タイの看護学生における職業上の健康リスクの発生と関連要因：横断的研究
2025 年 47 巻 2 号 p. 69-78
詳細
2025 年 47 巻 2 号 p. 69-78
Nursing students are exposed to health hazards during their clinical practice. This analytic cross-sectional study assessed such risks and the examined related factors in 219 nursing students. Participants were selected through cluster random sampling, and data were gathered via self-administered questionnaires that covered socio-demographic characteristics, occupational health literacy, support from teachers and healthcare personnel, clinical practice safety behaviors, and occupational health risks. Descriptive statistics and binary logistic regression analysis were used to analyze the data. Results indicated that psychosocial hazards were the most common risk (37.4%), followed by biological hazards (26.15%) and ergonomic factors (12.8%). Female gender (AOR = 4.15, 95% CI = 1.28–13.47), low clinical safety behaviors (AOR = 1.80, 95% CI = 1.03–3.14), and low occupational health literacy (AOR = 2.54, 95% CI = 1.13–5.74) were significantly associated with higher risks. This study highlights the need for targeted interventions to improve safety behaviors and occupational health literacy, emphasizing enhancements in training programs, support systems, personal protective equipment (PPE) adequacy, and ergonomic practices.
Nursing students are required to engage in a variety of nursing activities during their clinical training, which inherently carry the risk of infection from patients. Studies have reported varying rates of needle-stick injuries in student nurses, ranging from 18.2 to 88.6% [1–3]. The prevalence of blood and secretion exposures was found to be 8.3% [2], with a notably high rate of underreporting of such injuries and exposures [4]. In addition to risks of infection, nursing students may also be exposed to various other occupational hazards, including chemical, physical, ergonomic, and psychosocial health threats, akin to the risks faced by practicing nurses [5].
Despite being supervised by instructors during clinical practice, the complexity of nursing services often makes it challenging for instructors to provide immediate attention. Students may also encounter verbal, non-verbal, or physical aggression from healthcare personnel, nursing teachers, patients, and the families of patients [6]. Nursing students’ lack of clinical knowledge and experience, coupled with limited exposure to clinical settings, exacerbates these risks. Previous studies have indicated that approximately 95.7% of students have low levels of awareness regarding occupational health and safety [7], and 37.7% have poor knowledge of occupational hazards [8]. This knowledge gap often results in unsafe nursing behaviors and a low level of needle-stick safety practices, with between 58.4% and 96% of students not wearing gloves during body fluid exposure risk, and between 44% and 92.8% failing to wear protective glasses during such exposures. Additionally, a significant proportion of students, ranging from 36.1% to 57.6%, recap needles after use [9], they often exhibit unsafe nursing behaviors as well as a low level of needle-stick safety practices [1, 2], between 58.4% and 96% do not wearing gloves during body fluid exposure risk, and between 44% and 92.8% fail to wear protective glasses during such exposures. Moreover, a significant proportion of students, ranging from 36.1% to 57.6%, recap needles after use.
An analysis of empirical evidence indicates that the majority of them possess only a moderate level of health knowledge. Their clinical safety practices are at an even lower level, and there is no significant correlation between their health knowledge and their practices [10]. Exposure to occupational health threats during clinical training arises from the interaction between various components of the work system, including rules, protocols, medical equipment, social support, interpersonal relationships, and individual characteristics. A review of the literature identifies several factors associated with occupational health risks in nursing students, including age, educational level [4, 11], sex, previous injury experience [12], and knowledge of and adherence to safe work practices [1, 11].
The SHELL model, which highlights the interactions between “Software, Hardware, Environment, Liveware (individual), and Liveware (interaction with others),” serves as a comprehensive framework for addressing occupational exposures in nursing students [13, 14]. This study focuses on the Liveware (individual) component, examining personal characteristics; the Hardware component, exploring the availability and adequacy of personal protective equipment (PPE); the Software component, assessing safety behaviors in nursing practices guided by infection control and safety protocols as well as seeking safety-related information and occupational health literacy; the Environment component, evaluating occupational exposure risks; and the Liveware (interaction with others) component, analyzing support systems from peers, teachers, and healthcare personnel. By utilizing this model, the study identifies and addresses key factors contributing to risks associated with exposure to blood and body fluids during clinical practice, providing a basis for targeted interventions to enhance safety and well-being in nursing students.
