http://doi.org/10.33698/NRF0126 – Sarvjeet Kaur
Abstract : Biomedical waste means any waste which is generated during the diagnosis, treatment or immunization of human beings or animals or in research activities pertaining thereto or in the production or testing of biological according to the Bio-Medical Waste (Management and Handling) Rules of India. A comparative study was undertaken in three governmental hospitals that were above 500 bedded to assess the knowledge and practices of nurses regarding various aspects of biomedical waste management. A descriptive study design was used to assess various aspects related to biomedical waste management i.e. policies related to biomedical waste management, waste generation, segregation, colour coding, waste treatment and final disposal of waste in their hospitals. A total of 215 nurses were interviewed in three hospitals using a semi structured questionnaire with both close ended and open ended questions to obtain data. Non participant observation method was used to observe methods of waste generation, segregation and waste treatment and was scored on a Likert scale. The data was analysed using SPSS 16 and results evaluated using chi square test. It was found that nurses in Hospital III had better knowledge and practices related to biomedical waste policies and segregation while nurses in Hospital II had better knowledge regarding waste transportation compared to other two hospitals. Nurses of Hospital III were found to be completely responsible for biomedical waste management in the hospital and hence score highest on knowledge scores related to waste segregation. These nurses had knowledge on various aspects of waste segregation in ward beginning from indenting for biomedical waste management articles, infrastructure required for waste segregation to standing operative procedures for segregation in ward
Key words :
Nurse, biomedical waste management, segregation, hospital.
Correspondence at :
Maj Sarvjeet Kaur
Associate Professor
College of Nursing, Armed Forces Medical College Pune
Introduction
Man has inhabited the planet earth since many decades. Nomadic man was close to Mother Nature. Ever since the ancient times, humans and animals have used the resources of earth to support life and to dispose the waste. In those days, the disposal of waste did not pose significant problems as the population was very small and a vast expanse of land was available for the assimilation of such wastes. The earliest date on waste management dates back to the 19th century, when in the year 1842, a report in England linked diseases to unsanitary environmental conditions, thereby helping to launch the ‘age of sanitation’. In the year 1874, in Nottingham, England, a new technology called the ‘destructor’ provided the first systematic incinerator of municipal solid waste.1
According to World Health Organization Healthcare waste includes all the waste generated by healthcare establishments, research facilities, and laboratories. In addition, it includes the waste originating from minor or scattered sources such as that produced in the course of healthcare undertaken in the home (dialysis, insulin injections, etc.).2
In India, collection, segregation, storage, transpor tation and disposal of hospital waste also called the biomedical waste is unscientific and chaotic. The waste produced in the course of healthcare activities carries a higher potential for infection and injury than any other type of waste. Till the last century, the usual methods for disposal such as burning, land filling or burial, which were in conformity with the then existing public health knowledge and epidemiology were practiced by hospitals or most of the times, the waste thrown out of the hospitals was to be taken care of by the local municipalities.
According to the Bio-Medical Waste (Management and Handling) Rules of India, Biomedical waste means any waste which is generated during the diagnosis, treatment or immunization of human beings or animals or in research activities pertaining thereto or in the production or testing of biological (Government of India Gazette 1998).3 In the context of the present study, hospital waste, healthcare waste and biomedical waste were considered same i.e. the waste being generated in the research settings.
According to J Christen (1996)4 out of the total hospital waste generated, 80 per cent is general healthcare waste, which can be dealt with by the normal domestic and urban waste management system, 15 per cent pathological and infectious waste,1 per cent sharps waste, 3 per cent chemical or pharmaceutical waste, less than 1 per cent special waste, such as radioactive or cytostatic waste, pressurized containers, or broken thermometers and used batteries. Dorothy (2003)5 studied the knowledge, attitude and practice of 50 Nursing personnel and 14 supportive staff in relation to biomedical waste segregation and universal precautions in maternity ward and showed low correlation between knowledge and practice as well as attitude and practice.
