Hand Hygiene Compliance as a Practice Change

Healthcare Problem

Hospital-acquired infections (HAIs) constitute a serious problem in many healthcare organizations. They lower the quality of care for patients and expose visitors to life-threatening outcomes, complications, and unscheduled readmissions (Goldberg, 2017). This issue is closely connected to medical professionals’ adherence to hand hygiene practices described and suggested by the World Health Organization (WHO) as necessary (Desai, Rezmovitz, Manson, Callery, & Vearncombe, 2017; Karaoglu & Akin, 2018). An infection can be classified as an HAI if it is acquired during one’s stay at the hospital, including conditions that became evident after this person’s discharge (Uneke et al., 2014). These infections can not only lead to patients returning to the facility but also developing other conditions which may further complicate their path to recovery. In developing countries, the rate of HAIs can be exceptionally high, thus lowering the reliability of hospitals and increasing mortality rates (Phan et al., 2018).

Significance of Problem

It is vital for healthcare facilities to address HAIs in order to improve their quality of care. Moreover, the introduction of practice changes also reduces financial burdens closely connected to patients’ readmissions. Hospitals to which clients return regularly with developed HAIs have to care for the same individuals multiple times, spending additional resources or medicine and delegating staff, thus increasing their workload (Phan et al., 2018). Moreover, this problem needs to be addressed in countries with lower financial capabilities that cannot support medical facilities requiring these expenditures. As the rate of HAIs can be reduced with the help of interventions, it is essential for such organizations to implement new programs in order to help medical workers to provide and patients to receive better care.

Current Practice

Current practices for HAIs prevention are based on hand hygiene (HH), although they may vary from one facility to another. In organizations with improved processes, HH practices are encouraged and supported by the staff and patients as well. However, in developing countries and some clinics, workers and visitors can undervalue HH as a crucial part of healthcare. According to Phan et al., (2018), HH compliance in such hospitals is not appropriately maintained to ensure its high rates, often falling below the standard score outlined by the WHO. The current practice in these facilities may not include any of the suggested guidelines. For example, nurses and physicians may wash their hands only sometimes or use any type of soap. Some of them also wear rings or bracelets and have long painted nails. This lack of knowledge, as well as the absence of explicit and enforced rules, exacerbates the issue and decreases the rate of compliance for all specialists.

Impact on Background

The lack of HH education and high rates of HAIs have a significant effect on organizational culture in healthcare organizations. Workers who do not receive training about the importance of hygiene do not fully comprehend its role in providing care. As Salmon and McLaws (2015) note, nurses in such hospitals believe that HH is not required if they wear gloves. Furthermore, they base their hand washing activities not on clients’ safety but on their own fear of acquiring an infection. This focus misrepresents the core function of healthcare which needs to be patient-centered and holistic. Thus, the organizational culture in such facilities is further damaged as a result. Nurses and doctors who do not engage in regular and proper HH misunderstand the purpose of such procedures, dismiss the needs and rights of visitors, and fail to adhere to the guidelines highlighted by international organizations.

Medical professionals’ behavior in these situations also affects the way patients view their daily hygiene. If nurses and doctors do not demonstrate proper practices for hand washing and antisepsis, then they cannot expect their clients to adhere to these activities after discharge. Thus, patients’ self-care and health-related knowledge suffer as a result. They may infect other visitors while in a hospital or transfer the infection to their friends and loved ones. Moreover, the spread of diseases may be further increased if both the staff and patients continue to ignore the significance of hand hygiene.

PICO Table

P (Population/Problem) Patients/Hospital acquired infections (HAIs)
I (Intervention) Hand hygiene educational program for healthcare workers
C (Comparison) No specialized educational program
O (Outcome) Reduced rates of hospital acquired infections (HAIs)

PICO Question

Among patients, does an educational program about hand hygiene for medical workers, as compared to no specialized training, lower the rate of hospital acquired infections?