Previous studies have primarily been descriptive, focusing on the perception of occupational health hazards in nursing students, with limited research examining the factors associated with the actual occurrence of such risks. A deeper understanding of these exposures would enable nursing students to manage occupational health risks more effectively during practical training, thereby enhancing workplace safety and reducing the likelihood of injury or illness.
The data on exposure to health threats obtained from this study can be used to develop more targeted and effective preventive measures and enhanced support systems to mitigate these risks, ensuring the safety and well-being of nursing students. This study aims to investigate the occupational health risks in nursing students and examine the influencing factors.
1. The Study Design, Setting, and Period
The present study, with an analytic cross-sectional design, was conducted at a university in the eastern region of Thailand from July to September 2023.
2. Study population and sample
The population was composed of all the nursing students (n=338) in the 3rd and 4th year in the faculty of nursing.
2.1 Sample size determination
The sample size was calculated by the formula Z2pq/d2 (p = 88.4%, q = 11.6%) for estimating a single population proportion using the prevalence of exposure to occupational hazard in nursing students as 88.4% [8]. The margin of error was 5%, and the sample size for the study was 199. By adding 10% of non-response rate, the final total number of nursing students was 219.
The inclusion criteria was nursing students in the third- and fourth- years who have been in clinical practice and agreed to participate in the study.
2.2 Sampling Method and Sampling Procedure
Cluster random sampling was employed to select the sample groups, categorized by the academic year of the nursing students. Each academic year consisted of three groups. In the third academic year, each group included 58 to 60 students, while in the fourth academic year, each group included 56 to 58 students. The random selection process involved choosing two groups from the third academic year and two groups from the fourth academic year. All students in the selected groups were included as participants for ethical reasons. As a result, 116 third-year students and 114 fourth-year students were included, totaling 230 students. However, only 222 students returned completed questionnaires, accounting for a response rate of 96.5%. Among these, three questionnaires were incomplete, leaving a total of 219 valid questionnaires for data analysis.
3. Data Collection Tool and Technique
Data were gathered using a structured, self-administered questionnaire adapted from existing literature. The questionnaire was divided into five sections:
1) Socio-demographic Characteristics: This section includes variables such as age, academic year, history of vaccination, health checkups as chest x-rays, experience of needle-stick injuries or sharp object cuts, and incidents of blood/body fluid exposure in the past year.
2) Occupational Health Risks: This section evaluates nursing students’ perceptions of occupational hazards encountered during clinical practice, encompassing physical, chemical, biological, ergonomic, and psychosocial risks. It also examines the availability and adequacy of PPE and identifies symptoms or conditions that students attribute to their clinical training experiences. The section comprises 15 items, formatted as “Yes” or “No” responses.
3) Seeking Safety Practice Information: This section consists of six questions evaluating the search for information on disease and injury prevention during clinical practice. It includes various sources such as online platforms, textbooks, television/radio, inquiries from teachers and/or healthcare personnel, and discussions with peers. Responses are measured on a 4-point Likert scale, ranging from “never done” (1) to “always done” (4). The mean score for all questions is calculated, with higher scores indicating more frequent safety information-seeking behaviors.
4) Support from Teachers and Healthcare Personnel: This section consists of six questions that assess the support provided by teachers or healthcare personnel during clinical training. It covers areas such as provision of knowledge and information regarding safety behaviors in clinical practice, reminders to follow safety protocols, assistance in obtaining necessary immunizations, and provision of personal protective equipment. Responses are measured on a 4-point Likert scale, ranging from “did not receive support” (1) to “received the highest level of support” (4). The mean score was calculated, with higher scores indicating greater levels of support from healthcare personnel, reflecting significant assistance in disease and injury prevention during clinical training.
5) Occupational Health Literacy: This section covers three dimensions: basic health knowledge, health-related communication and interaction skills, and health reasoning. It includes 17 questions rated on a 4-point scale, ranging from “no knowledge” (1) to “high level of knowledge” (4). A higher mean score indicates a greater level of occupational health literacy, signifying a strong capacity to make informed decisions, promote and maintain personal health, and analyze health-related information effectively.
