Knowledge, Compliance Behaviors, and Associated Factors Regarding Needlestick Injuries Among Nursing Students in Palestine: A Cross-Sectional Study

Literature Review

International Evidence

Internationally, knowledge and adherence to biosafety protocols among nursing students represent critical determinants of occupational safety. A systematic review and meta-analysis encompassing 32 studies reported an overall NSI prevalence of 35.7% among nursing students, with higher rates in developing nations attributed to insufficient access to protective equipment and inadequate implementation of safety training [7]. In China, research among acupuncture practitioners revealed that 34.3% had experienced NSIs, with 46.0% remaining unreported, pointing to ongoing deficits in safety culture and knowledge of exposure protocols [14]. Similarly, studies in India documented variable safety compliance and knowledge gaps, with nursing students exhibiting disproportionately higher risk profiles during clinical rotations [11,15].

Knowledge deficits regarding NSI prevention and post-exposure management have been consistently documented across international settings. Research in Italy among 238 nursing students found that knowledge levels directly influenced risk perceptions, with second-year students demonstrating lower compliance with safety measures during drug administration [13]. In Turkey, a study of 280 nursing students revealed that carelessness and rushing were common contributing factors to sharp injuries, emphasizing the need for reinforced educational modules prior to clinical entry [6]. Furthermore, a systematic review across ten countries emphasized that lack of clear occupational safety training and fear of disclosure exacerbate psychological distress and hinder compliance with standard reporting procedures [5,16]. Additionally, research in specialized clinical domains underscores the prognostic and systemic value of standardized health practices and risk monitoring [17].

Regional Evidence

Within the Middle East, gaps in knowledge, safety practices, and compliance behaviors among healthcare personnel and students remain significant concerns. In Saudi Arabia, multiple studies have documented gaps in infection control knowledge and inconsistent safety practices among healthcare workers and students [18–20]. Among nursing students specifically, Al-Mugheed et al. [10] identified that limited awareness and poor adherence to infection control measures significantly elevated exposure risks during clinical training.

In Oman, a survey of 167 nursing students revealed that unsafe practices, particularly recapping needles (59%), were prevalent despite formal education, highlighting a persistent gap between theoretical knowledge and clinical practice [12]. Research in Iran among 264 nurses demonstrated a direct relationship between clinical competence, theoretical understanding of safety protocols, and the incidence of occupational exposure in high-risk units [21]. Furthermore, systematic evidence from Egypt and Iran indicated that healthcare workers with lower safety knowledge experienced higher anxiety and stress following exposure events [5]. These regional findings confirm that strengthening knowledge and enforcing practical adherence to safety standards remain key priorities across Middle Eastern healthcare education.

Low and Middle-Income Countries and Palestine

In low- and middle-income countries (LMICs), resource limitations, heavy clinical workloads, and inconsistent training infrastructure compound occupational safety challenges [22]. A global meta-analysis of 87 studies reported a pooled NSI prevalence of 44.5% among healthcare workers, with significantly higher rates in resource-constrained environments [22]. Studies in Ethiopia and Uganda emphasized that lack of safety training and inadequate knowledge regarding post-exposure prophylaxis were major contributors to unsafe clinical environments [23,24].

In Palestine, the healthcare and higher education systems operate under unique structural constraints related to ongoing political instability, economic limitations, and resource scarcity. Research among emerging adults and students in the West Bank has documented elevated levels of anxiety, depression, and stress associated with prolonged conflict and academic pressure [8,9]. Stress from frequent academic examinations and clinical expectations has been shown to impact emotional well-being and behavioral focus [9]. Studies among Palestinian nursing students have highlighted variable adherence to personal protective equipment and knowledge gaps regarding occupational hazards [25–27]. Furthermore, research examining nursing practice in Palestine—including quality of life during conflict [28], electronic medical record utilization [29], clinical alarm safety [30], and chronic disease management [31,32]—demonstrates the complex clinical context in which Palestinian nurses and students operate. However, detailed evaluations of NSI knowledge domains and their direct associations with reported safety behaviors remain under-researched in the southern West Bank.

Gaps in Literature and Study Aims

While occupational sharp hazards among nursing students have been widely studied globally, empirical evidence assessing specific knowledge domains, Bloom's knowledge classifications, and factors associated with NSI knowledge among nursing students in Palestine remains limited. Most available regional literature focuses on overall exposure rates without thoroughly evaluating specific knowledge gaps (e.g., sharps container fill limits, post-exposure hygiene) or how knowledge levels correlate with self-reported compliance practices such as glove use and recapping avoidance. Moreover, nursing students in the southern West Bank train across diverse university laboratories and hospital settings, making it essential to establish localized baseline data to inform nursing curricula.