According to WHO (1997)6 all employees of the hospital should be able to understand the biomedical waste management policy, which should contain details of the procedures to follow in case of emergencies like exposure to infected blood. Among all the hospital employees the nursing personnel usually constitute the largest proportion of the health professionals in the hospitals. They share major responsibility in waste generation and management since they are with the patient 24 hours a day and 7 days a week. The nursing service administration in the hospitals is usually three levels: at the base level, there were bedside nurses involved in direct patient care and ward administration, at the middle level were the middle level head nurses being called as Senior sister or Nursing Sister and they were managing the ward rotations along with intra and inter depar tmental aspects of administration. At the top were the Nursing Superintendents with the Deputy and Assistant Nursing Superintendents.
Since nursing personnel constitute the largest proportion of the health services in the hospitals they are responsible for biomedical waste management of their respective wards. Hence it is important to assess their knowledge related to biomedical waste management. Keeping it in mind current study was planned with the objective to assess the knowledge and practices of biomedical waste management among the nurses in the three hospitals.
Material and Methods
The scope of the present study was to study Hospital Waste Management in three selected hospitals of a well planned urban city of India. The healthcare institutions in the city were identified. The criterion for selection was based on the bed strength of the hospitals i.e. hospitals above 500 beds so as to be covered under the Biomedical Waste Management and Handling rules of India,
Government of India Gazette (1998). The current data on basis of cross section was collected by making number of visits to select hospitals. The administrators of the three hospitals i.e. Medical superintendent, Nursing Superintendent, Deputy Nursing Superintendent, Assistant Nursing Superintendent and the Nursing personnel responsible for infection control and in charge of the Sanitary inspectors were interviewed regarding the policies related to biomedical waste management in the three hospitals.
Nurses who were involved in patient care and were therefore waste generators and handlers were included in the study and proportionate sample from the three hospitals was drawn. Hospital I had a total of 402 nurses, Hospital II had 174 nurses employed and Hospital III had 70 nurses. For the study, a total 215 nurses were selected as sample for the study. Sample was further taken from the three shifts-morning shift, evening shift and night shift in which the nurses worked. As the hospital waste generation was found to be maximum in the morning hours 40 per cent of the sample were taken from the nurses working in the morning shift, 5 per cent each from the nurses working in the evening and the night shift.
Research instrument used was a questionnaire and an observation rating scale. A semi structured interview schedule was prepared with both close ended and open ended questions to obtain data. The questionnaire consisted of two parts-Section I consisted of socio demographic profile of nurses like their age, educational qualification and number of years of working in the hospital. Section II consisted of items related to knowledge of the nurses regarding biomedical waste management policies, segregation, colour coding, waste treatment, transportation and final disposal of waste. The answers were scored as adequate, partially adequate and inadequate against the gold standards of Biomedical Waste (Management and Handling) Rules of India (Government of India Gazette 1998). Those who answered to 80 percent and above of the questions correctly were described to have adequate knowledge, 79 to 50 percent were described to have par tially adequate knowledge and less than 50 percent were described to have poor knowledge regarding various aspects of biomedical waste management. An observation checklist was prepared to observe the actual practices of waste generation, segregation and waste treatment. This also included observing the use of needle cutters/destroyers, chemical disinfection, autoclave etc. The respondents were rated on three point Likert scale. The observations were catetorised as correct, partially correct and incorrect based on the above criteria. Both the instruments were validated by the exper ts in the field of Nursing, hospital administration and Public administration.
The pilot study was undertaken on the nurses in a similar kind of ter tiary care hospital. The reliability was established using inter rater reliability for the observation tool and test retest method for questionnaire. The result showed the tool was reliable. The inter rater reliability coefficient was 0.82 The test retest reliability coefficient was 0.88 indicating a good test-retest reliability. data was collected over a period of six months in three shifts, from morning 8 a.m. to 11 a.m, in the evening from 7 p.m. to 10 p.m. and in the night from 8 p.m. to 11 p.m. The questionnaire was administered as self-administered tool to the nurses in the three shifts. The nurses were asked to fill the questionnaire and return it the next day. Majority of the nurses returned the filled proformas within two to three days. . The data was analysed using SPSS 16.
