Occupational Hazards and Safety Nursing Guidelines for Pediatric Nurses in the Health Care Setting

Safety in the workplace was the major concern in a variety of occupations and workplace settings. In nursing, the main concern of research was concerned on patient safety; there was limited researches focused on nurses' safety in work setting. Therefore, the aim of this study was to evaluate the effect of implementing occupational hazards and safety nursing guidelines for pediatric nurses in the health care setting. A quasiexperimental research design using one group (pre-test & post-test measures) was used. A convenience sample of 173 pediatric nurses affiliated to Mansoura University children's Hospital (MUCH), Mansoura University, Egypt; and accepted to participate in the study was included. The study illustrated that, 77.9% of nurses suffered from fatigue, 69.5% of nurses had back pain. In addition, significant number of nurses are exposed to MRSA infection (61.7%) and 67.4% are exposed to needle stick injury. Before implementing the nursing guidelines, approximately half of nurses had low level knowledge (46.8%) compared to 15% after implementation of nursing guidelines & the difference was statistically significant. The study concluded that, the hazards associated with nursing profession were higher and critical. In addition, there was an improvement of nurse's knowledge and practice about safety with the implementation of educational guidelines. Therefore, the researchers' recommended developing standard of health care safety clarifying the role of health care institution in dealing with and overcoming the occupational hazards in the health care setting in order to improve nurses' safety and commitment to the health care environment.

The multiplying effects of injuries and diseases among nurses include economic loss, physical loss and psychological disorders such as depression and stress. Consequently, these have negative effect on the nurses, their families and the nation at large (Adelosoye et al., 2016). Nurses and other healthcare providers should receive training and education on ways of prevention of hazards in the hospital to protect their health (Smith, 2009). Safety in the hospital care setting means the presence of measures that minimize the risk of physical, biological, chemical and psychological harm. These can be achieved for example; safe patient handling and mobility practices and reasonable patient care assignments, and shift duration (Zolot, 2017). Nurses' constitute a large group of health care team; they are working with the patients and their family and they are exposed to different type of health risk during their work. Therefore, controlling and minimizing workplace hazards represent a unique challenge.

Significance of the problem:
Hospitals have many unique hazards that can potentially affect the health of employees. Exposures to occupational hazards throughout hospital departments are highly variable (Gorman, et al., 2014). Due to the importance of hospital safety, it is not surprising that a lot of research have been applied to this topic. There is no previous study was conducted on pediatric nurses in Mansoura University Children's Hospital on that area. Hence, this study was conducted to evaluate the effect of implementing occupational hazards and safety nursing guidelines for pediatric nurses in the health care setting

II. Subjects and methods Aim of the study:
This study aimed to evaluate the effect of implementing occupational hazards and safety nursing guidelines for pediatric nurses in the health care setting. This aim can be achieved through:-1. Assessment of actual physical, emotional, psychological and biological hazard as reported by nurses 2. Assessment of nurses perception about safety in hospital care setting 3. Assessment of nurses' knowledge and practice about safety measures of hospital care setting 4. Developing and implementing training program for nurses about safety in the work setting and hazard prevention 5. Evaluating the effect of training program on nurses knowledge and practice

Research hypothesis:
 Nurses who attend the occupational hazards and safety nursing guidelines have good knowledge and practice about safety in the hospital.  Nurses' knowledge and practices will improve after implementing the occupational hazards and safety nursing guidelines.

Study Design & Setting
A quasi-experimental research design using one group (pre-test & post-test measures) was used. The study included a convenient sample of 173 pediatric nurses who accepted to participate in the study. The study was conducted on eight departments including (Medical, Surgical, Operating room, Pediatric intensive care unit, Neonatal intensive care unit, Outpatient, Dialysis unit and Emergency) affiliated to Mansoura University children's Hospital (MUCH), Mansoura University; Egypt. Instruments:-Data were collected by using two tools: occupational hazard assessment questionnaire and occupational hazards prevention and safety checklist which were developed by the researchers after reviewing related literature (Osborne, 2002, Gao, 2011 and incorporated four parts. 1) Demographic characteristics of the studied nurses, 2) occupational hazard assessment questionnaire, 3) actual hazards facing nurses during their working in the hospital, 4) pediatric nurses' perception of safety in health care environment. Part 1: Demographic characteristics of the studied nurses include age, gender, marital status, residence, qualification, years of experience, department and attendance of any training regarding occupational hazard and safety measures. Occupational hazard assessment questionnaire was developed to evaluate nurses' knowledge about occupational hazard; it was consisted of 13 item related to contributing factors, prevention of hazards, needle stick injury and blood borne disease.
The third part of the questionnaire was developed to evaluate the actual hazards facing nurses during their working period in the hospital. This part was including 51 items categorized into four domains (physical hazard, chemical, social & emotional hazard) the nurses were respond with "yes" or "no" for every question. In the fourth part of questionnaire, the nurses were asked about their perception of safety in health care environment; it was incorporated 10 statements. The nurses responds to each item using 3 point likert scale: (3) strongly agree, (2) agree & (1) not agree. Tool (2) occupational hazards prevention and safety checklist was used to evaluate the pediatric nurses' practice related to prevention of occupational hazards and observe nurses practice during handling of sharp equipment, prevention of blood-borne disease and infection control practice. Each correct step of the procedure scored on the bases of "complete correct done" scored (2), & "Not done", scored (0). The nurses were considered had competent practice if the percent score was 80% or higher and incompetent practice if the percent score was less than 70%.