Number and Types of Articles

Using the mentioned above keywords, a number of articles were reviewed to address the PICO question. In total, more than 10.000 items came up as a result for searching the PubMed database. From these articles, 25 were reviewed to determine the most suitable research and non-research evidence. Among the chosen selection of literature, ten studies were concerned with qualitative aspects of hand hygiene. Scholars were mostly interested in nurses’ opinions about educational programs, attitude towards established standards, possible barriers to implementing new projects, and solutions to the outlined problems. Moreover, seven intervention-type studies focused on practice change were reviewed in the process. More specifically, they addressed the improvement of these rates and workers’ compliance. Next, three studies with a quasi-experimental design were located. Other studies were concerned with quality improvement (QI) assessment and guidelines’ descriptions. For example, three articles were developed as QI researches focused on visitor surveys. These evaluations revealed patients’ attitude towards HH practices and connected nurses and doctors’ behavior to quality of care, health outcomes, and their overall satisfaction with services. Finally, two guidelines’ implementation descriptions were considered for this research.

Research and Non-Research Evidence

The first discussed source is a non-research article which describes HH guidelines and presents an example of their implementation in a healthcare setting. Goldberg (2017) argues that a number of practices have to be included in the list of activities, according to the AORN (Association of periOperative Registered Nurses). For instance, hospitals should ask their workers to maintain fingernails healthy and clean, cutting their nails and removing nail polish if it was chipped or damaged. Moreover, all specialists have to care for their hands to avoid dermatitis, remove jewelry from their hands, wash hands regularly, and encourage patients to do the same. The article also provides an example of a nurse’s day at her workplace, noting each time she performs HH or advises others to follow the established rules. The author talks about each part of the guideline in detail, suggesting multiple possible problems for hospitals. Overall, the article does not have a research structure or findings, utilizing factual information from existing guidelines. Thus, its reliability is also dictated by the quality of supporting sources which are taken directly from major nursing associations.

The second non-research study is a quality implementation discussion that engages patients and hospital visitors. Desai et al. (2017) provide some feedback from patients in the form of surveys containing questions about healthcare providers’ adherence to HH. The audit tool used in this research also asks patients to state which type of professional was engaged and which procedure was performed. Desai et al. (2017) find that the rate of compliance among specialists is higher than the hospital target number, although nurses and doctors’ results are lower than those of non-specialists. The conclusions based on these surveys can be used as a patients’ perspective. Moreover, as nurses and other staff members are encouraged to promote HH, they are often required to perform all hand-washing activities in the presence of patients, thus making the findings in this article somewhat reliable. However, this study addresses only one aspect of the guidelines – hand washing, failing to address other practices. Nonetheless, as this step is often considered to be one of the major issues, this choice is understandable. The authors’ interpretation of findings is based on calculations and is devoid of unsupported statements.

The research article by Salmon and McLaws (2015) explores the opinions of Vietnamese healthcare workers about HH. The authors utilize a qualitative approach to facilitate and analyze the discussion about these practices. They enquire about professionals’ experience and knowledge about hygiene-related activities. Furthermore, the scholars also ask about noncompliance, its reasons, and ways to mitigate them. The study has a large number of participants, and it presents them with topics in the form of open dialogue to collect as many ideas as possible. The gathered data is displayed in the article with the help of direct quotations, increasing the quality of the authors’ conclusions. Moreover, the scholars create a visual representation (schematic diagram) of all problems that healthcare workers point out as barriers to better care. Salmon and McLaws (2015) demonstrate that low quality of care is facilitated by nurses’ prioritization of personal safety, lacking hospital guidelines enforcement, and limited access to hygiene products. It should be noted that the authors acknowledge the limitations of their study and state that it cannot represent all populations. Nevertheless, they argue that it can serve as a foundation for developing countries and hospitals with limited resources.

The effectiveness of education about HH is investigated in a nonrandomized quail-experimental study by Karaoglu and Akin (2018). In this source with research evidence, the authors assess nurses’ knowledge about HH and its effect on their compliance with proper practices. They present two major hypotheses related to the positive impact of training on nurses’ understanding and compliance levels. The authors compare participants’ answers before and after training by implementing a survey with questions about hand washing, antiseptics, bacteria types, and patient care. Additionally, they also collect data about observed cases to support workers’ statements with factual evidence. As a result, Karaoglu and Akin (2018) find that training is highly effective in providing nurses with knowledge about HH, although it does not increase the rates of compliance significantly. Nevertheless, education is still viewed as effective by the authors who present other studies to support their findings. Overall, the study contributes to the existing scope of research and suggests further topics for examination. It also recognizes limitations as nurses’ observation was focused on short-term changes.

