms of the problem/
population, intervention, comparison, and outcome (PICO)
(Huang et al, 2006). The PICO framework is also a strategy
for framing a research question (Beitz, 2006).
This study’s research question (does training and the use
of NSDs prevent NSIs?) was broken down into the four
PICO components to facilitate the identification of relevant
information (Box 1). A clinical question needs to be directly
relevant to the patient or problem at hand and phrased in such
a way as to facilitate the search for an answer. PICO makes
this process easier as it helps to formulate the search strategy
by identifying the key concepts that need to be investigated.
The agreed search terms were sufficiently selective to exclude
papers outside of the topic areas (Figure 1). Database searches
were undertaken in AMED, British Nursing Index, CINAHL,
HBE (Health Business Elite), HMIC, Embase, Medline,
PsycINFO, PubMed, Science Direct, Google Scholar and the
Cochrane Library. The use of comprehensive search engines is
consistent with recommendations given in a discussion paper
about systematised reviews for occupational health research
(Nicholson, 2007). The full process of the literature search is
shown in Figure 1. To identify which articles to include in the
review and to confirm that these are the only relevant articles
that could be obtained after the literature search, inclusion and
exclusion criteria were created.
Inclusion criteria were:
■ Search terms included in the title or abstract
■ Studies from 2007 to 2017
■ English language studies
■ European studies
■ Studies involving healthcare workers, hospitals
■ Studies that showed education, training and NSDs prevented
944 British Journal of Nursing, 2018, Vol 27, No 16
■ Studies that showed a numerical reduction in NSIs
■ Studies that showed a statistical significant reduction in NSIs.
Exclusion criteria were:
■ Studies that showed only a reduction in NSIs without
including training of staff
■ Studies that did not show a reduction in NSIs (some studies
did not provide information on NSI reduction, but simply
discussed the introduction of NSDs and/or training)
■ Studies that evaluated NSDs only (and did not include
■ Studies that evaluated training only (and did not include
■ Non-European studies
■ Studies where the full text could not be obtained (two
studies were in Spanish and could not be translated in the
time limit of the study)
■ Studies on blunt needles, double gloving, splashes and body
fluid exposure risk
■ Studies involving reporting and evaluating NSIs
■ Studies evaluating costs of NSIs
■ Studies looking at risk factors for NSIs.
Nineteen articles were assessed against the inclusion criteria.
Six were chosen for the study as they met the aim of this
systematised review, to assess if training given to healthcare
workers as well as the adoption of NSDs, has an impact on
preventing NSIs. The six studies comprised five cohort studies
and one randomised controlled trial (RCT) (van der Molen
et al, 2011) (Table 1). Of the 19 studies, the following were
excluded from the study: Falagas et al (2007), Lamontagne
et al (2007), Little et al (2007), Prunet et al (2008), Wicker
et al (2008a), Wicker et al (2008b), Brusaferro et al (2009),
Costigliola et al (2012), Dante et al (2014), Frickman et al
(2016), Ganczak et al (2016), Dulon et al (2017), and Bossi
et al (2016).
Quality and bias assessment
Empirical studies show that certain aspects of trials conducted
are associated with bias (Higgins et al, 2011). It was important
to assess the studies chosen for this review for bias. Those studies
with a low or high risk of bias may result in inappropriate
recommendations for practice or policy (Norris et al, 2011).
To prevent this, a critical appraisal is recommended to identify
which findings are most reliable (Higgins et al, 2011). To ensure
this review acknowledged the risk of bias, the author used two
quality screening tools. The Effective Public Health Practice
Project (EPHPP) tool was used to assess the non-randomised
studies for quality and bias, scrutinising six domains: selection
bias, study design, confounders, blinding, data-collection
methods and withdrawals/dropouts (Deeks et al, 2003). The
Cochrane Collaboration’s tool for assessing risk of bias was
utilised for the RCT (Higgins et al, 2011).
The EPHPP tool is used to assess study quality based on
component ratings. According to this tool, a study assessed
as ‘strong’ achieves four strong ratings and no weak ratings.
