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Introduction
The idea of getting nurses and physicians to observe hand hygiene is not new. The Hungarian physician, Ignác Fülöp Semmelweis (18181865) first tried this approach in the 1840s when he elaborated the importance of hand hygiene among physicians to prevent the spread of pathogens (Samuel, Almedom, Hagos, Albin & Mutungi, 2005). However, the medical community did not support the physicians recommendations. The physician noted that when health workers washed their hands thoroughly and frequently, they could avoid infections and save lives. It appears that from 1840s to the present, little or nothing has changed because hospital-associated infections have continued to rise across various health care facilities. Hand hygiene practices in health care facilities refer to handwashing with any form of approved antimicrobial disinfectants, soaps, or alcohol-based disinfectants.
One major puzzle is why health care workers have failed to observe simple hand hygiene practices. The Joint Commission has recognized that measuring health care worker adherence to hand hygiene practices is not a simple matter due to differences in opinions and misinformation (Joint Commission, 2009). It noted that evaluating the what, when, why, and how in hand hygiene performance was a challenging task. Moreover, health care workers needed to understand when to make decisions about hand hygiene. The Commission also acknowledged studies, which had indicated that adherence to hand hygiene practices and recommendations remained poor while any positive outcomes were often unsustainable (Joint Commission, 2009).
Generally, many studies have touted proper hand hygiene as the simplest and most effective mode of preventing hospital-related infections (Joint Commission, 2009; Samuel et al, 2005). These are mainly infections, which patients acquire during their stay at the hospital. One must recognize that patients are most prone to hospital-associated infections. Many of these infections are caused by common pathogens, including multi-drug resistant ones. These pathogens may result in bloodstream infections, pneumonia, urinary tract infections, and even surgical site infections.
This study is a critique of evidence in hand hygiene as best practice in adult care nursing.
Current practices and Outcomes in Hand Hygiene
Both past studies (Doebbeling et al, 1992) and current studies have noted the presence of hospital-associated infections (HAIs), which have presented major threats to patient health and safety and they are related to cases of mortality that ranged between 5% and 35% (Flodgren et al, 2013). In addition, they also accounted for patient morbidity in the intensive care unit (ICU).
There are critical risk factors that studies have associated with HAIs. They include the use of invasive medical instruments and techniques and poor adherence to infection prevention guidelines among health care workers during such medical procedures. These could be life-threatening medical cases and surgical procedures. There are certain risk factors for every device, but a general approach concentrates on the use of medical devices and the length of use, which determine the extent of infections to patients alongside organisms that cause infections (Flodgren et al, 2013). In most cases, these organisms are transmitted to patients through the hands of physicians or nurses during medical procedures. On the same note, outbreaks also occur in patients and transmission takes place from one patient to another through contaminated medical devices. Some of these pathogens have abilities to survive on hands for more than two hours (Doebbeling et al, 1992).
Since the period of Semmelweis, hand hygiene has proved to be effective in controlling cases of nosocomial infections among patients. Therefore, health care workers can control and interrupt the spread of many infections by observing proper hand hygiene practices (Doebbeling et al,1992). As in the past, the promotion of simple, effectual and affordable guidelines of hand hygiene continue to record gradual progress because of poor human behaviours associated with ignorance, attitudes, carelessness or arrogance among health care providers despite their levels of academic qualifications. In most cases, health care stakeholders have issued, revised, and improved hand hygiene guidelines regularly. In addition, there are ongoing education, technical training on hand washing, novel approaches and incentives for health care workers to observe hand hygiene (Hartocollis, 2013), yet the issue of hand hygiene continues to remain unresolved and persistent. Samuel et al. (2005) noted that worst cases of poor hand hygiene were noted among doctors working in ICUs, emergency areas, and post anaesthesia care units (PACU) in which there were several, highly susceptible patients. Further, some data from self-reports among doctors and gynaecologists have indicated poor adherence with justifications that range from a lack of adequate time to personal belief that hand hygiene have little or no health values to patients. Consequently, there have been a series of heated debates about the effectiveness of hand hygiene. On the other hand, one must recognise that a great many extremely qualified physicians, nurses and other health care providers strive to observe and promote hand hygiene in their institutions irrespective of little time and limited resources.
