Why don’t Nurses and Clinicians routinely wash their hands
One of the most simple and effective strategies for preventing infectious diseases and nosocomical infections is the practice of hand hygiene. Despite of many controls taken in the health care centers, there is still existing non-compliance or low compliance towards the recommended hand hygiene practices in various hospitals. Promotion and compliance is a main challenge for control experts for infection and no intervention has shown consistent compliance towards the hand hygiene improvement.
A recent study has been presented by Niles and Johnson (2016) at Association for Professional in Infection Control and Epidemiology (APIC) Conference. According to the study, many health-care practitioners are sluggish towards their hand hygiene. Around 4,000 instances have been observed where practitioners, nurses or clinicians entered into a patient’s room without washing their hands. 78% of those who washed their hands did not wash them properly as demonstrated by WHO to lessen the risk of spreading infection in patients. Therefore, it highlights the existing problem that needs to be considered and taken care of.
Many methods have been proposed by various studies for increasing health hygiene compliance by clinicians and nurses, as mentioned in the literature review. Therefore, the proposed project will work towards the increase in hygiene compliance and practice by introducing a care plan and strategies for reinforcing the hand hygiene practice.
Aim of the Project
The aim of the proposed quality improvement project is to improve safety of the patients and increase the compliance towards hand hygiene on regular basis by designing and introducing a Hand Hygiene care plan.
Background, Objectives and Significance of the Project
The role of hand washing for the patient care was recognized and understood in the 19th century. Infections associated with health care are attracting a good amount of concern from the patients, governments, insurers and regulatory bodies. The reason behind the increasing concern is the recognition of the fact that these infections are preventable. The medical community is experiencing extraordinary advancements in developing an understanding of the pathogenesis involved behind these infectious diseases and the persuasive control over the use of multi-drugs for the treatment of infections in the set-ups of health care. These factors have lead to the role of the basic yet crucial health care practices in the recent health care such as enforcing strict compliance towards maintaining hand hygiene for reducing risk of infections caused through cross-transmission. A global initiative “Clean Care is Safer Care” was taken by the World Health Organization (WHO) on the safety programmes for patient to formulate and implement the required policies for basic prevention practices towards infection in the health care Centers (World Health Organization, 2009a).
The objectives of the proposed project are:
- To study the relationship between hand hygiene and infectious diseases.
- To explore the factors behind the noncompliance towards hand hygiene/hand washing on daily basis.
- To evaluate the perception of both patients and clinicians towards hand hygiene.
- To design and implement a hand hygiene care plan in consideration with those factors.
Clinical Research Question
Why don’t nurses and clinicians routinely wash their hands?
Significance of the project
The research project will be significant in contributing towards the field of health education and health care because hand hygiene has been recognized as one of the most significant elements responsible for regulating activities related to infection control. The rise in severity level of the health care associated infections (HCAIs), complexity of pathogen infections caused by overuse of multi-drug resistant (MDR) and complexity of treatment by health care practitioners (HCPs) are returning back to the traditional preventing methods for infection i.e. hand hygiene or hand washing. The method has been observed and backed up by the scientific evidence that the proper practice of hand washing alone can significantly impact on the reduction of associated risks of cross-transmission of infection in facilities provided by health care.
Resident Flora and Transient Flora
The two main groups of microorganisms located on the skin are resident flora and transient flora. Resident flora usually resides on the skins and transient floras are the contaminants on the skin responsible for cross-transmission infections and are non-removable through proper hand washing (Pittet, 2001a).
Hand hygiene consists of actions for reducing the transient floras through hand washing or using hand disinfection. Hand washing in a process of washing hands properly with medicated or unmedicated detergent and water. The purpose of hand washing is to stop cross-transmission by removing loose transient flora or dirt from the hands till arms (Pittet, 2001b).
Hand hygiene compliance
The adherence towards the practice of hand hygiene on regular basis for the prevention of health associated infections is known as Hand hygiene compliance (Abdella et al., 2014a).