A study assessed as ‘moderate’ has fewer than four strong
ratings and one weak rating; and a weak study achieves two
or more weak ratings. The EPHPP tool was chosen because
it had been recommended as suitable for non-randomised
intervention studies (Deeks et al, 2003). The tool allows for
the evaluation of study designs and provides clear guidance
for assessment so that it could be applied and interpreted in
a logical format. The tool’s validity and reliability has been
tested in various studies (Thomas et al, 2004).
Box 1. Population, intervention, comparison, outcome (PICO) framework
P Population (healthcare workers, hospital, healthcare sector)
I Intervention (introduction of needle-safety devices and training, education,
C Comparison (no training and traditional sharps equipment)
O Outcome (rates of needlestick injuries)
Search terms examples:
■ Preventing needlestick injuries
■ Training and education reduces
■ Needle-safety devices prevent
Records limit to:
■ Inclusion criteria words in
title or abstract
■ Limit dates to 2007 to
■ English language articles
HDAS records screened for
Other sources of information:
European studies assessed
for inclusion criteria: (n=19)
European studies included in
systematised review (n=6)
Records identified through:
■ BMJ Journal Collections
■ Ganczak et al (2016)
■ Citation searching (n=3)
■ Existing systematic/
literature reviews on subject
■ Prüss-Üstün et al (2005)
■ Health and Safety Executive
■ Beswick et al (2012)
■ Royal College of Nursing
■ NHS Employers (2015)
■ Loveday et al (2014)
Figure 1. Flowchart showing database search strategy and combination of results
for identification of studies for inclusion in review
British Journal of Nursing, 2018, Vol 27, No 16 945
Data synthesis from the chosen studies
The review identified that the chosen studies identified moderate
quality evidence that training and NSDs do prevent NSI.
Nationality, language, publication information
The chosen articles were reports of research in Spain, Italy,
France, the Netherlands and Germany. There were very few
published articles undertaken on the subject in the UK that
combined both training and the use of NSDs as interventions
to reduce the number of NSIs. This review included only
evidence from published articles, which could be misleading if
conclusions are ultimately based on these criteria. The literature
shows that an article has a better chance of being published if it
is published soon after the study has taken place, shows positive
results and is financially supported by sponsors (Dubben and
Beck-Bornholdt, 2005). This is referred to as publication bias and
one way to counteract this is to access data from unpublished
work. Song et al (2013) stated that unpublished work should
be included in all systematised reviews and state this bias can be
reduced by searching trial registers for completed and ongoing
studies; searching informal publication sources including meeting
abstracts (included within Cochrane trial registers) and PhD
theses; searching regulatory bodies (such as the US Food and
Drug Administration (FDA) database); contacting the authors
of included studies; and contacting pharmaceutical or medical
device companies for further studies.
There were several articles published on the subject by Spanish
authors (Valls et al, 2007; Tejerina et al, 2008; Catalán et al, 2010;
Funes-Artiaga et al, 2012). However, as the research was limited
to English language articles, only one study was included (Valls
et al, 2007) because this showed that training and NSDs led to a
reduction in NSIs. The author is aware that exclusive reliance on
English language studies may mean that not all of the evidence is
represented in this review and may have introduced a language
bias and lead to erroneous conclusions. This was unavoidable as
the added time and cost of translation of articles was deemed
not feasible within the restrictive timeframe.
There were various study designs included in the review; five
could be broadly described as cohort studies, and the sixth was
an RCT. No reason was given by the authors of the five cohort
studies for choosing their study design or why they did not adopt
a more rigorous approach such as an RCT. This may have been
due to the disadvantages associated with RCTs in terms of the
large numbers of participants required, cost, time and the need
to obtain ethical approval, which can be a lengthy procedure.
However, RCTs, often described as the ‘gold standard’ of scientific
research, allow the investigation of the effect of an intervention
while eliminating common research bias. The quality of chosen
studies may have improved if they had undertaken an RCT. This
may have reduced bias associated with confounders (for example,
authors did not indicate how training before and after NSDs were
introduced differed or was similar).
Participants in the studies were not blind to the intervention
under investigation, which may have introduced bias. Descriptions
of data-collection methods and self-reporting of NSIs were
ambiguous. For these reasons the studies were deemed weak or
moderate in the quality assessment. Only one study included
withdrawal figures and dropout rates (Sossai et al, 2016). It is
necessary for research to indicate the dropout rate, as this is a
serious potential for bias. This may constitute a fatal flaw in a study,
as dropouts result in incomplete data that can lead to inaccurate and
spurious findings and erroneous results if dropout rates are high.