Therefore, hand hygiene contributes to major challenges in the provision of quality health care and improved outcomes for patients. This could provide accounts of patients susceptibility to hospital-associated infections despite advancements made in the health care sector (Mani, Shubangi & Saini, 2010).
As cases of nosocomial infections increase, academics and professions have questioned health care delivery and hygiene standards in hospitals because many studies have noted the relevance of hand hygiene in combating hospital acquired infections (Akyol, 2007).
Why are health care workers so poor at hand hygiene?
As noted earlier, some of the health care workers continue to perform dismally at hand hygiene practices. According to Hartocollis (2013), various studies have provided different accounts on poor hand hygiene practices among health care workers, which included dry skin, the pressures of an emergency environment, the tedium of hand washing and resistance to authority (doctors, who have the most authority, tend to be the most resistant, studies have found) (Hartocollis, 2013).
However, despite several cases of infections associated with hand hygiene, hand hygiene practices among physicians and nurses have remained unacceptably poor (Akyol, Ulusoy & Ozen, 2006; Samuel et al, 2005; Hartocollis, 2013). Studies have shown that hand hygiene practices in developed nations hardly achieve 50 percent compliance (Maxfield & Dull, 2011). Consequently, poor observation and compliance with hand hygiene guidelines have resulted in increased cases of morbidity and mortality (Flodgren et al, 2013). Such cases have led to increased medical costs. For instance, in the USA, there are at least 100,000 patient deaths every year associated with poor hand hygiene while the cost for hospital-acquired infections has reached $30 billion (Hartocollis, 2013). Under the new Federal rules on preventable infections, health care facilities will not receive Medicare compensation if patients suffer such nosocomial infections. Consequently, hospitals are willing to embark on extreme measures to ensure effective hand hygiene practices and reduce cases of transmission.
Cases of nosocomial infections vary from country to country. However, the simple yet complex hand hygiene remains the most effective and affordable method of controlling transmissions and reducing infections in hospitals. Various health care organisations have emphasised the relevance of hand hygiene practices in health care settings to reduce infections and related health complications and costs.
Hand hygiene in health care settings is critical because physicians and nurses who are exposed to medical devices and patients often are contaminated. Health care facilities should provide safety and promote recovery rather than infections among patients and health care workers. Therefore, the main goal of hand washing is to eliminate dirt, germs, reduce the presence of microorganisms on the skin and prevent transmissions of pathogens from health care workers to patients.
Nurses and physicians should comply with hand hygiene practices because of their working environments and patient safety. Moreover, there are obligatory roles that require nurses to observe hygiene in the course of their duties for their own safety and patients well-being. At the same time, nurses must act professionally, ethically and be responsible for their patients. The code of standards defines all conditions that nurses must meet when delivering care to patients. However, despite intense campaigns to observe hygiene and promote patient safety and outcomes, some nurses and doctors still disregard hand hygiene practices and guidelines and consider any infection as a part of patient infections, which they will handle (Maxfield & Dull, 2011). As noted above, several factors have contributed to poor hand hygiene practices among nurses and physicians. In addition, health care workers have to remember several procedures. Therefore, they might find it simple to forget easy, basic tasks like hand hygiene. At the same time, other health care providers have recognised hand gloves as alternatives to hand washing (Nazarko, 2009). Under such cases, they tend to use a single glove for multiple purposes and fail to wash their hands after medical procedures. In addition to dry skin cases, nurses also avoid hand washing for fear of developing skin conditions like dermatitis, particularly when they use alcohol-based sanitizers.
It is imperative for health care providers to observe hand hygiene before performing any intrusive medical procedures. After such procedures, contacts with contaminated medical instruments and with highly vulnerable patients should be limited. In this case, hand hygiene should be conduct before and after all medical procedures (Kampf & Loffler, 2010). Nurses may also note that hand hygiene requirements and practices may differ from one procedure to another, based on the extent of contamination and the resistance of pathogens on the skin. This may also raise the question of hand hygiene guidelines even if health care providers spend maximum time washing their hands. In other words, nurses must also learn how to perform hand-washing techniques because they may fail to wash their fingers, nails, thumbs and wrists among others properly.
