Abstract
Background
In the healthcare sector, the most common injuries include needle sticks and injuries from sharp objects. Consistent with nurses and other healthcare personnel, nursing students are similarly vulnerable to these occupational hazards during their clinical training.
Objective
This study aimed to assess nursing students’ attitudes toward the safe use of sharp medical instruments and to identify the factors influencing these attitudes.
Methods
This analytical cross-sectional study was conducted with a population of 680 student nurses, of whom 415 participated as the study sample at a university in western Türkiye. Descriptive characteristics were summarized using frequencies, percentages, and descriptive statistics.
Results
Most student nurses expressed concerns regarding sharps injuries. 23.6% reported experiencing sharps-related injuries, and only 50% reported the incident. The mean attitude score towards the safe use of sharps was 114.57 ± 10.96. A statistically significant association (p < 0.05) between gender, Grade Point Average (GPA), and attitudes toward sharps safety. Female students and students with a “good/excellent” GPA had higher sharps-safety attitude scores compared to male students and those with an “average” GPA.
Conclusions
The findings revealed that student nurses generally demonstrated safe sharps-handling practices. Female students and those with higher GPAs exhibited significantly safer sharps usage. These results highlight the need for structured training programs to enhance student nurses’ knowledge and awareness of sharps injuries before clinical placements and throughout practice. Additionally, institutional guidelines on sharps-injury prevention should be updated in line with current evidence, and adherence to these protocols should be monitored by mentor nurses or clinical instructors.
Keywords
Introduction
Occupational injuries remain a significant concern among healthcare workers, 1 with needlestick and sharps injuries representing the most prevalent hazards in the healthcare sector. 2 Sharps injuries, defined as trauma caused by medical instruments, 1 pose a substantial risk of bloodborne pathogen transmission, leading to infectious diseases with considerable morbidity and mortality. 3
Globally, over 35 million healthcare professionals experience sharps injuries annually, with needlestick injuries accounting for approximately 86% of all occupational infections. 1 Among reported sharps injuries, 32% involve disposable syringes, 19% involve surgical needles, 3% blood collection needles, and 6% intravenous catheters. 4 These injuries facilitate the transmission of more than 20 pathogens, including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV), potentially resulting in severe or life-threatening infections. 5 The risk of pathogen transmission following a sharps injury is estimated to be 6–30% for hepatitis B virus (HBV), 5–10% for hepatitis C virus (HCV), and approximately 0.3% for human immunodeficiency virus (HIV) in non-immune individuals. 1
Nurses, as frontline healthcare providers and the largest professional group in the healthcare workforce, are at high risk for occupational injuries and diseases. 6 Nursing is an applied discipline associated with occupational health and safety risks, 7 and nursing education relies heavily on clinical practice) to develop students’ competencies alongside theoretical instruction. 8 Consequently, nursing students face occupational hazards, including sharps injuries, during clinical training, similar to registered nurses.9,10 Factors contributing to sharps injuries among nursing students include high exposure to injection procedures, improper needle recapping practices, and limited clinical experience.11,12 The literature indicates that the use of safety-engineered devices, such as automatically deactivated or retractable needles, vacuum-assisted blood collection systems, adherence to infection control and occupational safety guidelines, appropriate use of personal protective equipment, including gloves, preference for single-use medical supplies, and proper disposal of sharps in puncture-resistant biohazard containers, can significantly reduce the incidence of sharps injuries.11,13,14
Despite these preventive measures, recent studies report that the occurrence and underreporting of sharps injuries remain persistent and serious concerns among nursing students.15–18 To reduce these risks, the establishment of an internal surveillance system is essential. Additionally, to reduce the occurrence and underreporting of sharps injuries, an internal surveillance system should be established, and nursing students should receive comprehensive preclinical training on nosocomial infections, universal precautions, bloodborne pathogens, injury reporting, and post-exposure prophylaxis to enhance their knowledge and awareness. In addition, students’ knowledge should be assessed before and after clinical practice, and training programs should be revised accordingly. Effective communication between students, instructors, and clinical staff is also among the recommended interventions to enhance adherence to safety protocols.11,13,19
While previous studies have examined nurses’ knowledge, behaviors, and attitudes regarding sharps injuries5,20,21 research on the factors influencing nursing students’ attitudes toward sharps injuries remains limited. Considering this gap, the present study aims to assess nursing students’ attitudes toward the safe use of sharp medical instruments and to identify the factors influencing these attitudes. Specifically, it sought to rigorously evaluate student nurses, who are identified as a high-risk group for sharp-instrument injuries, and their attitudes toward the safe use of sharp instruments during clinical training, thereby providing deeper insights into the factors associated with sharps safety within nursing education. The findings of the study are expected to contribute to the current literature and address the research gap in this area.
