Abstract
Objectives
This study aimed to investigate regional differences in needlestick injury (NSI) protection among clinical nurses across China’s economic regions and to explore the influencing factors including hospital management, training and assessment mechanisms.
Study design
A national cross-sectional survey was conducted using a stratified sampling strategy combined with online questionnaire dissemination. Mediation analysis was applied to examine the indirect effects of economic regions on NSI protection.
Setting
The survey was conducted across tertiary hospitals in 28 provincial-level administrative regions of China, covering the Eastern, Central and Western economic regions.
Participants
A total of 15 274 valid questionnaires were collected from in-service clinical nurses working in tertiary hospitals who held valid nurse qualification certificates.
Interventions
No interventions were applied in this observational study.
Primary and secondary outcomes
The primary outcome was the total score of nurses’ knowledge, beliefs and practices (KBP) regarding NSI protection. Secondary outcomes included individual KBP dimension scores, NSI incidence in the past year and indicators of hospital management, training and assessment related to NSI prevention.
Results
Significant regional differences were observed in NSI-related management, assessment, training and nurses’ KBP scores across different economic regions (all p<0.05). Nurses in the Central economic region demonstrated higher management quality, training, assessment and KBP scores than those in the Eastern and Western regions. In contrast, nurses in the Eastern region showed greater awareness and utilisation of needle-free infusion systems. Multivariable analyses indicated that economic region, hospital management, personnel training and assessment were independently associated with nurses’ NSI protection ability. Compared with nurses in the Eastern and Western regions, nurses in the Central region demonstrated significantly better NSI-related beliefs, behaviours and overall protection scores. Mediation analysis further showed that management, assessment and training partially mediated the relationship between economic region and NSI protection, with mediation proportions ranging from 7.964% to 37.745% (all p<0.05).
Conclusion
Strengthening hospital-level NSI management systems, standardised training and regular assessment programmes may improve nurses’ NSI protection ability and help reduce regional disparities. These findings highlight the importance of institutional management strategies in enhancing occupational safety among clinical nurses.
Trial registration number
Keywords: Occupational Health Services, Nursing Care, Cross-Sectional Studies
STRENGTHS AND LIMITATIONS OF THIS STUDY.
This large nationwide survey used stratified and network sampling with strict quality control to improve sample representativeness and data reliability.
A validated questionnaire with good reliability was used to standardise the assessment of nurses’ knowledge, beliefs and practice regarding needlestick injury (NSI) prevention.
Mediation analysis was applied to explore the indirect effect of economic regions on NSI protection via management, training and assessment.
The cross-sectional design restricts causal inference about the temporal relationship between influencing factors and NSI protection.
Self-reported data may carry recall bias despite strict quality control during data collection.
Introduction
As is well documented, needlestick injury (NSI) represents a significant occupational hazard for healthcare professionals. It not only poses a serious threat to the occupational safety of nurses1 2 but also imposes a considerable financial burden of US$747–2173 per case.3 4 Earlier studies have established that the incidence of NSI in nurses in India and Japan ranges between 46% and 50%, respectively.5 6 For surgical medical staff, an anonymous survey reported that 44% of surgeons had experienced NSIs.7 Previous international studies have reported substantial variation in NSI exposure among healthcare workers across different countries and study settings. For example, multicentre studies conducted in Italy reported cumulative occupational exposure rates ranging from 35.3% to 71% among healthcare workers during their professional careers.8 In China, the incidence of NSI is markedly high.9 In another large-scale retrospective survey involving 38 867 nurses, 76.55% reported experiencing at least one NSI over a 16-year observation period.10 Previous studies in China have reported regional variation in NSI incidence among nurses. For example, a national survey reported an annual NSI incidence rate of 20.73%,11 whereas a separate regional study conducted in Lhasa reported a substantially higher rate of 46.6%.12 Lhasa, located in Western China, represents a relatively underdeveloped region with unique geographical and healthcare resource characteristics. Previous studies from Iran and Japan reported annual NSI rates of 0.52 and 0.75 events per healthcare worker-year, respectively.6 13 14 Indeed, the incidence of NSI significantly varies across countries and regions. NSI remains an important occupational health problem in healthcare systems worldwide, particularly in many low-income and middle-income countries where occupational safety resources and standardised prevention measures may be limited. These differences are predominantly reflected in the incidence rates, the implementation of preventive measures and the related economic burden.6 13 15–18
