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Underreporting of Bloodborne Pathogen Exposures in Nursing Students

Black Thomas, Lisa M. PhD, RN, CNE, FAAN

Author Information
doi: 10.1097/NNE.0000000000000696


US hospital-based health care workers sustain approximately 33.8 percutaneous injuries per 100 occupied hospital beds, and the majority of these injuries are sustained by nurses.1 An extensive database exists in the literature that describes a multitude of antecedents and consequences of needlestick injuries (NSIs) in health care providers. However, little is known about bloodborne pathogen (BBP) exposures sustained by US nursing students during clinical practicum experiences.2

Although nursing students perform many of the same procedures as licensed nurses, students are inherently less skillful when handling needles and sharps3 and are at higher risk of injury than their licensed counterparts.2 The purpose of this study was to examine reporting behaviors of US nursing students who experience percutaneous exposures to blood and body fluids during clinical practicum experiences. A clinical practicum experience refers to any clinical experience in which a student provides direct care to patients.

Background and Significance

The Centers for Disease Control and Prevention estimates that approximately 385 000 percutaneous BBP exposures occur annually among US hospital-based health care workers.4 Extrapolating from a known national HIV seroprevalence rate of 0.6%,5 approximately 2300 hospital-based NSIs expose a health care worker to HIV annually.

An unknown number of these NSIs involve nursing students. Systematic reviews of nursing student BBP exposures2,6 show NSI rates among nursing students ranging from 9.4% (United States) to 61.9% (Turkey), although most available studies reflect small samples and are drawn from a single school of nursing or medical facility. A glaring consistency among the published studies is that between 39.4% and 95.8% of the NSIs experienced by nursing students were not reported at the time of the exposure.

The US Occupational and Safety Health Association (OSHA) standard requires that employers provide exposed employees access to appropriate postexposure evaluation and postexposure prophylaxis treatment when indicated.7,8 The efficiency of this system, however, is dependent on timely reporting of exposures by injured health care workers. Of concern, this OSHA mandate does not apply to nursing students participating in clinical practicum experiences in health care facilities. In most acute care facilities, nursing students do not report exposures to the employee health or infection control departments of the sponsoring agency. Rather, student exposures are typically referred to academic student health settings, emergency departments, or individual health care providers where their numbers, reporting statistics, and outcomes are difficult to track.2

Multiple authors2,9-15 describe high rates of NSI underreporting among students in all health care disciplines. Reasons cited for nonreporting among nursing students include the student's subjective opinion that the source patient was noninfectious, embarrassment, fears of “getting in trouble,” fears that the injury would affect their grades, not wanting to be perceived as having poor clinical skills, lack of awareness of reporting procedures, and lack of appreciation of the risks associated with contaminated sharps.2

While nursing students are often required to maintain individual health insurance, individual insurance policies typically require that students be evaluated in the office of a primary care practitioner or in a hospital-based emergency department. Average emergency department wait times exceed 4 hours in the United States,16 and the time required to see a primary care physician averages 29.3 days.17 Coupled with low reporting rates, these delays in evaluation and treatment of BBP exposures potentially expose nursing students to a higher risk of seroconversion in the event of a high-risk BBP exposure.


Research Design

This study used a retrospective cross-sectional survey design to examine percutaneous BBP exposures occurring during a clinical practicum experience. Descriptive and inferential analyses were used to describe the exposure characteristics and reporting patterns of nursing students who experienced a percutaneous exposure during an undergraduate nursing clinical practicum.

Subjects/Setting/Sample Size

To maximize the study sample, the sampling frame comprised all prelicensure nursing programs (N = 1407) accredited by the Commission on Collegiate Nursing Education (CCNE) or Accreditation Commission for Education in Nursing (ACEN). The sampling frame included 580 CCNE-accredited BSN programs, 166 ACEN-accredited BSN programs, and 661 ACEN-accredited associate degree in nursing (ADN) programs. A priori power analysis indicated that a final study sample of 198 students who had experienced at least 1 NSI would be required to detect a medium effect size with 95% power using goodness-of-fit contingency table analysis. An exposed sample of 172 is required to detect a medium effect with 95% power using multiple or logistic regression analysis with 6 predictors.18 Thus, the sampling strategy was expected to yield sufficient power to demonstrate statistical differences. Permission to conduct this research was obtained by the Office of Human Research Protection of the university with which the author is affiliated. Identifying information about respondents or their respective schools of nursing was not collected from participants.