Method
Study design and setting
This research was designed as an analytical cross-sectional study. Data were collected from nursing students enrolled in the Faculty of Health Sciences at a single-center university in western Türkiye between October and November 2024. The study population consisted of 680 nursing students, and 415 of them constituted the study sample.
Sample and procedure
The study population consisted of 680 student nurses, and the required sample size was determined as 246 using the OpenEpi online database, based on a 95% confidence interval and a 5% margin of error. 22 Participants were selected using proportional stratified sampling, with planned recruitment of 80 s-year, 87 third-year, and 79 fourth-year students. However, the final sample included 415 student nurses who voluntarily agreed to participate during the study.
Measures
Data were collected using a Descriptive Information Form and the Attitude Scale for the Safe Use of Sharps by Healthcare Workers.
Descriptive information form
Developed by the researcher, this form included demographic and academic characteristics such as age, gender, grade level, voluntary selection of department, general academic grade point average (GPA), occupational health and safety training status, vaccination history for hepatitis B and tetanus, history, and frequency of sharps injuries, the circumstances and instruments involved in injuries, post-injury reporting status, and reasons for non-reporting.
The attitude scale for safe use of sharps by healthcare workers
Originally developed to assess healthcare workers’ attitudes toward medical instruments, the scale was adapted into Turkish by Uzunbayır and Esen (2009). 23 It employs a five-point Likert format (1 = strongly disagree, 2 = disagree, 3 = undecided, 4 = agree, 5 = strongly agree) and consists of 25 items across three sub-dimensions: cognitive, affective, and behavioral. The scale comprises 15 positive statements (items 1, 2, 4, 5, 6, 8, 9, 11, 14, 15, 19, 20, 22, 24, 25) and 10 negative statements (items 3, 7, 10, 12, 13, 16, 17, 18, 21, 23). Sub-dimension scores are calculated using specific items: cognitive (1, 4, 8, 11, 13, 16, 18, 19, 20, 23, 24, 25), affective (2, 7, 9, 10, 14, 22), and behavioral (3, 5, 6, 12, 15, 17, 21). The total possible score ranges from 25 to 125, with higher scores indicating a greater likelihood of safe sharps use among healthcare workers. In the study by Uzunbayır and Esen (2009), the scale demonstrated a Cronbach's alpha reliability coefficient of 0.80. 23 In the present study, Cronbach's alpha values for the overall scale and its cognitive, affective, and behavioral sub-dimensions were 0.88, 0.80, 0.67, and 0.60, respectively.
Data analysis
Statistical analyses were conducted using IBM SPSS Statistics (Version 23.0). 24 Descriptive statistics, including frequency and percentage distributions, were calculated for the participants’ characteristics. The normality of data distribution was assessed using the Kolmogorov-Smirnov test and Skewness-Kurtosis values (the Attitude Scale for Safe Use of Sharps by Healthcare Workers: K-S = 0.173, p = 0.000; Skewness = −1.713; Kurtosis = 3.392). The Mann-Whitney U test, the Kruskal-Wallis test, and Spearman correlation analysis were used to analyze the data. Correlation coefficients were interpreted as follows: very weak (0.00–0.10), weak (0.10–0.39), moderate (0.40–0.69), high (0.70–0.89), and very high (0.90–1.00). 25 Additionally, the Grade Point Average (GPA) was based on the university's associate and undergraduate education regulations. Students with a GPA of 3.00–4.00 were classified as “good/excellent,” while those with a GPA of 2.00–2.99 were classified as “average.”
Ethical considerations
Ethics committee approval for the study was obtained from a university ethics committee (Decision Date: September 25, 2024; Decision No: 20.478.486/2643). Additionally, institutional permission was received from the relevant institution. Authorization to use the scale in the study was obtained via email from the authors of the validity and reliability studies.
