Ma. Elena Zavala-Alonso,1 Elsa Alvarado-Gallegos,2 Rafael Nieva-de Jesús3
1Hospital General de Zona 2 con Medicina Familiar; 2Coordinación de Cursos de Enfermería, Centro de Investigación Educativa y Formación Docente; 3Unidad de Medicina Familiar 3. Instituto Mexicano del Seguro Social, San Luis Potosí, San Luis Potosi, México
Registro Comité Local de Investigación en Salud R-2012-2402-24
Correspondence: Ma. Elena Zavala-Alonso
Received: October 28th 2015
Judged: January 20th 2016
Accepted: June 22nd 2016
Introduction: Safe care in relation to nursing inpatient care includes the use of information and resources for hand hygiene with the right technique, either with soap and water or alcohol based sanitizers. WHO believes that non-adherence to the practice of hand hygiene is associated with nosocomial infections, which are a global problem that involves high costs of care.
Objective: To describe the factors related to the practice of hand hygiene by nurses of a secondary- level hospital.
Methods: Cross-sectional study in a sample of 103 nurses. Nursing assistant staff nurse, and general hospital areas 3 shifts, and intensive care nurse specialist in the Intensive Care Unit was included. The instrument was designed on purpose and validated by experts in the field.
Results: 70.7% of the surveyed nurses have correct information on the practice of hand hygiene, 71% perceived adequacy of human resources in services, 90% reported the existence of supplies and 40% the existence of an evaluation system.
Conclusions: It was identified that the timeliness of information and evaluation are the factors that favor the practice of hand hygiene for nurses
Keywords: Hand disinfection; Inservice training; Human resources; Supervisory nursing
Despite its simplicity and effectiveness, hand hygiene (HH) is a practice that health workers often neglect:1 61% of workers do not wash their hands when necessary, and 31% of patients contract infection at the surgical site. More than 1.4 million people worldwide have contracted hospital-acquired infections. This problem prolongs hospitalization 3 to 20 days. It can cause disability and death, along with higher costs for patients and economic burden on health systems.
Preventing infections and reducing avoidable burden on health systems remain critical issues throughout the world, so it is essential to ensure that all persons seeking health services are treated safely. There is a risk associated with infection for hospitalized patients associated with hospital care that particularly increases for patients undergoing surgery.2
To ensure hospitalized patients' safety, employees need a clean computer, clean practices, clean procedures and clean hands.3 The most important part of those practices is to ensure that every service provider, healthcare professional, or caregiver maintains hygiene at all times, and knows correct procedures at the time indicated.4,5 According to the recommendations of the World Health Organization (WHO), when hands are not visibly soiled, they can be cleaned with an alcohol-based hand sanitizer. Rubbing hands together for 20-30 seconds is the preferred means to sanitize, considered quicker, more effective and better tolerated than washing with soap and water. When hands are visibly dirty, soiled with blood or other body fluids, or after using the toilet, they should be washed with soap and water for 40-60 seconds.6 Where there is suspicion or knowledge of being exposed to pathogens that release spores, and particularly outbreaks of clostridium difficile, the preferred method is handwashing with soap and water during the time recommended.6-8
It is recommended that health workers perform hand hygiene when visibly dirty, before and after touching the patient, after touching sources of microorganisms such as blood or body fluids, mucous membranes, non-intact skin or inanimate objects that may be contaminated.9
There are opportunistic pathogens that cause nosocomial infection, which is transmitted from one patient to another via the hands of hospital staff.10,11 Their colonization on health professionals' hands is unavoidable, and if there is no hand hygeine, the degree of contamination becomes greater. As urinary catheters, intravenous catheters, endotracheal tubes and drainage are exposed, there is an increased risk to the safety of patients, with or without compromised immunity.12,13
The use of standard precautions in the control of nosocomial infections is proven. It applies to all patients receiving care, regardless of their diagnosis, risk factors and their presumed infectious status; thereby risk of infection to the patient and hospital staff is decreased.14
In a study of handwashing and factors associated with noncompliance, it is noted that 30 seconds of handwashing reduces 90 to 95% of bacteria on the hands. Noncompliance is related to the lack of supplies, and to ignorance of nosocomial infections. It should be noted that the quality of handwashing by staff was insufficient. It was concluded that for health workers to improve hand hygiene the steps that must be taken are: continuing education, tracking and monitoring, and provision of supplies.15
Regarding hygiene conduct, there are three types of related factors: predisposing factors (receiving related information, valuing the effectiveness of hygiene, and the fact that it is possible to acquire infections through patients); facilitating factors (availability of alcohol-based hand santizer, hygiene that does not involve effort, lack of pressure) and reinforcing factors (supervisor gives importance to hygiene and imitation of positive behaviors). Conditioning variables regarding accessibility to hand hygiene, professionals’ beliefs of self-protection, modesty, skepticism, and models or reinforcements were identified.16-18
Following up on the international goal for patient safety in regards to reducing infection risks associated with care through an effective hygiene program, and based on the statistical data reported by the Nosocomial Infection Committee of the Hospital General de Zona 2 of IMSS, concerning rates of nosocomial infections and particularly surgical site infection, it is necessary to identify nursing staff compliance with hand hygiene, considering the time contact was established during patient care.