As a developing country, despite China ranking second in terms of global economic output,19 the economic aggregate significantly varies across provinces.20 During the period of China’s seventh Five-Year Plan, the country was divided into three economic regions, namely the Eastern, Central and Western regions, according to differences in natural conditions, economic resources, economic development level, transportation conditions and economic benefits. Notably, the Eastern region has a higher economic development level, production and construction efficiency, infrastructure, science and technology, operation and management capacities, which progressively decline from East to West.21 In 2021, the total national health expenditure was estimated at ¥755 936 billion, with government health expenditure contributing to ¥2071.85 billion, accounting for 27.4%. Government investment is a key economic source of medical and health development.22 Since the release of expert consensus on NSI protection in 2018, detailed proposals have been made on the management, training and specific strategies to reduce the incidence of NSI in Chinese clinical nurses.23 Medical investment is an important component of occupational safety systems and includes not only the provision of medical equipment but also personnel training, organisational management and assessment mechanisms. China’s Central economic region represents a transitional area between the more economically developed Eastern region and the relatively less developed Western region in terms of healthcare resources, economic development and hospital management systems. Using the Eastern, Central and Western economic regions as a framework, this study aimed to investigate regional differences in NSI protection among clinical nurses and to explore the influence of hospital management systems, personnel training and assessment mechanisms on nurses’ NSI protection ability. The findings may provide evidence to support the optimisation of occupational safety management and NSI prevention strategies in clinical settings.
Method
Object
The survey considered the level of economic development and regional characteristics. It included at least five tertiary hospitals from each provincial administrative unit, encompassing general hospitals, specialised hospitals, maternal and child healthcare hospitals, etc. Inclusion criteria for nurses: in-service and on-the-job clinical nurses working in tertiary hospitals holding valid nurse qualification certificates who voluntarily cooperated with the investigators. Exclusion criteria: nursing students, nursing managers, individuals taking maternity leave due to pregnancy or childbirth, refusal to participate in the survey, questionnaire completion time not meeting the minimum requirement, reverse entry selections and incomplete responses. All study subjects were informed of the survey details in advance and signed the informed consent form before accessing the survey page.
Questionnaire
This was a cross-sectional study. This survey included a custom-made questionnaire entitled ‘Survey on the status of needlestick injuries in clinical nurses’. It was designed by the researcher in collaboration with the experts of the clinical intravenous therapy team of the First Affiliated Hospital of Chongqing Medical University based on the ‘NSI protection expert consensus in 2018’23 and was completed through four rounds of discussion and revisions. The expert group consisted of 13 members (including one statistical expert) distributed across five cities, seven general hospitals and one medical college (statistical expert), among which 10 held senior titles and three held deputy senior titles. The questionnaire was reviewed by via four rounds of expert consultations from seven hospitals. Considering regional differences in language habits and written communication across China, 268 pilot questionnaires were conducted in representative cities from Western China (Chongqing), Southern China (Guangdong) and Northern China (Hebei) to evaluate questionnaire clarity, language comprehensibility and cultural adaptability. The purpose of the pilot survey was not to replicate the final economic-region classification used in the formal analysis, but to ensure that the questionnaire wording and content could be consistently understood by nurses from diverse regional and linguistic backgrounds before implementation of the nationwide survey. Finally, the questionnaire comprised three sections: (1) demographic characteristics of nurses, including region, hospital name, department name, age, years of experience, nursing role, nurse title, educational level, etc; (2) knowledge, beliefs and practice of nurses regarding NSI protection; (3) hospital management, training and assessment of the implementation of ‘NSI protection’. The Cronbach coefficient of the knowledge, beliefs and practice questionnaire was 0.789.
Based on the population data of each provincial-level administrative region in China in 2021,24 a stratified sampling strategy was adopted using a sampling ratio of 1 per 100 000 population for each region. Data were collected using an online questionnaire developed through Questionnaire Star, a widely used online survey platform in China (https://www.wjx.cn). The survey was disseminated through a structured professional online distribution process coordinated by the Chinese Nursing Association, the only national professional nursing organisation for nurses in China.
Specifically, the Hospital Infection Management Committee of the Chinese Nursing Association coordinated the survey through committee members located across 28 provincial-level administrative regions. After approval of the survey notification and questionnaire by the committee, provincial liaison officers contacted hospital nursing administrators through official professional communication networks. The questionnaire link was subsequently distributed to eligible clinical nurses through hospital nursing management systems and professional WeChat working groups.