Results
The mean age of student nurses was 20.82 ± 1.99 years, and 52.3% of the participants were over 20 years old. 71.6% were women, and 41.9% were in their second year. 69.2% of the students were determined to have chosen the nursing program voluntarily. Furthermore, 63.4% of the participants rated their academic achievement as “good/excellent.” All students received occupational health and safety training, and the vast majority regularly used personal protective equipment in clinical practice. When the vaccination status was examined, it was determined that 85.3% of the participants had received the Hepatitis B vaccine and 95.7% had received the Tetanus vaccine.
The vast majority of student nurses participating in the study were found to have significant concerns about sharps injuries (80.7%), and almost all of them stated that these injuries were preventable (92.5%). Nearly a quarter of the participants reported experiencing at least one sharps injury. When responses regarding the instruments causing the injury (n = 116) were examined, the most frequently reported cause was the syringe/needle tip used in injections (51.7%). Among the causes of sharps injuries assessed with multiple responses (n = 142), responses highlighting the most common responses were opening ampoules or vials (34.5%) and preparing medications (26.8%) (Table 1).
Opinions of student nurses about sharps and exposure to sharps (n = 415).
**Percentage distribution of multiple responses.
The mean score on the Attitude Scale for Safe Use of Sharps by Healthcare Workers was 114.57 ± 10.96, with subscale scores of 55.40 ± 5.17 (cognitive), 27.43 ± 3.11 (affective), and 31.72 ± 3.74 (behavioral) (Table 2).
Mean score distributions of the attitude scale for safe use of medical sharps by healthcare workers (n = 415).
IQR: Interquartile Range.
A significant difference (p < 0.05) was found between gender and GPA, with female students and those with a “good/excellent” GPA scoring higher than male students and those with an “average” GPA. No significant differences were observed in the mean scores on the Attitude Scale for the Safe Use of Sharps by Healthcare Workers in relation to age, academic year, voluntary choice of the nursing department, hepatitis B vaccination status, tetanus vaccination status, or the use of personal protective equipment during internships (p > 0.05) (Table 3).
Comparison of descriptive characteristics of student nurses and mean scores of attitude scale for safe use of sharps by healthcare workers (n = 415).
*p < 0.05, IQR: Interquartile Range KW: Kruskal Wallis test, z: Mann Whitney U test.
A weak but statistically significant positive correlation was found between student nurses’ GPA and their scores on the Attitude Scale for the Safe Use of Sharps by Healthcare Workers (rs = 0.208, p = 0.000).
No significant differences (p > 0.05) were observed between student nurses’ attitude scores and the type of instrument involved in the injury (syringe/needle tip vs. ampoule/vial). Similarly, the circumstances under which sharps-related injuries occurred—such as opening ampoules/vials, preparing medication, performing intramuscular or intravenous procedures, or recapping needles after injection/therapy—were not associated with significant differences in mean attitude scores (Table 4).
Comparison of student nurses’ opinions on sharps and exposure to sharps and mean scores of attitude scale for safe use of sharps by healthcare workers (n = 415).
*p < 0.05, IQR: Interquartile Range, z: Mann Whitney U test.
Discussion
This study examined nursing students’ attitudes toward the safe use of sharps and the factors influencing these attitudes. Nursing students frequently encounter high-risk procedures during clinical training, which increases their vulnerability to sharps injuries. 26 Consistent with this context, 80.7% of the students in our study reported concerns about sharps injuries, and 23.6% had experienced at least one injury.
A review of national and international studies on the prevalence of sharps injuries among nursing students reveals varying rates of exposure. Doğru and Akyol (2018) reported that 31% of nursing students experienced sharps injuries, while Jelly et al. (2015) found a rate of 39.7%. Similarly, Karataş et al. (2016) observed a prevalence of 62.6%, and Prasuna et al. (2015) reported 39.7%. Liu et al. (2015) and Zhang et al. (2018) documented even higher rates, at 60.8%.3,12,27–30 These findings highlight that nursing students constitute a high-risk group for sharps injuries. Additionally, it is possible that some students who reported no injuries may have experienced incidents they did not recall.
