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J Dent Educ. 70(10): 1081-1088 2006
© 2006 American Dental Education Association
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Milieu in Dental School and Practice

Student Occupational Exposure Incidence: Perception Versus Reality

A. Jeffrey Wood, D.D.S.; Nader A. Nadershahi, D.D.S., M.B.A.; Richard E. Fredekind, D.D.S., M.A.; Eve J. Cuny, M.S.; David W. Chambers, Ed.M., M.B.A., Ph.D.

Key words: occupational exposures, self-reports, needlesticks, dental clinics

Submitted for publication 04/04/06; accepted 07/31/06


   Abstract
Top
 Abstract
Methods and Materials
 Results
 Discussion
 Conclusions
 References
 
Reports of clinical injuries made to a dental school Office of Occupational Health and Safety at the time of their occurrence were compared to self-reports on a survey for dental students in five classes at various times over their educational careers. The majority of injuries were from needlesticks and mishaps with hand instruments. Underreporting at the time of injury was approximately one-third in the first clinical year and one-half in the final clinical year of the three-year program. Students reported a greater perceived likelihood of injury later in their education than at the beginning but a decreased fear of such injuries. Female students reported more needlesticks and a greater fear of injury than did male students. It is hypothesized that a personal interpretation of the meaning of clinical injuries influences reporting behavior.

Numerous published reports have examined occupational injuries in dental health care settings across different provider populations. Surveillance studies on practicing dentists,1–7 school-based dental health care workers (DHCW),8–20 and armed services personnel21 have been reported over the past ten years. The findings from these studies indicate a continuing problem in the profession.

Occupational injuries have been categorized based on who was injured,2,3,5,8,11,13,18 where the injury occurred,8,18 the type of exposure,2,13 the instrument in use at the time of the injury,2–5,7,8,13,18 the exposure incident rate,2,4,5,7,9,11,13,19 the anatomical location of the injury on the DHCW,4,5,7,8,13,18 the providers’ hepatitis B virus (HBV) immunity,8,18,19 and the source patient health status.2,13,18

There is, however, relatively little information about DHCWs’ perceptions of risk related to these injuries. Burke et al. found that negative perceptions correlated with increased stress and can have significant effects on the practitioner, including premature retirement.22 Klewer et al. analyzed data on health care students regarding the risk of HIV infection in different clinical situations.23 They found that student assessments were similar to the national prevalence of HIV and the number of daily contacts with HIV patients. Waddell examined the perceived risk of contacting HIV among Australian hygienists and dentists and found a change in behavior in those practitioners with a high perceived risk factor.24

DHCWs may have certain perceptions about occupational injury risk based on the likelihood of an untoward outcome (seroconversion) from such an injury. While the actual risk of an occupational exposure varies,2,4,5,7,9,11,13,19 the risk of HIV seroconversion remains very small in dentistry.25,26 With the advent of the hepatitis B vaccine, the risk of HBV seroconversion is effectively zero for those practitioners with appropriate blood titers. Hepatitis C has no vaccine as yet so remains a concern for those who receive an occupational exposure;27 however, its seroconversion rate is much lower than HBV.28 Importantly, following recommended infection control procedures and vaccination protocols provides a safe environment for both patients and DHCWs.24–26

Unfortunately, health care workers do not always follow these recommendations. Sulzbach-Hoke found noncompliance for many reasons including habit, forgetfulness, influence of managers, and perceptions that barrier precautions hinder performance.29 Sandman identified a number of additional reasons for noncompliance (therefore increasing risk), including the notion that "it can’t happen to me," ignorance of precautions, being uncomfortable with change, and cultural differences.30 Treanor commented that health care workers are exposed to significant risks by the very nature of their profession, some of which are obvious, unrecognized, or underestimated.31 These risks can then raise moral dilemmas for the health care worker and increase stress, which may impact behavior with patients, judgment, or decision making.31,32

This study was conducted to examine the perceptions of risk for occupational injuries among dental students and to examine these perceptions in light of demographic variables and students’ actual exposure to injuries. It is hypothesized that personal experience with occupational injuries in the dental clinical context explains only part of students’ perceptions of the likelihood and seriousness of occupational injuries. By discovering more about their perceptions, we may be able to adjust our training to better align students’ perceptions of risk, so that their behavior, judgment, and decision making are not negatively influenced.


   Methods and Materials
Top
 Abstract
 Methods and Materials
Results
 Discussion
 Conclusions
 References
 
This project was conducted among undergraduate dental students attending a U.S. school of dentistry. The school is located in an urban setting, in a city that has the fourth highest prevalence in the United States of HIV infection among its inhabitants. The dental school draws a diverse cultural and socioeconomic patient population, primarily from the city where the school is located.

