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Hand Hygiene: Your Patient’s Health is in Your Hands

Kathy A. Laminack
College of Nursing and Health Innovation, University of Texas at Arlington
NURS 4325 Nursing Research
Thomas Dombrowsky, PhD, RN
February 5, 2022
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Hand Hygiene: Your Patient’s Health is in your Hands
Hand hygiene is the single most important aspect of providing safe prevention of
infection that we are able to provide to our patients with little cost or effort. Nurses are taught
how to properly wash their hands from their nursing instructors before they are allowed to step
foot onto a nursing unit to care for patients. This paper’s PICO question concerns the effect of
knowledge and understanding of hand hygiene practices on the adherence of proper handwashing
techniques to reduce HAIs, or Healthcare Associated Infections, compared with usual care.
In their article, Health care associated infection – an overview, Haque et al. (2018) found by a
survey of over eleven thousand patients in 183 hospitals that 4% of patients developed at least
one HAI, with the most common infection being Clostridium difficile. Another HAI of concern
is CAUTI’s, or catheter-associated urinary tract infections. The complication of UTI’s are found
all over the world causing close to 40% of HAI’s. There are significant costs in terms of
mortality and morbidity, as well as the financial burden on the patient. This includes the
healthcare institution as well. Another alarming statistic concerns over 98,000 patients will
succumb to these often-preventable infections. As nurses, who spend the most time with patients
than any other discipline, it is our obligation and duty to be steadfast in our efforts to protect our
patients from these preventable complications.
Summary of Research Article
de Oliveira, et al. (2019) utilized a quantitative, descriptive, observational, cross-
sectional study to evaluate whether the healthcare professionals at one hospital in Joao Pessoa,
which is located in northeastern Brazil, were diligent in their hand hygiene practices. A brief
questionnaire of six dichotomous questions was given to the participants after obtaining a signed
consent form. The sample method was a convenience sample, which is often utilized in situations
where the study participants are readily found. In this case, an acute care hospital ward. The
questionnaire was adapted from one that has been recommended by the World Health
Organization concerning perceptions of health professionals about their knowledge of the
importance and efficiency, and how often they comply with standards of proper hand hygiene.
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The results of the study were conflicting. All of the professionals agreed regarding the
importance of hand hygiene. This also included when and how efficient they were in their
practice. The results of this questionnaire were presented in a table with 92.5 % of the
participants replying yes to the questions . Only 7.5% responded no. This, however, was not
reflected in the results of the observations of these same professionals. There was only an 8.5%
adherence rate as reported by the researchers utilizing the ‘Five Moments of Hand Hygiene’
model (WHO, 2009). This is a disturbing finding since they had already completed the
questionnaire where they agreed on the importance of proper hand hygiene in the prevention of
infection. Their results showed that although these professionals were knowledgeable about the
importance of hand hygiene and its implications for detrimental results, they did not adhere to
the standards of practice that would be an effective measure to safeguard their patients. Even
though the practice of hand hygiene has proven to be a simple, low-cost method to reduce
infection rates, they failed to practice the steps on a daily basis (de Oliveira, et al., 2019). Of
note, 36% openly admitted to non-adherence of proper hand hygiene. Regarding the PICO
question, the results of this study points to a conscious refusal to be compliant with performing
hand hygiene, not the lack of knowledge or availability of equipment or materials vital to
attaining the goal. Nurses must accept the responsibility for taking the time to perform proper
handwashing tasks. The only acceptable alternative to handwashing is alcohol-based
preparations. The amount of time it takes to apply these preparations would be slightly faster
than washing with soap and water. Making sure the gel or foam containers are in an accessible
place located near entry ways is essential to improve compliance. It is also the responsibility of
the nursing managers to ensure the supply of these preparations is kept at a proper maintenance
level
Major Variables
The conceptual definitions of the variables in this study would include whether nurses
adhere to the standards of handwashing practice. The attitudes and knowledge of these
professionals would be one of the operational definitions of the variables. This was
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accomplished by the results of the questionnaire. This was a nominal level of measurement
as the questions would only fit in one category or the other. Their responses were entered into a
database utilizing descriptive statistics. The operational definition of the variables were the
observations of these participant’s compliance in practicing appropriate hand hygiene in their
daily activities of caring for patients. The participants were observed with the assistance of the
‘Five Moments of Hand Hygiene’ method. This includes the following: 1) Before touching a
patient; 2) Before clean/aseptic procedures; 3) After body fluids exposure/risk; 4) After touching
a patient; and 5) After touching patient surroundings (WHO, 2009). This is also a nominal level
measurement as they are categorical. The questionnaire was formulated as a yes/no answer. The
researchers observed whether the participants performed hand hygiene or whether they missed
the opportunity.
Strengths and Weaknesses
One weakness of this article was the brief period of time of data collection. The study took
place within a two-month period of time. The sample size of these professionals that were
involved in the study numbered 56. It is unknown if the participants were aware when they were
being observed. The study does mention they did not disrupt their daily work, but it is not clear
whether they were aware they were being observed. Another weakness was they did not cite all
of the references they listed in the reference section of the article. They relied heavily on the
Ministry of Health for the majority of their references. One strength of note was the use of the
‘Five Moments of Hand Hygiene.’ This model was developed by the World Health Organization
in 2009 in an effort to decrease HAI’s. They also utilized a convenience sample, which is one of
the weakest methods of data collection.