Cross-sectional study in nursing staff categories: general nurse, Intensive Care specialist nurse, and nursing assistant; conducted in the following shifts: the morning, afternoon, and night shifts A and B, of the following departments: Emergency, Internal Medicine, Orthopedics, Surgery, Dialysis, Intensive Care Unit, and Operating Room.
Not included were: the chief nursing officer, deputy floor chief and heads of nursing, Operating Room specialist nurses and those working in Public Health, Preventive Medicine and Outpatient departments. Questionnaires with less than 80% filled out were eliminated.
Based on a probabilistic sampling strata, a sample confidence level of 95% and 5% error (STATS program v.2), were calculated. A sample of 103 nurses was obtained.
The dimensions studied are: a) Information and staff training regarding hand hygiene (HH); b) Coverage of human resources as a factor in HH compliance; c) Supply resources for HH, and d) HH Compliance evaluation systems.
To measure the factors involved in compliance with hand hygiene, a specially designed instrument was designed, based on World Health Organization guidelines and similar research studies. This instrument consists of a section of general information such as category, shift, department, educational level, seniority, age, and gender. Structured with 30 questions, the numerical value of the response options 0, 1 and 2, vary according to the type of survey item. In dichotomous questions, 0 = absent, 1 = right, 2 = wrong; and 0 = absent, 1 = Yes, 2 = no; in true and false questions: 0 = absent, 1 = true 2 = false. Questions regarding supplies were graded options: always (100%) = 1, often (75%) = 2, sometimes (25%) = 3, and never (0%) = 0. Questions about occurrences in a hospital were scored: always = 1, 75% complete = 2, 50% complete = 3, 25% complete = 4, never = 5; open-ended questions were also included.
Questionnaire validation regarding content relevance and reliability was performed by five clinical and methodological experts. After the review and corrections, 10% of the population proceeded to the pilot, the location chosen was similar to that of the sample. The instrument reached a degree of reliability with Cronbach's alpha of 0.80.
The information was processed with SPSS version 15 with descriptive statistics (mean, median, absolute and relative frequencies and standard deviation). The inferential statistics test was for the association of risk factors with response assessment and logistic regression to determine the statistical significance of the findings and their relationship to hand hygiene compliance. However, the statistical test showed no significant association between the variables investigated.
Signed informed consent was required of study subjects. The study was regulated under the guidelines of the Helsinki Declaration, which calls for a review of all research projects applied to people by an ethics committee, to safeguard respect of the interviewees at all times. It also complied with the ethical aspects of the Ley General de Salud, which establishes respect for human dignity in research studies.
Of all surveyed nurses, 100% have information about hand hygiene's role in the prevention of nosocomial infections, while almost 80% of staff believe that the hands are the main contact point for infection to occur. 96% of the staff gave an example of a nosocomial infection, however only 39% have information about the main germs found in the hospital. Regarding the elements of hand hygiene (HH), only 9% of nurses have accurate information about the HH steps, 42% about the concept, and 41% on the 5 steps. About the time recommended by the WHO for hand hygiene using antibacterial gel (HHAG), and for soap and water (HHSW), only 63% and 67% of staff have accurate information about the time for hand hygiene in both cases; about less than half the staff (42%) has information about the differences in technique.
