The purpose of this paper is to present a research proposal for nurse hand hygiene practices in a hospital setting. The paper will provide an introduction and literature review in order to identify gaps in the literature with respect to hand hygiene practice in hospitals. Finally, the paper will present a research project to address the issue.
1. Introduction
The relationship between nosocomial infections and hand hygiene has long been understood and established with Larson’s publication in 1988. Although hand washing had been established as a cornerstone of nursing practice, by 2003 compliance in hand hygiene in hospitals was still at approximately 50% (Grol & Grimshaw, 2003). According to the European Centre for Disease Prevention and Control (2012), from 20% to 30% of nosocomial infections are probably preventable with improved hand hygiene. In the United States, the burden of preventable nosocomial infections is estimated at 2.5 to 5 billion annually (Malliarou, Sarafis, Zyga, & Constantinidis, 2013).
2. Literature Review
Nosocomial outbreaks in health care institutions constitute a problem as they are responsible for increased mortality and morbidity among patients and extending hospital stays. Further, the containing and controlling of infectious outbreaks is a considerable financial burden, particularly if the outbreak goes unnoticed for some time (Dik, et al., 2016). Traditionally, hand hygiene training is conducted early in the medical education and consists of the six poses recommendated by the WHO (2009).
Noncompliance studies on hand hygiene frequently use a covert observational design and/or an intervention employing the six hand poses outlined by WHO’s Guidelines (2009). Luangasanatip, et al. (2015) conducted a network meta-analysis and systemic review on 41 studies promoting hand hygiene in the wake of the WHO 2009 hand hygiene campaign among health care workers in hospital settings. The research designs included in the review were randomized controlled and non-randomized trials, interrupted time series and controlled pre- and post-intervention trials. The study participants were all health care workers in hospital settings. All but four of the studies showed an improvement in compliance post intervention. The network meta-analysis found mixed results but concluded that interventions that included reward incentives, goal setting, and accountability further improved compliance. The 19 clinical studies included in the review demonstrated decreases in rates of infections due to improved hand hygiene, but did not result in the reduction of some critical hospital pathogens.
Kutafina, Laukamp, Bettermann, Schroeder, & Jonas (2016) identify two educational aspects of hand hygiene, training in cleaning techniques and compliance with the disinfection standard operations. Much of the research on hand hygiene entails both instruction and compliance. Laukamp, Kutafina, & Jones (2015) found that 5 out of 14 second year nursing students were capable of complete the sequence of the six hand poses. Some studies focus on relating novel instruction techniques with compliance. An example of this research line is Stewardson, et al. (2014), who conducted a controlled pre- and post-intervention with a video-measurement device that gave an immediate feedback on the degree of compliance with the six hand positions. The video-measuring and feedback was continued for at least four weeks. Blind observers assessed individual hand-washing techniques at baseline and post-intervention. Stewardson, et al. (2014) pointed out that the institution in which the study took place had a long history of hand hygiene promotion. The results were that at base-line, no participants were able to perform the six hand position sequence as recommended by the World Health Organization. Post intervention, no participants performed the full six poses, but the number of poses included in each hand washing session increased. Another novel way to teach hand hygiene is wearable technology. Kutafina,et al., (2016) used e-learning as means of hand hygiene instruction in which smart wearable sensors in the form of arm bands monitored hand and forearm movements and sent the signals to a monitoring device.
Scheithaur, et al. (2015) related hand hygiene compliance to workflow. Working conditions make Emergency Departments subject to greater workloads, patient turnover, and the crowding of health professionals and patients (Scheithauer, et al., 2013). Scheithaur, et al. (2013) developed an intervention based on optimizing workflow in Emergency Department that complied with the World Health Organization’s recommendations for hand hygiene. The research design included observation of hand hygiene opportunities and an educational intervention. The authors found that the optimized workflow increased the number of hand rub events and reduced the workload. Although hand rubbing events significantly increased from 21% to 45%, compliance was still less than half.
Other studies have demonstrated higher rates of compliance. In a pre- and post-intervention study, Sickbert-Bennett, et al. (2016) showed a statistically significant difference in hand hygiene practices when entering and exiting a patient’s room. The compliance at baseline was higher (82%) than observed in other studies with a compliance of 96% post training intervention. Sickbert-Bennett, et al. (2016) used a covert observation design to collect data in which all health care workers were potential observers. The Hawthorne effect is a problem with studies that use covert observation, especially one in everyone is aware that they could be observed. The increase in hand hygiene compliance after training has been found with previous studies, for example, Scheithaur, et al. (2015), but the Sickbert-Bennett, et al. (2016) high baseline rate is questionable and may be not typical of national practice.
Although there are problems with the research design of the Sickbert-Bennett, et al. (2016) study, the drop in healthcare associated infection is an important finding. Over the 17-month study duration, there was a steady and significant decrease in healthcare associated infection with an estimated 22 fewer deaths. The reduction in the rate of infection resulted in a savings of approximately 5 million USD.
Other means of promoting good hand hygiene is through the involvement of patients. Berger, Flickinger, Pfoh, Martinez, & Dy (2014) conducted a systematic review on studies related to patient-centered safety practices. Patient-centered practices encourage the patient and the patient’s family to become involved in their own care. Three studies in the review focussed on hand hygiene. The authors found that although between 80% and 90% of the patients professed willingness to ask their health care worker to wash their hands, only 60% to 70% actually made the request.
3. Gaps in the literature
Overall the literature indicates that training and awareness raising can improve hand hygiene in hospital settings. It is also abundantly clear that despite the training, hand hygiene in hospital settings remains at best 50 % (Scheithaur, et al., 2013). What is not well understood is the reason for the continuing lack of compliance with a relatively simple but vital procedure. Further, the literature is overwhelmingly quantitative. Therefore, another gap in the literature is the lack of qualitative data that would contextualize the reasons behind the lack of compliance in hand hygiene.
4. Research aim and question
The research question is how nurses feel about hand hygiene practices. The aim of the research is twofold: to identify the barriers to compliance with hand hygiene standards and to identify gaps in the knowledge of nurses regarding the transmission of infection. As the barriers are likely to be vary by type of work, different hospital departments and hospital occupations should be included in the study. The benefit to nursing practice is to improve hand hygiene instruction and practice. As Sickbert-Bennett, et al. (2016) have observed, an improvement in hand hygiene is associated with a reduction in nosocomial infection and decreased patient mortality.
5. Significance of the research
Overall, the literature suggests that compliance with hand hygiene remains a problem. The benefit to nursing practice is improved hand hygiene instruction and practice. The primary significance of the proposed research is improved patient care. With regard to health outcomes, the research of Sickbert-Bennett, et al. (2016) demonstrated that hand hygiene is associated with patient mortality.
The kinds of information derived from the qualitative research process are different than that derived from quantitative research. With respect to the hand hygiene education of healthcare personnel, the results of the proposed research could focus on situations that have not been addressed by the data emerging from quantitative research, for example, cultural beliefs and practices.
As for the applicability to day-to-day nursing practice, the proposed research results should yield information on the barriers to good hand hygiene that have previously gone unnoticed. The research results can be applied to modifying nurse procedures that would make hand hygiene a more convenient and more comfortable practice.
References
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