6) Clinical Safety Behaviors: This section encompasses various aspects of nursing practice, such as adherence to standards, infection prevention, hand hygiene, correct use of personal protective equipment, and maintaining a safe working environment. It contains 33 questions assessed on a 4-point Likert scale, ranging from “never practiced” (1) to “practiced regularly” (4). A higher mean score reflects a higher commitment to safe practice behaviors during clinical training, demonstrating substantial engagement in maintaining a safe healthcare environment.
3.1 Quality of instruments
The validity and reliability of the questionnaire were established through the opinions of experts in the field of occupational health nursing. The content validity index was 0.85. Reliability was evaluated using Cronbach’s alpha, with coefficients for sections 2–6 being 0.80, 0.85, 0.84, 0.90, and 0.76, respectively.
4. Ethical consideration
The study was approved by the Institutional Ethics Committee (IRB1-068/2566 date 26 June 2023). A consent form was also provided in the survey, and participants were asked to provide consent before participating in the survey. The survey questionnaire refrained from obtaining any personal and confidential information of the participants.
5. Data Analysis
The questionnaires retrieved from the student nurses were screened for completeness, coded and analyzed using IBM SPSS Statistics Version 27 Statistical Software (IBM Corp., Armonk, NY, USA). A descriptive statistics analysis was done to explore the distribution of all the variables. A binary logistic regression analysis was done to test the association between the demographic characteristics, health personal support, clinical safety practice information seeking, occupational literacy, safety behaviors and occupational health risks. Multiple logistic regression analysis was done to determine the effect of occupational literacy and clinical safety behaviors on the occupational health risks of nursing students, while other variables were controlled. The level of significance was set at P < 0.05 at a confidence interval of 95%.
General Characteristics of the Samples
The sample consisted of 91.8% females, with an average age of 20.91 years (SD = 0.73), ranging from 19 to 23 years. Approximately half of the participants were in their third (49.8%) or fourth year (50.2%) of study (Table 1). In the past year, 20.5% of students had reported experiencing needle-stick injuries or cuts from sharp objects, with the most common incidents occurring during the preparation of medical tools (0.9%) and medication (6.8%). Additionally, 6.4% reported exposure to blood or body fluids, primarily through eye contact (2.3%), skin contact (1.4%), and other means (2.7%), with suctioning sputum (2.7%) and handling used medical instruments (1.8%) being the main activities associated with exposure, as detailed in Table 2.
| Characteristics | Number (person) | % |
|---|---|---|
| Gender | ||
| Male | 18 | 8.2 |
| Female | 201 | 91.8 |
| Age | ||
| 19-20 years | 65 | 29.7 |
| 21-23 years | 154 | 70.3 |
| mean 20.91 years (S.D. 0.73) min 19, max 23 | ||
| Year of study | ||
| Third-year | 109 | 49.8 |
| Fourth-year | 110 | 50.2 |
| Experiences | Number (person) | % |
|---|---|---|
| Needle-stick Injuries or sharp object cuts | ||
| No | 174 | 79.5 |
| Yes | 45 | 20.5 |
| Activities leading to injury | ||
| Needle re-capping | 3 | 1.4 |
| Passing sharp instruments to others | 2 | 0.9 |
| Blood draws/IV catheter insertion | 22 | 10.0 |
| Preparation of medical tools/equipment | 2 | 0.9 |
| Handling/cleaning used medical equipment | 4 | 1.8 |
| Preparation/mixing of medications | 5 | 6.8 |
| Exposure to blood/body fluids | ||
| No | 205 | 93.6 |
| Yes | 14 | 6.4 |
| Routes of exposure | ||
| Eye exposure | 5 | 2.3 |
| Skin contact (ulcer) | 3 | 1.4 |
| Other (mouth, nose, skin no ulcer) | 6 | 2.7 |
| Activities Leading to Blood Exposure | ||
| Assisting in childbirth | 2 | 0.9 |
| Suctioning sputum | 6 | 2.7 |
| Wound care | 1 | 0.5 |
| Handling blood-stained linens/body fluids | 3 | 1.4 |
| Handling used medical instruments | 4 | 1.8 |
| Cleaning instruments | 1 | 0.5 |
| Other | 4 | 1.8 |
Seeking safety practice information, occupational health literacy, and clinical practice safety behavior
The average score for seeking safety practice information was moderate, with a mean of 2.61 (SD = 0.56). The most frequently utilized source was the internet, with a mean score of 3.26 (SD = 0.831). Support from healthcare personnel and nursing lecturers was also at a moderate level, with a mean score of 2.87 (SD = 0.56). The highest level of support was received through reminders during training, followed by advice or counseling on disease and injury prevention (mean = 3.60, SD = 0.59; mean 3.51, SD = 0.60, respectively). However, support for PPE, particularly safety goggles, face shields, and hair caps, was notably lower (mean = 1.65, SD = 1.0; mean = 2.11, SD = 1.16; mean = 2.39, SD = 1.12, respectively).