To improve sampling relevance and reduce uncontrolled public participation, the survey was disseminated through targeted professional channels rather than unrestricted open online distribution. Head nurses were asked to emphasise the voluntary nature of participation before sharing the questionnaire with nurses.
After each survey round, the research team reviewed the number of completed questionnaires in each province. Additional rounds of data collection were conducted in provinces that did not reach the target sample size by recontacting local liaison officers and hospitals.
The survey was conducted from 9 November 2022 to 16 February 2023. Each survey round lasted 1 week. The English version of the questionnaire is provided in online supplemental material 1.
Quality control
When transcribing the questionnaire into an electronic format, two researchers independently reviewed the questionnaire logic and content consistency. To exclude invalid responses and improve data quality, several quality-control measures were implemented within the online survey platform, including screening pages, mandatory response and logical validation settings, minimum response-time thresholds and restrictions on answer input formats.
Mandatory response and logical validation settings were used to reduce missing data and prevent inconsistent questionnaire responses. Minimum response-time thresholds were established to identify questionnaires completed unrealistically quickly, thereby reducing careless or invalid responses.
Additionally, access restrictions were imposed to allow login exclusively through WeChat, with each IP address and device permitted to submit the questionnaire only once.
Data collection
In order to ensure the ethical compliance and participants’ right to know our study, an informed consent page and explanation page were set up to detail the purpose and significance of the survey, as well as participant requirements, instructions, etc. The respondent could proceed with the questionnaire by selecting ‘agree to conduct the survey’. We set a series of strict questionnaire quality control measures, including mandatory item setting, complete response restriction and reasonable filling time threshold to ensure data integrity and survey reliability. The features of the questionnaire were as follows: (1) Set the questionnaire topic as the required topic; (2) requiring complete responses, with incomplete submissions being automatically rejected; (3) setting the minimum time of completion to 5′20″ according to the pre-survey, with submissions below this threshold automatically classified as invalid. A total of 17 164 questionnaires were collected, including 15 274 valid questionnaires, yielding an effective response rate of 89.89%.
Statistical method
Categorical data were described as frequencies and rates, and group comparisons were performed using the χ² test, with p values adjusted using the S method for post hoc pairwise comparisons. Measurement data following a normal distribution were presented mean±SD and compared using the two independent samples t-test or analysis of variance, and post hoc pairwise comparisons were conducted using the Student-Newman-Keuls-q test (SNK-q test). Variables with p<0.05 in the univariate analysis were incorporated in a multivariate linear regression model to identify factors influencing the total score of the respondents and were screened using the stepwise selection method.
Variables with p<0.05 in the univariate analysis were incorporated in a multivariate linear regression model to identify factors influencing the total score of the respondents and were screened using the stepwise selection method with inclusion criteria for p<0.05 and exclusion for p≥0.05.
The multiple mediation effect model was used to elucidate the association between economic regions and NSI and to quantify the indirect and direct associations between economic regions through NSI-related management, assessment and training as mediating variables. In the present study, considering that multiple mediating variables were dichotomous variables, the indirect effects were challenging to directly measure. Therefore, the indirect effect size was quantified by the percentage of mediation (percentage mediated, PM), formula 1 minus the ratio of the direct effect (DE) to the total effect (TE) multiplied by 100%: PM= (1-DE/TE) × 100%. This calculation was implemented using a partial macro programme.
All statistical analyses were performed using SAS V.9.4. p<0.05 was considered statistically significant.
Patient and public involvement
Patients or the public were not involved in the design, conduct, reporting or dissemination plans of our research.
Results
Relationship between economic regions and general characteristics of research subjects
A total of 15 274 questionnaires were collected. Significant differences were noted in the nature, departments, age, gender, educational level, professional title and years of experience of nurses (p<0.05), as detailed in table 1.