Evidence Matrix

Authors Journal Name/ WGU Library Year of Publication Research Design Sample Size Outcome Variables Measured Level Quality Results/Author’s Suggested Conclusions
Karaoglu, M. K., Akin, S The Journal of Continuing Education in Nursing 2018 Nonrandomized quasi-experimental (quantitative) 63 nurses HH knowledge levels and hand washing rates after intervention II B HH training has a positive effect on nurses’ compliance and knowledge levels.
Phan, H. T., Tran, H. T. T., Tran, H. T. M., Dinh, A. P. P., Ngo, H. T., Theorell-Haglow, J., Gordon, C. J. BMC Infectious Diseases 2018 Quasi-experimental (quantitative) 206 healthcare workers HH knowledge and compliance levels II B In countries with limited resources, HH education can have a long-lasting positive impact on nurses’ behavior and compliance.
Sadule-Rios, N., Aguilera, G. Intensive and Critical Care Nursing 2017 Exploratory, descriptive survey (qualitative) 47 critical care nurses Reasons for low HH compliance levels III C Main problems that decrease compliance levels include understaffing, increased workload, a lack of time, limited hygiene supplies, and inappropriately located hand washing stations.
Salmon, S., McLaws, M. L. American Journal of Infection Control 2015 Thematic analysis/ descriptive survey (qualitative) From 96 to 144 physicians and nurses (the total number is not specified) HH compliance barriers III C Prior to implementing educational interventions, hospitals need to be equipped with sufficient range of hygiene products, and such problems as busy schedules and overcrowding have to be resolved.
Uneke, C. J., Ndukwe, C. D., Oyibo, P. G., Nwakpu, K. O., Nnabu, R. C., Prasopa-Plaizier, N. The Brazilian Journal of Infectious Diseases 2014 Cross-sectional intervention (quantitative) 209 health workers (106 doctors, 63 nurses, 25 midwives, 5 other) HH compliance III B HH compliance rates can be increased with the help of educational programs that follow the methods of the World Health Organization.

Recommended Practice Change

The mentioned above articles suggest and support the project focused on education of staff on the topic of HH. According to Karaoglu and Akin (2018), after the training program was finished, workers’ knowledge levels improved significantly, while the rates of hand washing increased in the range “between 0% and 50%” (p. 366). Phan et al. (2018) found that compliance with HH among nurses in Vietnam rose substantially as a result of an educational intervention – from 43 to more than 60 percent. Uneke et al. (2014) revealed similar results with their program, improving HH practices in a Nigerian hospital to reach a 65 percent compliance level. Salmon and McLaws (2015) noted that learning has to become the first step in helping nurses understand why HH is vital in healthcare, while all other improvements can follow after the staff is knowledgeable enough to accept the duty of care. Finally, Sadule-Rios and Aguilera (2017), although outlining a set of barriers that may hinder the success of a training program, admit that education is a valid approach if healthcare professionals work in a suitable environment.

Key Stakeholders

All workers in a medical establishment need to be considered while one is introducing an educational intervention to them. However, some types of specialists can have a significant impact on the success of the project. First of all, nurse managers play a major role as they serve as a connection between different nurses and administration, collecting feedback and monitoring the state of their unit or department. Their strategy should involve information gathering to determine the current and ongoing status of the unit’s compliance. Moreover, they can assess all the resources that the hospital possesses which may assist in the process. Their leadership qualities can encourage the staff to accept the new guidelines and view them as a beneficial change. Secondly, nurse educators should be engaged because the core of this intervention lies in learning activities. Personnel will participate in training, and it is the duty of educators to provide them with clear instructions and reliable findings. Nurse educators can offer their opinion about the best ways to deliver information to other employees.