The dental school has approximately 440 predoctoral dental students enrolled in a three-year curriculum. Students in the International Dental Studies program did not participate in this study. The participating students have clinical involvement in all three years, with increasing involvement in their second and third years. The student population comes from across the country, with approximately 80 percent of enrolled students being residents of the state in which the school is located.

An eight-page survey was used to collect information on actual exposure incidents reported by students and others at the dental school. The form was developed at our institution in cooperation with the Training for Development and Innovative Design Technology (TDICT) project and was funded by a cooperative Centers for Disease Control and Prevention/National Institute for Occupational Safety and Health (CDC/NIOSH) grant.

Exposed individuals are instructed to report to a trained exposure incident responder, who interviews the exposed student to ensure consistency in the survey answers. The form also serves as an Occupational Safety and Health Administration (OSHA)-required sharps injury log and provides vital information to the medical professional who provides follow-up counseling and care.

A one-page, seven-item survey instrument was developed to assess students’ perceptions of their risk for dental injuries, whether these were reported or not. The survey instrument was reviewed for clarity by a small group of students, with representatives from each of the three classes being surveyed, prior to distribution. The survey was then distributed to all students in various classes as outlined in Table 1Go. Responses were anonymous. Nonresponding individuals were not resurveyed.


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  		Table 1. Sampling plan and surveys received for study of dental clinic occupational injuries
 
These surveys were distributed to students in the first week of summer quarter (July) of 2002, 2003, and 2004 and collected on the same day they were distributed. Additionally, the survey was distributed to the senior class just before their graduation (May) in 2005 and collected on the day of distribution. Data collected at matriculation are referred to as Year 0; data collected at the end of the first year are designated Year 1; etc.

The survey asked for self-reports on the following: a) demographic information for each respondent, including previous experience working in a dental setting; b) personal history of occupational exposure; c) respondents’ perceived likelihood that various devices could result in an exposure event—measured as "not likely," "somewhat likely," or "very likely"; and d) respondents’ fear of injuring themselves, various types of patients, and others in the delivery setting—measured as "not fearful," "somewhat fearful," and "very fearful."

Category coding rubrics were developed for the two open-ended questions. Experience working in dental offices before dental school was coded as a) chairside assisting, b) laboratory work, c) clerical positions, d) dental hygienist, and e) sterilization work. A dichotomous category (any experience/no experience) was also used. Survey form self-reports of previous injuries in dental school were categorized using the same set of sources available to respondents on the part of the form where perceived likelihood of injury was reported: a) dental hand instrument, b) syringe needlestick, c) scalpel, d) endodontics file, e) other hand instrument (curette, explorer, etc.), and f) suture needle.

Access databases for reports of actual incidents and for survey results were transferred to the SPSS files for statistical analysis and inspected for completeness and irregularity in recording. Preliminary analysis of basic statistical properties was conducted using frequency distributions and correlation matrices. Tests of hypotheses included t-tests, ANOVA, chi square, and correlation coefficients, depending on the properties of the variables involved. Higher-level exploratory analysis of potential reasons for differences between actual and perceived fear were conducted using factor analysis and multiple regression models.

Because individual identity of actual reported injuries is protected by privacy policy and survey self-reports were anonymous, it is not possible to analyze these data on an individual basis. Rather, cohort comparisons were made. Where comparisons were made between reports of actual events and self-reports on the survey, data were expressed as proportions of the appropriate samples.


   Results
Top
 Abstract
 Methods and Materials
 Results
Discussion
 Conclusions
 References
 
A total of 1,281 usable survey forms were available for analysis. This represents 92 percent of the number of surveys distributed. The number of surveys across classes is shown in Table 1Go. The design of the study presents two statistical challenges. First, only one class, the Class of 2005, was measured at all four points in their educational careers. There is a potential that years of experience and time in history are confounded. For all of the results reported below, preliminary two-way ANOVAs failed to reveal class-by-year interactions. Secondly, most of the students answering the survey in their first year also provided data in subsequent years; multiple measures are another potential confounding effect. Repeated measures ANOVAs were also performed, and they do not reveal any differences from the traditional reports. Inspections of frequencies and the correlation matrices revealed no cases of extreme skew or other characteristics that would vitiate the assumptions of the statistical tests used. Thus, traditional statistical analyses are reported below in order to make the results more widely understood.

Reports of actual incidents were taken from the files of the director of occupational health and safety. The potential exists that these represent an underreporting of actual incidents.

