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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE AND ADDRESS


Dr. Suguna. A
Post Graduate Student
Department of Community Health
St. Johns Medical College
Sarjapur Road
Bangalore 560034.
Karnataka, India.
2. NAME OF THE INSTITUTION
St. Johns Medical College, Bangalore
3. COURSE OF THE STUDY AND SUBJECT
MD - Community Medicine
4. DATE OF ADMISSION TO THE COURSE
1st June, 2013
5. TITLE OF THE TOPIC
Morbidity profile of nurses in a tertiary care hospital and the effectiveness of educational
interventions on their knowledge regarding occupational safety and health
6. BRIEF RESUME OF THE INTENDED WORK
6.1 INTRODUCTION

Nursing is a lifesaving profession and nurses play a pivotal role in health care service. If
nurses who are the symbol of service and humanity are troubled by their own ill-health, or
other stressful circumstances, then they will not be able to give their full attention to this
demanding task. No hospital can function effectively if there is high incidence of ill-health
among nurses.1 Quality of care for hospital patients is strongly linked to the performance of
nursing staff. In line with this, creating a healthy work environment for nurses is crucial to
maintaining an adequate nursing workforce.2
Nurses are a significant group of healthcare personnel in any tertiary care hospital. The nature
of their work exposes them to a variety of occupational health hazards. Health and safety
issues among nurses are becoming an increasingly important subject as a result of the
emergence of highly infectious diseases such as hepatitis and HIV. Among the heath care
workers, nurses have a critical role to play and they are an important population to study their
level of knowledge regarding occupational safety and health.3
Knowledge regarding occupational safety and health (OSH) among nurses is important to
protect them from occupational hazards.4 However, till date these issues have received only
limited attention and obtaining information may be useful for developing programs to
increase compliance to preventive and promotive interventions for this cadre of health care
workers.

6.2 NEED FORTHE STUDY


The occupation related health hazards that nurses are exposed to include biological, physical,
chemical, psychological and ergonomic hazards and mainly are related to the pressures of job
and non-standard work facilities.5 There is a need for studies on nurses that focuses on
preventive health care, health promotion and health restoration within the context of OSH in
working environment. However only very few studies have been done in India on this topic.6
By assessing the knowledge on occupational hazards; predisposing factors to occupational
hazards; and ways of preventing occupational hazards among nurses; recommendations can
be made to enhance their knowledge through health education sessions and specific protective
measures. In a study conducted among nurses in health facilities in Abeokuta, Ogun state,

Nigeria to investigate the level of knowledge on the predisposing factors to occupational


hazards, 86.7% suggested proper training and retraining of nurses on safety measures is
needed to protect them from occupational hazards.7
Identifying the level of knowledge regarding OSH among nurses will help formulate a
training programme for their benefit.
Studies that address the overall morbidity patterns in nurses are limited. Review of literature,
revealed that there are only few studies published in India which look at a comprehensive
morbidity profile of nurses. This study therefore plans to study the morbidity profile and risk
factors associated with morbidity in nurses so that effective health and safety measures may
be developed and implemented.

6.3 REVIEW OF LITERATURE


Literature has been reviewed under the following heads:
a. Global burden of occupational hazards among nurses
b. Occupational health hazards in nurses
c. Prevention of occupational hazards

Global burden of occupational hazards among nurses:


While blood-borne disease safety has received more financial and institutional backing
notably from HIV programs than other OSH issues in the developing world, it is estimated
that according to a WHO study, the annual estimated proportions of health-care workers
(HCW) exposed to blood-borne pathogens globally were 2.6% for HCV, 5.9% for HBV, and
0.5% for HIV, corresponding to about 16,000 HCV infections and 66,000 HBV infections in
HCW worldwide.8

International chemical standards have improved in recent years, but enforcement lags in
developing countries. Where task-shifting occurs, staff may not be adequately trained to
handle chemicals properly. They may lack an adequate supply of masks, gloves, and eyewear,
and may work in buildings with inadequate ventilation. In many developing contexts where
new technologies and chemical processes are introduced to the health system, the extent of
chemical exposures is not easily quantified, and additional research is needed.
In Malaysia, ergonomics was the area of OSH where health workers demonstrated the least
knowledge. For such reasons, health workers may not report an injury or strain; therefore,
they often do not receive proper treatment, and little is documented9.
Stress was documented to increase cardiovascular disease among health workers in Colombia,
Mexico and Brazil. Gender inequality, discrimination, and violence were cited as major
reasons for absenteeism and diminished productivity in Rwanda among the countrys largely
female health workforce. Further, womens double role at home and work often leads to
additional physical burden.
A cohort study done by Reis R J et al in 2007 in Belo Horizonte, Brazil for 4years looked into
common morbidities among workers in public hospital and reported that most common
diagnoses associated with sickness leave were acute upper respiratory infection (14%)
followed by dorsopathies (7%).10
Occupational health hazards in nurses:
Nurses are exposed to biological hazards such as exposure to infectious blood, body fluids
and droplets through spills, splashes, aerosols leading to infections like tuberculosis, human
immunodeficiency virus,11 hepatitis B,12 and hepatitis C, MRSA

