Regulations are a powerful tool to promote the adoption of health and safety practices and policies. But regulations alone may not produce intended results. How regulations are implemented matters.
That was one finding from an Institute for Work & Health (IWH) study on an Ontario regulation to reduce needlestick injuries in health-care settings. Lead researcher Dr. Andrea Chambers presented a plenary on her study at IWH last November. It examined how three Ontario acute-care hospitals responded to a 2007 regulation requiring health-care organizations to replace conventional needles with safety-engineered needles.
The effectiveness of the regulation depended on a complex interplay of factors, including the technology itself,
says Chambers.
The risk of needlestick injuries
The danger of needlestick injuries has long been a cause for concern in the health-care sector. In the busy and bustling setting of front-line health-care work, getting injured with a needlestick is a constant risk. A lab technician might jab herself when a patient makes a sudden move just as she’s trying to withdraw blood. A cleaner might be pricked when he’s removing bed linen or replacing overfilled disposal bins. An emergency room nurse might step on a needle that has fallen unnoticed during a traumatic event.
In Statistics Canada’s 2005 National Survey of the Work and Health of Nurses (conducted before the regulation was established in Ontario), nearly half of surveyed nurses reported being injured by a needle or another sharp tool at some time during their career. Eleven per cent reported such an injury in the previous year.
When needlestick injuries involve blood exposure, workers face the risk of contracting a potentially life-altering disease such as hepatitis B, hepatitis C or HIV. Though the chances of infection are low—and even lower with post-exposure monitoring and treatment—such incidents carry potentially large psychological consequences.
In 2007, Ontario introduced a regulation under the Occupational Health and Safety Act requiring health-care organizations to phase out the use of conventional hollow-bore needles starting in 2008. The bill gave organizations considerable flexibility. It was up to organizations to decide whether to carry out a needs assessment, what needles to adopt and what training to offer staff,
says Chambers.
The three acute-care hospitals she studied had different success rates in reducing needlestick injuries. Comparing the year prior to the transition to three years post-implementation, the decline in needlestick injuries was 37 per cent at one hospital, 57 per cent at another, and 80 per cent at the third. Through their stories, Chambers was able to identify those factors that contributed to greater and lesser degrees of success.
Overcoming implementation challenges
As one would expect with any systems change, initial resistance was seen across the three hospitals. The surprise for Chambers, however, was the level of resistance among nurses.
I was surprised in the sense that this regulation was intended for nurses,
she says. It was introduced after years of lobbying by nurses’ unions and associations.
One of the hospitals reported product hoarding, where conventional hollow-bore needles were being stored to avoid the use of the new safety devices. All three reported incidents of workers not activating or physically removing safety features of the devices.
Through interviews with workers, Chambers learned that many of the new safety devices were seen as more awkward to use and, on occasion, interfering with sight lines. There was a conflict between the changes imposed by the new devices and the values shared by front-line workers about performance and productivity,
says Chambers. This demonstrates the importance of fit between new technology and the values of staff for the successful implementation of a regulation.
Chambers found a number of important factors across the hospitals were linked to the smoother implementation of the regulation.
Gradual transition: Two of the hospitals in the study chose to integrate safety-engineered needles before the regulation came into effect. Starting early and introducing the new needles in phases provided an opportunity to schedule the changes around other administrative and policy changes at the hospital, and also provided an opportunity to use more comprehensive implementation practices.
Good communication: One hospital in the study experienced considerable resistance to product change. Many among the staff did not like the new safety butterfly needles and, most importantly, did not feel they had been adequately consulted. By contrast, another hospital launched a full awareness campaign prior to the rollout of safety-engineered needles to explain the rationale, timing and process for the change.
The need for widespread consultation before product change is important,
says Chambers. Communication to all front-line staff and across all departments is key.
Vendor support: In all three hospitals, vendors played a key role. Their services came at no cost and took some of the workload off the organization,
says Chambers. Vendor services included needs assessments, staff communications and product training. This external support was particularly helpful in implementing the regulation where resources and time were limited, adds Chambers.
To listen to the presentation by Chambers while viewing the slides, go to: www.iwh.on.ca/plenaries/2013-nov-19. To read the full study report, go to: www.iwh.on.ca/needlestick-injury-prevention-lessons-learned-from-acute-care-hospitals-in-ontario.