Reported Incidents
This section presents data on incidents reported at the time of their occurrence. Table 2Go displays reported incidents by source of injury subdivided by year in the curriculum and by gender. Year 2 data refer to average incident per student in the first clinical year of the curriculum (a combination of the Classes of 2003, 2004, and 2005); Year 3 refers to the average incidents for students in their third and final clinical year (Class of 2005 only). There were no injuries for Year 0 (prematriculation) and only two injuries in Year 1 (the first year of the dental program).


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  		Table 2. Incidents reported by percentage of class at the time of occurrence categorized by source of incident, clinical year, and gender
 
Hand instruments accounted for injuries to 12.2 percent of students, with about 43 percent of these injuries occurring in the third year (combining second- and third-year incidents). Eight percent of injuries reported at the time they occurred were attributed to needlesticks, and 41.3 percent of the needlesticks occurred in the third year. (Chi square analysis, collapsing scalpel, suture, and endodontics instruments into an "other" category, confirmed that this interaction between type of injury and clinical year was significant at 2=9.39, df=3, p<.02.) Students were 1.7 times as likely to report an incident during the third year of the program (p<.01 by the test for differences in proportions). Generally, students perform slightly more than twice as many clinical procedures during the final year of their program as they do in the preceding year.

There were no statistically significant differences by gender across source of injury. Female students were more likely to report needlestick injuries during the first clinical year (p<.05 by the test for differences in proportions).

Survey Results
This section reports results from the survey, as summarized in Table 3Go. One-way ANOVA tests were performed across rows in Table 3Go, and the results of these tests are reported in the p-value column.


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  		Table 3. Survey results of demographic, self-reported actual incidents, estimated likelihood of incidents, and fear of injuring various parties by source of injury, year in program, and gender
 
The average perceived likelihood is the average of ratings across the six noted sources of injury. On entering school (Year 0) and at beginning of clinic (Year 1), the average was between "not likely" and "somewhat likely." It rose during the first clinic year and reached a level of "somewhat likely" by graduation (Year 3).

Students entered dental school with their greatest fear being injury from burs, and by graduation, the greatest fear was from needlestick injuries. Female students were more likely to perceive risk from each source. The magnitude of effect is approximately 25 percent of the standard deviation. There was no interaction between gender and years of experience.

Incidence of injury increased with clinical opportunity. Males were slightly more likely to report having experienced a bur injury, and female students were slightly more likely to report having experienced a needlestick.

Average fear of injury remained constant through the first two years between "not fearful" and "somewhat fearful" and then declined by graduation closer to "not fearful." Initial fear of injuring patients decreased with experience and was replaced by fear of injuring oneself as the primary concern at graduation. Women were significantly more fearful of injury across the board: across years (no interaction) and across type of person injured. The magnitude of effect is large—approximately 50 percent of the standard deviation.

Male respondents were older and more likely to have had relatives who are dentists; female respondents were more likely to have worked in a dental setting prior to matriculation and worked longer.

Comparison Between Reported and Survey Incidents
Table 4Go shows a comparison between incidents reported at the time of their occurrence and incidents reported on the survey. Table entries are expressed as average incident per student. Raw numbers are found in preceding tables. Differences in subsample sizes makes actual numbers difficult to interpret for the following comparisons.


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  		Table 4. Average percentage of incidents reported at the time of occurrence and indicated on survey categorized by source of incident and clinical year
 
Students reported significantly more incidents on the survey than at the time of the incident occurring. For Year 2, 1.77 times as many incidents were reported on the survey (p<.001 by the test for differences in proportions). For Year 3, 2.01 times as many incidents were reported on the survey (p<.001). Injuries involving hand instruments are most likely to be underreported at the time of their occurrence in both the second and third years; needlesticks were also likely to be underreported, especially in the third year.

These trends are graphed in Figure 1Go.


Figure 1
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  		Figure 1. Injuries reported at the time of their occurrence and on a survey in the second year of the clinical program, by source of injury

 

   Discussion
Top
 Abstract
 Methods and Materials
 Results
 Discussion
Conclusions
 References
 
This dataset involving surveys and records of reported clinical injuries from four classes of dental students permits comparison of objective and perceived occurrence, likelihood of occurrence, and fear related to occurrence of exposures. Ten percent of students reported an injury of some type during their first two clinical years; 17 percent reported an occurrence during their final year. Eighty-five percent of the injuries reported in the first clinical year were from syringe needles and hand instruments (in roughly equal proportions); in the final year, 50 percent of injuries were from these sources. Needle-sticks dropped from being half of the injuries in the first clinical year to being approximately 20 percent in the final year. Although there were more injuries reported in the final year, students were actually safer: 1.7 times the injuries with more than twice the opportunities.