(methicillin resistant

staphylococcus aureus) etc.


Physical hazards include fall on a wet floor, cut injuries with broken glassware or microtome
knife, lifting of heavy objects, cumulative trauma disorders, electric shock, fire danger,
battery injuries and other mechanical hazards.13

Chemical injuries include latex allergy and exposure to toxic chemicals. Allergic sensitization
to NRL (Natural Rubber Latex) glove has become an important occupational health problem
among nurses.14 Exposure levels of cyclophosphamide as detected on the hands during
nursing tasks in wards were higher than those measured in the hospital pharmacy during
preparation of cyclophosphamide resulting in increased risk of a prolonged time to pregnancy
(on average one-month) among nurses with relatively high exposure to antineoplastic agents
(>0.74 g/week). Exposure to antineoplastic drugs also results in premature delivery and low
birth weight, spontaneous abortion, stillbirth, congenital anomalies.15
Ergonomic hazards due to the nature of their work, shift work, and the long hours spent at
their jobs which may consist of awkward and static postures, excessive force, repetitive
movements with insufficient rest or recovery time may result in musculoskeletal disorders and
headache. Studies showed that a large number of nurses suffer from work-related
musculoskeletal disorders (WMSDs).16,17 WMSDs are common among health care workers,
with the nursing population that constitutes about 33% of the hospital workforce at
particularly high risk, and accounting for 60% of the reported occupational injuries.18
Psychological feelings of depression, grief, behavioural problems including irritability, temper
tantrums, self-injurious behaviour are said to be common among nurses. Burn out and high
levels of job stress are known as some of major sources of occupational hazards for nurses.19
Other occupational hazards include physical assault, threatened or verbal abuse, exposure to
radiation etc. Studies have shown that newly recruited nurses are at increased risk of assault.14
Prevention of occupational hazards:
Primary prevention by health education is one of the most cost effective interventions in
prevention of occupational hazards. Hazards that are avoidable can be taken care of through
adequate vigilance and carefulness on the part of the nurses. By enhancing the knowledge
among nurses on OSH, significant proportion of occupational hazards can be prevented.
Studies have shown the effectiveness of educational interventions in reducing needle stick
injuries.20, 21

It is interesting to note that, although nurses face a multitude of hazardous exposures there is
not even a single nursing programme to teach safety or that even mentions the job hazards
associated with this career.22
6.4 OBJECTIVES
1. To assess the morbidity profile of nurses in a tertiary care hospital over a period of six
months.
2. To assess the effectiveness of educational interventions on their knowledge regarding
occupational safety and health.
7. MATERIALS AND METHODS
7.1. SOURCE OF DATA:
Study Design: Descriptive Study
Study Period: Six months (November 2013 - April 2014).
Study Site: St. Johns Medical College Hospital, a private tertiary care teaching hospital
rendering outpatient services including various specialty services to approximately 2000
patients per day and inpatient services with bed strength of about 1500 beds and bed
occupancy rate of approximately 85%.
Sampling unit: All nurses in St. Johns Medical College Hospital.
Sample Size: Sample size will be calculated using the formula:
n = z2 (p q)
d2
Where,
z = relative deviate (at 95% confidence interval) i.e. 1.96
p = prevalence (assumed prevalence) i.e. 50%
q = 1-p
d = precision (precision taken is 10%)
1.96*1.96*0.5*0.5
0.1*0.1
= 96.04
Further, the calculated sample size is corrected for a finite population using the formula,
N = n/ 1+n
P
n = calculated sample size
p = population
N = 96.04

