Introduction
Workplaces often expose individuals to a variety of environmental risk factors that can significantly impact their health and increase their vulnerability to illness. The healthcare sector is no exception, as professionals in this field face a wide range of hazards, including physical, chemical, biological, psychosocial, and ergonomic risks. Among these, biological hazards are the most pervasive due to the inherently interactive and clinical nature of healthcare activities [1]. Nurses, as essential members of the healthcare workforce, are particularly vulnerable to such risks because of their frequent and direct technical interactions with patients in hospital settings [1, 2].
Research investigating occupational hazards within the nursing profession is of paramount importance. Numerous studies consistently highlight that healthcare professionals, particularly nurses, are disproportionately affected by biological hazards compared to other healthcare workers [1]. One of the most pressing global concerns in healthcare settings is needle-stick injuries (NSIs) [3]. NSIs are defined as puncture wounds caused by sharp instruments, such as needles or other sharp objects, that inadvertently penetrate the skin during routine clinical tasks [3, 4].
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Healthcare workers are at the highest risk of occupational infections caused by biological agents due to their frequent exposure to bodily fluids. Contact with blood, exposure to bodily fluids, NSIs, and injuries from sharp objects directly compromise the safety and well-being of healthcare personnel. Such exposures not only threaten their health but also adversely affect the quality of care they provide [5]. Nurses, in particular, face numerous challenges in their clinical and educational environments that endanger both their own safety and that of their patients [6]. Among these challenges, NSIs emerge as a particularly critical issue [6, 7].
According to the World Health Organization (WHO), approximately 35 million needle-stick and sharp object injuries occur annually among healthcare providers, with 2 million of these incidents resulting in skin exposure to infectious diseases. Globally, such injuries account for an estimated 39% of hepatitis C infections, 37.6% of hepatitis B infections, and 4.4% of human immunodeficiency virus (HIV) infections among healthcare workers [3, 8, 9, 10].
According to a systematic review conducted by Halimi et al. in 2024, the prevalence of needle-stick injuries among Iranian nurses was found to be 46%, highlighting the considerable frequency of these incidents, particularly among nurses employed in teaching hospitals [11]. Similarly, a study carried out by Fereidouni, et al. in 2019 in Fasa, a city in southern Iran, revealed that 51% of hospital staff had experienced at least one needle-stick injury, with nurses being the most affected group [12].
Monitoring and analyzing the prevalence of needle-stick injuries within healthcare institutions is of paramount importance [13]. It is imperative for these facilities to systematically assess the occurrence of such injuries among their workforce on an annual basis. In addition to the physical health risks they pose, needle-stick injuries can result in severe emotional and psychological strain for healthcare professionals [14]. Furthermore, quantifying the frequency of these injuries underscores the critical need for educational programs aimed at promoting adherence to safety protocols among nursing staff.
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On the other hand, inadequate knowledge and insufficient skills among nurses significantly elevate the likelihood of encountering needle-stick injuries [15]. Therefore, assessing the knowledge and performance levels of nurses becomes essential [16]. One effective approach to understanding their knowledge and performance is through evaluating their clinical competence, as nursing competence encompasses a multifaceted blend of knowledge, practical skills, attitudes, values, and overall performance [17, 18]. Moreover, enhancing nurses’ competence levels could potentially contribute to a reduction in needle-stick injuries. Consequently, measuring the clinical competence of nurses is crucial for minimizing costs, interrupting the chain of infection transmission associated with needle-stick incidents, improving mental well-being, and optimizing the design of nurse training programs.
As healthcare systems grow increasingly complex, there has been a heightened emphasis on ensuring professional competence among nurses. The World Health Organization (WHO) has emphasized the necessity of maintaining high standards of nursing competence to effectively navigate these challenges [19, 20].
Given the multifaceted nature of clinical competence, addressing the obstacles nurses encounter within healthcare systems requires professionals to possess a wide range of practical skills. This demand has underscored the need to identify essential competencies for nurses, leading to a substantial expansion of the body of research on nursing proficiency [21]. Assessing competence is crucial, as it not only elevates the quality of patient care but also creates pathways for nurses to engage in professional growth and advance their careers [16]. Since nurses play a pivotal role in the delivery of healthcare services, it is vital to identify factors that can reduce the likelihood of NSIs within this workforce. One potential factor, hypothesized by the researcher, is the level of clinical competence possessed by nurses, highlighting the importance of evaluating this attribute to support ongoing education and enhance care quality.
