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Nurses Role in Infection Control Through Hand Hygiene Emily W. Kosmicki Ferris State University

2 NURSES ROLE IN HAND HYGIENE Abstract Hand washing is a key component in infection control, yet compliance continues to be an issue with health care workers. This paper explores the nurses role within the healthcare environment related to increasing hand washing compliance and efficacies and theories which support this role. Consequences of the current state of hand washing compliance are explored as well as limitations of change initiatives. Recommendations for nurse-led quality and safety improvements are made to improve and enhance overall hand hygiene compliance.

3 NURSES ROLE IN HAND HYGIENE The Nurses Role in Infection Control Through Hand Hygiene The Center for Disease Control (CDC) has substantial evidence that hand-washing is the most effective way to prevent hospital acquired infections (CDC, 2013). As stated by the American Association of College of Nursing (AACN), nurses are the largest single component of hospital staff (2014). Increasing nursing compliance with hand hygiene policies can have drastic effects on decreasing the number of hospital-acquired infections. As stated by the CDC, it is estimated that 50% of diarrhea related deaths could be prevented as well as a 16% reduction in the risk of respiratory infections by through proper hand-washing with soap and water (CCD, 2013). With the increased convenience and popularity of alcohol based hand-sanitizer (ABHS), it can be questioned if this measure is as effective as washing hands with soap and water. Hospital acquired infections are the 11th leading cause of death in the United States, costing the health care system close to $4.5 billion annually (Salamon, 2009). Waltman, Schenk, Martin, & Walker report that the CDC estimates that 10% of all hospital admissions result in hospital acquired infection related deaths (2011). The central question which arises given these statistics is what barriers are preventing nurses and other healthcare workers from engaging in proper hand hygiene at all times? It is important that all individuals interacting with patients on a daily basis are educated and executing the methods necessary to effectively reduce the spread of infection through proper hand washing. Individuals can include family members, physicians, therapists, dietary staff, and even visitors. With the wide range of individuals interacting with a patient at a given time, there will be a variety of learning styles, educational background, and varying experiences that may alter how an individual practices and remembers to participate in hand hygiene. Nurses can

4 NURSES ROLE IN HAND HYGIENE serve as primary educators for patients, families, and co-workers on the importance of hand hygiene as nurses are the primary health care providers in the hospital setting. Theory Base The concept of practicing medicine in a clean environment to reduce complications of infection became evident with the nursing theory of Florence Nightingale. As discussed by Alligood, Nightingale was ahead of her time in understanding the effect of a clean environment in a healing patient. It was believed that health could be maintained through environmental control and nurses accepting responsibility. Through continual emphasis on hygiene in practice, an ongoing list of environmental problems, results, and solutions can help minimize infections (2013). Nightingales Book, Notes on Nursing, discusses how environmental factors can influence health. The environmental factors Nightingale focused on were air and water quality, noise, light, and nutrition as those were the needs of patients in her time. This theory is the groundwork for infection control. In order for patients to heal and maintain optimal health, there needs to be an environment that supports this. As discussed by ShanerMcRae, McRae & Jas, several contemporary theorists such as Jean Watson continue to use Nightingales model for provision in recognizing that the environment should promote healing (2007). Hand hygiene is a vital component of maintaining a clean environment. Through nurses accepting responsibility for their actions in minimizing spread of infections, the ultimate goal of maintaining health can become more attainable. The Social Cognitive Theory by Albert Bandura explains how people acquire and maintain certain behavioral patterns while also providing basis for intervention strategies (Bandura, 1997). This theory establishes a distinction between performance, competence, and self-efficacy. Self-efficacy is an individuals awareness to reach a certain goal (Desbiens,

