According to the Centers for Disease Control and Prevention (CDC), a needlestick injury (NSI) is defined as an accidental penetrating wound to the skin caused by a hollow-bore needle or any sharp object that is contaminated with another person’s blood or body fluids (1). In contrast, a sharp injury (SI) refers more broadly to penetrating skin injuries caused by sharp instruments occurring in the healthcare setting. Both needlestick injuries and other sharps injuries represent significant occupational health and safety concerns among healthcare workers (HCWs) worldwide, as they pose substantial risk for the transmission of blood-borne pathogens, including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV), through cuts, puncture, or splashes in the workplace.

In addition to blood-borne infections, HCWs, particularly nurses, are at risk of acquiring approximately 20 other infections transmissible via needles, including tuberculosis, syphilis, and malaria (2). Globally, among an estimated 39.5 million HCWs, approximately 3 million experience NSIs annually (3). The occurance of NSIs varies across countries and is influenced by the level of economic development. In Malaysia, the reported occurrence was six NSI cases per 1,000 healthcare workers 2016 (4).

Within healthcare environments, sharp instruments such as needles and ampoules are routinely handled during daily clinical activities, posing a significant threat to the physical and psychophysical well-being of HCWs, particularly nurses. The estimated annual global risk of occupational exposure to blood-borne pathogens among HCWs ranges from 2.7–10.0% for HCV, 1.9–40% for HBV, and 0.2–0.44% for HIV (5). A study conducted in Qatar reported that operating theatres accounted for the highest proportion of NSIs (31.5%), followed by inpatient wards (21.6%), emergency departments (18%), intensive care units (8.1%), and other settings, including delivery rooms, laboratories, outpatient clinics, and ambulances (6).

Under the Occupational Safety and Health Act of 1994 (OSHA), sharp injuries are considered preventable. The Ministry of Health Malaysia (MOH) has identified NSI as a national indicator under the healthcare quality assurance programme, with a target of zero. However, studies have shown persistent unsafe practices among HCWs. For example, Bhargava, Mishra (7) reported that 37% of doctors, 19% of nurses, 31% of technicians, and 58% attendants believed that recapping or bending needles after use was acceptable, despite needle recapping being prohibited under OSHA blood-borne pathogen standards. Consequently, prompt exposure management, including the administration of post-exposure prophylaxis (PEP), crucial in reducing the risk of infection following accidental occupational exposure. Nevertheless, awareness of PEP remains suboptimal; one study reported that only 10% of HCWs were knowledgeable about PEP (8).

Recent evidence indicates that NSIs continues to occur in Malaysian healthcare settings. A study conducted in Malaysia reported that 23.6% of nurses indicated a self-reported history of needlestick injury in Selangor (4, 9). Similarly, an earlier study conducted at Hospital Canselor Tunku Muhriz, Universiti Kebangsaan Malaysia (HCTM), found that 34.9% of house officers experienced NSIs during the training period (10).

Given the significance of this occupational hazard and the limited number of studies focusing on nurses in Malaysian teaching hospitals, the present study was conducted to assess knowledge, attitudes, and practices related to needlestick injury prevention and to describe self-reported needlestick injury occurrence among nurses at a teaching hospital in Kuala Lumpur. The findings are expected to inform the development of targeted preventive strategies aimed at reducing the occurrence of such injuries. Therefore, the primary objective of this study was to assess knowledge, attitudes, and practices related to needlestick injury prevention among nurses at HCTM. A secondary objective was to describe self-reported needlestick injury occurrence within the preceding one-year period.

This study provides valuable insight into the knowledge, attitudes, and practices of nurses regarding NSI at HCTM. Of the total nursing workforce, a proportion consented to participate, resulting a modest response rate. Although this response rate may reflect time constraints or limited research engagement in research activities, the sample size was sufficient to provide meaningful overview of NSI-related issues within the hospital setting. Despite generally high levels of attitudes and practices, the continued occurrence of NSI highlights persistent occupational risks faced by nurses.

The demographic profile of respondents was largely reflective of the nursing workforce in Malaysia with women comprising the majority of participants. This gender distribution is consistent with national and international trends, where nursing remains a female-dominated professions. In term of educational background, most nurses held diploma-level qualifications, which may partly explain the moderate level of NSI-related knowledge observed. This finding contrasts with the study by Yazid et al. (11), who reported higher levels of NSI-related knowledge among nurses in another Malaysian public hospital. This discrepancy may be attributed to differences in hospital settings, exposure to training programmes, or participant characteristics. Similarly, Nawafleh et al. (12) reported poor knowledge of NSI-related topics among nursing students in Jordan, particularly regarding appropriate post-exposure management. In that study, students selected inappropriate first-aid measures, such as squeezing or applying pressure to the puncture site, rather than the recommended practice of washing the affected area under running water. Overall, variations in NSI-related knowledge across studies may be influenced by differences in educational curricula, clinical experience, and healthcare culture across countries (13).