Although earlier research has explored the prevalence and contributing factors associated with NSIs in nursing, no study has specifically investigated the link between clinical competence and the occurrence of NSIs. Understanding how a nurse’s clinical proficiency affects their risk of experiencing needle-stick injuries can yield critical insights for designing targeted training programs and intervention strategies. These efforts aim to mitigate occupational risks while simultaneously improving both patient safety and healthcare outcomes. Accordingly, this study seeks to examine the relationship between clinical competence and the frequency of needle-stick injuries, as well as to identify the factors contributing to such injuries, among nurses in southern Iran.
Methods
Study design
This descriptive cross-sectional study was conducted between March 2023 and May 2023 and involved 275 nurses employed across three hospitals in Fars Province, southern Iran. The participating nurses worked in various departments, including the Operating Room (OR), Surgical Intensive Care Unit (ICU Surgery), Coronary Care Unit (CCU), Post-Cardiac Care Unit (PCCU), Emergency Room (ER), General Surgery, Internal Medicine, Male Surgery, Pediatrics, Female Surgery, Infectious Diseases, Psychiatry, Dialysis, Oncology, and Laboratory. Each nurse alternated between morning, afternoon, and night shifts in their respective departments throughout the week.
In Iran, individuals seeking to enter the nursing profession must pass a national entrance examination. Upon successful admission, students complete a four-year academic program at a nursing school, which culminates in the award of a bachelor’s degree in nursing.
Initially, 275 nurses working in educational hospitals in Fasa were recruited for this study through convenience sampling. However, 11 participants were excluded because they did not meet the inclusion criteria, leaving data from 264 nurses for the final analysis. A previous report from our location estimated the rate of NSSI among nurses to be 24%. However, we believed this estimate was lower than the actual rate. The latest meta-analysis indicates a rate of 64%. Consequently, we selected a prior study that reported a higher rate of NSSI to calculate the sample size [12, 22]. The sample size for the study was originally calculated as 64 participants, based on the findings of Putra et al. [22]. In their study, the incidence rate of needle-stick injuries among nurses was 0.313, while the rate among nurses who had not experienced such injuries was 0.687. The sample size calculation was performed using Stata software version 17, with an 80% statistical power, a 95% confidence level (α = 0.05), and the following formula for comparing two proportions:
$$\:n=\frac{{\left.\left(({z}_{1-\frac{\alpha\:}{2}}+{z}_{1-\beta})\right.\right)}^{2}{[p}_{1}\left(1-{p}_{1}\right)+{p}_{2}(1-{p}_{2})]}{{{\left({p}_{1}-{p}_{2}\right)}^{2}}_{.}}$$
To account for the design effect, which was set at 2, the sample size was adjusted to 128 participants. Furthermore, to accommodate potential participant dropout, ensure diversity across subgroups, and enhance the generalizability of the findings, the final sample size was increased to 275 participants. Including a diverse sample that considers the design effect is a notable strength of this study, as it ensures the production of robust and reliable results, thereby allowing for broader representation and applicability to wider populations. In this study, sampling was conducted among nurses working in three hospitals. The primary goal was to select a sample proportional to the distribution of nurses in these hospitals. The total number of nurses in each hospital was identified, and the proportion of nurses in each hospital relative to the total population was calculated as follows: Hospital 1: 64%, Hospital 2: 22%, and Hospital 3: 14%. Based on these proportions, the number of samples to be taken from each hospital was determined.
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Inclusion and exclusion criteria
The inclusion criteria for this study were as follows:
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Participants had to be employed in the nursing profession.
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Participants were required to have a minimum of one year of work experience.
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Participants needed to express willingness to take part in the study.
The exclusion criteria included:
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Failure to complete all sections of the questionnaire.
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Withdrawing from the study at any point during the research process.
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Data collection
Data collection was conducted using two instruments: a demographic information questionnaire and a clinical competence questionnaire. After obtaining approval from the ethics committee, a member of the research team distributed the questionnaires to various departments in Shariati, Emam Hosein, and Valiasr educational hospitals.
The data collection process involved the following steps:
1.
Necessary permissions were secured, and arrangements were made to visit hospital departments at the start of nurses’ shifts.
2.