Students entered this dental school feeling that the likelihood of clinical injuries was between "not likely" and "somewhat likely" and graduated feeling that they were "somewhat likely." Needlesticks and injuries involving hand instruments and burs were judged most likely. This pattern reflected reports of injuries on the survey form.

Although it was not possible to compare reports at the time of injury with survey reports on an individual basis, aggregate class comparisons showed a tendency toward underreporting of injuries at the time of their occurrence. It is estimated that 33 percent of actual injuries are not reported in the first clinical year and 50 percent are not reported in the final clinical year. Hand instrument injuries were likely to be underreported in both years and needlestick injuries underreported in the final year.

Students entered this school reporting that they were between "not fearful" and "somewhat fearful" of clinical exposures. By graduation, they were, on average, "not fearful." Thus, while students increased their estimate of the likelihood of exposure, they simultaneously decreased their fear of such incidents. This may contribute to the observed tendency to underreport injuries, especially in the final clinical year. Students entered the program being most concerned about injuring patients; they left being more fearful of injuring themselves.

Self-reported dental experience prior to dental school and having relatives who are dentists were not associated with survey reports of estimated likelihood or fear of various types of injuries. Gender was, however, a predictor of both survey results and reports of injuries at the time of their occurrence. Although there was no difference between genders for incidents reported at the time of their occurrence, female students were marginally more likely to report on the survey that they had experienced a needlestick, and they reported a greater perceived likelihood of an exposure from all sources of potential injury. They also reported a significantly greater fear of injuring themselves and others. These findings are consistent with previously published studies.33–35

From the comparison of records of reported occurrences with survey self-reports, it is apparent that some combination of factors, as yet not understood, intercedes between clinical events and their identification and management in the formal occupational safety program of a dental school. It is likely that among the factors is a psychological construct involving "fear of occupational exposure." From one-third to one-half of events are reported, and the likelihood of reporting decreases with clinical experience. Students are actually less likely to experience an event as they gain clinical experience (corrected for opportunity), but they report being somewhat more likely to have such an occurrence. At the same time, their fear of such events declines. It appears that there is a subjective overlay of interpretation that modifies the objective clinical experience involving injuries. There appear to be gender differences in this interpretive overlay, with female dental students retaining a greater fear of injury. The fact that female students, especially in the first clinical year, are more likely to report a needlestick at the time of its occurrence may be due to their experiencing more such injuries or to their having a greater fear of them—or both.

The constituents of "fear of occupational exposure" in the dental clinical context should be explored in further research.


   Conclusions
Top
 Abstract
 Methods and Materials
 Results
 Discussion
 Conclusions
References
 
By comparing survey perceptions of clinical injury exposures with reports made at the time of injury to the office where they are managed, it is possible to estimate that students in a dental education program underreport incidents by 33 to 50 percent. By comparing survey results across years, it appears that students increase their perception of the likelihood of injury while decreasing their perception of fear associated with such injuries. Female students are more likely to report fear of injury, especially of needlesticks, and concern shifts during the education program from fear of injuring patients to injuring oneself. Further research is needed to understand the role of personal interpretation of the significance of injury in actual likelihood of injury and in the reporting of such injuries.


Figure 2
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  		Figure 2. Injuries reported at the time of their occurrence and on a survey in the third year of the clinical program, by source of injury

 

   Acknowledgments
 
The survey instrument used by the school on actual exposure incidents was developed in cooperation with the Training for Development and Innovative Design Technology (TDICT) project and was funded by a cooperative CDC/NIOSH grant.


   Footnotes
 
Dr. Wood is Chair, Department of Pediatric Dentistry; Dr. Nadershahi is Chair, Department of Dental Practice and Community Services; Dr. Fredekind is Associate Dean for Clinic Services; Ms. Cuny is Director, Environmental Health and Safety; and Dr. Chambers is Associate Dean for Academic Affairs and Scholarship—all at the University of the Pacific, Arthur A. Dugoni School of Dentistry. Direct correspondence and requests for reprints to Dr. A. Jeffrey Wood, Arthur A. Dugoni School of Dentistry, University of the Pacific, 2155 Webster Street, San Francisco, CA 94115; 415-929-6557 phone; jwood{at}pacific.edu.


   REFERENCES
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 Abstract
 Methods and Materials
 Results
 Discussion
 Conclusions
 References
 

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