Finally and most importantly, floor nurses should participate in the process of designing and implementing this program. They can monitor the compliance of other workers and create reports that will describe main barriers, improvements, and suggestions for further change. Their role is crucial to the outcome because the influence of each nurse in a team may alter the way the staff understand and interpret change – as a positive and caring intervention or as a disruptive and unnecessary initiative.

Barriers

Change in practice is often met with negative feedback from workers and the establishment itself. In this case, barriers to implementation can be caused by the hospital’s lack of resources and funding to support the intervention. As Sadule-Rios and Aguilera (2017) point out, understaffing is a serious problem that stops some organizations from introducing strict HH policies and providing workers with education. The lack of HH products and well-positioned hygiene stations is another issue that should be overcome. Nurses who develop the intervention should interpret the findings from research in order to apply them to their particular workplace. Thus, they should remember to evaluate their hospital in terms of its resources’ delegation and availability and compare it to studies with similar conditions. Otherwise, the results of the implementation may be drastically different.

Strategies to Barriers

Nurses may address the first set of barriers connected to financial concerns by contacting their local and federal nursing organizations, working with the administration to find new resources, or engaging specialists to find affordable strategies. The solution to these issues lies in the collaborative work of the hospital and its employees – their outreach to non-profit organizations or fundraisers may help nurses to develop a sound project. Understaffing is another challenging problem that cannot be resolved without finding alternatives. However, as studies discover, high HH compliance can positively influence the rate of readmissions and returning patients, thus lowering clinicians’ workload (Phan et al., 2018). In regards to research, it is important for nurse managers to use recent and trustworthy research to measure the current state of the hospital. For instance, they can use the guidelines proposed by the WHO which is utilized in a similar study by Uneke et al. (2014). This approach provides specialists with a specific framework and standardizes results for easy comparison.

Indicator to Measure Outcome

In this project, the rates of HAIs and HH compliance should be considered as primary measurements to assess the outcomes of the proposed intervention. Infections are closely connected to the staff’s hand washing and sanitizing activities. Therefore, the number of patients with HAIs should decrease after the educational program is completed. One can record the number of HAIs before and after the intervention and continue monitoring its change to see whether this initiative has a long-term effect on professionals’ behavior. Levels of HH compliance can also be evaluated to determine whether the correlation between them and HAIs rates is significant. Here, the hospital should engage both employees and patients to gather data about the clinicians’ HH activities.

References

Desai, C., Rezmovitz, J., Manson, J., Callery, S., & Vearncombe, M. (2017). Engaging patients as observers in monitoring hand hygiene compliance in ambulatory care. Canadian Journal of Infection Control, 32(3), 150-153.

Goldberg, J. L. (2017). Guideline Implementation: Hand hygiene. AORN Journal, 105(2), 203-212. Web.

Karaoglu, M. K., & Akin, S. (2018). Effectiveness of hygienic hand washing training on hand washing practices and knowledge: A nonrandomized quasi-experimental design. The Journal of Continuing Education in Nursing, 49(8), 360-371. Web.

Phan, H. T., Tran, H. T. T., Tran, H. T. M., Dinh, A. P. P., Ngo, H. T., Theorell-Haglow, J., & Gordon, C. J. (2018). An educational intervention to improve hand hygiene compliance in Vietnam. BMC Infectious Diseases, 18, 116. Web.

Sadule-Rios, N., & Aguilera, G. (2017). Nurses’ perceptions of reasons for persistent low rates in hand hygiene compliance. Intensive and Critical Care Nursing, 42, 17-21. Web.

Salmon, S., & McLaws, M. L. (2015). Qualitative findings from focus group discussions on hand hygiene compliance among health care workers in Vietnam. American Journal of Infection Control, 43(10), 1086-1091. Web.

Uneke, C. J., Ndukwe, C. D., Oyibo, P. G., Nwakpu, K. O., Nnabu, R. C., & Prasopa-Plaizier, N. (2014). Promotion of hand hygiene strengthening initiative in a Nigerian teaching hospital: Implication for improved patient safety in low-income health facilities. The Brazilian Journal of Infectious Diseases, 18(1), 21-27. Web.