Results
The table-1describes the socio- demographic attributes of the nurses in the three hospitals under study. Age of nurses ranged from 22 years to 56 years with average age 38.6+10.1 years while 73.1% nurses were in age range of 21 to 40 years. Most of the nurses were having professional qualification General nursing midwifery (GNM) in all the three Hospital i.e. 85.3 per cent in Hospital I, 90.7 per cent in Hospital II and 80 per cent in Hospital III.most of the nurses (87.9%) were permanent employees of the hospital while 12.1 % of nurses were employed on contract bases in Hospital I and Hospital II. Working experience of nurses ranged from below 1 year to 11 years with average 3.3+1.9 years of experience. Nearly half of nurses (48.8%) were having experience between 1 to 5 years.
Table 1 : Socio demographic profile of the nurses in the three hospitals
| Attributes | Hospitals | Total n-215 | ||
|
H o s p i t a l I n = 7 5 |
H o s p i t a l I I n = 7 5 |
H o s p i t a l I I I n = 6 5 |
||
|
A g e i n y e a r s |
||||
| · 21-40 | 61 (81.3) | 45 (60.0) | 51 (78.5) | 157(73.1) |
| · 41-50 | 11 (14.7) | 14 (18.7) | 14 (21.5) | 39(18.1) |
| · >50 | 03 (04.0) | 16 (21.3) | – | 19(8.8) |
| Professional Qualification | ||||
| · GNM | 64 (85.3) | 68 (90.7) | 52 (80.0) | 157(85.6) |
| · BSc Nursing | 11 (14.7) | 07 (09.3) | 13 (20.0) | 31(14.4) |
| Employment | ||||
| · Contract | 14 (18.7) | 12 (16.0) | – | 26(12.1) |
| · Permanent | 61 (81.3) | 63 (84.0) | 65 (100.0) | 189(87.9) |
| Duration of work in years | ||||
| · Below 01 | 03 (04.0) | 07 (09.3) | 05 (07.7) | 15(7.0) |
| · 01-05 | 17 (22.7) | 29 (38.6) | 59 (90.8) | 105(48.8) |
| · 05-10 | 24 (32.0) | 11 (14.7) | – | 35(16.3) |
| · 10-15 | 22 (29.3) | 14 (18.7) | – | 36(16.7) |
| · >15 | 09 (12.0) | 14 (18.7) | 01 (01.5) | 24(11.1) |
The table -2 shows knowledge of nurses regarding different aspects of biomedical waste management (BMWM). The knowledge of the only one third of nurses related to hospital policies regarding BMWM was found adequate and another one third had par tially adequate knowledge. While looking at different hospitals it was observed that in Hospital III two third nurses (63 per cent) had adequate knowledge and in i.e. followed by 28 per cent nurses in Hospital I had adequate knowledge and only 6.7 per cent nurses from Hospital II had adequate knowledge.
Table 2 : Knowledge of nurses regarding Biomedical waste management
| Knowledge scores | Total N=215 | Hospital I n=75 | Hospital II n=75 | Hospital III n=65 | c2 | p |
| Policies | ||||||
| · Adequate | 67(31.2) | 21 (28.0) | 05 ( 6.7) | 41(63.0) | 65.1 | <0.001 |
| · Partially adequate | 76(35.3) | 37 (49.3) | 27 (36.0) | 12(18.5) | df=04 | |
| · Inadequate | 72(33.5) | 17 (22.7) | 43 (57.3) | 12(18.5) | ||
| Waste segregation | ||||||
| · Adequate | – | – | – | – | 69.9 | <0.001 |
| · Partially adequate | 142(66.0) | 62 (82.6) | 22 (29.3) | 58 (89.2) | df=02 | |
| · Inadequate | 73(34.0) | 13 (17.4) | 53 (70.7) | 07 (10.8) | ||
| Waste transport | ||||||
| · Adequate | 193(89.8) | 57 (76.0) | 74 (98.6) | 62 (95.4) | 11.1 | <0.01 |
| · Partially adequate | 14( 6.5) | 10 (13.3) | 01 (1.4) | 03 ( 4.6) | ||
| · Inadequate | 8( 3.7) | 08 (10.7) | – | – | ||
| Waste treatment | ||||||
| · Adequate | 9( 4.2) | 08 (10.7) | – | 01 ( 1.5) | 50.5 | <0.001 |
| · Partially adequate | 31(14.4) | 25 (33.3) | 01 (1.2) | 05 ( 7.7) | ||
| · Inadequate | 175(81.4) | 42 (56.0) | 74 (98.6) | 59 (90.8) | ||
| Final disposal of waste | ||||||
| · Adequate | – | – | – | – | 108.1 | <0.001 |
| · Partially adequate | 61(28.4) | 05 ( 6.7) | 06 ( 8.0) | 50 (77.0) | ||
| · Inadequate | 154(71.6) | 70 (93.3) | 69 (92.0) | 15 (23.0) |