1+96.04
701
= 85
However, presuming an attrition rate of 20%, the number of nurses that this study will cover
will be approximately 102.
Sampling method: Stratified random sampling
Inclusion criteria:
All staff nurses working at St. Johns Medical College Hospital.
Exclusion criteria:
Staff nurses who are not willing to participate
Operational definition of certain terms used in the study:
Occupational safety and health: Occupational safety and health should aim at: the
promotion and maintenance of the highest degree of physical, mental and social well-being of
workers in all occupations; the prevention amongst workers of departures from health caused
by their working conditions; the protection of 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 capabilities; and, to
summarize, the adaptation of work to man and of each man to his job.23
Occupational Hazards: A working condition that can lead to illness or death. Occupational
Hazards can be physical, chemical, biological, ergonomic and psychological among others.24
Ergonomics Hazards: Ergonomic hazards refer to workplace conditions that pose the risk of
injury to the musculoskeletal system of the worker.25
Morbidity: Morbidity can be described as any disturbance in general wellbeing or being in a
state of illness. Under morbidity profile morbidities such as needle stick injuries, chemical
injuries, latex allergy, work related musculoskeletal disorders, psychiatric illness, assaults and
other acute and chronic illness will be assessed.
7.2 METHOD OF DATA COLLECTION
List of nurses will be collected from nurses in-charge office. After doing stratified random
sampling, that is, nurses will be divided into various strata such as those from medicine and
allied departments, surgery and allied departments and nurses from OT (operation theatre)
number of nurse from each stratum will be decided according to the probability proportional
to the size. Nurses from each strata will then be selected by simple random sampling and the

details of selected nurses will be collected from the Personnel Department of the
Hospital.After obtaining the informed consent, the selected nursing staff will be interviewed
to collect information regarding age, education, date of employment, type of occupation,
working conditions, duration of work, shifts and present health status. Clinical examination of
all nurses will be done.

Chronic illness will be elicited by thorough past history and review of the nurses hospital
record if available.
The health status and acute illness of the nurses will be assessed once in three months by the
following two methods:
1. Interview with nurses to identify any significant illness in the past three months
2. Review of applications for sick leave maintained in the personnel department.
All nurses will be assessed regarding their knowledge on occupational safety and health,
using a pre-tested and validated questionnaire. At the end of six months, following an
intervention in the form of, health education on occupational safety and health; their
knowledge will be reassessed using the same questionnaire.
7.3 ANALYSIS
Data collected will be analysed using simple descriptive statistics. Means and proportions will
be applied. Tests of association like Chi Square test will be done to identify significant
relationships between exposure factors and outcomes.
7.4 Does your study require any investigations or interventions to be conducted on
patients or other humans or animals? If so, please describe briefly?
Yes, intervention in the form of education (lecture, booklet)
7.5 Has ethical clearance been obtained from your institution?
Yes
8. LIST OF REFERENCES
1. South African Department of Health, OH services for health care workers in the national
health service of South Africa: A guideline booklet, 2003; pp.1-72.
2. Tankha. G, A comparative study of role stress in government and private hospital nurses:
Journal of Health Management, 2006; 8(1), pp.11-22.

3. Feldt T, Oette M, Goebels K, Wenning M, Kroidl A, and Haussinger D, Hemodynamic


crisis and reversible multi organ failure caused by HIV post-exposure prophylaxis after
needle stick injury in a health care worker: HIV Medicine,2004;(5), pp.125-127
4. Chan R, Molassiotis A, Chan E, Chan V, Ho B, Lai CY, Lam P, Shit F, Yiu, Nurses
knowledge of and compliance with universal precautions in an acute care hospital:
International Journal of Nurses Study, 2002;( 39), pp.157-163.
5. Mosadegh-rad AM, The relationship between knowledge of ergonomic and occupational
injuries among nursing staff: Journal of Shahr e Kord University of Medical Sciences:
2004; 6(3), pp.21-32.
6. Angelillo IF, Mazziotta A, Nicotera G, Nurses and hospital infection control, knowledge,
attitudes and behavior of Italian operating theatre staff: Journal of Hospital Infections,
1999; ( 42), pp.105-112.
7. A.M. Amosu, Degun, N.O.S. Atulomah, M.F. Olanrewju and K.A. Aderibigbe, The Level
of knowledge regarding occupational hazards among Nurses in Abeokuta, Ogun State:
Nigeria Current Research Journal of Biological Sciences, 2011; 3(6), pp.586-590
8. Pruss-Ustun A, Rapiti E, Hutin Y. Sharps injuries: Global burden of disease from sharps
injuries to health-care workers. Geneva: World Health Organization; 2003. (WHO
Environmental Burden of Disease Series, No. 3)
9. Lugah V, Ganesh B, Darus A, Retneswari M, Rosnawati MR, Sujatha D ,Training of
occupational safety and health: knowledge among healthcare professionals in Malaysia:
Singapore Med. J, 2010;51(7): pp.586-591.
10. Reis R J, Rocca P D F L, Basile l, Navarro A, Martin M. Cohort profile: The Hospital das
Clinicas Cohort Study, Belo Horizonte, Minas Gerais, Brazil. Int. J. Epidemiol. 2007; Vol
37(4): pp 710-15
11. Ejilemele A, Ojule A C, Health and safety in clinical laboratories in developing countries,
safety consideration: Nigerian Journal of Medicine, 2004, Apr-Jun; 13(2), pp.182-88.
12. Naz S, Ahmad M, Asghar H, Prevalence of hepatitis B among hospital personnel in
Combined Military Hospital, Muzaffarabad, Pakistan: International Journal of Agriculture
and Biology, 2002 Apr; 12(2), pp. 227-30.
13. Thakare D B, Borkar D B, Health Hazards in Laboratory Services: Indian Journal of
Occupational Health, 2000, Apr-Jun; 43(2), pp.90-108.