Table 1. Comparison of sociodemographic characteristics among the clinical nurses in different economic regions.
| Variables | Total | Economic region | ||||
|---|---|---|---|---|---|---|
| Central (n=4741) |
Western (n=3459) |
Eastern (n=7074) |
χ² | P value | ||
| Type of hospital | ||||||
| Public | 14 741 (96.51) | 4677 (98.65) | 3228 (93.32) | 6836 (96.64) | 169.205 | <0.001 |
| Private | 533 (3.49) | 64 (1.35) | 231 (6.68) | 238 (3.36) | ||
| Department | ||||||
| Internal medicine | 5156 (33.76) | 1734 (36.57) | 1167 (33.74) | 2255 (31.88) | 248.962 | <0.001 |
| Surgery | 3553 (23.26) | 1121 (23.64) | 887 (25.64) | 1545 (21.84) | ||
| Intensive care unit | 788 (5.16) | 205 (4.32) | 88 (2.54) | 495 (7.00) | ||
| Operating room | 873 (5.72) | 301 (6.35) | 133 (3.85) | 439 (6.21) | ||
| Emergency | 743 (4.86) | 198 (4.18) | 141 (4.08) | 404 (5.71) | ||
| Gynaecology | 620 (4.06) | 190 (4.01) | 103 (2.98) | 327 (4.62) | ||
| Paediatric | 548 (3.59) | 163 (3.44) | 106 (3.06) | 279 (3.94) | ||
| Other | 2993 (19.60) | 829 (17.49) | 834 (24.11) | 1330 (18.80) | ||
| Age | ||||||
| <25 years | 1644 (10.76) | 447 (9.43) | 417 (12.06) | 780 (11.03) | 44.467 | <0.001 |
| 25~30 years | 4936 (32.32) | 1577 (33.26) | 1141 (32.99) | 2218 (31.35) | ||
| 31~35 years | 7318 (47.91) | 2361 (49.80) | 1558 (45.04) | 3399 (48.05) | ||
| >35 years | 1376 (9.01) | 356 (7.51) | 343 (9.92) | 677 (9.57) | ||
| Gender | ||||||
| Male | 585 (3.83) | 161 (3.40) | 130 (3.76) | 294 (4.16) | 4.516 | 0.105 |
| Female | 14 689 (96.17) | 4580 (96.60) | 3329 (96.24) | 6780 (95.84) | ||
| Education level | ||||||
| Junior college | 9170 (60.04) | 2769 (58.41) | 2033 (58.77) | 4368 (61.75) | 16.183 | <0.001 |
| Bachelor and above | 6104 (39.96) | 1972 (41.59) | 1426 (41.23) | 2706 (38.25) | ||
| Title | ||||||
| None | 1762 (11.54) | 516 (10.88) | 375 (10.84) | 871 (12.31) | 37.860 | <0.001 |
| Junior | 8111 (53.10) | 2653 (55.96) | 1878 (54.29) | 3580 (50.61) | ||
| Intermediate | 4344 (28.44) | 1248 (26.32) | 982 (28.39) | 2114 (29.88) | ||
| Senior | 1057 (6.92) | 324 (6.83) | 224 (6.48) | 509 (7.20) | ||
| Clinical nursing years | ||||||
| <5 years | 2856 (18.70) | 899 (18.96) | 678 (19.60) | 1279 (18.08) | 29.305 | <0.001 |
| 5~10 years | 5286 (34.61) | 1624 (34.25) | 1234 (35.68) | 2428 (34.32) | ||
| 11~20 years | 5000 (32.74) | 1625 (34.28) | 1027 (29.69) | 2348 (33.19) | ||
| >20 years | 2132 (13.96) | 593 (12.51) | 520 (15.03) | 1019 (14.40) | ||
(a) Comparison with central region p<0.05; (b) Comparison with western region p<0.05.
Relationship between economic regions and related management, assessment, training, knowledge, belief and practice
As presented in table 2, significant differences were observed in management, assessment, training, knowledge, beliefs and practice across different economic regions (p<0.05). Interestingly, nurses in the Central region had higher knowledge, beliefs, practice and total scores compared with those in the Western and Eastern regions, which was associated with the lowest incidence of needlestick injuries. Moreover, the protective knowledge, practice and total scores of Eastern nurses were lower than those in the West, with the highest incidence of needlestick injuries (p<0.05).