Eligible nurses were provided with a detailed explanation of the study’s objectives, the procedure for completing the questionnaire, and the overall research methodology.
3.
Nurses were instructed to fill out the questionnaire and submit it to the head nurse of their respective departments.
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Head nurses received comprehensive guidance on the questionnaire’s completion process to address any questions or concerns from participants.
5.
One week later, the research team retrieved the completed questionnaires from the head nurses.
Research instruments
The tools used for data collection in this study consisted of two distinct sections. The first section gathered demographic and occupational data, including participants’ age, gender, marital status, educational qualifications, department assignments, years of professional experience, and weekly working hours.
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The second section utilized the Clinical Competency Inventory for Registered Nurses (CCIRN), a validated tool comprising 55 items divided into seven key dimensions: clinical care (10 items), leadership (9 items), legal and ethical practice (8 items), professional development (6 items), interpersonal communication (8 items), teaching and mentoring (6 items), and critical thinking and research aptitude (8 items).
Responses to the CCIRN were scored on a five-point Likert scale ranging from 0 to 4, with the following options:
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0 = not competent.
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1 = slightly competent.
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2 = somewhat competent.
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3 = competent enough.
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4 = very competent.
The overall score for the instrument ranged from 0 to 220, where higher scores reflected greater levels of competency. Based on the mean scores, participants were classified into three categories: those scoring above 3 (165–220) were identified as highly competent; those with scores between 2 and 3 (110–165) were classified as moderately competent; and those with scores below 2 (below 110) were categorized as having low competency.
The reliability of the CCIRN was originally verified by Liu et al. (2008), with a reported Cronbach’s alpha of 0.908 for the entire instrument and coefficients ranging from 0.718 to 0.903 across its dimensions. The Persian translation of the CCIRN was subsequently validated by Ghasemi et al. (2013), demonstrating a Cronbach’s alpha of 0.893 overall and reliability coefficients between 0.791 and 0.860 for individual dimensions. In the current study, the CCIRN achieved an impressive Cronbach’s alpha of 0.96, further confirming its reliability and validity as a research instrument [19].
Data analysis
Descriptive statistics were expressed as percentages to illustrate the occurrence or absence of needle-stick injuries.
To examine the relationships among the three competency groups (low, moderate, high), two statistical approaches were employed depending on how the variable was analyzed. When needle-stick injury was treated as a continuous variable, the Kruskal-Wallis test was applied due to the non-normal distribution of the data. However, when it was analyzed as a binary variable (injury present vs. injury absent), the Chi-square test was used. To control for potential confounders, multiple logistic regression analysis was performed, and the results were expressed as odds ratios (ORs) to indicate the strength of associations. All statistical tests were conducted with a significance threshold set at p < 0.05. Data analysis was carried out using SPSS software, version 16.
Results
A total of 275 nurses from Fasa teaching hospitals participated in the study. Of these, 11 participants were excluded due to incomplete questionnaire responses, leaving a final sample of 264 participants for analysis. The sample included 98 male nurses (37.1%) and 166 female nurses (62.9%). Regarding educational qualifications, 7 participants (2.7%) held associate degrees, 238 (90.2%) had bachelor’s degrees, and 19 (7.2%) possessed master’s degrees in nursing. The mean age of the participants was 31.88 ± 6.979 years (Table 1).
The results indicated that 178 participants (67.42%) had experienced needle-stick or sharp injuries within the past year. Among these individuals, 63 were male (35.3%), and 115 were female (64.6%).
The highest incidence of needle-stick and sharp injuries occurred in the Operating Room (91.7%), followed by the Dialysis Unit (88.9%), Pediatrics (80%), Surgical Intensive Care (76.5%), the Emergency Department (74.3%), Women’s Surgery (70%), Post-Cardiac Intensive Care (69.2%), Oncology (63.6%), Internal Medicine (59.1%), Surgery and Infectious Diseases (54.5%), Laboratory and Cardiac Intensive Care (52.9%), Men’s Surgery (50%), and the Psychiatric Ward (41.2%) (Table 1).
Statistical analysis revealed no significant differences in the incidence of needle-stick injuries based on age, gender, educational level, work experience, or weekly working hours. However, significant differences were observed across hospital departments (P = 0.018). Furthermore, a significant disparity was noted between married and single participants, with married individuals reporting higher rates of needle-stick and sharp injuries (P = 0.024) (Table 1).