This review was unable to find a sound scientific methodology
in any of the six chosen studies. An ideal environment for
undertaking research is one that is controlled, allowing a
hypothesis to be tested under set conditions. However, this is
frequently impossible in certain areas, particularly busy hospital
wards. The practice of experimental control and reproducibility
can have the effect of diminishing the potentially harmful effects
of personal bias (when researchers tend to observe what they
expect to observe). Using the RCT format should reduce the
likelihood of such biases occurring and enable clinicians to have
confidence to base practice on the findings.
Table 1. The six studies included in the review
Authors Title Study setting Training given? Needle-safety
Valls et al
Use of safety devices and the prevention of percutaneous injuries
among healthcare workers
Spain Yes Yes Yes
Sossai et al
Using an intravenous catheter system to prevent needlestick injury
Italy Yes Yes Yes
Tosini et al
Needlestick injury rates according to different types of safety-
engineered devices: results of a French multi-centre study
France Yes Yes Yes
van der Molen
et al (2011)
Better effect of the use of a needle safety device in combination
with an interactive workshop to prevent needlestick injuries
Netherlands Yes Yes Yes
Reduction of needlestick injuries in healthcare personnel at a
university hospital using safety devices
Germany Yes Yes Yes
Sosai et al
Efficacy of safety catheter devices in the prevention of
occupational needle stick injuries: applied research in the Liguria
Italy Yes Yes Yes
946 British Journal of Nursing, 2018, Vol 27, No 16
In one study in which new NSD devices were introduced,
healthcare workers still had access to the conventional devices
during the intervention period (van der Molen et al, 2011).
NSIs caused by the conventional devices may have been mis-
categorised as occurring when using the new NSDs, reducing
the effect of the intervention and the quality of the research.
All the studies chose participants who were employed in a hospital
and had clinical experience using sharps equipment. There was
no selection bias introduced by the selection of the individuals
in the studies, as the healthcare workers were representative of
the population under review.
Of the six studies analysed, the number of participants was
included in only four:
■ Valls et al, 2007 (n=75)
■ Sossai et al, 2010 (n=4636)
■ van der Molen et al, 2001 (n=491)
■ Hoffmann et al, 2013 (n=6683).
Two studies did not disclose the number of participants but
gave the number of NSDs used and the numbers of NSIs in the
time period of the study (Tosini et al, 2010; Sossai et al, 2016). This
total of 11 885 participants would not be considered representative
of the vast numbers of health workers who use NSDs and so
no real significance or positive correlation could be inferred.
When undertaking scientific research, the study population is
an important feature and an essential item to be included to
reduce the probability of error, respect ethical standards, and
define the logistics of the study (Martínez-Mesa et al, 2014). It
allows conclusions to be drawn about the target population, as
long as it is representative of the latter.
Needlestick injury reporting
Under-reporting of NSIs was acknowledged in all the studies. This
was recognised as a possible confounder and an issue that needed
to improve in future studies if the extent of NSI occurrence is to
be identified. All studies undertook purposive sampling, which is
where the researchers have purposely selected the members of
population to study. This is subjective sampling, usually used to
save time and money. It can, however, have low levels of reliability
and high levels of bias, making it difficult to generalise to the wider
population. Undertaking research outside the hospital setting
(which none of the studies included) may have had a different
outcome. Healthcare settings such as nursing homes, GP clinics,
private hospitals, ambulance trusts and community services all use
sharps equipment but were not included in any of the research
studies. Researchers may have wanted a more homogenous
sample for ease of research, but diversifying the methodology
and including other groups outside the hospital setting may have
provided richer data and lead to stronger conclusions.
The study of NSI incidence when using NSDs could benefit
from a long-term analysis. This was lacking in the studies selected.
By including a long-term analysis of interventions, outcomes
may have proved different from short-term effects, which can be
misleading (Pelton and van Manen, 1996). Using the NSDs for
longer could have potentially showed injuries return to the levels
before the NSDs were introduced because healthcare workers may
revert to their usual practices once a short-term study has finished.