The Nursing Student Bloodborne Pathogen Exposure Inventory is a 45-item survey created by the principal investigator that queries participants about (a) BBP exposures sustained during a clinical practicum experiences, (b) characteristics of percutaneous exposures, (c) source patient characteristics, (d) reporting behaviors, (e) postexposure evaluation and treatment, and (f) student demographics. The survey tool has been subjected to expert content review to establish content validity and has been pilot tested with undergraduate nursing students in a baccalaureate nursing program. Split-half internal consistency of the instrument is excellent (r = 0.96 [SD, 0.12]).


The Nursing Student Bloodborne Pathogen Exposure Inventory was distributed electronically to the directors of all participating schools of nursing. Program directors were requested to electronically disseminate the recruitment materials to all prelicensure students currently participating in clinical practicum experiences. All students (whether or not they had sustained an exposure) were asked to respond to the survey. The Nursing Student Bloodborne Pathogen Exposure Inventory questions were presented in a branched format that exposed participants only to the survey items that applied to their exposure experience.

Initial survey responses were reviewed after a total of 3 electronic mailings. Responses from each state were compared with the population of RNs in each state.19 Estimates of the total number of nursing students by state were not available to the researcher, so RN population was used as a proxy for student nurse population to ensure representativeness between the study sample and the distribution of RNs in the United States. From these measures, a desired number of responses per state was calculated. Underrepresented states, defined as those where the actual number of respondents from that state was fewer than half the desired number, were then resampled. The final sample included 4140 nursing students enrolled in prelicensure programs throughout the United States.

Data Analysis

Survey responses were downloaded from the electronic survey software and converted to a STATA data file using StatTransfer. All data were analyzed using STATA version 14.0 (StataCorp, College Station, Texas). Survey data were merged with key demographic variables based on each respondent's county of residence. Descriptive analyses including response frequency and cross-tabulation were performed on all survey items. Spearman rank order correlation and χ2 testing were used to identify relationships between study variables. Finally, a multivariate logistic regression model was fitted to predict reporting behavior of BBP exposures.


Sample Demographics

Of the nursing students who responded to the original survey, 88.1% (3646/4140) were female with an average age of 29.7 (SD, 8.6) years. The respondents were nearly evenly split between students enrolled in an ADN program (1894/4140 [45.8%]) and students pursuing education at the baccalaureate level (2109/4140 [50.9%]). Eleven percent (457/4140) of the respondents reported having experienced a BBP exposure during a clinical rotation. Sixty percent (274/457) of these exposures were percutaneous in nature. The remainder of this article reports only percutaneous injuries as these exposures carry the greatest risk of BBP communicability.

Percutaneous Exposure Experience of Students

Of those who reported a percutaneous BBP exposure, 92.5% experienced only 1 exposure, and nearly half of reported exposures occurred during the second quartile of the student's nursing education. This second-quartile exposure incidence is more than double the injury rate of any other quartile of the respondents' education (Table 1, Supplemental Digital Content 1,

Most reported NSIs (86.1%) were to sharps contaminated with blood or body fluids, and 40.4% of these had visible blood on the device at the time of injury. All participants described the severity of their injury as superficial (53.1%) or moderate (46.9%) in nature. Nearly all (94.7%) of reported student exposures were to a hollow-bore needle, and 82.5% of these devices were equipped with a safety device intended to prevent injury. Fifty-eight percent of injuries occurred during intramuscular or subcutaneous injection, and 31% occurred during intravenous cannulation. Participants were asked to identify the phase of the procedure in which the injury occurred. More than half of reported NSIs occurred after use of the device (Supplemental Digital Content, Table 1,

Student Perception of NSI Risk

Students were asked to respond to Likert-scale statements describing their perception of risk from an NSI occurring during a clinical practicum experience. Thirty-eight percent (100/266) of students who sustained an NSI during clinical practice indicated a belief that only exposures from high-risk patients needed to be reported (Table 2, Supplemental Digital Content 2, This belief was inversely correlated with actual reporting behavior (rs = −0.71, P < .01). In fact, only 17.5% (17/97) of students who responded that only high-risk exposures needed to be reported actually reported an NSI that was sustained during a clinical practicum experience (χ21 = 78.7, P < .01).