Therefore, this study aimed to evaluate knowledge, safety compliance behaviors, and associated demographic and training factors regarding needlestick injuries among nursing students in Palestine. Specifically, the objectives were to: (a) Assess the level of knowledge regarding needlestick injuries among undergraduate nursing students using a standardized knowledge scale and Bloom's cutoff criteria; (b) Identify specific knowledge strengths and deficits across key NSI safety domains; (c) Evaluate self-reported safety practices, specifically glove usage and recapping avoidance; and (d) Determine demographic, training-related, and behavioral factors associated with NSI knowledge scores.

Study Design and Setting

A quantitative, cross-sectional, descriptive design was employed to evaluate knowledge, safety practices, and associated factors regarding needlestick injuries among nursing students in Palestine. This design allows efficient collection of data from a target population at a single point in time to assess knowledge levels and examine associations with demographic and behavioral characteristics [33]. The study was conducted in the southern region of the West Bank, Palestine, across four major universities offering accredited Bachelor of Science in Nursing programs: Palestine Polytechnic University, Hebron University, Bethlehem University, and Palestine Ahliya University. These institutions represent the primary centers for nursing education in the region, encompassing diverse student cohorts and clinical affiliation sites.

Population and Sampling

The target population comprised undergraduate nursing students enrolled in the four participating universities who had completed at least one clinical training course. Based on university registrar records, the total eligible population was approximately 2,420 students. The required sample size was calculated using the Raosoft® sample size calculator, assuming a 5% margin of error, a 95% confidence level, and a 50% response distribution. The minimum recommended sample size was 377 participants. To compensate for potential non-response or incomplete surveys, 450 questionnaires were distributed. Non-probability convenience sampling was utilized to recruit eligible students across academic years, lecture halls, and laboratory sessions.

Inclusion and Exclusion Criteria

Students were included if they: (a) were enrolled in a Bachelor of Nursing program at one of the four participating universities; (b) had completed at least one clinical training course; (c) were aged between 20 and 30 years; (d) were proficient in reading English; and (e) provided written informed consent. Students were excluded if they: (a) had prior professional healthcare experience (e.g., bridging students); (b) submitted incomplete questionnaires; or (c) were not currently enrolled in active academic study.

Instrumentation

Data were collected using a structured, self-administered questionnaire structured into two primary sections: Section 1: Demographics and Clinical Training Factors: Collected data on age, gender, academic year of study, completion of laboratory training, infection control training status, general safety training perception, and self-reported adherence to standard precautions (always wearing gloves during procedures with needles/sharps; always avoiding recapping used needles). Section 2: NSI Knowledge Scale: Adopted from the validated 8-item knowledge scale developed by Al-Mugheed et al. [10]. The scale evaluates essential NSI knowledge domains: definition of NSI (K1), recapping risk (K2), hepatitis B vaccination prevention (K3), safer devices and glove requirements (K4), bloodborne pathogen transmission (K5), maximum capacity of sharps containers (K6), immediate post-exposure washing with soap and water (K7), and proper sharps container disposal (K8). Items were answered as "True," "False," or "Not sure." Correct answers received 1 point, while incorrect or "Not sure" answers received 0 points. Total knowledge scores ranged from 0 to 8 points and were converted to percentage scores (0–100%). Bloom's cutoff points were applied to categorize overall knowledge: Poor (≤59%), Moderate (60–79%), and High (≥80%) [10]. The scale demonstrated good content validity, reviewed by a panel of three nursing faculty experts, and showed high internal reliability in pilot testing (Cronbach's α = 0.81).

Data Collection Process

Following ethical approval, administrative permissions were obtained from the deans and department heads at each university. Questionnaires were distributed in paper format during classroom lectures and laboratory sessions, and an electronic version via Google Forms was shared through official student groups to maximize access. Researchers were present during paper administration to answer procedural queries and collect completed forms on the same day. Data collection took place from October to November 2025. Out of 450 distributed questionnaires, 400 were returned, and 365 were fully completed and included in the final statistical analysis (net response rate of 81.1%).

Data Analysis

Data were analyzed using IBM SPSS Statistics version 26.0. Descriptive statistics (frequencies, percentages, means, standard deviations) were calculated for demographic characteristics, training variables, individual knowledge items, and Bloom's knowledge categories. Bivariate inferential statistics were conducted to determine factors associated with overall knowledge percentage scores. Independent-samples t-tests were used for binary categorical variables (gender, lab training, glove use, recapping avoidance). One-way Analysis of Variance (ANOVA) was performed for variables with more than two categories (academic year). Pearson's correlation coefficient (r) was calculated to assess the relationship between age and continuous knowledge score. Statistical significance was established at p < 0.05 (two-tailed).

Ethical Considerations

Ethical approval was granted by the Institutional Review Board (IRB) of Palestine Polytechnic University. The study adhered strictly to the ethical standards of the Declaration of Helsinki. Participants were provided with written information detailing the study's purpose, voluntary participation, and freedom to withdraw at any time without academic consequence. Written informed consent was obtained prior to questionnaire administration. All data were anonymized, coded, and stored securely in password-protected electronic files accessible only to the principal research team.