5 NURSES ROLE IN HAND HYGIENE Gagnon, & Fillion, 2012). As a member of the interdisciplinary team, the nurse can collaborate with varying health-care professionals in emphasizing awareness each action (hand-washing) is targeting to produce a positive outcome (reducing the number of HAI). As a whole, if a sense of accountability is upheld by all members of the interdisciplinary team, then the ultimate goal of decreasing the number of infections can be more easily attained. Assessment of Healthcare Environment An assessment of the healthcare environment can be an indicator as to what policies or interventions are influencing compliance to hand hygiene. A Conchane review by Gould, Moralejo, Drey, & Chudleigh reported that the majority of health care acquired infections are spread through direct hand contact. Therefore, hand washing is considered the most effective way to prevent spread of infection yet compliance to these policies is poor (2011). Spectrum Health in Grand Rapids, Michigan increased hand hygiene compliance among nurses from 60% to over 90% through an initiative led by the hospitals Infection Control and Prevention Team (Maxfield, Dull, Ostrowski & Ozarow, 2011). This initiative applied the Influencer Model which utilizes six sources of influence, finds vital behaviors, which results in clarifying measureable results. Personal motivation, personable ability, social motivation, social ability, structural ability and structural motivation were identified as the six sources of influence. Each of these categories motivates and enables individuals to make changes through personal and social means. Vital behaviors established include the Wash-In-Wash-Out policy (washing hands upon entering and leaving a patients room), accountability to self and others, and saying thank you to other staff members when reminded to wash hands. The clarifying measurable results indicated that nurses can serve as leaders in implementing behavior changes in handhygiene compliance (Maxfield, Dull, Ostrowski & Ozarow, 2011). Challenges for this particular

6 NURSES ROLE IN HAND HYGIENE policy may include long-term compliance of abiding by all aspects of the Influencer model. A study by Zaragoza, Salls, Gomez, Bayas, & Trilla, discusses maintaining compliance with various approaches to improve hand washing in that shortly after introduction to new polices, compliance rates will often return to baseline (1999). Varying ideas of when hand hygiene is appropriate, dependent on the nursing task completed presents as another factor to compliance. A study by Gl,, stnda, & Zengin used the Fulkerson scale (a means to rank contact with certain things as clean or dirty) in having nursing students assess whether or not a given task was considered clean or dirty and if hand hygiene should be performed. Results show a discrepancy between answers which indicates that individuals can benefit from hand washing policy and procedure education (2012). Challenges associated to the findings of this study may be indicative that multidisciplinary approaches may need to be taken to ensure that a baseline education is practice by all health care providers in hand hygiene. Health care organizations may assume that employees received adequate hand hygiene education in school or training programs. However, educational programs may only give a brief overview of proper hand hygiene with the assumption that more training will be given once in the health-care setting. The Joint Commission developed a monograph on measuring hand hygiene and overcome the challenges associated relating to adherence. Through collaboration with several healthcare organizations including the World Health Organization (WHO) and the CDC, a framework was developed to help guide health care professionals (nurses) measure and improve hand hygiene compliance. It is often expected that health care professionals are educated and trained on how to properly adhere to hand hygiene at all times, yet there are varying opinions and barriers for compliance (Joint Commission, 2009).

7 NURSES ROLE IN HAND HYGIENE Contents include aiding organizations on decisions on how, what, when, and why measuring hand hygiene amongst employees is necessary. The first chapter of the monograph describes current hand hygiene guidelines established by the WHO and CDC then describing the difference between hand hygiene indications and discuses current barriers to health care professionals. The importance of choosing a measurement method that best fits the needs of the organization is discussed as well as the assessment process needed to measure. A comprehensive review of when the observing will occur, who will be observed, and who will do the observing are measurement methods which need to be established. The measurement of product use include any advantages or limitations pertaining to specific products (soap, hand sanitizer, paper towel, etc.). It is also important to assess hand hygiene thoroughness including length of washing, nail, jewelry, and glove usage. Data results should then be displayed to best fit the learning styles of the organizations employees in order to visualize the difficulty tracking hand hygiene compliance and infection rates. Based on data outcomes, an overview of possible resources as well as improvement strategies and interventions can be developed (Joint Commission, 2009). Inference/Implications/Consequences Waltman et al. found that through active involvement and participation in hand hygiene programs there was a direct effect on increased compliance to CDC guidelines (2011). The study had baccalaureate nursing students take a hand hygiene knowledge survey, hand washing opinion survey, and a hand hygiene practice survey to become aware of own knowledge and attitudes on hand hygiene compliance. Once surveys were completed, the nursing students were paired up with hospital employees to monitor hand hygiene throughout a shift. Observations were random, occurring on different days, and different shifts in order enhance data representation. Through a hands-on approach, students were able to expand their knowledge on