Some studies have shown that NSIs still occur despite NSDs
being used (Sohn et al, 2004; Tarigan et al, 2015; Dulon et al,
2017). Long-term studies are required for this subject to give
more of a balanced account of their lasting effectiveness and
trends on injury rates. However, this type of research can have
problems with dropout rates, maintaining funding, and waning
enthusiasm among participants and researchers, all of which
ultimately impacts on the validity of results.
The chosen studies had different denominators used to analyse
the effects of the interventions to reduce NSIs. The denominators
for the self-reported NSIs were patient-days and patients (Valls
et al, 2007), medical devices purchased (Sossai et al, 2010; Tosini
et al, 2010; Hoffmann et al, 2013; Sossai et al, 2016) and numbers
of healthcare workers (van der Molen et al, 2011).
Tarigan et al (2015) stated that many studies measuring the
effect of introducing NSDs on NSIs have given the denominator
as a combination of the number of devices used, devices purchased,
full-time equivalent staff, working hours, occupied beds, patient
days and healthcare workers. It has been argued that the best
denominator would be patient days, because of the availability of
accurate figures (Chen and Gluud, 2005). The author argues that
a standard denominator needs to be recognised across all NHS
trusts so comparisons can be made on which are performing
well in the reduction of NSIs and which are failing. Currently
there is no objective measure across NHS trusts.
The authors of the six chosen studies did not indicate whether
ethical approval had been sought or gained for the research
including the authors of the RCT. The investigators may not
have sought ethical approval as they considered introduction of
the NSDs and training in their use would reduce the risk of harm
to participants. Ethics screening tools are available to determine
if ethical approval is required (Endacott, 2004), but their use was
not discussed in the studies. The studies might have benefited
from alluding to the potential risks (of using new devices) and
the inclusion of ethical terminology such as ‘maintaining privacy’,
‘confidentiality of data’ and obtaining ‘informed consent’ from
participants. These terms, indicating good research accountability,
were missing from the studies and should have been documented
to ensure the research was conducted in a safe and principled
way (Smajdor et al, 2009).
There is an emphasis on quality improvement programmes in
the NHS (Wenborn and Mountain, 2016). Making a distinction
between what constitutes audit, quality improvement and research
is important in the context of enhanced clinical and research
governance requirements. When conducting research clinicians
should not rely on professional judgement as an alternative to
formal ethics committee procedures. The ethical approval process
analyses the risks involved in the research and how to manage
those risks, helping to protect participants from harm (Endacott,
2004; Smajdor et al, 2009). Ethical approval also helps in cases
of litigation if, for example, any of the participants in a study
acquired an NSI using the NSDs.
British Journal of Nursing, 2018, Vol 27, No 16 947
Alternative research techniques
The addition of qualitative research techniques or using a mixed
methodology could have improved the studies. Incorporating
observations or interviews may have added another dimension to
research into preventing NSIs. Interviewing participants may have
elicited information on NSIs that were not reported. Healthcare
workers may not have reported NSIs due to the time it takes to
complete the reporting process. Interviews may have gathered
information on why staff did not report a NSI and which NSI-
preventing measures work in practice. Counting the number
of NSIs reported may have been a misrepresentation (even a
falsification if all NSIs were not reported) of the problem, and
including a richer, deeper understanding of the work environment
and practices through interviews may have elicited further
precursors to injuries. During data analysis, qualitative data can
assist with interpreting, clarifying, describing, and validating
quantitative results (Doorenbos, 2014).
The chosen studies were liable to researcher bias, where the
researchers performing the research influence the results, in
order to portray a certain outcome (Pannucci and Wilkins, 2010).
Another factor was that the researchers in the six chosen studies
were not nurses but doctors or academics based in universities,
so findings may not be applicable to NHS nurses. Nurses need
to be more involved in research, especially when the outcome
could affect their clinical practice. Barriers to nursing research
have been found to be a lack of time, funding or practical support,
and difficulties navigating regulations (Tanner and Hale, 2002).
More nursing research will enhance the status of nursing and
help to improve nursing care.
