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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 4  |  Issue : 1  |  Page : 1-4

There is more to hand hygiene than routine training of health workers and display of promotional materials


Department of Microbiology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India

Date of Web Publication31-Mar-2017

Correspondence Address:
Marina Thomas
Department of Microbiology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2214-207X.203539

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  Abstract 

Background/Objective: Hand hygiene (HH) non-compliance is a major cause of hospital-acquired infections, and a gap between knowledge and practice is observed widely. Health researchers are now using a new approach called 'Positive Deviance' (PD) to tackle such behavioural/cultural/social problems leading to adverse health issues. Therefore, can PD approach be used to improve knowledge and compliance of HH practices also? This study is designed to find what are the reasons for PD among nursing staff of our hospital and whether these behavioural changes can be imbibed by others if motivated and trained appropriately.
Materials and Methods: The level of compliance to HH and PD among 25 Intensive Care Unit nurses was noted. This was followed by a second and a third interface consisting of focus group discussions and one-to-one interviews to motivate them based on the PD noted and to detect the possible betterment of compliance to HH.
Results: The practice of HH was followed by 20% of the nurses, and they were identified as positive deviants and when reasons which made them to be compliant were reinforced and impressed on the rest of the nurses, a further 32% became compliant. Awareness of the fact that HH prevents colonisation with potential pathogens was shown by 100% after the intervention.
Conclusions: A PD strategy yielded an improvement in HH compliance. An improvement in knowledge and practice of HH was noted. Multimodal interventions are needed to induce sustained HH practice improvements and this will reduce the gap between knowledge and practice of HH in hospitals and thereby reduce hospital-acquired infections.

Keywords: Compliance, hand hygiene, infection control behaviour, multimodal interventions, positive deviance


How to cite this article:
Srianand A, Thomas M. There is more to hand hygiene than routine training of health workers and display of promotional materials. J Patient Saf Infect Control 2016;4:1-4

How to cite this URL:
Srianand A, Thomas M. There is more to hand hygiene than routine training of health workers and display of promotional materials. J Patient Saf Infect Control [serial online] 2016 [cited 2017 Nov 23];4:1-4. Available from: http://www.jpsiconline.com/text.asp?2016/4/1/1/203539




  Introduction Top


Hospital-acquired infection (nosocomial infection) is an infection which is favoured by a hospital environment, meaning presence of large number of sick people harbouring a variety of microbes and presence of health-care workers (HCWs) who take part in patient care activities. The most important and frequent mode of transmission of microbes causing nosocomial infection is by contact which can be easily minimised by hand hygiene (HH).

HH non-compliance is a major cause of hospital-acquired infections,[1] and HH is the single most effective infection control behaviour that stops the spread of infection.[2] Studies in literature have repeatedly documented that the importance of HH is not sufficiently recognised by HCWs, and compliance with recommended practices is unacceptably low.[3],[4]

HH is the action of cleaning hands using an alcohol-based hand rub, which kills organisms in seconds or, when hands are visibly soiled, using soap and running water.[5] Microorganisms are normal on human skin. Staphylococcus epidermidis, coagulase-negative staphylococci and Staphylococcus aureus, especially in hospital staff, are important bacterial flora found on skin. In a hospital environment where sick people are given care, the risk of acquiring new bacteria by contact and other means is more. Therefore, HH assumes greater importance in a hospital milieu. Advocates of HH improvement recommend that multimodal interventions are needed to induce sustained HH practice improvements and should be based on theories of behavioural change.[6]

Health researchers are now using a new approach called 'Positive Deviance' (PD) to tackle such behavioural/cultural/social problems leading to adverse health issues. PD is an approach to behavioural and social changes based on the observation that in any community, there are people whose uncommon but successful behaviours or strategies enable them to find better solutions to a problem than their peers, despite facing similar challenges and having no extra resources or knowledge than their peers. These individuals are referred to as positive deviants.[7],[8],[9]

The PD approach has been applied in hospitals in The U.S., Brazil, Canada, Mexico, Colombia and England to stop the spread of hospital-acquired infections. The Centers for Disease Control and Prevention evaluated pilot programs in the U.S. and found that units using the approach decreased their infections by 30%–73%.[10]

Aims and objectives

The aims and objectives of this study were as follows:

  • To find the prevalence of HH compliance among nursing staff
  • To find which behaviour/strategy among nursing staff make them to be compliant
  • To share these findings with the non-compliant staff and motivate them and find whether this intervention has improved the HH compliance.



  Materials and Methods Top


A questionnaire based on the knowledge and compliance of HH was administered to 25 Intensive Care Unit (ICU) nurses. The nurses' level of compliance and PD, if any, were noted. In the second interface (after 2 weeks) with the same nurses, through a series of focus group discussions (FGDs), the following knowledge about HH based on 'positive deviants' was impressed upon them.