Table 2. Comparison of management, assessment, training and KBP and NSI incidence among different economic regions.
| Variables | Economic region | ||||
|---|---|---|---|---|---|
| Central (n=4741） |
Western (n=3459） |
Eastern (n=7074） |
F/χ2 | P value | |
| NSI-related management, assessment and training | |||||
| Designated personnel or positions responsible for NSI prevention, including training, promotion and implementation of related measures | 4116 (86.82) | 2908 (84.07)a | 5947 (84.07)a | 19.282 | <0.001 |
| NSI prevention was incorporated into hospital-level quality control standards | 4093 (86.33) | 2907 (84.04)a | 5913 (83.59)a | 17.216 | <0.001 |
| Completed hospital-organised assessments on NSI prevention knowledge or skills within 1 year | 4399 (92.79) | 3181 (91.96) | 6435 (90.97)a | 12.674 | <0.001 |
| Epidemiology training on bloodborne diseases was conducted at the hospital or department level within the past year | 4371 (92.20) | 3200 (92.51) | 6406 (90.56)ab | 15.609 | <0.001 |
| New employees receive training on NSI prevention on induction | 4298 (90.66) | 3123 (90.29) | 6347 (89.72) | 2.888 | 0.236 |
| New employees receive NSI prevention training at least two times per year | 1344 (28.35) | 987 (28.53) | 1843 (26.05)ab | 10.809 | <0.001 |
| KBP regarding needlestick injuries | |||||
| Knowledge | 6.07±1.59 | 5.96±1.64 a | 5.8±1.67ab | 38.535 | <0.001 |
| Belief | 28.26±2.54 | 28.04±2.41 a | 28.13±2.41 a | 7.917 | <0.001 |
| Practice | 26.74±4.76 | 25.96±4.93 a | 25.74±5.23ab | 57.961 | <0.001 |
| Total scores of KBP | 61.06±6.33 | 59.97±6.55 a | 59.68±6.89ab | 63.783 | <0.001 |
| NSI incidence in the past year | 3.88% (3.37%,4.46%) | 5.04% (4.37%,5.81%)a | 5.82% (5.29%,6.39%)a | 20.283 | <0.001 |
(a) Comparison with central region p<0.05; (b) Comparison with western region p<0.05.
KBP, knowledge, beliefs and practices; NSI, needlestick injury.
The aforementioned data were adjusted for age, gender, first degree, title, years of nursing experience, hospital type, department, receipt of hepatitis B vaccine, familiarity with injection needle infusion system and use of indwelling needles, infusion connectors and needle-free intravenous infusion (positive pressure joint, diaphragm joint, etc).
Knowledge and use of needle-free infusion systems by nurses in different economic regions
Nurses in the Eastern economic region were superior in terms of the utilisation of needle-free infusion systems compared with those in the Central and Western regions, as listed in table 3.
Table 3. Awareness and use of needle-free infusion systems among nurses in different economic regions.
| Variables | Total | Economic region | ||||
|---|---|---|---|---|---|---|
| Central (n=4741） |
Western (n=3459） |
Eastern (n=7074） |
χ2 | P value | ||
| Knowing needle-free infusion systems | ||||||
| Yes | 10 024 (65.63) | 3058 (64.50) | 2129 (61.55) | 4837 (68.38) | 51.876 | <0.001 |
| No | 5250 (34.37) | 1683 (35.50) | 1330 (38.45) | 2237 (31.62) | ||
| Ways of connecting an intravenous catheter and infusion set | ||||||
| Heparin cap to steel needle | 7002 (45.84) | 2010 (42.40) | 1956 (56.55) | 3036 (42.92) | 271.161 | <0.001 |
| Infusion set to needleless connector | 4743 (31.05) | 1503 (31.70) | 752 (21.74) | 2488 (35.17) | ||
| Infusion set directly to catheter | 3529 (23.10) | 1228 (25.90) | 751 (21.71) | 1550 (21.91) | ||
| Proportion of needle-free intravenous connectors (eg, positive pressure connectors, septal connectors) used for intravenous infusion | ||||||
| <30% | 4195 (27.46) | 1323 (27.91) | 1181 (34.14) | 1691 (23.90) | 237.627 | <0.001 |
| 30~60% | 5051 (33.07) | 1540 (32.48) | 1263 (36.51) | 2248 (31.78) | ||
| >60% | 6028 (39.47) | 1878 (39.61) | 1015 (29.34) | 3135 (44.32) | ||
Analysis of factors influencing the total score of the knowledge, belief, practice
Variables with p<0.05 in the univariate analysis were included in the multivariable linear regression model. Table 4 presents the assignment and coding of independent variables included in the regression analysis, including economic region and NSI-related management, training and assessment variables. Variables were selected using stepwise regression with inclusion and exclusion criteria of p<0.05 and p≥0.05, respectively.