Healthcare-associated infections (HCAIS) have become a continuous challenge in developing and developed countries. The Hand Hygiene practice is recognized as the most beneficial strategy for preventing these infections, but unfortunately the compliance of healthcare workers towards hand hygiene is quite poor (Gluyas, 2015). The following literature review will be exploring the factors that contribute towards the continuous challenge of noncompliance, the relationship between hand hygiene and related infections, the previous methods that have been introduced for increasing compliance towards hand hygiene and the impact of those methods.
Hand Hygiene and related Infections
Hand hygiene is a form of health care and infections caused by the poor health care have caused major health problems across the world. This is the reason why WHO has emphasized on the importance of hand hygiene. 1.4 million infections are caused by poor hand hygiene which leads to 50,000 mortality and 2 million morbidity in the developed countries annually. Reducing these infections can save cost of treatment and lower down the socio-economic burden (Lau, 2012a). Diseases like airborne illnesses, Hepatitis A, Noroviruses (Gastrointestinal) and Hand-foot-mouth disease take place due to less practice or absence of hand washing by the patients themselves. The same is applicable for the practitioners as they might be carrying some diseases themselves or treated patients with such diseases, following with treating other patient before washing hand. This is known as cross-contamination (Lau, 2012b). According to the findings from the previous research studies, hands of healthcare workers serve as the major pathway for transmission of bacteria towards the patients (Paul, Das, Dutta, Bandyopadhyay, & Banerjee, 2011). One third of the Health associated infections can be prevented through proper hand washing and hand hygiene practice, especially infections occurring due to drug-resistant Acinetobacter baumannli and methicillin-resistant Staphylococcus aureus (Chen et al., 2011a).
Health Hygiene Compliance and associated factors
Karaaslan et al. (2014) indentified 704 opportunities was health hygiene during the period of observation in neonatal and intensive care units. The overall compliance rate was found to be 37% (261/704). The compliance varied according to various roles such as 41.4% compliance was shown by nurses and 31.9% by the doctors. Both alcohol-based hand washing soap and disinfectants and waterless disinfectants were utilized and showed equal efficacy in the research study. Non-compliance towards hand hygiene was also assessed by Mahfouz, El Gamal, & Al-Azraqi (2013) in which 536 observations were collected from all the units of the hospital. 34 physicians and 179 nurses were included in these observations and the overall observed non-compliance rate was 41.0%. According to the findings, the following significant factors were observed for hand hygiene non-compliance, i.e. the events before coming in contact with the patient, being a physician and working in the intermediate care unit.
A longitudinal field study was done on more than 4,157 care givers employed in 35 different health care set-ups and experienced 13.7 million opportunities for hand hygiene. A decline in the compliance rate was found by an average estimate regression of 8.7% points from the beginning till end of usual work shift for 12 hours. The cause behind the drop rate was found to be the increase in work intensity (Dai, Milkman, Hofmann, & Staats, 2015). Abdella et al. (2014b) conducted a cross-sectional study in Gondar University Hospital by interviewing and observing 405 participants to evaluate hand hygiene compliance among health care providers and associated factors. The results showed 16.5% of compliance rate. 95% had knowledge, training and the availability of all the hand hygiene products and materials. Despite of these factors, the compliance among these health professionals turned out to be very low. A cross-sectional study in China on 137 clinicians showed 61% of non-compliance towards utilizing gloves and 40% for hand hygiene. Shortage of gloves or water was one of the factors and the ratio for it was 15% and 66% considered them to be inconvenient and unnecessary. The main risk factors were lack of knowledge and institutional support (Ji, Yin, & Chen, 2005). Factors like absence of orientation for internees (Gluck et al., 2010) and improper training of the doctors also contributed as the reason non-compliance towards hand hygiene. Compliance among trained doctors in Turkey was 82% and in trained nurses it was 76% (Teker et al., 2015). Dryness and hand irritation caused by antiseptic products also showed decrease in hand hygiene compliance (Lau, 2012c). Other than these factors, being a nursing assistant than a nurse, physician instead of nursing assistance, gender difference, and care intensity of patient and use of automated sinks also contributed towards the non-compliance (Pittet, 2001c).