Eighty-eight percent of respondents who experienced an NSI reported being afraid of sustaining an NSI while caring for a patient during a clinical practicum (Supplemental Digital Content, Table 2, Despite their reported fear, more than a third of students responded that they did not know how to report an NSI should one occur. Lack of reporting knowledge was negatively correlated with level of fear of sustaining an NSI during a clinical program (rs = −0.21, P < .05), meaning that students who did not know how to report an NSI were more afraid of sustaining one. Sixty-seven percent of students who had experienced an NSI agreed that their assigned clinical faculty could effectively advocate for them. However, 63.9% of respondents also believed that they would receive a lower clinical grade if they reported an NSI that occurred during clinical practice (Table 2, Supplemental Digital Content 2,

Exposure-Related Reporting Factors

Whether the student was using appropriate personal protective equipment (PPE) at the time of the NSI greatly affected the likelihood that a student would report an NSI (χ21 = 64.9, P < .001). Specifically, 80.7% (50/62) of students who were wearing gloves at the time of their NSI reported their exposure, whereas 93% (53/57) of those who were not wearing gloves at the time of the exposure did not report. Source patient factors impacted the likelihood that a student would report an NSI. Nearly all students (33/34 [97.1%]) whose percutaneous exposure was to a patient with a known BBP infection reported their exposure. Likewise, nearly all exposures (28/29 [96.6%]) where the source patient had a known history of intravenous drug use were reported.

Reporting behaviors did not vary by gender (χ21 = 0.9, P = .32), although student age was a strong predictor of reporting behavior. Students older than 30 years were significantly more likely to report an NSI sustained during a clinical practicum experience than younger students (χ24 = 43.3, P < .001). Reporting behaviors also differed by educational program (χ21 = 10.3, P < .01). Sixty percent (52/86) of BSN students with an NSI reported that exposure, whereas only 39% (60/154) of similarly exposed ADN students reported their exposure.

Of NSIs that were reported to a faculty member or reference nurse, 79.6% were reported within 15 minutes of the event. Fifty-five percent of student NSIs were reported initially to a faculty member, and 45.1% were initially reported to a reference nurse or preceptor. However, more than half of students did not report their NSI at all (Table), even though 89.7% (114/127) of these nonreported injuries resulted from exposure to a contaminated sharp object and 47.2% (60/127) had visible blood on the sharp at the time of the exposure.

Nursing Student BBP Exposure Reporting (n = 274)

Reasons for Nonreporting

Respondents were asked to identify reasons that they chose not to report an NSI that occurred during a clinical practicum experience (Table). The study tool permitted students to choose multiple options, so total responses to these items exceed the number of students with an unreported exposure. Eighty-four percent of those who did not report an NSI occurring during a clinical practicum indicated that they feared they would “get in trouble” for having sustained the exposure, 64.6% indicated they feared the exposure would affect their clinical grade, and 48.9% indicated concern about being perceived as lacking clinical skills. Approximately 27% of students cited that a perception that the source patient was noninfectious was a reason for not reporting an exposure. Only 3.1% of students with an unreported NSI cited lack of knowledge of reporting procedures as a reason for failing to report.

Analytic Findings

A multivariate logistic regression model reporting odds ratio was fitted to the data (Table 3, Supplemental Digital Content, Sixty-six percent of the variance in reporting behavior among students who experienced an NSI is explained through examination of 4 variables (χ24 = 87.3, P < .001). Use of appropriate PPE, knowledge of how to report an NSI, belief that a faculty could advocate for the student in the event of an NSI, and belief that reporting an NSI would not affect the student's clinical grade were positive predictors of actual reporting behavior. The adjusted odds that a student would report an NSI increased by 8.5 (confidence interval [CI], 1.45-49.4) if the student felt the faculty could advocate in the event of an NSI, by 9.9 (CI 3.78-25.79) if the student believed that reporting an NSI would not affect the student's clinical grade, by 11.5 (CI 1.5-87.9) if the student knew how to report an NSI, and by 128.6 (CI 16.6-998.6) if the student was wearing appropriate PPE at the time of the NSI.