Occupational health literacy was at a moderate level (mean = 3.34, SD = 0.38). Students had an understanding of their own risks in nursing practice and methods to mitigate these risks (mean = 3.68, SD = 0.49). They were confident about selecting reliable sources for information on disease and injury prevention (mean = 3.51, SD = 0.58; mean = 3.51, SD = 0.57, respectively).
Clinical practice safety behaviors were similarly at a moderate level (mean 3.48, SD = 0.29). Consistently high-rated behaviors included explaining information to patients and seeking their cooperation before providing care (mean = 3.74, SD = 0.51; mean = 3.63, SD = 0.62, respectively). While most behaviors for preventing sharp injuries were rated highly, the behavior of not using hands to assist in needle threading during suture removal required improvement (mean = 2.89, SD = 1.23). Infection prevention behaviors needing enhancement included the use of PPE during suctioning of patients, specifically wearing goggles and hair caps (mean = 2.89, SD =1.23; mean = 1.98, SD = 1.11, respectively). Additionally, the use of aprons during nursing procedures involving potential exposure to blood or bodily fluids was infrequent (mean = 2.77, SD = 1.18). Despite all students wearing masks consistently during training, the average score for not touching the outside of the mask was 2.23 (SD = 1.26). Ergonomic behaviors that required improvement included stretching muscles and performing eye exercises during lunch breaks or when experiencing fatigue (mean = 1.91, SD = 1.23).
Occupational health risk
The most prevalent occupational health risk encountered by nursing students was psychosocial hazards, with 37.4% of students reporting experiences of being spoken down to by teachers, healthcare staff, patients, or relatives of patients in the patient ward. Biological hazards followed, particularly needle-stick and sharp injuries, representing 22.55% of reported cases. Among these, 13.3% (6 individuals) involved needles that had come into contact with patients, including two students who recapped needles, one student involved in blood sampling/injection, and three students responsible for cleaning medical equipment.
A significant proportion of needle-stick injuries, 48.89% (22 students), occurred due to equipment that had not yet come into contact with patients, primarily during equipment preparation or medical device handling. The second most common risk was related to medication preparation, involving 28.89% (13 students). Additionally, 3.65% (8 students) experienced exposure to blood or secretions from patients splashing into their eyes or onto injured skin.
Ergonomics-related hazards, such as lifting or moving heavy patients single-handedly, accounted for 12.8% of the risks. Physical hazards due to dim lighting constituted 9.6%, while chemical hazards from exposure to chemicals were reported by 6.8% of the students. Additionally, 10% of the students reported latex glove allergies. Overall, 51.4% of the students faced some level of occupational health risk, as detailed in Table 3.
| occupational health risks |
Number (person) |
% |
|---|---|---|
| Physical hazards | ||
| Dim light | 21 | 9.6 |
| Chemical hazards | ||
| Chemical expose | 15 | 6.8 |
| Allergic to latex gloves | 22 | 10.0 |
| Allergic to alcohol-based solution | 4 | 1.8 |
| Biological hazards | ||
| Needle-stick, sharp injuries | 45 | 22.5 |
| Blood and blood and secretion exposures | 8 | 3.65 |
| Ergonomics | ||
| Lifting/moving heavy patients single-handedly | 28 | 12.8 |
| Psychosocial hazards | ||
|
Mentally harmed by derogatory remarks made by nursing teachers, healthcare staff, patients, or relatives |
82 | 37.4 |
| Total of those who have encountered at least one risk factor | 110 | 51.4 |
This comprehensive analysis underscores the multifaceted nature of occupational health risks encountered by nursing students, highlighting the need for targeted interventions and enhanced support systems to ensure their safety and well-being during clinical training.