Table 1
Demographic information of the participants
Variables | Group | Needle Stick and Sharp Injuries | p-value | |||||
|---|---|---|---|---|---|---|---|---|
No (N (%)) | Yes (N (%)) | |||||||
Sex | Male | 35(35.7) | 63(64.3) | 0.403 | ||||
Female | 51(30.7) | 115(69.3) | ||||||
Marital status | Single | 44(40.4) | 65(59.6) | 0.024 | ||||
Married | 42(27.1) | 113(72.9) | ||||||
Education status | Associated | 3(42.9) | 4(57.1) | 0.712 | ||||
Bachelor | 78(32.8) | 160(67.2) | ||||||
Master | 5(26.3) | 14(73.7) | ||||||
Working Department | Operation room (OR) | 3(8.3) | 33(91.7) | 0.018 | ||||
Intensive care unit (ICU) | 4(23.5) | 13(76.5) | ||||||
Cardiac care unit (CCU) | 8(47.1) | 9(52.9) | ||||||
Post cardiac care unit (PCCU) | 4(30.8) | 9(69.2) | ||||||
Emergency room (ER) | 9(25.7) | 26(74.3) | ||||||
Surgery | 5(45.5) | 6(54.5) | ||||||
Internal | 9(40.9) | 13(59.1) | ||||||
Male Surgery | 8(50.0) | 8(50.0) | ||||||
Pediatric | 3(20.0) | 12(80.0) | ||||||
Female Surgery | 5(29.4) | 12(70.6) | ||||||
Infectious | 5(45.5) | 6(54.5) | ||||||
Psyche | 10(58.8) | 7(41.2) | ||||||
Dialysis | 1(11.1) | 8(88.9) | ||||||
Oncology | 4(36.4) | 7(63.6) | ||||||
Laboratory | 8(47.1) | 9(52.9) | ||||||
Age | 20–30 | 42(34.7) | 79(65.3) | 0.505 | ||||
30–40 | 28(27.5) | 74(72.5) | ||||||
40–50 | 12(35.3) | 22(64.7) | ||||||
50< | 4(57.1) | 3(42.9) | ||||||
Work Experience(years) | 1–10 | 54(31.0) | 120(69.0) | 0.396 | ||||
10–20 | 22(32.4) | 46(67.6) | ||||||
20–30 | 10(45.5) | 12(54.5) | ||||||
Hour Working per Week | 30–40 | 8(26.7) | 22(73.3) | 0.325 | ||||
40–50 | 31(29.0) | 76(71.0) | ||||||
> 50 | 47(37.0) | 80(63.0) | ||||||
The data analysis, as illustrated in Fig. 1, reveals that among the procedures associated with needle-stick and sharps injuries (NSSI) in the nursing population studied, intravenous (IV) cannula insertion accounted for the highest frequency, followed by needle recapping. In contrast, procedures such as blood sample collection and surgical knife usage exhibited the lowest incidence rates.
Fig. 1
Frequency of needle-stick and sharp injuries
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The findings further demonstrated that 39.4% of the nurses displayed high levels of competency, 51.5% were categorized as having moderate competency, and 9.1% were classified as having low competency. These results indicate that the majority of participants exhibited moderate levels of clinical competence.
An analysis of the frequency of NSSI among nurses with varying levels of clinical competency revealed rates of 54%, 77%, and 57% for nurses with low, moderate, and high competency levels, respectively. Notably, nurses with moderate competency experienced the highest frequency of NSSI incidents, while those with low competency reported the lowest frequency (Fig. 2).
Fig. 2
Level of clinical competence and frequency of NSSI
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A Kruskal-Wallis test was conducted to examine the differences in the frequency of NSSI across the three competency groups. The test results were statistically significant, as shown in Table 2.