Although most nurses demonstrated positive attitudes and appropriate safety practices, misconceptions regarding the protective role of gloves were evident. Specifically, only a minority of respondents recognised gloves as protective against NSI, which contrasts with findings by Sriram (14), where most healthcare workers were wearing gloves at the time of injury. This finding, therefore, highlights the need to strengthen education on the role of personal protective equipment in preventing NSI.

Furthermore, practice scores were significantly associated with age, gender, and educational level. Higher practice scores among nurses aged 31–40 years may reflect an optimal balance of clinical experience and physical capability. In contrast, lower scores among older nurses may be related to age-associated changes in dexterity and stamina, as previously reported by Mahmood and Hamzah (15). Supporting this observation, a study conducted in Ethiopia reported a higher occurrence of NSI among nurses with less than 5 years of experience, supporting the importance of knowledge in safe needle-handling practices (16). Conversely, nurses in the 51–60 years age group exhibited the lowest mean practice score, which may be attributed to age-related declines in physical stamina and manual dexterity (15).

In addition, gender-related differences in practice scores observed in this study align with findings by Saadeh et al. (17), suggesting that workplace safety behaviors may vary between male and female nurses. Notably, male nurses may encounter specific occupational barriers or be more exposed to risks associated with NSI. Moreover, nurses with higher educational attainment tended to demonstrate better mean practice scores, whereas those with lower educational levels showed comparatively lower scores. Overall, these results underscore the importance of implementing comprehensive NSI prevention programmes for nurses that incorporate not only training but also effective monitoring to ensure adherence to appropriate safety practices in the workplace.

Notably, the absence of significant correlations between knowledge, attitudes, and practices indicates that adequate knowledge alone does not necessarily translate into safer clinical practice. Although nurses may be aware of recommended guidelines for preventing NSI, the implementation of such knowledge in daily practice can be influenced by multiple factors, including workload, time constraints, availability of protective equipment, and institutional enforcement of safety policies (18). Emerging evidence supports this interpretation. Studies conducted in crisis-affected and high-stress healthcare settings demonstrate that psychological strain, reduced resilience, and organizational instability can undermine safe clinical practice even when knowledge and training are adequate. Aqtam et al. (19) reported that nursing students exposed to political violence exhibited lower adherence to safe clinical practices, which was associated with reduced psychological resilience and diminished perceived control within clinical settings. Similarly, studies conducted during the COVID-19 pandemic reported that increased occupational stress, moral distress, and organizational strain among intensive care nurses were associated with suboptimal safety behaviors despite prior training and professional experience (20). These findings are consistent with the results of the present study, in which no significant associations were observed between knowledge, attitudes, and practices. These findings underscore the importance of organizational and system-level interventions that move beyond education alone and incorporate continuous skills-based training and ongoing supervision to promote safe practices across healthcare settings.

Finally, the findings of this study can inform the planning of future interventions, not only at the study site but also in other hospital settings. Nevertheless, several limitations should be acknowledged. First, the response rate was modest, which may introduce selection bias. Nurses with greater awareness of occupational safety or prior experience with needlestick injuries may have been more likely to participate, potentially leading to an overestimation of knowledge and reported safety practices. Consequently, the findings should be interpreted cautiously and may not fully reflect the experiences of nurses with lower safety awareness or engagement. As such, the findings may not fully represent the broader nursing workforce at the study hospital or other healthcare settings. Second, data were self-reported and may be subject to recall and social desirability bias. Finally, the cross-sectional design limits the ability to infer temporal or causal relationships between knowledge, attitudes, practices, and injury occurrence.

This study found that nurses demonstrated moderate knowledge and relatively high attitudes and self-reported preventive practices related to needlestick injury prevention. Nevertheless, self-reported needlestick injuries were still observed among nurses at the study hospital, indicating that occupational exposure remains present despite reported awareness and compliance. These findings suggest that higher levels of knowledge and reported practice do not necessarily correspond to lower injury occurrence in a cross-sectional context. The results highlight the limitations of relying on individual-level training alone and underscore the importance of system-level approaches, including institutional safety culture, enforcement of safety policies, organizational support, and working conditions. Preventive strategies should therefore emphasize structural and organizational factors alongside continued education to support consistent implementation of safety practices across healthcare settings. Such programmes may enhance awareness of NSI hazards and ultimately reduce the risk of infection among healthcare workers and translating knowledge into sustained safe practice.