Comparison of Occupational Health Risk Exposure Between Fourth- and Third-Year Nursing Students
A comparative analysis of occupational health risk exposure between fourth- and third-year nursing students revealed that fourth-year students face significantly higher risks in several areas. Specifically, fourth-year students reported insufficient PPE more frequently when providing care, with an odds ratio (OR) of 2.350 (95% CI: 1.18–4.67). They also experienced higher rates of physical or psychological abuse, such as being demeaned by instructors (OR = 5.14, 95% CI: 1.68–15.72) and by nurses (OR = 2.76, 95% CI: 1.32–5.77), compared to third-year students, as shown in Table 4. This analysis underscores the heightened occupational health risks faced by fourth-year nursing students compared to third-year students, highlighting the need for enhanced protective measures and supportive environments, especially for those in their final year of training. Addressing issues such as insufficient PPE and incidents of abuse can significantly improve the safety and well-being of nursing students during their clinical education.
| Occupational health risk | Risk level |
3rd yr. Students (n=109) n (%) |
4th yr. Students (n=110) n (%) |
OR (95%CI) | 95% Confidence Interval (CI) |
|---|---|---|---|---|---|
| Exposure to secretions | Ever | 7 (6.4%) | 8 (7.3%) | 1.14 | (0.40-3.27) |
| Never | 102 (93.6%) | 102 (92.7%) | |||
| Chemical exposure | Ever | 7 (6.4%) | 8 (7.3%) | 1.14 | (0.40-3.27) |
| Never | 102 (93.6%) | 102 (92.7%) | |||
| Lifting/moving heavy patients single-handedly | Ever | 12 (11.0%) | 16 (14.5%) | 1.38 | (0.62-3.06) |
| Never | 97 (89.0%) | 94 (85.5%) | |||
| Slips and falls | Ever | 1 (0.9%) | 7 (6.4%) | 7.34 | (0.89-60.70) |
| Never | 108 (99.1%) | 103 (93.6%) | |||
| Insufficient PPE | Ever | 15 (13.8%) | 30 (27.3%) | 2.350 | (1.18-4.67)** |
| Never | 94 (86.2%) | 80 (72.7%) | |||
| Inadequate lighting | Ever | 10 (9.2%) | 11 (10.0%) | 1.10 | (0.45-2.71) |
| Never | 99 (90.8%) | 99 (90.0%) | |||
| Physical or Psychological abuse from instructors | Ever | 4 (3.7%) | 18 (16.4%) | 5.14 | (1.68-15.72)** |
| Never | 105 (96.3%) | 92 (83.6%) | |||
| Physical or Psychological abuse from nurses | Ever | 12 (11.0%) | 28 (25.5%) | 2.76 | (1.32-5.77)** |
| Never | 97 (89.0%) | 82 (74.5%) | |||
| Physical or Psychological abuse from patients or relatives | Ever | 4 (3.7%) | 8 (7.3%) | 2.06 | (0.60-7.05) |
| Never | 105 (96.3%) | 102 (92.7%) |
**: P< 0.5
Factors associated with occupational health risk
In the sample group, 110 individuals (51.4%) were identified as having at least one occupational health risk factor. Univariate analysis revealed several factors associated with occupational health risks. These included gender, with females at higher risk compared to males (OR = 3.38, 95% CI = 1.17–11.56, P = 0.03), safety behaviors during training (compared to those exhibiting very good behaviors, OR = 2.09, 95% CI = 1.19–3.69, P = 0.04), occupational health knowledge (compared to those with good knowledge, OR = 2.79, 95% CI = 1.26–6.19, P = 0.02), and information-seeking behavior regarding disease and injury prevention (compared to those with high knowledge, OR = 2.09, 95% CI = 1.19–3.69, P = 0.01).