Source: Computed from primary data. Figures in parenthesis are percentage
The knowledge scores related to waste segregation was not adequate in any hospital however more than 80% nurses from hospital I and III had partially adequate knowledge and in hospital II only 29.3% nurses had partially adequate knowledge. The knowledge of the nurses about waste transpor t in all the hospitals was quite adequate i.e. more than 90% nurses in hospital I and II and 76% nurses from Hospital II had adequate knowledge.
While assessing the knowledge of the nurses for waste treatment, it was seen that nurses in all the three hospitals had very low scores on adequate knowledge regarding waste treatment i.e. more than 90% of nurses in Hospital II and II had inadequate knowledge however the 10.7% nurses had adequate knowledge and 33% had partially adequate knowledge. Further nurses scored very low in knowledge on final waste disposal i.e. more than 90% nurses had inadequate knowledge in hospital I and II while 77% nurses from hospital III had partially adequate knowledge. The difference ion each aspect of BMWM in three hospitals was highly significant statistically as per chi square test
Table 3 depicts the knowledge score of nurses regarding use of universal precautions. The nurses in Hospital III were found to have best scores for knowledge with 75.4per cent having adequate knowledge. This was followed by Hospital I with 41.3per cent nurses having adequate knowledge . Knowledge scores were found minimum for Hospital II with 26.6 per cent nurses having adequate knowledge. The knowledge of nurses regarding risk in biomedical waste management was assessed and it was found that. 41.3 per cent of nurses in Hospital II always perceived risk in biomedical waste management while 58.7per cent had perceived risk sometimes. This was more as compared to perceived risk in Hospital I where only 8 per cent nurses perceived risk always, 53.3 per cent sometimes and 38.7 per cent occasionally. In Hospital III, 67.7 per cent nurses perceived risk occasionally and 32.3 per cent sometimes. None of the nurses verbalized complete freedom from risk. On an average most of the nurses perceived biomedical waste management hazardous in the three hospitals.
Table 3 : Knowledge of nurses regarding universal precautions and Perceived risk regarding BMWM
| Attributes /
Knowledge scores |
Hospital I | Hospital II N=215 | Hospital III n=75 | c2
n=75 |
p n=65 |
| Use of universal precautions | |||||
| · Adequate | 31 (41.3) | 20 (26.6) | 49 (75.4) | 32.1 | <0.001 |
| · Partially adequate | 44 (58.7) | 51 (68.0) | 16 (24.6) | df=2 | |
| · Inadequate | – | 04 (05.4) | – | ||
| Perceived risk regarding BMWM | |||||
| · Always | 06 (08.0) | 31 (41.3) | – | 93.4 | <0.001 |
| · Sometimes | 40 (53.3) | 44 (58.7) | 21 (32.3) | df=4 | |
| · Occasionally | 29 (38.7) | – | 44 (67.7) | ||
| · Never | – | – | – |
Source : Computed from primary data. Figures in parenthesis are percentage
The table 4 depicts the correct practices of nurses related to biomedical waste management in three hospitals made by three consecutive observations by the researcher.
In Hospital I, maximum nurses i.e. 86.2 percent were found following partially correct practices. In Hospital II, 38.7 percent nurses were following correct biomedical waste management practices and 60 percent nurses were following practices that were partially correct. In Hospital III, 74.3 percent nurses were found following correct practices and 25.1 percent were found following partially correct practices. While comparing the practices in three hospitals, it is seen that nurses in Hospital III were found following correct particles more as compared to Hospitals II and I.