14. Myers, C. and S.E.M. Jackson, Palo Alto, CA. Moens, C. and S.E.M. Jackson: Burn out
Inventory, Consulting Psychologists Press, Palo Alto, CA, 1993;Vol 2, pp: 48.
15. Fransman W, Peelen S, Roeleveld N, Kromhout H, Heederik D. Nurses with dermal
exposure to antineoplastic drugs - Reproductive outcomes. Epidemiology 2007; (in press).
16. Orr, S, Depression and burnout syndrome in intensive care unit nurses. Crit Care,
1997;8(1), pp.340.
17. Owen, A., O. Hayran and H. Sur, Predictors of burn out and job satisfaction among
Turkish physicians. Q J M., 1999; (3), pp. 161-169
18. Scott, C.R., communication, social support and burnout: A brief literature review. Micro
Organizational communication theory Res. New Left Rev, 2006; 83 pp. 3-24.
19. Poncet, M.C., P. Toullic, L. Papazian, N. Kentish-Barnes, J. Timsit, F. Pochard, S.
Chevret, B. Schlemmer and . Azoulay, . Burn out syndrome in critical care nursing staff.
Am. J. Resp. Crit. Care Med., 2007; (1750, pp. 698-704.
20. Wang H, Fennie K, He G, Burgess J, Williams AB. A training programme for prevention
of occupational exposure to bloodborne pathogens: impact on knowledge, behaviour and
incidence of needlestick injuries among student nurses in Changsha, Peoples Republic of
China.J Adv Nurs 2003; (41): pp. 187194.
21. Gershon R, Pearse L, Grimes M, Flanagan P, Vlahov D. The impact of multi-focused
interventions on sharps injury rates at an acute care hospital. Infect Control Hosp
Epidemiology 1999; (20):pp. 806811.
22. U.S. Department of labour, Occupation Module [Online], Safety and Health
Administration

(OSHA)

(2004,

August

13).

Module[Online].

Available:

http://www.osha.gov/SLTC/etools/hospital/er/er.html , accessed on 9/9/2013.


23. Occupational

health

facts-WHO

definition.

(Online),

Available

at

http://www.who.int/topics/occupational_health/en/, accessed on 11/9/2013.


24. University

of

Chicago

(environmental

health

and

science),

Available

at

http://safety.uchicago.edu/tools/faqs/ergonomics.shtml, accessed on 11/9/13


25. Health, safety and environment (university of petroleum and engineering studies),
Available at http://www.slideshare.net/mechportal/occupational-hazards, accessed on
12/9/13

9. SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDE


A neglected aspect of the health and well-being of an important group of employees in a
tertiary care hospital. The results of this study are likely to have policy implications at local
and regional settings, if not beyond.
11. NAMES AND DESIGNATION
11.1 SIGNATURE OF THE GUIDE:
11.2 GUIDE:
DR. BOBBY JOSEPH
Professor
Department of Community Health
St. Johns Medical College
Bangalore-560 034
11.3 SIGNATURE OF THE CO-GUIDE:
11.4 CO-GUIDE:
DR. NAVEEN RAMESH
Assistant Professor
Department of Community Health
St. Johns Medical College
Bangalore-560 034
11.5 SIGNATURE OF THE HEAD OF THE DEPARTMENT:
11.6 HEAD OF THE DEPARTMENT
DR. BOBBY JOSEPH
Professor and Head
Department of Community Health
St. Johns Medical College
Bangalore-560 034
12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL

12.2 SIGNATURE