Multivariate analysis using the forward conditional method, controlling for other factors, further identified significant associations. Safety behaviors during professional practice were significantly associated with occupational health risks (compared to those with very good behavior, with an adjusted odds ratio (AOR) = 1.80, 95% CI = 1.03–3.14, P = 0.04). Occupational health literacy was also a significant factor (compared to those with good health literacy, AOR = 2.54, 95% CI = 1.13–5.74, P = 0.02), as shown in Table 5.
| Factors | Number | Risk | univariate analysis | multivariate analysis | |||
|---|---|---|---|---|---|---|---|
|
yes n (%) |
no n (%) |
OR (95%) | P-value | AOR (95%) | P-value | ||
| Gender | |||||||
| female | 201 | 103 (51.2) | 98 (48.8) | 3.68 | .03* | 4.15 | .018** |
| male | 18 | 4 (22.2) | 14 (77.8) | (1.17-11.56) | (1.28-13.47) | ||
| Academic year level | |||||||
| 3rd | 109 | 60 (55.0) | 49 (45.0) | 1.649. | .09 | ||
| 4th | 110 | 47 (42.7) | 63 (57.3) | (0.96-2.80) | |||
| Clinical safety behaviors | |||||||
| Moderate to good | 113 | 63 (55.8) | 50 (44.2) | 2.09 | .04* | 1.80 | .04** |
| Very good | 106 | 44 (41.5) | 62 (58.5) | (1.19-3.69) | (1.03-3.14) | ||
| Occupational health literacy | |||||||
| low | 33 | 23 (69.7) | 10 (30.3) | 2.79 | .016* | 2.54 | .02** |
| high | 186 | 84 (45.2) | 102 (54.8) | (1.26-6.19) | (1.13-5.74) | ||
| Support from teacher and health care personal | |||||||
| low | 117 | 56 (47.9) | 61 (52.1) | 1.32 | .37 | ||
| high | 102 | 46 (45.1) | 56 (54.9) | (0.78-2.56) | |||
| Seeking safety practice information | |||||||
| low | 141 | 78 (55.3) | 63 (44.7) | 2.09 | .01* | ||
| high | 78 | 29 (37.2) | 49 (62.8) | (1.19-3.69) | |||
*, **: P< 0.5
This study identified that the most prevalent occupational health risks among nursing students were psychosocial hazards (37.4%), followed by biological hazards (22.5%) and ergonomic hazards (12.8%). Psychosocial risks were notably significant, aligning with the Liveware-Liveware interaction in the SHELL model [13], which underscores the importance of human interactions within clinical settings and their impact on student well-being. Fourth-year nursing students face various challenges that require them to adapt to new roles and responsibilities, such as demonstrating greater autonomy in patient care, making clinical decisions under supervision, mentoring junior students, and collaborating effectively with the healthcare team. They must also manage increased workloads, adhere to safety protocols, and exhibit professionalism and compassion in their approach to patient care. Despite prior clinical training, these students encounter the added complexity of new specialty areas, necessitating adaptation and multifaceted role execution, including being learners, knowledge providers, and trusted caregivers. This dynamic can lead to negative feedback from instructors, healthcare staff, and patients or their relatives, consistent with previous findings that psychosocial factors are a predominant hazard in nursing students [8, 11, 12].
Biological hazards primarily stem from needle-stick injuries and sharp injuries, which pose risks of pathogen transmission due to inadequate technical preparation or distractions during clinical practice. These injuries often occur during activities such as handling and preparing medical instruments and administering injections. The study’s results align with the existing literature, which highlights the significant risks associated with needle-stick injuries and sharp object handling in clinical settings [1, 2, 15]. Ergonomic hazards, including the manual handling of heavy patients without proper assessment or adjustment to the bed height, were also significant. These issues reflect broader findings that frequent student incidents involve manual handling activities and workplace violence [6, 16].
Occupational health literacy among the students was moderate. While students received orientation on self-protection from diseases and accidents and had good support from healthcare personnel, their practical safety behaviors were suboptimal. Despite students’ efforts to seek information on disease and injury prevention, their clinical safety behaviors were inconsistent with the recommended practices. This discrepancy indicates that while students possess theoretical knowledge, practical application remains a challenge. For instance, students often fail to evaluate their physical capabilities before patient handling, do not properly adjust bed heights, and sometimes neglect to use appropriate PPE during procedures. These practices align with previous studies that noted moderate adherence to standard precautions and safety behaviors [9, 17], though they contrast with other findings suggesting generally good safety behaviors in nursing students [2, 15].