In this study, among students who reported experiencing sharps injuries, 66.3% had experienced a single incident, 25.5% had experienced two to three incidents, and 8.2% had experienced four or more. These results are consistent with previous studies indicating that nursing students may experience repeated sharps injuries throughout their clinical education.3,29,31,32 The high injury rates observed both in the literature and in the present study suggest that exposure risk varies but remains consistently significant in clinical settings. The possibility of unreported or forgotten injuries highlights potential weaknesses in safety culture, particularly regarding injury reporting practices. Although students demonstrate positive attitudes and awareness, their actual clinical behaviors may not always fully reflect their knowledge and attitudes. Strengthening simulation-based skills training, ensuring consistent enforcement of safety protocols, and establishing structured mentoring systems may support the development of safer clinical practices. Additionally, implementing non-punitive reporting systems may improve the accuracy and frequency of incident reporting, facilitating ongoing risk monitoring and supporting evidence-based improvements in both clinical and educational processes.
The present study found that 51.7% of injuries were caused by syringe or needle tips, while 34.5% occurred during the opening of ampoules or vials. These findings align with previous literature, which reports that syringes are the most common source of sharps injuries21,32–34 and that injuries frequently occur during needle handling and drug preparation processes.19,35,36 Current evidence suggests that the use of appropriate techniques and safety-engineered needles can substantially reduce such injuries.11,37
Increasing the availability of these protective technologies in clinical settings, along with ensuring that student mentors provide training that emphasizes the correct and safe use of equipment, represents a key strategy to reduce injury risk. In practice, this can be achieved by emphasizing safe injection techniques during clinical training, adopting standardized procedures for opening ampoules and vials, and offering structured supervision to students during these tasks to reinforce safe practices.
In this study, 80.7% of the student nurses were concerned about sharps injuries; however, only 50% of those who experienced an injury reported it. Among the non-reporting group, 91.8% stated that they did not report the injury because the instrument involved had not come into contact with a patient. These findings align with previous research emphasizing the issue of underreporting injuries in healthcare settings. For instance, Hambridge (2023) reported that 65.6% of students did not report sharps injuries, and Zhang et al. (2018) found that 86.9% of sharps injuries sustained by nursing students went unreported.12,19 In the current study, the perception among students that incidents involving instruments not contacting a patient do not require reporting (91.8%) may explain the high non-reporting rate. Zhang et al. (2018) also identified other reasons for non-reporting, such as the belief that the device was not used on a patient, the patient was not considered infectious, and uncertainty about how to report the incident. 12 Additionally, Çolak et al. (2017) reported that healthcare workers may avoid reporting injuries due to fear or unclear reporting protocols. 38 Collectively, these findings underscore the critical need for improved nursing education on the importance of reporting sharps injuries, as well as the establishment of clear and accessible reporting procedures. Nursing schools and clinical practice institutions should implement policies to minimize sharps injuries by providing appropriate tools and equipment and by regularly evaluating the effectiveness of these measures.19,39
In this study, 100% of participants reported receiving occupational health and safety training, demonstrating that these institutions prioritize safety. Additionally, the high vaccination rates for Hepatitis B (85.3%) and Tetanus (95.7%), and the widespread use of personal protective equipment during internships indicate strong adherence to safety protocols. These findings align with previous studies emphasizing the importance of occupational health and safety training and vaccination in preventing injuries among healthcare workers. 40 However, despite these safety measures, 23.6% of students experienced sharps injuries, indicating that significant risks remain. Similar trends have been observed in other studies, where healthcare workers face injury risks even after receiving safety training.19,41 This suggests that while current training provides a foundation, additional ongoing support, enhanced guidance, and targeted safety interventions are necessary to further mitigate risks in clinical settings.
Student nurses’ attitudes toward the safe use of sharps were assessed using a 5-point Likert-type scale, with higher scores reflecting safer sharps practices. The scale, designed for healthcare workers, allows for scores ranging from 25 to 125. In this study, student nurses scored above average in all measured domains: cognitive (mean: 55.40 out of 60), affective (mean: 27.43 out of 30), and behavioral (mean: 31.72 out of 35), indicating a high level of safe sharps use. Overall, the attitude towards the safe use of sharps score was also above average (mean: 114.57 out of 125), consistent with those reported in the literature.42,43
Moreover, the finding that students with a “good/good” GPA had higher attitude scores suggests a relationship between academic achievement and safety awareness, indicating that higher-performing students may place greater emphasis on safe practices during their training. Similarly, Koshy et al. (2017) reported that students with higher academic achievement demonstrated more positive safety behaviors. 42 Providing targeted safety training and structured mentoring for students with lower academic achievement may help reduce disparities in safety attitudes.