Table 2
Comparison of needle Stick and Sharp Injuries across the competency groups and domains
Categories | Level of Competency | ||||||||
|---|---|---|---|---|---|---|---|---|---|
Low | Moderate | High | |||||||
Mean | SD | Mean | SD | Mean | SD | ||||
Competency domains | Clinical care | 1.61 | 0.26 | 2.55 | 0.40 | 3.54 | 0.34 | ||
Leadership | 1.47 | 0.30 | 2.61 | 0.38 | 3.50 | 0.36 | |||
Interpersonal relationship | 1.84 | 0.35 | 2.52 | 0.33 | 3.39 | 0.39 | |||
Legal/ethical practice | 1.43 | 0.39 | 2.95 | 0.38 | 3.66 | 0.32 | |||
Professional development | 1.82 | 0.33 | 2.57 | 0.41 | 3.44 | 0.41 | |||
Teaching-coaching | 1.34 | 0.68 | 2.35 | 0.54 | 3.49 | 0.36 | |||
Critical thinking/research aptitude | 1.71 | 0.29 | 2.35 | 0.35 | 3.41 | 0.42 | |||
Needle Stick and Sharp Injuries | Mean (MED) | SD | Mean (MED) | SD | Mean (MED) | SD | |||
1.51 (1) | 2.30 | 2.35 (2) | 2.56 | 1.37 (1) | 2.35 | ||||
As displayed in Table 3, a significant difference was observed between the groups with moderate and low competence, as well as between the groups with high and moderate competence, in terms of the number of needle-stick incidents (P = 0.001 and P = 0.04, respectively).
Table 3
Comparison of NSSI frequency among nurses with low, moderate, and high competency levels
Groups | Test statistic | Sig. |
|---|---|---|
High competency- Low competency | 0.294 | 0.895 |
High competency -moderate competency | 8.245 | 0.04 |
low competency - moderate competency | 11.51 | 0.001 |
A logistic regression model was employed to assess the likelihood of experiencing needle-stick injuries based on demographic variables. The analysis revealed that nurses working in the operating room faced nine times higher odds of experiencing NSSI compared to those working in the infectious disease ward, while nurses in the dialysis unit had seven times higher odds. These results highlight the significantly elevated risk of NSSI among operating room and dialysis unit nurses compared to nurses in other departments. Additionally, the analysis showed that nurses with fewer than 10 years of experience and those with 10–20 years of experience were less likely to experience NSSI compared to nurses with over 20 years of experience (OR = 0.91 and OR = 0.61, respectively, Table 4).
Table 4
Logistic regression model
Group | Coefficient | OR | S.E. | p-value | ||
|---|---|---|---|---|---|---|
Sex | Male | -0.013 | 0.987 | 0.327 | 0.968 | |
Female | - | - | - | - | ||
Marital Status | Single | -0.671 | 0.511 | 0.338 | 0.047 | |
Married | - | - | - | - | ||
Education Status | Associated | -1.374 | 0.253 | 1 | 0.211 | |
Bachelor | -0.492 | 0.612 | 0.62 | 0.427 | ||
Master | - | - | - | - | ||
Working Department | OR | 2.21 | 9.12 | 0.8 | 0.005 | |
ICU Surgery | 0.672 | 1.96 | 0.8 | 0.399 | ||
CCU | -0.107 | 0.9 | 0.73 | 0.883 | ||
PCCU | 0.695 | 2 | 0.81 | 0.388 | ||
ER | 0.979 | 2.67 | 0.66 | 0.139 | ||
Surgery | -0.186 | 0.83 | 0.82 | 0.819 | ||
Internal | 0.076 | 1.08 | 0.7 | 0.913 | ||
Male Surgery | -0.184 | 0.83 | 0.76 | 0.809 | ||
Pediatric | 1.04 | 2.83 | 0.83 | 0.213 | ||
Female Surgery | 0.52 | 1.69 | 0.76 | 0.495 | ||
Laboratory | -0.291 | 0.75 | 0.82 | 0.724 | ||
Psyche | -0.497 | 0.61 | 0.73 | 0.495 | ||
dialysis | 1.99 | 7.38 | 1.25 | 0.109 | ||
Oncology | 0.282 | 1.32 | 0.82 | 0.732 | ||
Infectious | - | - | - | - | ||
Age | 20–30 | 1.83 | 6.21 | 1.64 | 0.27 | |
30–40 | 1.99 | 7.34 | 1.6 | 0.213 | ||
40–50 | 1.34 | 3.8 | 1.44 | 0.354 | ||
50< | - | - | - | - | ||
Work Experience(years) | 1–10 | -0.095 | 0.91 | 1.01 | 0.926 | |
10–20 | -0.477 | 0.62 | 0.92 | 0.604 | ||
20–30 | - | - | - | - | ||
Hour Working per Week | 30–40 | 0.434 | 1.54 | 0.46 | 0.347 | |
40–50 | 0.039 | 1.04 | 0.351 | 0.911 | ||
> 50 | - | - | - | - | ||
Discussion
This study aimed to examine the relationship between nurses’ competency levels and the incidence of needle-stick injuries (NSIs), sharps injuries, and their contributing factors across various departments in Iranian teaching hospitals. Among the participants, 64.3% of male nurses and 69.3% of female nurses reported experiencing NSIs in the past year. The findings indicated no statistically significant difference in NSI rates between genders. These results are consistent with those reported by Co et al. (2014) and Galougahi et al. (2010) [23, 24]. However, studies conducted by Kasatpibal et al. (2016), Abdo Almoliky et al. (2024), and Wang et al. (2019) identified a significant association between NSI rates and gender, with women showing a markedly higher prevalence of NSIs [25, 26, 27].