Table 4. Assignment of independent variables in the multiple linear regression model.
| Variables | Assignment of variables |
|---|---|
| Economic region | Set dummy variables with ‘Eastern region’ as the reference category. Central region=(Z1=1,Z2=0) Western region=(Z1=0,Z2=1) |
| Designated personnel or positions responsible for needlestick injury prevention, including training, promotion and implementation of related measures | NO=0；YES=1 |
| Needlestick injury prevention was incorporated into hospital-level quality control standards | NO=0；YES=1 |
| Completed hospital-organised assessments on needlestick injury prevention knowledge or skills within 1 year | NO=0；YES=1 |
| Epidemiology training on bloodborne diseases was conducted at the hospital or department level within the past year | NO=0；YES=1 |
| New employees receive training on needlestick injury prevention on induction | NO=0；YES=1 |
| New employees receive needlestick injury prevention training at least two times per year | NO=0；YES=1 |
As shown in table 5, economic region, designated NSI prevention personnel, incorporation of NSI prevention into hospital-level quality control standards, hospital-organised assessments, epidemiological training on bloodborne diseases and regular NSI training for new employees were significantly associated with higher total scores of nurses’ knowledge, beliefs and practices regarding NSI protection (all p<0.001). Compared with nurses in the Eastern region, nurses in the Central region had significantly higher total scores, whereas no significant difference was observed for the Western region.
Table 5. Analysis of the factors influencing the total scores of nurses’ knowledge, beliefs and behaviours regarding needlestick injury protection.
| Variables | β | SE | Standardised regression coefficient | t | P value |
|---|---|---|---|---|---|
| Constant | 52.358 | 0.381 | — | 137.369 | <0.001 |
| Economic region | |||||
| Central region | 1.165 | 0.120 | 0.081 | 9.716 | <0.001 |
| Western region | 0.232 | 0.133 | 0.015 | 1.745 | 0.081 |
| Eastern region | reference | ||||
| Designated personnel or positions responsible for needlestick injury prevention, including training, promotion and implementation of related measures | |||||
| No | reference | ||||
| Yes | 2.154 | 0.170 | 0.116 | 12.685 | <0.001 |
| Needlestick injury prevention was incorporated into hospital-level quality control standards | |||||
| No | reference | ||||
| Yes | 1.827 | 0.164 | 0.099 | 11.117 | <0.001 |
| Completed hospital-organised assessments on needlestick injury prevention knowledge or skills within 1 year | |||||
| No | reference | ||||
| Yes | 1.819 | 0.212 | 0.075 | 8.587 | <0.001 |
| Epidemiology training on bloodborne diseases was conducted at the hospital or department level within the past year | |||||
| No | reference | ||||
| Yes | 1.829 | 0.210 | 0.076 | 8.703 | <0.001 |
| New employees receive needlestick injury prevention training at least two times per year | |||||
| No | reference | ||||
| Yes | 1.111 | 0.118 | 0.074 | 9.380 | <0.001 |
Model F=114.552, p<0.001; R²=0.0815, adjusted R²=0.0798.
Intermediary effect between NSI-related management, assessment and training on knowledge, belief, practice among different economic regions
As illustrated in online supplemental table 1, compared with nurses in the Western regions, those in Central regions had higher NSI protection beliefs, behaviours and total scores, with total effects ranging from 0.204 to 0.972 (p<0.05), with the mediation effect size of NSI-related management, assessment and training ranging between 7.964% and 9.423% (p<0.05). Likewise, compared with nurses in the Eastern regions, those in Central regions had higher knowledge, beliefs, practice and total scores, with total effects ranging from 0.126 to 1.073 (p<0.05) and the mediation effect size for NSI-related management, assessment and training being 10.684–37.745% (p<0.05). Lastly, compared with nurses in the Eastern regions, those in Western regions had higher NSI-related knowledge, practice and total scores, with total effects ranging from 0.181 to 0.449 (p<0.05) and the mediation effect size mediated by NSI-related management, assessment and training being 12.574–30.955% (p<0.05).
Overall, these results collectively demonstrated that hospital management, nurse training and assessment positively enhanced the knowledge, belief and practice of nurses in NSI protection, as delineated in online supplemental figure 1.