  • HH prevents transfer of microbes among patients and HCWs
  • Prevents HCWs from being colonised with potential pathogens
  • You must frequently view the posters for HH put up near the wash
  • You must be good examples to students watching you.


Each of them were given two stickers (size) depicting the five moments and 6 steps of HH. After a gap of 2 weeks, in the third interface, the same questionnaire was administered to the same nurses. Their level of compliance and PD were noted and analysed.


  Results Top


All staff were aware of the fact that HH prevents transfer of microbes from HCWs to patients and their surroundings. The practice of HH was followed by 20% of the nurses. These 20% were identified as the positive deviants, and the reason why they were able to consistently perform HH were frequent viewing of posters at the wash area, presence of student nurses along with them, and frequent visits by infection control nurses (ICNs) who remind them of the same. When they were asked specifically about the steps of handwashing (HW) and moments of HH, the same 20% of staff gave the correct sequential response.

During the third interface and FGD with the same nurses, it was found that 52% of nurses were able to correctly identify all the steps of HW and all moments of HH. It was found that frequent viewing of the sticker which was stuck to the inside of their hand bag became a constant reminder to HH in 52% of staff. Motivation to look at the poster was admitted by 32% of staff after the intervention.

Hand hygiene compliance and results of the intervention

[Table 1].
Table 1: Hand hygiene compliance and results of the intervention

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The two-sided sticker provided to all the participants

[Figure 1] and [Figure 2].
Figure 1: The sticker provided to the participants on Moments of HH

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Figure 2: The sticker provided to the participants on the Steps of HW

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  Discussion Top


HH is the single most effective infection control behaviour that stops the spread of infection in hospital, and therefore the observation that only 20% of the nursing staff in ICU following them is most appalling. The compliance ranges from 2% to 50% in various studies.[11],[12],[13] In most instances including our study, all staff were aware of the fact that HH prevents transfer of microbes from HCWs to patients and their surroundings. Thus, a gap between knowledge and practice was noticed in this study as well as in other studies.[14] Making HCWs aware that HH prevents colonisation with potential pathogens is important information which must be consciously impressed upon them and this may help HH compliance.

After an intervention, the HH compliance increased to 52% in this study. Similar success was reposted in other studies also,[15] but whether this effect is sustained or not has to be ascertained by further studies. Adherence to HH is expected to be enhanced by role-modelling, posting HH reminders and presenting audience summaries to clinical teams reminded of complications for the patient. Positive deviants were identified by the nurse managers and they in turn identified others who were good at performing HH.[16]

In this study, frequent viewing of sticker depicting the five moments and six steps of HH, presence of student nurses in the same room when an occasion for HH arises and frequent supervision by ICNs were the items of 'PD' noted by one-to-one interviews. When these factors which helped 20% of staff to perform HH were reinforced to the rest of the staff during the second interface, 20%–32% more staff remembered and demonstrated the attribute. This maybe a moderate increase, but if this process is continued, it will result in a very substantial improvement in HH practices. HCWs were much less likely to perform HH if a peer or a high-ranking person in the room did not perform HH. Compared to HCW who entered a room alone, group behaviour did not seem to improve if the peer or high-ranking person did wash his/her hands.[17]

Exchanging experiences and reading articles related to HH studies are ways to exhibit PD that need to be encouraged so that all doctors and nurse improve HH compliance. Telling your peers how often you succeed and how often you fail can be a good beginning.[18]

A better understanding of planned behavioural change by peer pressure and linking attitude and behaviour affecting HH to various models of health behavioural change can increase the potential for success of HH program.[19] Thereby, staff nurses may be used as models to apply their PD factor to other participants not showing the desirable behaviour. An increased awareness about the dangers of transmission of hospital bugs from patient to self and vice versa has resulted in a changed behaviour in our participants. This was achieved by one-to-one interviews and FGD. Therefore, by increasing awareness, the participants may plan to change their practice. When HCWs observe their peers and supervisors performing HH according to the correct technique, they are motivated to follow the steps. Therefore, planting staff with known desirable behaviour in high-risk areas would become a tailored intervention to predict and motivate an individual to a desirable change according to the trans-theoretical model of health behavioural change.

Based on these theories, multimodal interventions are needed to induce sustained HH practice improvements. On an individual level, the intervention should target provider education and motivation regarding HH practices; on the interpersonal level, patient empowerment and cues to action should reinforce proper HH practices; and on the organisational level, organisational structure and philosophy should be supportive of proper practices.[6]

A PD strategy yielded a significant improvement in HH. The practice of HH was followed by 20% of the nurses initially. After the intervention, it was found that 52% of nurses were able to correctly identify all the steps of HW, all moments of HH and executed them. Motivational techniques with FGDs and one-to-one interviews seem to bridge the gap between knowledge and practices. Hence, there is more to HH than mechanically training HCWs and display of promotional materials.