Female student nurses exhibited higher attitude scale scores than their male counterparts, which may be attributed to the traditionally female-dominated nature of the nursing profession and potentially high professional sensitivity among women. Mohsin et al. (2016) reported that female healthcare workers have a greater awareness of occupational risks than their male colleagues. 43 Similarly, Singh et al. (2018) found that female nurses were more conscious of safety issues, likely influenced by their professional training.43,44 These observations align with studies indicating that female healthcare workers generally engage in more cautious and safety-oriented behaviors than men.4,15
The study also demonstrated that students who expressed concerns about sharps injuries received higher scores on the attitudes toward safe use of sharps scale, a finding consistent with Akyol and Güney (2020), who observed an improvement in safety behaviors with increasing anxiety levels. 45 This finding suggests that risk perception may be an important determinant of students’ safety behaviors. Heightened concern about sharps injuries can serve as a protective mechanism, motivating students to act more cautiously in clinical practice. In this context, incorporating educational sessions, case-based discussions, and safe-practice simulations to enhance students’ risk awareness in a balanced manner may be beneficial. Moreover, clinical mentors who provide regular feedback and foster a learning environment that reinforces safe practices can contribute to the sustainable development of positive safety attitudes.
Notably, no significant differences in attitude scores were observed between students who had experienced injuries and those who had not, nor between those who reported injuries and those who did not. This indicates that, although students are aware of the risks associated with sharps, this awareness does not always translate into safe behaviors. Similar studies have emphasized that awareness alone is insufficient; continuous training, simulation exercises, and reinforcement of safety protocols are essential for fostering lasting behavioral change.40,41 In this context, strengthening institutional arrangements to ensure consistent implementation of safety protocols, systematically integrating scenario-based simulations to improve decision-making and risk management skills, and explicitly modeling safe practices during clinical training are recommended strategies to bridge the gap between attitudes and behaviors.
Limitations
This study was conducted with nursing students from a single university, and the findings reflect the educational context of that institution. Therefore, generalization of the results to other populations should be done cautiously. Retrospective reporting of sharps injuries may have led to under- or overestimation of the true incidence due to recall bias or unreported events. Additionally, the study assessed only attitudes and did not include objective measures of actual behavior, limiting the ability to fully examine the attitude-behavior relationship. Given the cross-sectional design, relationships between variables should be interpreted as correlational rather than causal. Finally, considering potential differences in curricula, frequency of clinical practice, and institutional safety culture, multicenter studies with larger samples across various educational and clinical settings are recommended to validate and extend these findings.
Conclusion
The study showed that although most student nurses were concerned about sharps injuries, 23.6% had experienced such incidents, with the majority experiencing a single occurrence, and only 50% of those injured reporting it. Overall, student nurses demonstrated generally safe sharps handling practices. Notably, female students and those with a “good/excellent” GPA exhibited higher safety standards. Based on these findings, it is recommended that student nurses receive comprehensive training to enhance their knowledge and awareness of sharps injuries both prior to and at regular intervals during clinical practice. Because sharps injuries can be substantially prevented through appropriate techniques and the use of safety-engineered devices, institutions should establish or update procedures in line with current evidence. Student nurses should be monitored by mentor nurses or instructors to ensure adherence to safety protocols. Furthermore, creating a supportive, non-punitive environment for reporting sharps injuries and actively encouraging students to report any incidents are essential strategies to improve safety in clinical practice.
Footnotes
Acknowledgments
Not applicable.
Ethical approval
Ethics committee approval for the study was obtained from Manisa Celal Bayar University ethics committee (Decision Date: September 25, 2024; Decision No: 20.478.486/2643).
Informed consent
All nursing students signed an informed consent form prior to enrollment in the study.
CRediT authorship contribution statement
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