Discussion
The government’s financial input significantly and positively impacts the spillover effect on the supply of medical and health services. According to an earlier study, government health expenditure plays a decisive role in the supply of medical and health services,25 signifying that economic development enhances the government’s financial capacity, thereby increasing investment in the medical and health field and improving medical facilities and resource supply, eventually reducing the incidence of needle injury.26–29 In 2000, the US Congress enacted the Needle Stick Safety and Prevention Act to reduce occupational exposure to sharps injuries and bloodborne pathogens by promoting the use of safety-engineered medical devices among healthcare workers.30 Previous studies have shown that the incidence of NSI is associated with factors such as the medical environment, work intensity, workload and availability of occupational safety resources,8 all of which may vary across different levels of economic development.31 In less developed areas, limited medical resources, inadequate access to safety-engineered devices and inconsistent operating procedures may increase the risk of needlestick injuries among healthcare workers.32
In the present study, nurses in the Eastern region demonstrated higher awareness and utilisation rates of needle-free infusion systems compared with those in the Central and Western regions of China (table 3). This finding may be associated with the relatively higher level of economic development and healthcare investment in Eastern China, which may facilitate greater availability and implementation of safety-engineered medical devices in clinical practice. As a result, nurses in economically developed regions may have more opportunities to access, receive training on and routinely use needle-free infusion systems. Safety-engineered puncture equipment and infusion systems have been shown to reduce the risk of NSI.33 34 However, the implementation and accessibility of such equipment are closely associated with regional economic development and healthcare resource allocation.31 Previous research has demonstrated that the coordination between economic development and primary healthcare resource allocation in the Eastern, Central and Western regions of China has improved progressively over time.35 Therefore, continued investment in occupational safety equipment and healthcare infrastructure may contribute to improving NSI protection among clinical nurses.
However, further analysis exposed the indirect impact of the regional economic development level. In an article published in the Canadian Journal of Infectious Diseases and Medical Microbiology in 2021,17 researchers compared the incidence of needlestick injuries between developed countries and developing countries and reported that developed countries effectively reduced the incidence of needlestick injuries by taking standardised preventive measures,32 as well as providing protective and safe medical equipment, enhancing education, managing and optimising the training of medical staff on the safe use and disposal of needles.23 As presented in table 2, significant differences were observed in the management, assessment and training across the three economic regions and the relationship between the management, assessment and training of local nurses (p<0.05). In the Central region, management, training, assessment and nurses’ knowledge, beliefs, practices and total scores regarding NSI protection were higher than those in the Eastern and Western regions. In contrast, although the Eastern region had the highest level of economic development, nurses’ knowledge, practice and total scores regarding NSI protection were lower than those in the Western region (p<0.05). This finding suggests that economically developed regions do not necessarily demonstrate better occupational safety performance.
According to data from the National Bureau of Statistics,36 the Eastern region had the highest economic aggregate and growth rate in 2024, whereas the Western region remained relatively underdeveloped. However, the present findings indicate that economic development alone may not guarantee stronger NSI protection ability among nurses.
Several factors may explain this phenomenon. First, economically developed regions generally experience higher healthcare resource utilisation, greater patient turnover, heavier workloads and increased occupational stress among nurses. Second, hospitals in economically developed regions may place greater emphasis on medical efficiency, technological advancement and performance indicators, potentially resulting in relatively less attention to occupational safety culture and NSI prevention training. Third, differences in nurse training systems and occupational safety management mechanisms may contribute to regional variation in NSI protection ability.
Similar observations have been reported in international studies,37 38 which have shown that healthcare workers in high-intensity clinical environments may remain at elevated risk of occupational injuries despite more advanced healthcare systems. Therefore, occupational safety outcomes may be influenced not only by economic development but also by organisational management, workload, occupational safety culture and training mechanisms.
To our knowledge, this study is among the first nationwide investigations to compare nurses’ NSI protection ability across China’s major economic regions while further exploring the mediating roles of management systems, personnel training and assessment mechanisms.