Participant Characteristics

Table 1 summarizes the demographic and training-related characteristics of the 365 participating nursing students. The mean age was 20.82 years (SD = 1.04). The majority of participants were female (80.5%, n = 294) and enrolled in their fourth year of study (51.8%, n = 189). Most students reported completing laboratory training (84.4%, n = 308) and infection control training (57.3%, n = 209). Regarding standard safety precautions, 79.7% (n = 291) reported always wearing gloves during sharp procedures, and 73.4% (n = 268) reported always avoiding needle recapping. Regarding general safety training, 42.5% (n = 155) agreed and 9.6% (n = 35) strongly agreed that they had received adequate safety instruction.

Knowledge of Needlestick Injury

Table 2 presents the breakdown of correct and incorrect responses across the eight NSI knowledge items. Correct response rates were highest for proper disposal in a sharps container (K8: 92.9%) and the definition of NSI (K1: 92.1%), followed by awareness of safer devices and gloves (K4: 90.1%) and bloodborne pathogen transmission (K5: 87.9%). Conversely, the lowest proportion of correct responses was observed for the item on sharps container maximum capacity (K6: 58.6% correct; 41.4% incorrect/not sure) and immediate handwashing with soap and water following exposure (K7: 66.8% correct; 33.2% incorrect/not sure).

Table 2: Knowledge of needle stick injury among nursing students (N = 365)

Knowledge Level Categories Based on Bloom's Cutoff Points

Table 3 displays the distribution of overall knowledge levels according to Bloom's classification. The mean knowledge percentage score across all participants was 79.18% (SD = 18.87). Overall, 55.6% (n = 203) of students achieved a High knowledge level (≥80%), 32.9% (n = 120) demonstrated Moderate knowledge (60–79%), and 11.5% (n = 42) scored in the Poor knowledge category (≤59%).

Table 3: Knowledge level categories based on Bloom's cutoff points (N = 365)

Factors Associated with Knowledge of Needle Stick Injury

Table 4 presents bivariate analysis results examining associations between demographic/training factors and total knowledge scores. Female students demonstrated significantly higher mean knowledge scores than male students (81.34% vs. 70.25%, t = -4.564, p < 0.001). Furthermore, students who reported always wearing gloves during sharp procedures scored significantly higher than those who did not (80.46% vs. 74.16%, t = -2.585, p = 0.010). Similarly, students who reported always avoiding needle recapping attained significantly higher knowledge scores (80.55% vs. 75.39%, t = -2.324, p = 0.021). No statistically significant differences in knowledge were observed based on laboratory training completion (p = 0.103) or academic year of study (F = 0.450, p = 0.638). Age showed no significant correlation with overall knowledge score (r = -0.050, p = 0.338).

Table 4: Factors associated with knowledge of needle stick injury among nursing students (N = 365)

Limitations

Several limitations should be considered when interpreting these findings. First, the cross-sectional design restricts inferences regarding temporal causality between knowledge scores and clinical behaviors. Second, self-reported data regarding glove usage and recapping avoidance may be subject to social desirability bias or recall bias, potentially overestimating compliance. Third, convenience sampling across four universities in the southern West Bank may limit the generalizability of findings to other geographical areas of Palestine or different health discipline programs. Fourth, observational audits of clinical practices were not conducted, which would provide an objective measure of procedural compliance alongside survey responses.

Implications and Recommendations

For Academic Institutions

• Refine Curricular Focus: Nursing faculties should update infection control modules to address specific knowledge gaps, particularly sharps container capacity rules (75% limit) and standardized immediate post-exposure procedures. • Targeted Education: Implement dedicated educational workshops for male nursing students to close the identified gender gap in biosafety knowledge. • Reinforce Simulation Training: Integrate active biosafety scenarios and no-recapping drills into pre-clinical simulation laboratories prior to hospital placements. • Stress-Support Integration: Integrate coping and anxiety-management strategies into clinical preparation, considering the high background academic and contextual stress faced by Palestinian students [8,9].

For Healthcare Institutions

• Enhanced Clinical Supervision: Hospital preceptors and clinical instructors must closely monitor nursing students during sharp-handling procedures to ensure theoretical knowledge translates into compliance. • Point-of-Care Equipment: Ensure adequate provision of sharps disposal containers placed directly at points of care to eliminate the temptation to recap needles or transport unsheathed sharps. • Clear Exposure Pathways: Display clear, visual post-exposure management flowcharts (including immediate soap-and-water washing) in all clinical utility rooms accessible to students.

For Policy and Future Research

• Standardized National Guidelines: Health and higher education ministries should formulate standardized occupational safety competencies required for all nursing students prior to clinical entry. • Future Research: Longitudinal and observational studies are recommended to track changes in safety knowledge and actual bedside behaviors over time across all regions of Palestine.