What can the implementation of the 2010 EU Directive on Sharp Injuries teach us about preventing COVID-19 infection in nurses in clinical settings?
Florence Nightingale’s influence on the fields of society and politics; philosophy; science; education; and literature is well documented, demonstrating that on political matters she was an astute behind-the-scenes political activist. She campaigned based on the data she collected to show politicians the evidence for her arguments to improve the working conditions for nurses. At times of the EU COVID-19 crisis and emergency situation, it is key to reflect on existing EU legislation to strengthen healthcare systems in the EU and importantly, support and protect frontline nurses while doing their job.
Therefore, the European Directive on Sharp Injuries provides an opportunity to look at its professional and societal impact through the legacy of Florence Nightingale. It is key to look into how EFN lobbied the EU to improve the working environments of three million EU nurses, making sure the European Parliament, the European Commission and the European Council not only develop EU legislation, but equally important transpose Directives into daily reality. That transposition in the COVID-19 crisis is key to save the lives of both citizens and healthcare professionals.
Why did we need a European Directive 2010/32/EU; and why this Directive is important to tackle COVID-19?
Sharps injuries, and particularly needlestick injuries, bring the risk of potentially life-threatening infections into the daily working life of millions of health care providers. More than 30 dangerous bloodborne pathogens are transmitted by contaminated needles, including hepatitis B, hepatitis C and HIV. The bore of the needle acts as a reservoir for blood and other body fluids and small amounts of blood can result in potentially life-threatening infection. Additionally, the emotional impact of a sharps injury can be severe and long lasting, even when a serious infection is not transmitted.
Sadly, every year in Europe approximately 1.2 million needlestick injuries are incurred by healthcare staff (European Commission, 2009). A study from one European country reported that needlestick injuries were the most reported type of significant exposure, with 63% of those injuries caused by hollow bore needles. 45% of these occurred amongst nursing professionals and 37% amongst healthcare professionals. A much lower incidence was identified amongst allied ancillary staff, with most being sustained from inappropriately discarded needles in rubbish bags. Another European country study reveals that the highest risk area for the likelihood of needlestick injury is venous blood drawing (>38%), and that only 20% to 50 % of all needlestick injuries are reported.
Although the EFN and its members actively keep on campaigning to eliminate the risk of needlestick injury for nurses, focusing upon developing European standards to reduce the use of needles, ensuring the protection for exposed sharps through the use of medical devices, and ensuring safe work practices including through better education and training, it is important to focus down our actions and set priorities during the pandemic. The EFN’s 2015 report ‘We are not prepared unless we are all prepared’ recommended greater support for the EU health workforce, in particular nurses, to respond to the challenges of Infectious Diseases of High Consequences (IDHC) without compromising its safety and wellbeing; through measures including:
- Co-ordinating and building capacity in the nursing workforce;
- Providing further access to vital education and training, including opportunities for regular drills on donning and doffing PPE; and
- Assuring the provision of adequate resources and support for a safe working environment.
10 years on from the Directive, what has changed for nurses and healthcare providers?
The EFN 2013 report on the implementation of Directive 2010/32/EU in the hospital and healthcare sector concludes that the transposition and implementation into practice at the workplace shows a positive impact of the implementation of Directive 2010/32/EU into the clinical practice, in most EU Member States. A majority of respondents from the 28 countries represented in the analysis have measures in place to prevent sharps injuries. The data show that implementation of EU legislation on sharp injuries is well on track – however, more needs to be done to reach ‘zero tolerance’ in the field of sharp injuries.
Is this initial implementation progress still measurable in 2020? Do we know what is going on when it comes to sharp injury prevention in all EU Member States? Do we know how many nurses incurred injuries with a ‘sharp instrument/needle’ this year? The same holds for COVID 19 infections.
The 2019 report from HOSPEEM and EPSU, titled ‘Follow-up on the Directive 2010/32/EU’, focusing mainly on the role and impact of the national social partners during relevant stages of the transposition and implementation of the Directive, reports on 30 replies from European Hospital and Healthcare Employers’ Association (HOSPEEM) members and European Federation of Public Service Unions (EPSU) affiliates from 20 countries. The recommendations to the national and EU-level social partners, to European institutions (in particular to the European Commission and EU-OSHA) and the EU Member States are clear, but not surprisingly, these recommendations refer to ‘continue to share’, ‘exchange of experiences’, ‘awareness-raising, while respecting national settings’, ‘continue to elaborate and promote’: all quite soft approaches in the current emergency situation occasioned by COVID-19. It is clear, without collecting data, that nurses and doctors, are at high risk on a daily basis. Therefore, it is key to move now from ‘recommendations’ to ‘rules’. Therefore, it is key that the EFN, representing three million EU nurses, takes a tougher stand; as politicians need to be reminded about their responsibility to protect frontline staff.
COVID-19: prevention and protection for safer work environments
The Directive 2010/32/EU certainly helped reduce needlestick injuries in some EU Member States. The standardisation of registration, reporting and follow-up systems of injuries with sharps injuries is an important step forward – but there is no EU-wide approach to measure accidents; and this is the key problem, both for sharps injuries and COVID-19 infections. Even with the technologies currently available, we have no concrete solution to monitor the unmet needs of frontline healthcare professionals (HCP), who are in survival mode daily and risking their own lives. It is time to move from ‘patchwork’ to ‘EU co-ordination’ and stop hiding behind ‘subsidiarity’. We need to go beyond sharing best practices, if we want focused support to frontline nurses.
Furthermore, Continuous Professional Development (CPD) is an equally important step forward, but also here we see a lot of patchwork, with nurses lacking working time to follow face-to-face courses. During the time of COVID-19, there is hardly time to become a ‘link COVID nurse’, which is not a specialist nurse, but a general care nurse with a specific attention on each unit.