The study also revealed a significant correlation between NSI rates and marital status, with married individuals exhibiting a higher risk of injury. This increased vulnerability may be attributed to stressors associated with marital life. In contrast, Belachew et al. (2017) reported a lower risk of NSIs among married individuals, attributing their findings to a heightened sense of responsibility among this group [28]. It is noteworthy that most prior studies have not considered marital status as a variable, focusing instead on demographic factors such as age, gender, department, occupation, and work shifts. The inclusion of marital status in the present analysis represents a distinctive strength of this study, and further investigation of this variable is recommended for future research.
A logistic regression model was employed to compare injury prevalence across hospital departments, revealing that operating room nurses faced the highest risk of NSIs (OR = 9.12). The operating room reported the highest NSI incidence rate, with 91.7% of nurses in this department experiencing NSIs. These findings align with those of Sofia et al. (2021), whose cross-sectional study, as well as Abdo Almoliky et al.‘s (2024) retrospective analysis, both identified the operating room as the department with the highest prevalence of NSIs [25]. Similarly, a cross-sectional study conducted by Kasatpibal et al. (2016) involving 2,500 operating room nurses from 247 hospitals in Thailand documented a high prevalence of NSIs among operating room personnel, with 71.5% reporting at least one NSI in the previous year [26].
The elevated NSI rates in operating rooms can be attributed to several factors, including irregular staff training, inadequate availability of protective equipment, the absence of comprehensive preventive guidelines, time constraints, insufficient awareness of associated risks, and persistent staff shortages.
Given that operating rooms have the highest rates of NSIs, several contributing factors can be identified. These include the frequent insertion of intravenous (IV) cannulas for anesthesia induction, procedures involving blood and fluid therapy, the use of sharp instruments during surgical interventions, heavy workloads, and emergency surgical cases. A review of the literature further highlights that insufficient training in injection techniques, failure to wear gloves during IV cannula insertion, a significant disconnect between theoretical knowledge and practical application, outdated guidelines, noncompliance with safe injection protocols, understaffing, and limited awareness are critical factors contributing to NSIs among operating room personnel [26, 29, 30, 31].
Although this study did not identify a significant correlation between the educational level of participating nurses and the rate of NSIs—a finding consistent with the cross-sectional study conducted by Abdo Almoliky et al. (2024)—other studies provide contrasting evidence. For example, cross-sectional studies by Lakbala et al. (2014) and Faris Ahmed et al. (2020) demonstrated a significant association between nurses’ educational attainment and the incidence of NSIs, which contrasts with the findings of this research [30, 32]. Specifically, Lakbala et al. (2014) reported that among individuals with varying educational levels—including diploma holders, associate diploma holders, bachelor’s degree recipients, and master’s degree holders—those with a diploma experienced the highest rate of NSIs [30].
Furthermore, this study found that IV cannula insertion accounted for the highest frequency of procedures leading to NSIs. This procedure, which is a routine practice in operating rooms, aligns with the findings of Smith et al. (2010) and Sriram (2019). However, in contrast, Galougahi et al. (2010) reported that IV cannula insertion ranked third in frequency, following syringe injection and needle recapping [23, 33, 34].
To mitigate the risk of infection transmission and reduce the prevalence of NSIs, healthcare staff must participate in comprehensive educational and preventive interventions. Assessing nurses’ competency levels and examining their relationship with the incidence of NSIs could provide valuable insights in this regard. According to our research, no prior studies have explored the relationship between nurses’ competency levels and the prevalence of NSIs or sharps-related injuries in any country. This gap underscores a notable strength of the present study in comparison to earlier research.