All the studies disclosed that funding was obtained to support the
research. There can be a negative perception of funded research,
as it can be seen as potentially skewing the results in favour of
a new drug or device. This potential bias should be highlighted
in the research and identification of the supporting company
should always be given (Pannucci and Wilkins, 2010).
Thematic analysis of findings and discussion
This systematised review was unable to find a sound scientific
methodology in any of the chosen studies. The studies showed
evidence of bias in the areas of selection, study design, blinding
and lack of dropout rates. Attention to these areas in future studies
would improve research quality and enable generalisations to be
made to the wider population. The recurring themes from the
research were that training and safety devices can prevent NSIs;
however, information on what form the delivery of the training
should take and what type of device is most effective was absent.
Descriptions of the training provided varied in all studies. Some
studies did not mention the content of the training (Tosini et
al, 2010; Hoffmann et al, 2013). Training in two of the studies
included several hours of taught sessions, including hands-on
training with the devices, with some of the training being
provided by the manufacturers of the NSDs (Valls et al, 2007;
Hoffmann et al, 2013). Training given to the participants in three
studies (Valls et al, 2007; Sossai et al, 2010; van der Molen et al,
2011) was varied and incorporated taught sessions depicting issues
around preventing, managing and reporting injuries. Some studies
included the dangers of blood-borne infectious diseases such as
hepatitis B, hepatitis C and HIV in their training (Valls et al, 2007;
Sossai et al, 2010; Hoffmann et al, 2013; Sossai et al, 2016). The
training highlighted practices to minimise the risk of exposure to
these infections and the wearing of personal protective equipment.
Written instructions regarding the handling of sharp needles and
other instruments were provided to participants with risks relating
to exposure to blood. Training depicted standard precautions and
mandatory protocols to adopt in case of injury or exposure and
to whom and how to report any injury.
Training as an intervention to prevent NSIs was of particular
interest to the author as it was hoped that information gathered
here would inform and instruct future training sessions to prevent
NSIs in the author’s workplace. As an infection prevention and
control (IPC) nurse who teaches NSI prevention, the mode
of delivering this training was of particular interest. However,
information on this topic was lacking in the six selected studies.
Content, delivery techniques, measures of assessing training needs,
modes of delivery (such as e-learning, face-to-face learning in the
classroom, webinars, workbooks and lectures) and competency
assessing were overlooked in the research. This was disappointing
as the author was hoping use such information to improve practice
in her trust.
Training in the NHS
Training can enhance the skills, capabilities and knowledge
of staff in the workplace (Royal College of Nursing (RCN),
2013). The training process in the NHS is continuous, as new
skills, knowledge and techniques are frequently introduced.
Appropriately trained workers waste less time, money and
resources and have fewer accidents (Health and Safety Executive
(HSE), 2016). So it is imperative that organisations get the training
right. There are many challenges in delivering training in the
NHS, such as the overwhelming number of subjects that need
to be covered. Training can soon become out of date as new
directives are published and new equipment is purchased. It also
often takes nurses away from patient care. Tailoring training to
an organisation’s or individual’s needs will help overcome many
challenges. All training must have clearly stated learning outcomes.
The way in which training is delivered also needs more
attention; an external trainer can be beneficial as they may be
an expert in the field and deliver the training in a professional
and interesting way. However, they may be expensive and lack
awareness of the culture of the organisation.
Delivering training in the NHS can be challenging as it has
to be delivered to members of different hierarchies, cultures
and generations (Sarre et al, 2018). Trainers must consider
different learning styles, languages and how members of
different generations prefer to be trained. Ensuring that all staff
are fully engaged in learning is another of the problems faced
in training and development. An effective approach to ensuring
engagement is to make the trainees stakeholders in their own
948 British Journal of Nursing, 2018, Vol 27, No 16
learning. Undertaking personal staff appraisals, using surveys and
appealing to their organisational and individual goals can make
employees feel that they have been fully involved in training
development (The King’s Fund, 2015).
A training method most commonly used in the NHS is
e-learning. This is probably because it is inexpensive, quick and
does not entail staff leaving the workplace. However, this model
of training can be problematic in trying to capture all staff due to
the lack of computers and staff unable to find time to complete
it during their busy duties. Using e-learning also does not
guarantee that staff will increase their knowledge on preventing
NSIs as there is sometimes no discussion, tests or competency
assessment afterwards. E-learning for teaching prevention of NSIs
can be challenging for IPC staff, as it is fraught with issues—staff
may have minimal computer literacy skills, there may be technical
problems, and issues with time management and self-motivation
(RCN, 2013). These may all negatively impact staff learning
about NSI prevention.