Validity and reliability
The validity and reliability of the developed tools was done. These tools were revised by a panel of 10 experts in pediatric and community health nursing and medicine at Mansoura University. Minor modification was done on the tools. Tools reliability were done using Alpha Cronbach's coefficient test, the alpha reliability of tool 1 was (α =0.83), while, reliability of tool 2 was (α =0.90).

Workplace hazards prevention & safety nursing guidelines
Workplace hazards prevention & safety nursing guidelines was developed the researchers based upon recent, current, national, and international literature & updated articles and evidence based nursing practice The nursing guidelines were discussed for nurses on six sessions divided into two theoretical & four practical sessions. The time consumed for each session was ranged from 30-45 minutes. The nurses were assigned to groups ten (10) nurses in each group. The researchers were represented the nursing guidelines via using Power point, lectures, brain storming, and clinical application. In addition, posters and educational book were used and available in the units for every nurse. The nursing guidelines cover the following outline about hazards prevention & safety such as: Purposes of occupational health, occupational hazards types, causes, and preventive methods, infection control universal precautions, prevention of needle stick injuries, prevention of transmission of blood born & infectious disease, stress and its management & standard safety precautions.

Ethical Considerations
Ethical authorization was gained from ''Research Ethics Committee at the Faculty of Nursing, Mansoura University''. Agreement to carry out the study was obtained from the principal of the hospital after explaining and clarifying the aim of the study. Written consent was obtained from nurses after amplification of the aim of the study. Privacy of information and nurses right to depart the study whenever was disclosed to each mother before collecting data.

Data collection
The data was collected from February to the end of December, 2016; the questionnaire was distributed to all nurses working in the previously mentioned departments and collected by the researchers representing response rate of 69.2%.

Pilot study
A pilot study was carried out on 17 nurses to ascertain the feasibility, applicability and clarity of the tool and there is no modification required.

Data Analysis
Data were analyzed with SPSS version 21. The normality of data was first tested with one-sample Kolmogorov-Smirnov test. Qualitative data were described using number and percent. Continuous variables were presented as mean ± SD (standard deviation) for parametric data and Median for non-parametric data. The two groups were compared with Student t test (parametric data). The level of significance for all testes was at p < 0.05.  (1); it was clear that, more than one third of the nurses (38.7%) were in the age group from 19 to 29 years, while minority of them (11.0%) had 50 years and more. It was also apparent that, the majority of them was females & married (90.8% & 82.7% respectively). Regarding the educational level, this table revealed that, the highest percentage of the nurses (45.1%) had bachelor degree in nursing. In addition, one third (30.1%) of studied nurses' had from 6-10 years of experiences. It was also evident that (54.9%) of the nurses did not attain any previous training courses related to workplace hazards. As regards most workplace department (24.3%, 20.8%, and 16.2%) of them were found in NICU, PICU and dialysis respectively. nurses' self-report of physical hazards exposure; more than two thirds of the studied nurses had complain from fatigue, back pain and leg pain (77.9%, 69.5%, and 56.8% respectively). It was also apparent that, 53.7% of the nurses had work overloaded. Concerning the nurses' self-report of social & emotional hazards exposure. This figure revealed that, more than one third had exposed to sadness and easy excitability (42.5% & 38.3%). Also, 30.5% of them had difficulties in social relation. that, more than two third (67.4%) of them had exposed to needle stick injury. Also, infectious biological hazards observed as MRSA infection, infectious diseases and hepatitis C by percentage of 61.7%, 40% and 17.3% of the nurses respectively. this table showed that, the majority of the nurses were replied that work overload and standing for long period of time and lack of lifting tools and transportation of patients were the most common risk factor for hazards (96.9% and 83.8% respectively). Moreover, 82.6% of nurses were reported that appropriate training for nurses on safety procedures was the most common preventive measures for hazards in the hospital.  Table (4) illustrated nurses perception about safety in the health care environment; it was clear that, the nurses were disagree with the statements related to action taken to reduce the risks, the nurses are encouraged to participate in the peace and health procedures & the support between the unit worker with the mean (1.84±0.9, 1.93±1.1&1.84±1.01 respectively).