Before we start teaching, it is essential that nurses have the materials they need. The elimination of unsafe procedures as well as the transition to safe sharps protection mechanism and devices is key for frontline nurses – and this holds equally true for COVID-19!
On 24 March 2020 12 European organisations of healthcare professionals published a statement to the European Commission, calling urgently for equipment, resources and support:
‘European organisations representing all healthcare professionals addressed common concerns and discussed what is right now needed to support the HCP…. Many HCP are now getting infected, and several doctors and nurses are dying. All HCP share the same concerns regarding the lack of safety in the workplaces. HCP are on the first line of response in the fight against the COVID-19. HCP are faced with a distressing lack of personal protective equipment (PPE) in practically every Member State, as few governments and employers are prepared for pandemics after years of austerity. There is an imminent need for more resources to be able to manage the pandemic, including staffing levels, PPE and financial resources. It is therefore essential to work together to monitor and support the Commission’s efforts to make sure that the protective equipment needed to combat COVID-19 is able to quickly reach the member states and HCP facing shortages. The European Union must make it a priority to ensure that all member states pull together resources and harmonise prevention protocols to ensure the protection of lives.’
We need to look at these issues from an EU perspective and propose co-ordinated solutions, with EU funds put together to address this emergency situation, in which DG ECHO should play a crucial role, due to their experiences outside of Europe. Specific attention should go to the lack of economic resources to provide safe protection equipment needed in Southern, Central and Eastern Europe, where health systems are already very vulnerable without the additional crisis of a global pandemic.
This automatically brings us to the empowerment of nurses in advanced role in public procurements: nurses need to formulate the procurement criteria to buy those materials that support reduction of their workload and projects them from infections and injuries. Within this context it is important industry continues developing safety-engineered solutions, needle-free systems and safer hardware disposal solutions; but most important is that these solutions are developed in partnership with the frontline professionals. A good example is that of PPE, which is mostly designed by men to fit male bodies, while the nursing workforce mainly consists of women. Masks and PPE need to be developed by nurses and for nurses – but for this to happen, the industry needs to be more proactive and not reactive. Co-creation and co-design are essential, so nurses on the frontline, in hospitals and community care, can use materials that are fit for purpose.
Opportunities and challenges for the next years to create a safer and healthier work environment for nurses
The main question is whether we have become complacent in the matter of sharps injuries. Do we have accurate frontline data on the different aspects of the Directive, including ‘Risk assessment’ (Clause 5), ‘Elimination, prevention and protection’ (Clause 6), ‘Information and awareness-raising’ (Clause 7), ‘Education and training’ (Clause 8), ‘Reporting’ (Clause 9), ‘Response and follow-up’ (Clause 10) and especially ‘Implementation’ (Clause 11)? Do we have the data to show the frontline reality for nurses and nursing? How could the digitalisation of the healthcare sector facilitate these developments?
All these clauses in Directive 2010/32/EU are relevant to the COVID-19 crisis in the EU; however, Clause 6 is now a top priority to save lives: elimination, prevention and protection are key. Meanwhile Clause 8, education and training, is key to making sure nurses can focus their activities in the optimal way to protect themselves.
Being prepared needs to come back onto the political agenda. EFN states that ‘what is good for citizens and patients, is good for nurses’. The safety of patients and citizens was dropped from the EU political agenda, unfortunately; and the European Agency for Safety and Health and the World Health Organization have other political priorities. Also, within the European Social Pillar, little room for manoeuvring will be possible within the 20 principles to address the impact of Directive 2010/32/EU on being prepared, on frontline nurses. Being prepared at all times, in a co-ordinated way, becomes a real challenge at the EU level.
This EU co-ordination can be done by focusing on the collection at the EU level of robust data from the professions concerned – in our case three million nurses – to assess the impact of not being prepared; not to blame and shame; to learn and to be better prepared for the next crisis. The HOSPEEM-EPSU Report says clearly that ‘most of the problems reported are linked to deficits regarding the elimination, prevention and protection of risks from injuries and/or infections from medical sharps’. The EFN 2015 report on Preparedness adds:
‘Continue to encourage investment in preparedness, learning from the lessons and knowledge gained so far, and enhancing monitoring and follow up initiatives. Protecting the health workforce, as well as the public, from future health threats should continue to remain a priority for all Member States individually and the European Commission collectively, ensuring that relevant protective equipment, appropriate education and training, and protocols are made available to frontline staff.’
We must turn this COVID-19 crisis into more frontline EU actions, not just an awareness campaign; not another CPD course or a National congress to talk about the challenge instead of solving it. A frontline approach, supported by the EU institutions, Parliament, Commission and Council, is urgently needed to protect EU citizens and its health workforce in times of emergency and crisis. Nurses still get injured and infected because we lack the appropriate material in hospital and community care to protect nurses from Infectious Diseases of High Consequences.
We have conducted 10 years of awareness raising and training; it is now time to push for an EU approach to visualise Infectious Diseases of High Consequences and sharps injuries; and develop appropriate actions with the co-ordinated support of the EU institutions.
Standardisation of registration, reporting and follow-up systems of IDHCs and injuries with sharps implies the need for a structured centralised system, which is interoperable at a European level. Respecting the responsibilities of the Member States in relation to the ‘organisation and delivery of health services’ is one thing, but protecting the lives of frontline nurses in carrying out their frontline job needs to become an EU legislative priority.
Professor Dr Paul De Raeve, RN, MSc, MStat, PhD
European Federation of Nurses Associations
This article is from issue 14 of Health Europa. Click here to get your free subscription today.