The mediation findings of this study may have important implications for clinical nursing practice and occupational safety management (seen in online supplemental table 1). It suggested that management systems, personnel training and assessment mechanisms may partially explain the regional differences observed in nurses’ NSI protection ability across China. Regions with more comprehensive occupational safety management and training systems generally demonstrated better performance in nurses’ NSI-related knowledge, beliefs and practices. These findings highlight the important role of institutional management strategies in improving occupational safety among clinical nurses. In addition to economic development, organisational support, standardised training and regular assessment may contribute substantially to strengthening nurses’ awareness and implementation of NSI prevention measures. From a clinical perspective, strengthening standardised NSI prevention training, improving occupational safety education and implementing regular assessment programmes may enhance nurses’ awareness and adoption of protective practices in daily clinical work. Importantly, these interventions may be particularly valuable in healthcare settings with limited medical resources. From a global nursing perspective, disparities in workload, occupational safety culture and healthcare resource allocation exist across many healthcare systems worldwide. Therefore, the present findings suggest that strengthening institutional management and occupational safety training may represent practical and transferable strategies for improving NSI prevention among nurses internationally.
Evidently, management systems, personnel training and assessment mechanisms were important factors influencing nurses’ knowledge, beliefs and practices regarding NSI protection (online supplemental figure 1). This finding is consistent with previous studies indicating that the development and implementation of standardised operating procedures,29 together with strengthened occupational safety education and training, may effectively reduce the occurrence of needlestick injuries.26 28
In summary, the present study suggests that organisational management systems, NSI-related training programmes and assessment mechanisms may play primary roles in improving nurses’ NSI protection ability. Advanced medical equipment and safety-engineered devices also contribute to reducing occupational exposure risk; however, in this study, their role appeared to be more supportive than the direct effects observed for management and training-related factors. Therefore, strengthening hospital-level occupational safety management systems, standardised NSI training and regular assessment mechanisms may represent important strategies for reducing the occurrence of needlestick injuries among nurses.
This large-sample cross-sectional survey was conducted using stratified and network sampling based on the national population proportion, covering tertiary hospitals in the Eastern, Central and Western economic regions of China with strict quality control. The final valid sample size was 15 274, which ensured good representativeness of Chinese clinical nurses working in tertiary hospitals. Therefore, our results regarding regional differences in NSI protection knowledge, beliefs, practice and the mediating effects of management, training and assessment can be reasonably generalised to clinical nurses in tertiary hospitals across mainland China. However, this study only enrolled nurses from tertiary hospitals; thus, the findings may not be directly generalised to secondary or primary medical institutions. In addition, given the cross-sectional design and potential recall bias from self-reported data, the causal inferences should be made with caution when extrapolating the present results to other settings or populations. Future studies with a longitudinal design and including multilevel medical institutions are warranted to verify and extend the generalisability of our conclusions.
Conclusion
Significant regional differences were observed in nurses’ knowledge, beliefs and practices regarding NSI protection across China. Although economic development influenced healthcare resources and access to safety-engineered devices, management systems, personnel training and assessment mechanisms appeared to play more direct roles in improving nurses’ NSI protection ability.
These findings suggest that strengthening hospital-level occupational safety management, standardised NSI prevention training and regular assessment programmes may help reduce regional disparities and improve occupational safety among clinical nurses.
Supplementary material
Acknowledgements
We would like to express our sincere gratitude to Director Cai Meng and her team from the Hospital Infection Committee of the Chinese Nursing Association and the youth committee members of administrative units in various provinces and cities, the intravenous therapy team from the First Affiliated Hospital of Chongqing Medical University and the intravenous therapy alliance of Chongqing City. Besides, we would like to express our special gratitude to Yuan Luo, Jing Luo, Qiqi Chen, Xiaxiao Li, Jing Cen, Qing Li, Lu Wang, Xinhua Wei, Li Jiang, Hong Qu, Lin Tang, Han Han, Jing Fan, Wenyan Tang, Pan Hong, Jia Nie, Xiaofang Chen, Qinhua Zhang, Li Tan, Hongjie Yi, Xia Li, Ying Gao, Feili Li et al for their assistance and guidance throughout the course of the study.
Footnotes
Funding: This study was supported by 2024 First-class Disciplines - Nursing Discipline Construction Fund ; Project Code: 03010205040301.
Prepub: Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2025-107635).
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Ethics approval: This study was approved by the Ethics Committee of the First Affiliated Hospital of Chongqing Medical University, Chongqing, China (K2023-19). This project has been registered in the ClinicalTrials.gov (ClinicalTrials.gov ID: NCT06733779). This study adhered to the Declaration of Helsinki and respect for all participants and protect their health and rights.
Data availability statement
Data are available upon reasonable request.
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