The author believes that the delivery of training needs to
improve if the NHS is to make a noticeable reduction in NSIs.
Training can be delivered via many multi-modal routes (Zafar
et al, 2009) and its success tested using pre- and post-training
questionnaires (Rajkumari et al, 2015). NSI prevention training
in the NHS needs to be more creative to engage staff and make
learning more worthwhile, interesting and meaningful. Practical
training in relation to NSD use may be more successful in helping
to prevent NSIs than e-learning. Further research is required on
the effectiveness of training and the reduction of NSIs.
The studies in this systematised review (n=6) described the NSDs
used and the practices for which they were being used. Practices
undertaken using the NSDs were phlebotomy, intramuscular
injections, subcutaneous injections, intravenous access and blood
gas analysis. All the studies except two (Valls et al, 2007; van der
Molen et al, 2011) included and explained the characteristics of
the NSDs and categorised the NSDs as either ‘passive’ or ‘active’
devices. Passive NSDs do not require additional steps to initiate
the safety feature.
Two literature reviews (Parantainen et al, 2011;Yang and
Mullan, 2011) have observed that passive devices were the most
successful type of NSD in reducing NSIs. Passive devices in the
study by van der Molen et al (2011) also showed a reduction
in NSIs but the study did not make a comparison with active
NSDs. Active NSDs require the healthcare worker to press the
syringe so the needle retracts after use on the patient and this
may be the reason for the increased difficulty when using them.
Use of passive devices may reduce the likelihood of NSIs as the
user can safely cover the needle and does not have to press to
retract the needle.
Only one study compared passive and active devices (Tosini
et al, 2010) and also subdivided the active NSDs into those
with a protective sliding shield, those with a protective needle
shield aligned to the bevel-up position and toppling over the
needle, and those with a semi-automatic safety feature (i.e.
an automatic safety feature requiring one-handed activation
by pushing a button or a plunger). An evaluation of the
effectiveness of the different NSDs found that the passive
devices were more effective in reducing NSIs (Tosini et al,
2010). Specifically, self-retracting lancets (for capillary blood
collection) showed the lowest incidence of NSI among the
product types included in the study. The study did not evaluate
passive venous blood-collection devices and so caution should
be exercised so as not to generalise findings obtained from
just one type of blood-collection device.
Results and implications for practice
This review found that nurses have the highest incidences of NSIs
(van der Molen et al, 2011; Motaarefi et al, 2016), so targeting
this group of staff for raising awareness and training is imperative.
However, as it is not only nurses who use sharps equipment,
all healthcare workers (doctors, laboratory staff, phlebotomists
etc.) prone to injuries must receive training. Studies have shown
that less experienced staff have more NSIs (Sharma et al, 2010)
so particular attention is required to inform new starters in
healthcare organisations about the prevention of NSIs. Fourie
and Keogh (2011) argued that educational initiatives on needle
safety should be focused on safety during administering injections
and recapping of needles (now banned in the NHS) as most
injuries occur during these times. Therefore, specifically targeting
training and injury prevention around these procedures is vital.
As a result of undertaking this review, further improvements
in clinical practice to prevent NSIs have been revealed. Training
compliance of all healthcare workers should be monitored
centrally in all NHS trusts, with compliance rates being produced
monthly to ascertain if staff have completed the mandatory
training (Dulon et al 2017). In consultation with unions and
staff, trusts might consider penalising, fining or disciplining staff
for not undertaking their training. A root cause analysis (RCA)
on all NSIs is also a consideration to reduce NSIs. However, the
author believes that RCAs can be ineffective if undertaken by
inexperienced personnel, if they are not supported by managers,
and can lead to a focus on ineffectual action plans that do not
take wider organisational constraints into consideration (NSIs
still occur because managers do not want to pay for RCAs). To
maximise learning from RCAs, descriptions of implemented
risk controls and their effectiveness need to be shared within
and across organisations (Peerally et al, 2016).