Studies have noted poor practices in hand hygiene among doctors relative to nurses (Akyol, Ulusoy & Ozen, 2006; Samuel et al, 2005; Hartocollis, 2013). Thus, the rate of hand hygiene practices among health care workers differed considerably.
On this note, researchers have noted that attitudes and behaviours among nurses and doctors could have significant impacts on observing hand hygiene practices (Ott & French, 2009). In this case, health care workers have questioned the effectiveness of hand washing. In addition, personal values and belief systems are a part of barriers that hinder effective adoption of hand hygiene guidelines.
One may wonder how health care workers can promote and achieve favourable impacts in hand hygiene practices. In this case, it is necessary to track hand hygiene practices, teach staff, reward best performers and punish defaulters as if they have dishonoured critical health care policies. Overall, nurses and physicians require thorough education and training on hand hygiene practices.
The practice in hand hygiene should not be restricted to nurses alone. Instead, all hospital stakeholders, including patients and leaders should promote hand hygiene practices at their levels. Therefore, patients and nurses should promote hand washing by enquiring if they do actually observe the practice. However, the extent of enquiring about hand hygiene between patients and their health care providers could be difficult to determine. Nurses and physicians must recognise that patients value their trust and feel reassured if they observe good hand hygiene practices.
While other studies have cited poor attitudes, behaviours and lack of time for health care workers to observe hand hygiene, other studies have cited a lack of scientific knowledge and awareness as major contributors to poor hand hygiene (Akyol, 2007; Mani et al, 2010). In this case, training opportunities have failed to introduce nurses to practical aspects of hand washing and observation with patients in real-life situations. Still, Ott and French (2009) noted that health care workers attitudes and cultures during their duties had a significant impact in their clinical training and development. Some of these habits could have originated from trainers who demonstrated poor hand hygiene training. They tended to be busy and had little time for effective hand washing practices. Nurses and physicians undergo training on recommended approaches of controlling and limiting infections, including precautions they must observe (Ott & French, 2009). However, the training programmes do not emphasise hand hygiene throughout the study period. On this note, it is important to remind nurses of precautions that can limit transmission of pathogens to patients. At the same time, it is necessary for health care stakeholders to organise education programmes and seminars to emphasise the importance of hand hygiene for health care workers and patients (Nazarko, 2009). Such training programmes can reinforce compliance and enhance best practices in health care provision.
Another factor that has led to poor outcomes in observing hand hygiene is misconception about the practice. This may involve situations in which nurses and doctors use gloves to substitute hand washing. In addition, they have also claimed that certain skin conditions arise from frequent hand washing with some hand washing gels (Mani et al, 2010). Moreover, nurses and physicians have experienced increasing workloads, constrained time, few staff, lack of mentoring from seniors, organisational support, different views about the recommended hand hygiene practices, and poor motivation (Akyol, 2007). These factors have contributed to poor outcomes in hand hygiene practices (Mani et al, 2010). In addition, some facilities lack adequate or recommended hand hygiene facilities and products. Such provisions include running water, antiseptic soaps, hand or paper towels and alcohol-based hand scrubs. The situation has become unbearable in developing nations, which may lack even proper facilities for patient care. Thus, their outcomes in hand hygiene practices remain unacceptably poor.
Interventions to promote hand hygiene among health care worker
From the literature reviewed and critiqued, there are several factors, which have contributed to poor hand hygiene among health care workers. These studies have presented various accounts of the problem of observing hand-washing practices. However, according to Gould, Moralejo, Drey and Chudleigh (2010), the qualities of intervention studies, which are intended to enhance hand hygiene and compliance among health care workers have remained low. While some interventions have achieved some positive effects, there are insufficient data to attribute such approaches to improved hand hygiene campaigns among health care workers. Hence, one cannot draw a firm conclusion based on such claims. Consequently, these researchers have concluded that there is an urgent need to undertake methodologically robust research to explore the effectiveness of soundly designed and implemented interventions to increase hand hygiene compliance (Gould et al., 2010).