The findings of this study indicate that 39.4% of nurses exhibited high levels of competency, 51.5% demonstrated moderate competency, and 9.1% displayed low competency. These results suggest that the majority of nurses in this study possessed a moderate level of clinical competency.
A systematic review and meta-analysis conducted by Zeydi et al. (2022) in Iran concluded that the competency levels of Iranian nurses are generally acceptable [35]. This conclusion aligns with findings from studies conducted in the United States [36], China [37], Finland [38], Australia [39], and Saudi Arabia [40], as well as with the results of the present study. However, research by Kim et al. (2015) in South Korea assessed nurses’ competency levels as high [41]. Similarly, Ying et al. (2007) reported high competency levels among nurses in their study, which contrasts with findings from other studies conducted in China and Taiwan. Factors such as extensive work experience, higher educational qualifications, greater professional maturity, and exposure to patients with complex conditions in hospitals were identified as key contributors to the higher competency levels observed in these studies [37].
A particularly noteworthy finding of the present study is the significant correlation between nurses’ competency levels (high, moderate, and low) and their rates of NSIs. This significant relationship was further evident in pairwise comparisons, particularly between nurses with moderate and low competency levels, as well as between those with high and moderate competency levels. Nurses with high competency levels experienced fewer NSIs compared to those with moderate competency, highlighting the protective effect of enhanced clinical skills and proficiency.
An analysis of the seven dimensions of competency revealed that nurses with high competency levels achieved the highest mean scores in the Legal/Ethical Practice and Clinical Care dimensions. These findings are consistent with those reported by Feliciano et al. (2019), Kim et al. (2019), and Chen et al. (2021) [42, 43, 44]. However, the study by Emami Zeydi et al. (2022) indicated that the Legal/Ethical Practice dimension was evaluated at an average level based on the scores obtained [35]. Accordingly, the present study underscores the importance of legal and ethical performance as a critical dimension of competency that contributes to reducing the incidence of NSIs. Nurses who adhere to policies established by organizations promoting patient rights charters—policies grounded in legal and ethical principles—must possess the requisite knowledge, skills, and abilities in legal and ethical performance. These competencies enable them to carry out their nursing responsibilities independently, accurately, safely, and successfully, without the need for supervision [45].
The findings further demonstrate that nurses with higher mean scores across the seven competency dimensions and lower rates of NSIs have effectively acquired the necessary knowledge, skills, and abilities, particularly in the Legal/Ethical Practice dimension. This suggests that such nurses have a strong awareness of their professional obligations to perform duties in accordance with established legal, ethical, and behavioral standards. Furthermore, the historical evolution of nursing highlights that ethical and legal performance has been a fundamental pillar of the profession since its inception [46].
A comparison of mean scores in the Legal/Ethical Practice dimension (Table 2) reveals a progressive increase in scores across the low-, moderate-, and high-competency groups. Notably, this dimension exhibited the most pronounced increase, achieving the highest mean score among all dimensions. This finding underscores its greater influence on overall nursing competency compared to the other dimensions.
Additionally, a significant relationship was observed between the rate of NSIs and the competency levels of nurses in the moderate- and low-competency groups. Interestingly, nurses in the moderate-competency group experienced higher rates of NSIs compared to those in the low-competency group. This unexpected finding presents one of the most challenging aspects of the present study, raising the question of why nurses with moderate competency are more susceptible to NSIs than their less-competent counterparts. Conversely, nurses with high competency levels experienced significantly fewer NSIs compared to those in the moderate-competency group.
To refute the study’s hypothesis—that there is a relationship between nurses’ competency levels and their rate of needle-stick injuries (NSIs)—one would need to address the results, which indicate that nurses with high competency levels experience significantly lower rates of NSIs compared to those in the moderate- and low-competency groups. This issue presents a critical challenge that demands further investigation.
One plausible explanation lies in the educational nature of the hospitals included in this study. In such settings, a portion of procedures that may lead to NSIs are performed by nursing students, particularly those in their final year of training. Consequently, staff nurses with lower competency levels, owing to their limited clinical expertise, are more likely to delegate these procedures to nursing students. This delegation reduces the number of high-risk procedures performed by less-competent nurses, thereby lowering their direct exposure to NSIs.