Training to prevent NSIs is fundamental and requires a radical
shift in the way it is currently delivered. The author believes
that reliance on e-learning as a panacea is futile, with many
staff unwilling or unable to do it, and with little benefit gained
from those staff who have done it, in the author’s experience.
Other ways of delivering training need to be considered. This
review provided no useful models for the delivery of training.
NHS England (2014) has stressed the importance of training,
retraining and retaining staff. However, a huge investment is
required. Training to prevent NSIs should be regularly reviewed,
audited for its effectiveness and be part of the annual mandatory
training requirements to which all NHS organisations (and non-
NHS organisations) should adhere (Beswick et al, 2012).
The training required when introducing new NSDs
(Cheetham et al, 2016) can be provided by representatives from
manufacturers or led by trained clinicians. Training should involve
British Journal of Nursing, 2018, Vol 27, No 16 949
practical sessions focusing on the different procedures undertaken,
such as blood collection or injections (Tosini et al, 2010). Further
research on what constitutes effective training in the NHS is
required. An inspection carried out in 2015-16 within 40 NHS
organisations across England, Scotland and Wales revealed that
83% were not complying with sharps regulations (HSE, 2016).
The HSE inspection found there was still widespread use of non-
safe devices, staff not being provided with adequate information
and a lack of consistency with reporting injuries. This is obviously
disappointing considering the European Directive had been
published 6 years earlier (European Council, 2010). However,
due to the political landscape changing and the introduction of
austerity measures into the NHS, many organisations had to make
some difficult decisions in terms of cost savings and perhaps staff
training and the introduction of modern safety devices were the
unfortunate casualties (NHS England, 2014).
This systematised review has shown that NSDs do reduce NSIs
and organisations should be using them as a means of reducing
injuries. There is minimal evidence that a passive NSD is safer
to use than an active NSD or vice versa (Tosini et al, 2010; Yang
and Mullan, 2011). Further research on this is required to analyse
which types of devices are the safest to use. An evaluation is
required periodically when NSDs are introduced to measure
their efficacy and any possible changes to injury rates that have
occurred. When safeguarding/incident forms are completed
because a healthcare worker has sustained an NSI despite using
an NSD, this should trigger an investigation to determine what
happened, why it happened and how such an injury could be
prevented in the future (HSE, 2016). Findings should also be
reported to the manufacturers that supplied the NSD.
Nurses should be aware that, despite their potential to reduce
NSIs rates, NSIs can still occur when using NSDs (Sohn et al,
2004; Tarigann et al, 2015; Dulon et al, 2017) and no study has
shown that their use has completely eradicated NSIs. Therefore
any new device should be approached with a degree of caution.
Implementing any change into practice has many challenges
and these changes to practice should be managed using project
management skills and change management theories, and
involve all stakeholders (Gopee and Galloway, 2017). These are
the leadership and management philosophies that are vital to
integrate research and theory into new practices to develop an
evidence base and improve safety (Gopee and Galloway, 2017).
As well as the financial cost of an NSI, the psychological and
human cost is also high, with healthcare workers comparing
the effect to post-traumatic stress disorder (Green and Griffiths,
2013). Therefore it is imperative that occupational health
(OH) departments that manage staff after NSIs offer support
or counselling to stem the anxiety that the injury may cause
(Wicker et al, 2014). However, the author notes that this may
be an unrealistic expectation as many NHS trusts are unable
to fund OH services adequately due to resource implications.
Further improvements are about ensuring that IPC teams work
closely with health and safety staff, and using OH at a strategic
level for maintaining continuous improvement in the prevention
and management of sharp injuries.
Procurement staff should also play a part in removing and
replacing traditional sharps with safer devices and no non-safety
devices should available on hospital equipment ordering systems
(HSE, 2016). Reducing the costs of NSDs will also increase their
appeal and present less of a barrier to using them (Mannocci et al,
2016). Finally, an initiative to improve practice and reduce NSIs
Table 2. Checklist to prevent a needlestick injury
Organisational level Yes No Notes
■ Are sharps injuries identified on the corporate risk
■ Is there an organisation-wide policy on the prevention and
management of sharps injuries?
■ Is the prevention of sharps injuries on the agenda of the
health and safety committee?