Bischoff, Reynolds, Sessler, Edmond, and Wenzel (2000) noted that education and feedback interventions had positive effects among health care workers in different units. For instance, a baseline study of hand hygiene compliance among health care workers revealed that medical ICU recorded an improvement from 9 percent to 22 percent, whereas those in cardiac surgery ICU noted an improvement of 10 percent from 3 percent. However, after the education/feedback intervention initiative, there were notable improved outcomes. Hand washing compliance improved from 14 percent to 25 percent in medical ICU and from 6 percent to 13 percent in cardiac surgery ICU. This was possible because of changes made in the facility, which included the introduction of accessible hand hygiene facilities and products. It resulted in high rates of hand washing among health care workers. Therefore, the researchers concluded that education/feedback intervention and patient awareness programs did not increase hand washing compliance, whereas the introduction of easily accessible dispensers with an alcohol-based waterless hand washing antiseptic led to significantly higher hand washing rates among health care workers (Bischoff et al, 2000). Therefore, education to enhance hand washing practices and compliance must be supported with the necessary hand hygiene products and facilities.
On this note, intervention programmes should focus on specific problems and adopt task-oriented strategies alongside education and feedback to enhance hand hygiene compliance.
Studies also cited a lack of adequate time for observing hand hygiene among nurses. In this regard, intervention programmes should promote clustering of nursing procedures and reducing handling of medical devices. This would overcome time barriers as Lam, Lee and Lau (2004) noted. In addition, constant auditing and regular feedback could help in sustaining the adopted compliance procedures. Moreover, based on the Joint Commission recommendations, health care facilities should develop measures for evaluating the effectiveness of hand hygiene practices (Joint Commission, 2009). On this note, Hartocollis (2013) noted that some health care facilities have turned to technologies to track and provide feedback on hand hygiene practices among their health care workers. Such systems provide immediate feedback on defaulters. Therefore, intervention programmes should consider technologies in tracking hand hygiene practices among health care workers.
Studies recognised that hand hygiene was the most effectual and affordable means of controlling hospital-associated infections. However, Jumaa (2005) noted that relying on hand hygiene alone to improve practice in health care setting and control infections might not yield the desired outcomes. There were other factors, such as environmental, staffing needs, education and training to consider in hand hygiene intervention programmes. Therefore, hand hygiene practices should be integrated with other intervention programmes to limit the spread of nosocomial infections.
Studies have asserted that compliance with hand hygiene guidelines has remained poor throughout the world (Jumaa, 2005). The processes of hand hygiene are rather simple. However, there are other interdependence factors, which affect behaviours and result in poor outcomes. On this note, intervention programmes must focus on changing human behaviours. Therefore, contributions from behavioural science in intervention programmes could help in addressing negative attitudes towards hand hygiene practices among health care workers. Moreover, such intervention programmes should also account for social and cultural needs of different groups (Akyol et al, 2006).
Conclusion
Literature reviewed and critiqued has shown that hand hygiene practices can limit the transmission of nosocomial infections among patients. These studies have also shown that hand hygiene guidelines are simple, but many health care workers have failed to sustain the recommended guidelines. Consequently, there are cases of morbidity and mortality linked to hospital-associated infections.
Nurses and physicians have failed to adhere to hand hygiene guidelines. Studies have identified several factors, which include lack of adequate time, poor attitudes and behaviours, lack of adequate hand hygiene products and resources, scientific knowledge and training on effective hand washing techniques, differences in personal beliefs and the recommended guidelines among others.
Based on these observations, it is clear that intervention programmes to enhance effective hand hygiene among health care workers must be multifaceted with a clear focus on individual and facility related factors. Such intervention programmes must include continuing health care worker training, reviewing of current practices, constant feedback, the use of technology and enhancing access to hand hygiene products and facilities. In addition, all stakeholders must participate in hand hygiene in health care settings. Specific interventions must focus on low staffing and time management. Unless health care workers change their behaviours, hand hygiene practices and outcomes will remain dismally low.
References
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