  Conclusion Top


A Positive Deviance strategy yielded an improvement in Hand Hygiene compliance. We can see that it is time and skill intensive but at the same time it facilitates an unique vantage point to build and sustain a positive impact.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cummings KL, Anderson DJ, Kaye KS. Hand hygiene non-compliance and the cost of hospital acquired MRSA infection. Infect Control Hosp Epidemiol 2010;31:357-64.  Back to cited text no. 1
    
2.
Larson E. Skin hygiene and infection prevention: More of the same or different approaches? Clin Infect Dis 1999;29:1287-94.  Back to cited text no. 2
    
3.
Ji G, Yin H, Chen Y. Prevalence of and risk factors for non-compliance with glove utilization and hand hygiene among obstetrics and gynaecology workers in rural China. J Hosp Infect 2005;59:235-41.  Back to cited text no. 3
    
4.
Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Infection Control Program. Ann Intern Med 1999;130:126-30.  Back to cited text no. 4
    
5.
World Health Organization. WHO guidelines on hand hygiene in health care. (NLM Classification: WB 300). Geneva, Switzerland: World Health Organization; ©2009.  Back to cited text no. 5
    
6.
World Health Organization. WHO Guidelines on Hand Hygiene in Health Care:First Global Patient Safety Challenge; 2009. Available from: http://www.who.int/gpsc/country_work/en/. [Last accessed on 2011 Nov 22].  Back to cited text no. 6
    
7.
Tuhus-Dubrow R. The Power of Positive Deviants: A Promising New Tactic for Changing Communities from the Inside. The Boston Globe; 29 November, 2009.  Back to cited text no. 7
    
8.
Sternin J, Choo R. The Power of Positive Deviancy. Brighton, Massachusetts: Harvard Business; 2000.  Back to cited text no. 8
    
9.
Singhal A, Dura L. Protecting Children from Exploitation and Trafficking Using the Positive Deviance Approach in Uganda and Indonesia. Washington DC: Save the Children Federation Inc.; Journal of Creative Communications; 2009. p. 1-17.  Back to cited text no. 9
    
10.
Awad SS, Palacio CH, Subramanian A, Byers PA, Abraham P, Lewis DA, et al. Implementation of a methicillin-resistant Staphylococcus aureus (MRSA) prevention bundle results in decreased MRSA surgical site infections. Am J Surg 2009;198:607-10.  Back to cited text no. 10
    
11.
Liu WI, Liang SY, Wu SF, Chuang YH. Hand hygiene compliance among the nursing staff in freestanding nursing homes in Taiwan: A preliminary study. Int J Nurs Pract 2014;20:46-52.  Back to cited text no. 11
    
12.
Al-Wazzan B, Salmeen Y, Al-Amiri E, Abul A, Bouhaimed M, Al-Taiar A. Hand hygiene practices among nursing staff in public secondary care hospitals in Kuwait: Self-report and direct observation. Med Princ Pract 2011;20:326-31.  Back to cited text no. 12
    
13.
Bukhari SZ, Hussain WM, Banjar A, Almaimani WH, Karima TM, Fatani MI. Hand hygiene compliance rate among healthcare professionals. Saudi Med J 2011;32:515-9.  Back to cited text no. 13
    
14.
Harsha Kumar HH, Dileep D. An epidemiological study on hand washing practices among health care workers in hospitals of Mangalore City. Natl J Community Med 2013;4:261-6.  Back to cited text no. 14
    
15.
Feyissa GT, Gomersall JS, Malt SR. Compliance to hand hygiene practice among nurses in Jimma University Specialized Hospital in Ethiopia: A best practice implementation project executive summary background. JBI Database System Rev Implement Rep 2014;1:318-37.  Back to cited text no. 15
    
16.
Marra AR, Guastelli LR, de Araújo CM, dos Santos JL, Lamblet LC, Silva M Jr., et al. Positive deviance: A new strategy for improving hand hygiene compliance. Infect Control Hosp Epidemiol 2010;31:12-20.  Back to cited text no. 16
    
17.
Lankford MG, Zembower TR, Trick WE, Hacek DM, Noskin GA, Peterson LR. Influence of role models and hospital design on hand hygiene of healthcare workers. Emerg Infect Dis 2003;9:217-23.  Back to cited text no. 17
    
18.
Gawande A. On washing hands. N Engl J Med 2004;350:1283-6.  Back to cited text no. 18
    
19.
Al-Tawfiq JA, Pittet D. Improving hand hygiene compliance in healthcare settings using behavior change theories: Reflections. Teach Learn Med 2013;25:374-82.  Back to cited text no. 19
    


    Figures

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    Tables

  [Table 1]



 

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