In contrast, nurses in the moderate- and high-competency groups perform the majority of these procedures themselves. This observation is supported by the higher mean scores recorded in the Clinical Care and Teaching/Coaching dimensions among nurses in these groups. These findings suggest that nurses with moderate and high levels of competency, while performing procedures, frequently engage in teaching activities, aiming to enhance the students’ training by assuming leadership roles as clinical caregivers and educators. However, the findings of O’Leary (2012) and Ying (2007) diverge from the results of this study, as they identified the Teaching/Coaching dimension as one of the weakest aspects of clinical competence among nurses [36, 37].
Conversely, nurses with lower competency levels often rely on their colleagues within the department to carry out high-risk procedures, particularly those with an elevated likelihood of causing NSIs. This reliance effectively reduces their direct exposure to such injuries. Meanwhile, nurses in the moderate- and high-competency groups, due to their involvement in a broader array of procedures within their units, face a greater risk of sustaining NSIs.
A noteworthy aspect of this study is the finding that the majority of nurses employed in the hospital fall within the moderate-competency group, accounting for 51.5% of the total nursing staff. Among this group, approximately 77% reported experiencing NSIs in the past year. Given that nurses, as indispensable members of the healthcare system, bear the critical responsibility of maintaining clinical competency [47], it is imperative to implement targeted interventions aimed at reducing the incidence of NSIs within this cohort. Continuous and well-structured educational programs should be designed and delivered to elevate their competency levels. Nursing competency is integral to ensuring the delivery of safe and effective patient care, particularly in executing practical procedures that carry inherent risks of NSIs.
High competency among nurses and other healthcare professionals is associated with positive outcomes, including enhanced operational efficiency, improved patient safety, and better overall health outcomes for patients. Conversely, low competency within the nursing workforce heightens the risk of errors, compromises patient safety, and diminishes the overall quality of care [48]. Moreover, the implications of nursing competency extend beyond patient outcomes to encompass the safety and well-being of nurses themselves [49]. This underscores the critical importance of competency in significantly reducing NSI-related injuries, thereby protecting both patient welfare and the resilience of the nursing workforce.
Limitations
First, the research was conducted solely in teaching hospitals, excluding other types of healthcare facilities, which constrains the applicability of the findings to a wider context. Second, the relatively small sample size of 264 participants restricts the extent to which the results can be generalized to the broader nursing population. Third, the study could have benefited from a larger-scale investigation, potentially encompassing regional or national levels, to enhance both the reliability and generalizability of the findings. Fourth, the cross-sectional design of this research limits its ability to provide insights into how competency levels among nurses evolve over time. A longitudinal approach would offer stronger evidence regarding trends and changes in nurses’ competencies. Lastly, the study could have included additional variables, such as job satisfaction, workload within specific departments, availability of departmental resources, work shift patterns, completion of relevant training programs, and adherence to personal protective equipment (PPE) protocols, to provide a more comprehensive understanding of factors influencing needle-stick injuries (NSIs).
Conclusion
Since the majority of hospital-based nurses exhibit moderate or low levels of clinical competency, it is imperative for hospitals to implement an annual process for evaluating the clinical skills of their nursing staff. Regular competency assessments and initiatives to enhance skill levels not only improve the quality of patient care but also contribute to lowering the incidence of NSIs among healthcare providers. Furthermore, hospitals and medical centers should adopt targeted strategies to minimize the risk of NSIs across all departments, with particular emphasis on high-risk areas such as operating rooms and dialysis units, where these injuries are more prevalent. Tackling these issues through advanced training programs and continuous professional development is crucial for fostering a proficient nursing workforce capable of delivering safe, high-quality healthcare services.
Acknowledgements
The authors would like to appreciate Fasa University of Medical Sciences & Clinical Research Development Unit of Fasa Valiasr hospital for financially supporting this research.
Declarations
Ethics approval and consent to participate
All the participants gave written informed consent to participate in the study. The present study was conducted in terms of the principles of the revised Declaration of Helsinki, which is a statement of ethical principles that directs physicians and other participants in medical research involving human subjects. The participants were assured about their anonymity and confidentiality of their information. Moreover, the study was approved by the Institutional Research Ethics Committee of Fasa University of Medical Sciences, Fasa, Iran (Ethical code: IR.FUMS.REC.1402.117).
Consent to publish
Not applicable.
Competing interests
The authors declare no competing interests.
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