■ Do procurement and health and safety officers attend the
infection prevention and control (IPC) committee?
■ Are data on sharps injuries reported to the IPC
■ Do risk assessments exist for sharps injuries at a ward/
departmental level or for procedures?
■ Have control measures been introduced in line with the
hierarchy of controls (Royal College of Nursing, 2013)?
■ Is training provided for all at-risk staff on the prevention of
sharps injuries, safe use of equipment, reporting and first
■ Is training attendance compliance monitored?
■ Are sharps injuries (i.e. after needle-safety device use)
routinely investigated and root causes identified?
Ward/department/community level Yes No Notes
■ Are there information posters available for staff on dealing
with a sharps injury, with contact numbers for reporting?
■ Do staff know how and to whom to report a sharps injury?
■ Are accident-reporting systems (online or hard copy)
readily available for staff?
■ Are staff given feedback on the results of incident
■ Are staff offered hepatitis B vaccination?
■ Are staff able to attend training on sharps safety?
■ Where possible, are sharps and needles replaced with
■ Are safer needle devices used instead of conventional
■ Are sharps bins in use compliant with current standards
■ Are sharps bins readily available at the point of use?
■ Do staff know how to assemble and use sharps bins?
■ Do staff know how to dispose of (and lock) sharps bins?
■ Are sharps bins closed and removed when three quarters full?
■ Is personal protective equipment (gloves, goggles, aprons)
readily available for use with sharps equipment?
950 British Journal of Nursing, 2018, Vol 27, No 16
is the adoption of a safety checklist (RCN, 2013). This amended
version by the author can be used as part of a workplace inspection
or a sharps safety audit (Table 2). The author has included all the
pertinent points amassed from the wealth of literature included
in this review and produced a list of policies, procedures and
practices that prevent NSIs. It is hoped that adherence to this
checklist would assist organisations in reducing their injury rates.
The use of either a passive or active NSD combined with
training is an effective strategy to reduce NSIs. However, caution
is required as this systematised review was unable to provide strong
methodological, unbiased, long-term evidence to support such a
statement. Although the six chosen studies provided findings that
both NSDs and training increased staff awareness and reduced
NSIs, their methodological approaches were flawed and they
were small studies. They had a large number of biases in terms
of location, language, publication and researcher, and were
conducted by doctors and university academics. More nursing
research is needed. Longer-term research is required to bridge the
knowledge gaps that exist on what constitutes effective training
and what type of device (active or passive) is more robust and
reliable to achieve a consistent (and cost-effective) benefit for
This review has highlighted implications for practice and
discovered ways in which nurses can prevent NSIs. Improving
practices with training, adopting NSDs and being aware of the
financial and human costs of a NSIs is imperative if safety is
to improve. The delivery of training to improve NSIs needs to
improve with financial commitment and a reduced reliance on
e-learning in this area. Educators and trainers need to be more
creative and adopt models that engage healthcare workers by
making learning interesting and meaningful. This may help to
improve sharps safety. Further work is required to encourage staff
to use NSDs, with manufacturers playing their part in making
them easy to use, reducing costs and offering training. Under-
reporting of sharps incidents and injuries also needs to improve.
The findings from this review have enabled the author to create
a checklist (Table 2) which will be reviewed by the IPC team
with a view to being introduced into the author’s organisation.
Annual audits of this checklist (with a comparison of NSI rates)
will ensure the components have been used and practice has
improved. Information on the hazards of using needles and the
causes of NSIs need to be readily available to staff so they can
acknowledge these risks and take steps to mitigate against them.
Further research is required to support nurses in preventing NSIs,
improving practices and reinforcing the use of evidence-based
Declaration of interest: none
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CPD reflective questions
■ What are the main causes of needlestick injuries in your workplace and how could these have been prevented?
■ Does your workplace employ methods to reduce needlestick injuries, such as training and needle-safety devices? Is
the content of training in relation to the prevention of needlestick injury effective and is there a system of review to
■ Reflect on whether the use of the checklist (Table 2) would help to prevent needlestick injuries in your organisation
■ Are needlestick injuries being investigated and their psychological impact on staff being recognised in your organisation?
952 British Journal of Nursing, 2018, Vol 27, No 16
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