Counselling · Intermediate · Infectious Diseases

Needlestick Injury in a Hospital Nurse

Practise this PLAB 2 counselling station on Needlestick Injury. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in the occupational health department. You are seeing Miss Eve Payne, a 31-year-old registered nurse who sustained a needlestick injury at work one hour ago. She is anxious and wants immediate advice and management. Please counsel her on the immediate management, blood-borne virus testing protocols, and post-exposure prophylaxis options.

Background notes: PMH: Fit and well, Non-smoker, Social drinker, Regular exercise

What this station tests

  • Time-critical PEP initiation: HIV PEP within 1 hour ideally, no later than 72 hours
  • Risk assessment: hollow-bore needle, percutaneous, visible blood as higher-risk features
  • Source patient testing: urgent BBV testing (HIV, hepatitis B, hepatitis C) with consent
  • Hepatitis B post-exposure management: depends on vaccination status and anti-HBs level
  • Quantifying HIV risk: 0.3% per percutaneous needlestick from HIV-positive source, further reduced by PEP

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, establish what patient already knows and understands.
  • 1-3 min — Explain Condition: Explain diagnosis or condition using chunk-and-check technique. Use simple language, avoid jargon.
  • 3-5 min — Management Options: Discuss treatment options. Shared decision-making. Risks, benefits, alternatives.
  • 5-7 min — Address Concerns: Explore and address specific concerns. Check understanding. Discuss lifestyle implications.
  • 7-8 min — Closing: Summarise agreed plan. Safety netting. Arrange follow-up. Written information offer.

Consultation approach

The opening

Needlestick injury management is time-critical: HIV PEP must be started within 72 hours (ideally within 1 hour) if indicated. The candidate must assess risk, provide immediate management, and address the nurse's anxiety. Eve is 31, an RN, sustained a needlestick 1 hour ago during venepuncture. She is anxious. Open with: 'Eve, I know this is very stressful. Let me help you through the process step by step.'

Core approach

Immediate wound care should already be done: bleeding encouraged (not squeezed), washed under running water, dressed. Confirm this has happened.

Risk assessment. Source patient: elderly patient admitted with sepsis, blood-borne virus status unknown. The source patient needs urgent BBV testing (HIV, hepatitis B, hepatitis C) with their consent. If the source patient is known positive for HIV, PEP is indicated. If unknown: risk assessment based on prevalence and nature of exposure.

Nature of exposure. Hollow-bore needle (higher risk than solid needle). Percutaneous injury (needle through skin, the highest risk category). Visible blood on the needle? (Increases risk.) This is a significant exposure. HIV transmission risk from a single percutaneous needlestick from an HIV-positive source is approximately 0.3%.

Eve's BBV status: is she vaccinated against hepatitis B? (Most healthcare workers are.) Check her anti-HBs level (should be >10 mIU/mL for adequate protection). Her HIV and hepatitis C status will need baseline testing.

Closing and safety netting

Immediate actions. Source patient BBV testing (with consent). Eve's baseline bloods: HIV, hepatitis B surface antigen, hepatitis B surface antibody, hepatitis C antibody, liver function tests, FBC. If HIV PEP is indicated (source HIV-positive or high-risk unknown): start within 1 hour ideally, no later than 72 hours. PEP regimen: typically a 28-day course of triple antiretroviral therapy.

Hepatitis B: if she is vaccinated with adequate anti-HBs (>10), no action needed. If inadequate response or unvaccinated: hepatitis B immunoglobulin plus booster. Hepatitis C: no PEP available, monitor with repeat testing at 6 weeks, 12 weeks, and 6 months.

Address her anxiety. 'The risk of HIV transmission from a single needlestick is about 1 in 300, and with PEP it is reduced further. We are acting quickly to minimise the risk.' Complete an incident report (Datix). Offer occupational health follow-up and psychological support. Safety net: follow-up BBV testing at 6 weeks, 12 weeks, and 6 months.

How examiners mark this station

Examiners will assess your ability to explain needlestick injury and its management in a patient-centred way. Domain 2 (Clinical Management) and Domain 3 (Interpersonal Skills) are equally weighted and primary. Expect marks for accurate information delivery, shared decision-making, chunk-and-check technique, and addressing the patient's specific concerns. Domain 1 (Data Gathering) is assessed through how well you establish the patient's baseline understanding and elicit their concerns.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Wound care confirmed. Exposure characterised (hollow-bore, percutaneous). Source patient status assessed. Eve's vaccination status checked. Baseline bloods planned.

Costs marks: Not characterising the exposure. Not checking source patient. Not checking hepatitis B vaccination.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: PEP timing understood (within 1 hour). Source patient testing arranged. Baseline bloods for Eve. Hepatitis B management based on vaccination status. Incident report completed. Follow-up BBV testing schedule.

Costs marks: Not mentioning PEP timing. No source testing. No incident report. No follow-up schedule.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Acknowledging her anxiety immediately. Quantifying the risk proportionately (1 in 300). Structured step-by-step approach reduces panic. Offering psychological support.

Costs marks: Dismissing her anxiety. Being alarmist. Disorganised approach increasing her panic.

Common examiner feedback (and how to fix it)

Did not provide adequate explanation or plan to the patient

Fix: Use chunk-and-check: deliver one concept, check understanding, then move to the next. Offer all relevant treatment options with risks and benefits before helping the patient decide.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: Before and during counselling, explicitly ask what concerns the patient most. Respond to emotional cues with empathic statements before continuing with information.

Common mistakes in this station

  1. Delaying PEP consideration. HIV PEP is most effective within the first hour. Candidates who complete a thorough risk assessment but do not mention the time pressure for PEP initiation miss the urgency.
  2. Not testing the source patient. The source patient's BBV status determines the management pathway. Candidates who manage the injury without mentioning source patient testing cannot complete the risk assessment.
  3. Not completing an incident report. Needlestick injuries require formal documentation (Datix) for occupational health, medicolegal, and governance purposes. Candidates who manage clinically without mentioning incident reporting miss a professional requirement.

Resitting PLAB 2?

If counselling stations have been a challenge, the most common issue is information overload: delivering too much clinical detail without checking understanding. Practise the chunk-and-check technique until it becomes automatic. Remember that shared decision-making, not lecturing, is what scores highly in Domain 3.

Example opening

Hello, my name is Dr [Name]. I understand you've come in today to discuss [topic]. Before I explain things, could you tell me what you've been told so far, so I know where to start?

Frequently asked questions

How should I approach needlestick injury counselling in this PLAB 2 station?

Needlestick injury management is time-critical: HIV PEP must be started within 72 hours (ideally within 1 hour) if indicated. The candidate must assess risk, provide immediate management, and address the nurse's anxiety. Eve is 31, an RN, sustained a needlestick 1 hour ago during venepuncture.

What are examiners marking in this needlestick injury station?

Marks are won for: Wound care confirmed. Exposure characterised (hollow-bore, percutaneous). Source patient status assessed. Eve's vaccination status checked. Baseline bloods planned. Marks are lost for: Not characterising the exposure. Not checking source patient. Not checking hepatitis B vaccination.

What is the most common mistake candidates make in this needlestick injury station?

Delaying PEP consideration. HIV PEP is most effective within the first hour. Candidates who complete a thorough risk assessment but do not mention the time pressure for PEP initiation miss the urgency.

How do I prepare for this station if I have not managed needlestick injury in clinical practice?

This station rewards process over personal experience. The skill being assessed: Risk assessment: hollow-bore needle, percutaneous, visible blood as higher-risk features. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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