This study identified significant factors associated with occupational health risks in nursing students, with 51.4% of the sample group experiencing at least one occupational health risk. Univariate analysis revealed that gender, safety behaviors during training, occupational health knowledge, and information-seeking behavior regarding disease and injury prevention were key factors. Multivariate analysis further confirmed that safety behaviors during professional practice (AOR = 1.80, 95% CI = 1.03–3.14, P = 0.04) and occupational health literacy (AOR = 2.54, 95% CI = 1.13–5.74, P = 0.02) remained significant, even when controlling for other factors. These findings underscore the urgent need for targeted interventions to enhance safety behaviors and occupational health literacy in nursing students.
The SHELL model offers a comprehensive framework to understand these findings by conceptualizing the interaction between Software, Hardware, Environment, Liveware (individual), and Liveware (interaction with others). The software component, which includes protocols and training programs, was highlighted by the significant impact of inadequate safety behaviors during training. This indicates a pressing need for improved training programs that emphasize practical safety skills and strict adherence to protocols. Evidence from previous research supports the critical role of robust training programs in reducing occupational hazards [11].
The Hardware component focuses on the physical equipment and tools used in clinical settings, such as PPE. The inadequacy of PPE was a notable risk factor, suggesting that ensuring sufficient and appropriate PPE is crucial for mitigating risks. Studies have shown that the proper use of PPE significantly reduces exposure to biological hazards [8]. The Environment component encompasses the physical clinical environment, including lighting and ergonomics, which are critical in mitigating occupational health risks. Poor lighting and ergonomic challenges, such as lifting heavy patients, were significant risk factors in this study. Enhancing the physical environment of clinical settings to meet ergonomic standards can reduce these risks [5].
The Liveware-Liveware components represent the individual nursing students and their interactions with others, such as instructors, healthcare personnel, and patients. The significant association between occupational health literacy and risk highlights the importance of enhancing individual knowledge and skills. Effective educational interventions are essential for improving health literacy and promoting safe practices [10]. Gender as a significant risk factor, with females being more at risk, could reflect broader social and interpersonal dynamics within clinical settings. Ensuring supportive and respectful interactions can reduce psychosocial hazards [6].
This study highlights significant occupational hazards faced by nursing students, analyzed through the framework of the SHELL model. Psychosocial risks, the most prevalent, align with the Liveware-Liveware component, highlighting challenges in interpersonal dynamics among students, instructors, healthcare personnel, and patients. Biological risks, such as needle-stick and sharp injuries, are closely tied to the Hardware component, emphasizing the need for appropriate and sufficient PPE and tools. Ergonomic risks, primarily related to manual handling tasks, reflect both Environmental factors, such as workspace design, and Liveware (individual) factors, including students’ physical preparedness and adherence to safety behaviors.
While students demonstrated moderate occupational health literacy, representing the Software component, gaps in adherence to safety protocols and infection control practices suggest the need for enhanced training and practical reinforcement. These findings underscore the importance of addressing all SHELL model components to provide a comprehensive strategy for minimizing risks and enhancing safety during clinical practice.
Addressing these hazards requires targeted interventions across the SHELL model components. For the Software component, safety training programs should be strengthened to focus on practical applications of infection control and occupational health protocols, and should include workshops and simulations to reinforce safety practices. The Hardware component necessitates ensuring the consistent availability and adequacy of PPE and ergonomic tools that reduce physical strain during manual tasks. The Environment must enhance clinical settings by addressing ergonomic challenges, improving lighting, and streamlining workflows to reduce exposure to occupational hazards.
The Liveware (Individual) component should promote occupational health literacy and encourage self-assessment of risks through tailored educational initiatives that support safe practices. The Liveware (Interactions) component should foster supportive interpersonal relationships by implementing mentorship programs and collaborative frameworks between nursing students, teachers, and healthcare personnel, reducing psychosocial risks and creating a safer clinical environment. By integrating these recommendations into nursing education and clinical practice, institutions can address the multifaceted occupational hazards nursing students face, ensuring their safety and well-being while enhancing the overall quality of clinical training.
We wish to extend our heartfelt thanks to the Faculty of Nursing, Burapha University for research funding.
All contributing authors have no financial conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