Table 4 : Observation on practices of nurses related to BMWM
Practices of nurses Hospital I Hospital II Hospital III related to BMWM n- 225 n- 225 n- 195
Correct practices 30(13.4) 87(38.7) 145(74.3)
Partially correct practices 194(86.2) 135(60.0) 49(25.1)
Incorrect practices 1(0.4) 3(1.3) 1(0.6)
Relating socio demographic profile of nurses with the knowledge on BMWM it was observed that as the duration of working in the hospital increased, the knowledge regarding biomedical waste treatment and segregation increased among the nurses in the three hospitals with Hospital I having maximum scores. It was further observed that permanently employed nurses were found to have more knowledge scores as compared to nurses employed on contract.
Interviewing the administrators revealed that by implementing a health-care waste management policy at their ends, the middle level nursing administrators were aiming towards the achievement of a healthy and safe environment for their employees and communities.
There was an appointment of Sanitary Inspector in all the hospitals and Infection control nurse in Hospital I and III who were responsible for the administration of biomedical waste management in the hospital. The Infection control nurse was found to be repor ting to the head of the depar tment directly. She maintained the attendance register for all the staff detailed for the biomedical waste management in the hospital. Sanitary Inspector was reporting to the Infection control nurse. The Sanitary Inspector was found to be responsible for the proper functioning of the incinerator and the shredder as well the supervision of the waste segregation in the wards and its correct transportation to the kerb area and finally to the municipal bins, incinerator, shredder and the vermipit. In Hospital III periodic in-service education programmes were being conducted almost on monthly basis
Discussion
Florence Nightingale, pioneer of Nursing, after her first experience of hospital sepsis, wrote about the impact of poor hygienic conditions on public health in her book “Notes on Hospital.7,5 She as a pioneer brought out the impor tance of hospital hygiene in treatment of ailments and promotion of health. The main purpose of the nursing services in the three hospitals under the study was the prevention of disease, preservation and promotion of health and to provide economic and efficient health services to people. The hospitals have a responsibility to care for the environment and for public health particularly in relation to the waste they produce. By planning and implementing a health-care waste management policy by the hospital administration is a mean of achieving a healthy and safe environment for their patients, employees and community at large.
All the nursing personnel in the three hospitals were responsible in biomedical waste management their hospitals while the main responsibility was on middle level nursing staff. There was an appointment of Infection control nurse in the two hospitals to look after the biomedical waste management in the hospital. She was found to be reporting to the head of the department directly. She maintained the attendance register for all the staff detailed for the biomedical waste management in the hospital. Sanitary Inspector was to reporting to the Infection control nurse. The Sanitary Inspector is responsible for the proper functioning of the incinerator and the shredder as well the supervision of the waste segregation in the wards and its correct transportation to the kerb area and finally to the municipal bins, incinerator, shredder and the vermipit.
The knowledge of the nurses regarding biomedical waste management policies in Hospital III was found adequate followed by hospital I and least knowledge score was obtained by the nurses of Hospital II. The better knowledge of the nurses could be attributed to the fact that there was more involvement of nurses in Hospital I and III in hospital waste management by appointing infection control nurse who was responsible for HBMW policy formation, implementation and revision. Another reason for better knowledge of nurses in hospital III on HBWM was periodic in-service education programmes being conducted in the hospital, almost on monthly basis which was not being conducted in Hospital I and II.
Though nurses in Hospital II were found to have inadequate knowledge regarding waste management policies and segregation, but their knowledge of waste transpor t and disposal was found more as compared to other two hospitals. The reason for this was that in Hospital II, the nurses were responsible directly to supervise the waste transportation and its feedback to medical officer in charge of ward and were hence responsible for the same. This hospital though had a post of sanitary inspector, did not have a daily ward inspection by this sanitary inspector. Hence the waste transportation responsibility was found to be taken over by the ward nurses. In Hospital I, this role was completely taken over by sanitary inspector and hence nurses did not involve themselves in waste transport and disposal.