Discussion
Hospitals are the most common high risk workplace characterized by higher level of exposure to hazardous agents, which dramatically endangers the health and peace of the health care worker especially nurses (Arazoo et al., 2015 and Abidoye et al., 2016). Many studies have indicated the need to identify & evaluate hazards associated with nursing profession, as well as preventive measures to overcome the hazards and improve health and safety of nurses (Shimizu, et al., 2010). The study was conducted to investigate the effect of implementing nursing guidelines on occupational hazards and safety of pediatric nurses on the health care environment and to represent the most common hazards the nurses exposed during their working years.
The study found that the levels of physical, chemical & biological hazards as reported by nurses working in MUCHs were critical. While, social & emotional hazards level were tolerable. Regarding physical hazards, the current study illustrated that the most common physical hazard encountered by nurses was fatigue and it was highest problem as it was reported by more than three quarters (77.9%) of nurses. Since for most procedures the nurses are standing for long time in providing different care for pediatric patient as (feeding, bathing, lifting, medication, blood sampling and moving patient from one place to another for further diagnostic procedure) and this is consequently becomes a burden on nurses health. In addition, more than half of nurses reported that they having back pain & leg pain (Figure 1). This result may be due to long working hours per shift, standing long time during providing the patient care and shortage of nursing staff members. This result was in an agreement with the study achieved by Shimizu, et al., (2010) who explained that, neck pain and back pain were major workplace health problem and illustrated a huge burden on nursing staff members. Similarly Sreekala (2010), reported in his study that, the majority of nurses having varicose vein.
In relation to chemical & biological hazards, this study clarified that, the most hazards facing nurses in their workplace were needle stick injury followed by MARS infection. This was in an agreement with Almurr, (2013); Bhargava et al. (2013) and Eljedi (2015), who revealed in a similar study that, the prevalence of sharp injuries were high. Concerning to nurses' social & emotional hazards exposure, more than one third of nurses suffered from sadness & easy excitability as in (Figure 2). This result may be attributed to that the nurses are overwhelming by hard work and caring for critical patient and patients with terminal illness and dying patient which in turn influencing on nurses social and emotional state & shortage of nursing staff. Moreover, in the public hospital in the Federal District, a study conducted by Shimizu, et al., (2010) revealed that, the occurrence of physical hazards for nurses working at intensive care units were serious at a single Brazilian institution; while, the psychological and social hazard levels were reasonable. Moreover, the study results in Gaza, by Eljedi, (2015) indicated that, exposure to psychological hazards was high within all occupational hazards for nursing students.
The majority of the studied nurses reported that work overload, standing for long period of time & lack of lifting tools for patients' transportation were considered the main predisposing factors for hazards in health care setting. Similarly, Abou El-enein and El Mahdy (2011) confirmed that the factors and barriers that influenced safety practice measures and that interfere with the safe practice of care was the high work load or lack and inaccessibility of sinks.
In spite of higher prevalence of nurses self-reported workplace hazards; we found limited knowledge about hazards among nurses, with approximately half of nurses had poor knowledge about prevention hazards in health care environment. Finally the study demonstrated the effect of educational intervention in improving nurses' knowledge and practice as it was reported in table (3)  study about "effect of in-service education workshop on occupational health and safety in terms of knowledge and awareness among nurses in a selected tertiary care hospital in India: an evaluation" that, the program was effective in improving the knowledge and awareness of nurses regarding occupational health and safety.

Limitation of the study
The limitation of the study was that, the effect of the occupational hazard prevention & safety program evaluate the nurses knowledge, practice and perception; while, the prevalence of hazards not evaluated after the implementation of the program. Moreover, the prevalence of hazards represented in the study was nurses' selfreported and not recorded incidence in the hospital.

Conclusion & Recommendation
The study concluded that, the hazards associated with nursing profession were higher and critical. Many of these hazards are avoidable & preventable and others are inevitable. From the study 77.9% of nurses suffered from fatigue, 69.5% of nurses had back pain. In addition, significant number of nurses are exposed to MRSA infection (61.7%) and 67.4% are exposed to needle stick injury. In addition, the nurses' knowledge and practice was significantly improved after implementation of the occupational hazards and safety nursing guidelines. The researchers recommended developing recording & reporting system for hazards facing health care worker especially nurses to improve their safety and commitment to the health care setting. Developing standard of health care safety clarifying the role of health care institution in dealing with and overcoming the occupational hazards in the health care setting. Regular physical examination must be done annually and at time of infection outbreak for all health care workers. Further researches are required to investigate factors affecting reporting of workplace hazards and why nursing staff continue to work after their affection with occupational hazard.