The findings of this study provide the first known examination of the reporting behaviors of US nursing students who experience NSIs during clinical practicum experiences. Nursing students are at equal, if not greater, risk of BBP exposure as their licensed nursing counterparts. However, students do not have the same level of institutional or legal protection that is available to health care workers employed by the facility in which care is provided. This lack of timely access to triage and testing creates a dynamic of unique risk among US nursing students who are exposed to BBPs during clinical practice. These delays in evaluation and treatment of percutaneous injuries create a gap in the ability to provide timely postexposure care to an exposed nursing student and potentially expose nursing students to a higher risk of seroconversion in the event of a high-risk BBP exposure.

In part, the findings of this study suggest a need for additional curricular focus on the importance of reporting any BBP exposure that occurs during a clinical practicum experience, regardless of how minor the student perceives the risk to be. Handiyani and colleagues20 describe a hierarchy of measures intended to prevent BBP exposures whereby emphasis of correct PPE use is balanced with engineering controls and elimination of hazards. Elimination of hazards is of paramount importance when working with nursing students. Students are excited to “get their feet wet” and practice new skills in the clinical setting. This enthusiasm should be tempered with caution to protect both the patient and nursing student from unnecessary exposure and avoidable harm.

Improving NSI Reporting

Consistent with previous authors,2,9-15 the results of this study demonstrate alarmingly low levels of NSI reporting among US nursing students. This study's findings suggest that students are informed of the process they should follow if they are exposed to a BBP during a clinical practicum but that they choose not to report because of fears that their clinical success would be jeopardized if they were to report an injury. With more than half of student NSIs unreported, it is essential that steps are taken to provide students with an avenue to report BBP exposures without fear of reprisal.

Positive student-faculty relationships are an important factor in the development of clinically competent, confident, and professionally socialized nurses.21 However, Ingraham et al22 found that nearly 50% of nursing students described faculty as being inaccessible, unapproachable, and/or uncommunicative. Further, Mott23 includes fear and intimidation as common descriptors nursing students use when describing their relationships with clinical faculty. It is alarming that more than 90% of students in this study who were not in compliance with PPE guidelines did not report their NSI, even though the majority of exposures described by students were to contaminated sharps with visible blood present on the device causing the injury.

While faculty describe their communication style to be clear, direct, and intended to convey rigor, students often perceive this communication style as intimidating and uncivil and occasionally crossing the line to bullying.23 It is unacceptable that students fear nursing faculty to the degree that they are willing to jeopardize their own health and safety to avoid what they perceive will be a negative interaction. For as long as nursing students remain afraid of and intimated by faculty, a student-faculty relationship that supports open reporting of student BBP exposures cannot exist. Change in the student-faculty dynamic is imperative, and the onus of this change is on the faculty.

Dramatic shifts have occurred in health care to break down the culture of blame that discourages error reporting in health care settings. While some have promoted a just culture where blame is balanced with accountability,15 others have found that threat, perceived or real, of unfavorable consequences “drove evidence of noncompliance underground, encouraging people to conceal [errors].”24 This same logic applies to reporting of student BBP exposures in the clinical setting, particularly those that bring potentially life-altering consequences for the student should an error go unreported. While accountability is an admirable ideal in nursing education, it is essential that nursing faculty foster a blame-free culture that encourages open reporting of BBP exposures sustained by students during undergraduate practicum experiences. The cost of any other course of action is far too high.


All data obtained for this study reflected the student's voluntary, self-reported exposure experience. This sampling methodology may introduce sample or response bias, which may have influenced the findings. While all feasible steps were taken to ensure representativeness of the sample, representativeness cannot be guaranteed. Additionally, the instrument was created by the researcher. While it was pilot tested before use, it has not been subjected to large-scale reliability and validity testing.


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bloodborne pathogen; injury reporting; needlestick injury; nursing student; reporting

Supplemental Digital Content

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