It is relevant to note that 95% and 100% of nurses reported that the use of gloves does not replace hand hygiene and especially not if the patient is immunocompromised; 92% also know that hand hygiene is important to start before any activity or procedure (Table I).
|Table 1. Staff information and training about Hand Hygiene (n = 103)|
|Staff information about:||Correct||Incorrect||No answer|
|The concept of HH||43||42||52||50||8||8|
|HH prevents HI||103||100||0||0||0||0|
|The 5 steps of HH||42||41||53||51||8||8|
|Recommended time for HH / AG||65||63||36||35||2||2|
|Recommended time for HH / SW||69||67||31||30||3||3|
|Difference between HHAG and HHSW||42||41||59||57||2||2|
|The HH steps||9||9||90||87||4||4|
|Hands as principal contact point||79||77||14||13||10||10|
|Use of gloves doesn’t replace HH||98||95||4||4||1||1|
|Types of infectious fluids||103||100||0||0||0||0|
|HH in care of immunocompromised patients||103||100||0||0||0||0|
|What is the most common germ in the hospital||40||39||61||59||2||2|
|Importance of HH upon hospital entry||95||92||6||6||2||2|
|An example of NI||99||96||2||2||2||2|
|HH = Hand hygiene; HI = hospital-based infection; AG = Antibacterial gel; SW = Soap and water. Fuente: LM-IMSS-2012 Survey|
Regarding the human resource coverage dimension of hand hygiene compliance, 59% of the personnel indicated that departments are partially covered. 75% of this group proposes alternative solutions to organization to improve HH compliance. Also 84.5% responded positively and in favor of efforts to do the HH technique correctly and put the 5 steps into practice, including using their own resources to supply soap or alcohol gel, and even educate families about HH. Furthermore, 12% and 14% said that staff departments are covered 100% and 50%, respectively. Only 5% say that departments have low coverage of 25% (Figure 1).
Figure 1. Dimension of Human Resource coverage of HH compliance (n = 103). Source: LM-IMSS-2012 Survey
With regard to supply materials for HH, 95% of nurses said that they have potable water and 75% indicated the availability of disposable towels. A lesser proportion has liquid soap (45%), bar soap (50%) or alcohol gel available 58% (Figure 2).
Figure 2. Supply dimension of HH compliance (n = 103). Source: LM-IMSS-2012 Survey
In the evaluation system dimension of HH compliance, 40% of nursing staff report being evaluated, 75% of them say they are notified of the results, 48% receive feedback, and only 8% say that they are given recognition of compliance (Figure 3).
Figure 3. Evaluation system dimension for the practice of HH by nursing staff (n = 103). Source: LM-IMSS-2012 Survey
Based on the available information on hand hygiene, continuous practice and the formation of a habit in professional health personnel is a challenge to achieve a satisfactory level in compliance with the right technique and the 5 steps of handwashing.11,12 In that respect, the benefits of hand hygiene to control hospital-based infections have been demonstrated.13 It is a primary measure of care quality and patient safety in all settings.14 Despite the availability of resources such as water, supplies such as disposable towels and liquid soap, the resources are insufficient for the night shift.
In related studies, the supply of materials, a necessity for staff to adhere to hand hygiene compliance is addressed as a common problem in public assistance hospitals.15
Monitoring, providing information and training staff about hand hygiene, although they are the responsibility of each staff member, are paramount in the exercise of leadership by the department head.16 Incidental or formal feedback is relevant through in-service education. Feedback provides information on the skills acquired and developed in staff, i.e. what the staff knows, what they do, and about how they do it. Discovering the perspectives, thoughts, feelings, and actions of people in their environment allows for performance recognition, including how to improve it in the future. Performance recognition has a high impact on the person and motivates them to improve every day.17
Therefore, it is necessary to strengthen the evaluation system as regards recognition and feedback from both staff, both for compliant staff and those in the process of achieving compliance rates in the practice of hand hygiene, and other practices that ensure patient safety.
Information and training, and evaluation systems, two of the most important factors involved in compliance with hand hygiene practice by nurses, are the areas of opportunity identified by these results.