Practice Guidelines
The practice guideline for this paper was Hand hygiene for all initiative: Improving access
and behaviour in health care facilities (WHO, 2020). This document can be found at
https://www.who.int/publications/i/item/9789240011618. There are several recommendations
found in this paper that are specifically concerned with hand hygiene procedures and nursing
practice. Education and training are the foundations of achieving healthcare facilities’ goals for
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compliance in the workplace. This starts with leaders in the unit that engage their staff on
adhering to policies and procedures related to infection control standards already in place This
would include adequate staffing, supplies, and support to succeed in these endeavors. Another
recommendation is the continuous monitoring of hand hygiene by all members of the healthcare
team and feedback to these professionals regarding their failure to comply with standards of
practice. This is in regard to proper techniques pertaining to hand hygiene. One cannot dismiss
the facility’s responsibility to provide adequate supplies needed to successfully accomplish this
goal. One additional recommendation is the use of visual aids to remind staff to practice hand
hygiene. This can be in the form of posters, stickers, etc. to remind healthcare workers of the
fundamentals of infection control. Nurses are able to provide vocal cues to their peers to remind
them to practice good hygiene procedures to prevent infection. This simple behavior promotes
positive attitudes rather than relying on punitive actions that could be taken as a negative action
to demean the nursing staff.
Fourth Resource
A how-to article written by Ford & Park (2018), provided a step-by-step guide on the use
of liquid soap. This guide would be appropriate to place at every wash station as a reminder to
wash your hands. They discussed the implications of not properly drying one’s hands. The lack
of drying the skin could potentially damage the stratum corneum. This in turn could lead to skin
breakdown which invites microorganisms to multiply on the skin surface. An additional fact that
was mentioned was the importance of not wearing jewelry or sleeves that extend past the elbow.
Contamination from these items present a rich environmental source for pathogens to hide and
grow. Acrylic nails are discouraged due to the added length of the nail and the space between
the natural nail and the acrylic nail can cause trapping of microorganisms. They also made
mention of the problem with wearing nail varnish. In time, the varnish will tend to show signs of
wear, as well as flaking off. This invites microorganisms to invade the ridges of the nail surface
to become an easy place to flourish. The recommended time to wash your hands is 40-60
seconds.
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If you are utilizing an alcohol hand gel or foam, the recommended time is 20-30 seconds
(WHO, 2009). The implications in this article clearly define what we, as nurses, learned in
nursing school.
Conclusion
To sum up the evidence in this paper; what is the effect of knowledge and understanding
of hand hygiene practices have on the adherence of proper handwashing techniques to reduce
HAI’s, compared with business as usual? Hospital nurses are capable and able to provide the
care that is needed to ensure preventable infections. We should never knowingly cause undue
paint and suffering to our patients. Given all of the research that is available on the subject of
hand hygiene, it is clear that we, as good stewards for our patients, can and must, be leaders in
preventing complications from infection when we are capable. Nurses are regarded as
trustworthy advocates for our patients. This includes maintaining good skin and nail integrity to
prevent harboring dangerous microorganisms that transfer from our hands to our patients. WHO
(2009) developed the ‘Five Moments of Hand Hygiene’ to reinforce the practice of handwashing
at the right opportunities. In their latest practice guideline on the importance of having the
materials and the equipment to carry out adequate hand hygiene, they also encouraged
continuous monitoring and feedback on their performance of hand hygiene (WHO, 2020). Ford
& Park (2018) gave us a step-by-step guide on how to properly wash our hands with liquid soap.
de Oliveira, et al. (2019) was able to observe the handwashing habits of healthcare professionals
which contradicted the beliefs they stated versus their behaviors. Recommendations for future
research on hand hygiene would be prudent in enlisting the ideas of nurses on the reasons why
we do not consistently practice hand hygiene and constructing pilot studies to determine causes.
What antibacterial products reduce skin irritation? Replication studies in other healthcare
facilities may shed light on how to combat this issue. Should we consider alternative methods of
hand hygiene? How does the use of lotions and creams after hand washing affect its efficacy to
kill microorganisms? In conclusion, your patient’s health is truly in your hands.
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References
de Oliveira, M. A., de Menezes Leuthier, R., Rodrigues Oliveira Filho, J., Pereira Leite, M. A.,
Alves Fernandez, L. G., dos Santos, A. F., de Albuquerque, K. F., & Guedes Correia, K.
(2019). Hand hygiene: Knowledge and attitudes of healthcare professionals. Journal of
Nursing UFPE , 13, 33-37. https://doi.org10.5205/1981-8963.2019.236418
Ford, C., & Park, L. J. (2018). Hand hygiene and handwashing: Key to preventing the transfer
of pathogens. Br J Nurs. Nov 8;27(20), 1164-1166. doi: 10.12968/bjon.2018.27.20.1164
Haque, M., Sartelli, M., McKimm, J., & Abu Bakar, M. (2018). Health care-associated infections
– an overview. Infection and Drug Resistance, Nov.15(11), 2321-2333.
doi: 10.2147/IDR.S177247. PMID: 30532565; PMCID: PMC6245375
World Health Organization. (2020). Hand hygiene for all initiative: Improving access and
behaviour in health care facilities.
https://www.who.int/publications-detail-edirect/9789240011618