Hand Hygiene Preventive measures
Hand washing was proposed as an important strategy by the US Centers for Disease Control and Prevention for reducing the risk of health care workers in cross-transmission of micro-organisms (Chen et al., 2011b). The guidelines given by the WHO on the Centers for disease control and prevention and hand hygiene in health care, instructs to observe and measure the compliance towards hand hygiene and consuming hand hygiene products (Pittet et al., 2006). According to WHO (2009a), direct observation of the health care set-ups helps in identifying the strengths and areas of improvement in opportunities for hand hygiene behavior and in evaluating techniques and feedback for the healthcare workers (HCWs). The studies mentioned above also used this method to measure the hand hygiene compliance. However, the potential bias that can occur in this method is the Hawthorne effect i.e. the tendency of the workers to behave in the favorable way to produce the expected results that they picked through observation. When the health care workers are aware that they are being observed, chances are that they will improve their performance. But the reinforcement towards the improvement cannot be guaranteed.
Outline of the project procedure
The attempt of the project will be addressing the non-compliance of hand hygiene at the chosen hospital by using PDSA (Plan, Do, Study and Act) approach for implementing and ensuring the compliance of practitioners:
Plan — The first step of the project will be to prepare and design the strategy and procedure for the successful implementation of the project. The desired objectives will be described in order to structure the implementation process. A questionnaire will be prepared to assess the existing compliance rate of hand hygiene and to determine the possible factors behind the inpractice of hand hygiene. Another questionnaire will be prepared for the phase of post-intervention where compliance rate will be determined after intervention of the hand hygiene care plan/program. The design will be based on the training sessions for the health practitioners on the way of proper hand washing as instructed in the “WHO Guidelines on Hand Hygiene in Health Care” (World Health Organization, 2009b).
Do — The project will be carried out by approaching the relevant authorities for the approval to conduct the desired project in the chosen hospital. A passionate and devoted team will be prepared for conducting the project into three phases. The first phase will be the Pre-intervention phase in which the observations will be collected based on the existing hand hygiene practice and the first survey questionnaire will be provided to all the health care practitioners in the host hospital. The second phase will be the Intervention Phase which will be based on the promotion and hand washing and hygiene training sessions.
Study — The procedure will be evaluated and the findings before the intervention will be compared with the findings after the intervention in the third phase i.e. Post-intervention phase. The effect of the intervention will be evaluated by carrying out the second survey and secret monitoring. Also, the strengths and pitfalls of the project procedure will be studied.
Act — The authority will be requested to order recent organic hand hygiene supplements and products for encouraging the use of hand washing. A penalty chart will be prepared and supervised by the assigned resident or attendant to monitor the practice and negative consequences will be faced by the non compliant practitioners. A token of appreciation and picnic will be planned for the compliant practitioners.
Abdella, N., Tefera, M. A., Eredie, A. E., Landers, T. F., Malefia, Y. D., & Alene, K. (2014a). Hand hygiene compliance and associated factors among health care providers in Gondar university hospital, Gondar, North West Ethiopia. BMC Public Health, 14(1), 96. doi:10.1186/1471-2458-14-96
Abdella, N., Tefera, M. A., Eredie, A. E., Landers, T. F., Malefia, Y. D., & Alene, K. (2014b). Hand hygiene compliance and associated factors among health care providers in Gondar university hospital, Gondar, North West Ethiopia. BMC Public Health, 14(1), 96. doi:10.1186/1471-2458-14-96