In Hospital III, 95.4 per cent nurses were found to have adequate knowledge and were found being assisted by sanitary JCO in hospital for waste transport Relating socio demographic profile of nurses with the knowledge on BMWM it was observed that as the duration of working in the hospital increased, the knowledge regarding biomedical waste treatment and segregation increased among the nurses in the three hospitals with Hospital I having maximum scores. It was further observed that permanently employed nurses were found to have more knowledge scores as compared to nurses employed on contract.
In any healthcare establishment, nurses and housekeeping personnel are the main groups at risk of injuries. In the present study it was found that all the nurses in the three hospitals had perceived risk from biomedical waste handling and management irrespective of their qualification or age. Nurses in Hospital III expressed less perception of risk followed by nurses in Hospital I and then nurses in Hospital II. Similar findings were stated by P Chakraborty (2006)8 who suggested that in any healthcare establishment, nurses and housekeeping personnel are the main groups at risk of injuries with annual injury rates of 10 to 20 per 1000 workers.
The nurses in Hospital III were found following correct practices as compared to other two hospitals. This was associated with their high knowledge scores regarding biomedical waste management.
The management of biomedical waste emanating from hospitals is posing a great challenge in the present-day scenario requiring active & immediate concern & considerations of the medical fraternity. The role of nurse in biomedical waste management is undisputable. Nurses are responsible for providing an environment for the patients that are free of infectious agents. Proper handling and disposal of hospital waste is also an impor tant component of strategies for prevention and control of hospital acquired infections. Nurses are involved with these strategies from the time the infective waste is generated, during its proper segregation and there after its disposal.
The study is indeed befitting with the times & matured decisions on lacunas brought out by the study urgently need to be addressed like wearing of protective apron & disposable gloves while biomedical waste handling, active involvement of Infection Control Nurse in supervision and policy making, pre- vaccination screening & Hepatitis-B vaccination among the staff members & monitoring the record, supervision of biomedical waste programme in the hospital & its documentation, conducting the orientation programme for the new staff members and organizing continuous awareness programme amongst the staff members.
Effective confinement of waste and safe handling measures provide significant health protection. It is important to incorporate the quality control measures in biomedical waste management policies to inform and educate the nurses and update their knowledge through orientation programmes and on the job training of nurses in the hospitals. The need to carry out effective on-the-job & off- the-job training cannot be emphasised enough. The nurses have to be integrated well into Hospital Waste Management programmes. Their training has to include technical knowledge as well as plan for behavioural modification. They must be motivated enough so that they can supervise & self regulate the mechanism with limited suppor t from the management / administration.
References
- Garbage-then and now. The Environmental Industries Association. Washington DC; 2006:9-11.
- Management of waste from hospitals and other healthcare establishments. Report on a WHO meeting (EURO Reports and Studies, No. 97), Copenhagen. World Health Organization Regional Office for Europe Bergen, 28 June-1 July 1983:3-8.
- inistry of Environment and Forests Notification. Bio-Medical Waste (Management and Handling) Rules New Delhi; 20th July, 1998:2.
- Christen J. Dar es Salaam Urban Health Healthcare waste management in district health facilities: situational analysis and system development. St Gallen, Switzerland, Swiss Centre for Development Cooperation in Technology and Management (SKAT); 1996:37.
- Dorothy Knowledge, Attitude and practice of nursing personnel and supportive staff in relation to universal precautions in maternity wards. 8th National Biennial Conference, Nursing Research Society of India 2003:28.
- Product information sheets: equipment for Expanded Programme on Immunization, Acute Respiratory Infections, Blood Safety, Emergency Campaigns, Primary Healthcare document WHO/EPI/LHIS/97.01. World Health Organization, Geneva, Switzerland 1997:3.
- Florence Nightingale as in Janice Rider Ellis and Celia Love Nursing in today’s world-challenges, issues, trends. publishers Lippincott Williams and Wilkins 2002:81-82. Chakraborty P. A. textbook of Microbiology. New Central Book Agency publi