Chen, Y.-C., Sheng, W.-H., Wang, J.-T., Chang, S.-C., Lin, H.-C., Tien, K.-L., Hsu, L.-Y., & Tsai, K.-S. (2011a). Effectiveness and limitations of hand hygiene promotion on decreasing Healthcare–Associated infections. PLoS ONE, 6(11), e27163. doi:10.1371/journal.pone.0027163
Chen, Y.-C., Sheng, W.-H., Wang, J.-T., Chang, S.-C., Lin, H.-C., Tien, K.-L., Hsu, L.-Y., & Tsai, K.-S. (2011b). Effectiveness and limitations of hand hygiene promotion on decreasing Healthcare–Associated infections. PLoS ONE, 6(11), e27163. doi:10.1371/journal.pone.0027163
Dai, H., Milkman, K. L., Hofmann, D. A., & Staats, B. R. (2015). The impact of time at work and time off from work on rule compliance: The case of hand hygiene in health care. Journal of Applied Psychology, 100(3), 846–862. doi:10.1037/a0038067
Gluck, P. A., Nevo, I., Lenchus, J. D., Sanko, J. S., Everett-Thomas, R., Fitzpatrick, M., … Birnbach, D. J. (2010). Factors Impacting hand hygiene compliance among new interns: Findings from a mandatory patient safety course. Journal of Graduate Medical Education, 2(2), 228–231. doi:10.4300/jgme-d-09-00106.1
Gluyas, H. (2015). Understanding non-compliance with hand hygiene practices. Nursing Standard, 29(35), 40–46. doi:10.7748/ns.29.35.40.e9929
Ji, G., Yin, H., & Chen, Y. (2005). Prevalence of and risk factors for non-compliance with glove utilization and hand hygiene among obstetrics and gynaecology workers in rural china. Journal of Hospital Infection, 59(3), 235–241. doi:10.1016/j.jhin.2004.09.027
Karaaslan, A., Kepenekli Kadayifci, E., Atıcı, S., Sili, U., Soysal, A., Çulha, G., Bakır, M. (2014). Compliance of healthcare workers with hand hygiene practices in neonatal and pediatric intensive care units: Overt observation. Interdisciplinary Perspectives on Infectious Diseases, 2014, 1–5. doi:10.1155/2014/306478
Lau, C. (2012a). Factors affecting hand hygiene compliance in intensive care units. Retrieved from http://hub.hku.hk/bitstream/10722/179908/1/FullText.pdf?accept=1
Lau, C. (2012b). Factors affecting hand hygiene compliance in intensive care units. Retrieved from http://hub.hku.hk/bitstream/10722/179908/1/FullText.pdf?accept=1
Mahfouz, A. A., El Gamal, M. N., & Al-Azraqi, T. A. (2013). Hand hygiene non-compliance among intensive care unit health care workers in Aseer central hospital, south-western Saudi Arabia. International Journal of Infectious Diseases, 17(9), e729–e732. doi:10.1016/j.ijid.2013.02.025
Niles, M., & Johnson, N. (2016). Hawthorne effect in hand hygiene compliance rates. American Journal of Infection Control, 44(6), S28–S29. doi:10.1016/j.ajic.2016.04.190
Paul, R., Das, N., Dutta, R., Bandyopadhyay, R., & Banerjee, A. (2011). Bacterial contamination of the hands of doctors: A study in the medicine and dermatology wards. Indian Journal of Dermatology, Venereology, and Leprology, 77(3), 307. doi:10.4103/0378-6323.79700
Pittet, D. (2001a). Improving adherence to hand hygiene practice: A Multidisciplinary approach. Emerging Infectious Diseases, 7(2), 234–240. doi:10.3201/eid0702.010217
Pittet, D. (2001b). Improving adherence to hand hygiene practice: A Multidisciplinary approach. Emerging Infectious Diseases, 7(2), 234–240. doi:10.3201/eid0702.010217
Pittet, D. (2001c). Improving adherence to hand hygiene practice: A Multidisciplinary approach. Emerging Infectious Diseases, 7(2), 234–240. doi:10.3201/eid0702.010217
Pittet, D., Allegranzi, B., Sax, H., Dharan, S., Pessoa-Silva, C. L., Donaldson, L., & Boyce, J. M. (2006). Evidence-based model for hand transmission during patient care and the role of improved practices. The Lancet Infectious Diseases, 6(10), 641–652. doi:10.1016/s1473-3099(06)70600-4
Teker, B., Ogutlu, A., Gozdas, H. T., Ruayercan, S., Hacialioglu, G., & Karabay, O. (2015). Factors affecting hand hygiene adherence at a private hospital in turkey. The Eurasian Journal of Medicine, 47(3), 208–212. doi:10.5152/eurasianjmed.2015.78
World Health Organization. (2009a). WHO guidelines on hand hygiene in health care First global patient safety challenge clean care is safer care. Retrieved from http://apps.who.int/iris/bitstream/10665/44102/1/9789241597906_eng.pdf
World Health Organization. (2009b). WHO guidelines on hand hygiene in health care First global patient safety challenge clean care is safer care. Retrieved from http://apps.who.int/iris/bitstream/10665/44102/1/9789241597906_eng.pdf