8 NURSES ROLE IN HAND HYGIENE the lack of adherence to hand hygiene policies of others and make positive changes to their own practice of infection control (Waltman et al., 2011). The dispute on best practice between washing with ABHS and soap and water continues to be a debatable topic. Carter (2013), reports the disadvantages of using ABHS as the primary means of hand hygiene unless hands are visibly soiled. ABHS are not effective in killing certain strains of pathogens that include the norovirus and Clostridium-difficile. The question of whether over-use and over reliance on ABHS has contributed to the development of super-bugs that are resistant to treatment and are responsible for infection outbreaks across the nation. It is also suggested that individuals may not be using adequate amounts of sanitizer or are wiping hands before sanitizer is completely dry (CDC, 2013). The CDC recommends using soap and water as primary means for hand-washing but when not available, hand sanitizer with at least 60% alcohol is recommended (CDC, 2013). Gl et al. (2012), used self-reporting of hand hygiene by nursing students to measure knowledge and identify barriers that can be used in developing new educational strategies for compliance. Zaragoza et al., found that although health care professionals are educated on the importance of hand washing for effective infection control, it has been repeatedly shown that compliance rates are less than optimal. The study also found that manually turning on the faucet and touching handles without paper-towel were the most common unintentional breaks in hand washing policies (1999). Recommendations for Quality and Safety Improvements There are several interventions that can be implemented by nurses to improve quality and safety in the acute care setting through means of hand-washing. The American Nurses Association (ANA) has set forth professional practice standards for nurses to follow in practice

9 NURSES ROLE IN HAND HYGIENE to ensure that patients are receiving the highest quality and ethical care. In addition, Quality and Safety for Nurses (QSEN) was developed as a national effort to enhance quality and safety competencies through knowledge, skills, and attitudes necessary among nursing students to instil in their future practice (QSEN Institute, 2014). The ANAs Scope and Standard of practice has identified how quality and safety can be improved through various strategies which can then be applied to hand-hygiene to reduce infection rates. Standard of practice 5B-Health Teaching and Health Promotion, states that the registered nurse employs strategies to promote health and a safe environment (ANA, 2010, pg. 41). Through proper hand washing techniques, the nurse is engaging in risk-reducing behaviors which is a competency identified in this standard. As discussed by Patrick and Van Wicklin (2012), proper hand-washing techniques should be heavily discussed in the orientation process well as ongoing education to ensure that hand washing policies are being maintained. Standard 9-Evidence Base Practice and Research states the registered nurse must integrate evidence-based findings into practice and patient care (ANA, 2010). Knowing best practice when deciding whether to wash hands with soap and water versus washing with ABHS, is a challenge the nurse faces on a daily basis. QSEN identifies integrating best current evidence into practice through understanding, demonstrating, and evaluating the current literature available on a given nursing topic (hand hygiene) (QSEN Institute, 2014). Carter (2013), discusses the growing popularity of ABHS since 2002, yet as previously discussed there are issues associated with the over-use of this product indicating that hand washing with soap and water can be identified as evidence-based practice for nurses. Standard 16-Enviromental Health states, the registered nurse practices in an environmentally safe and healthy manner (ANA, 2010, pg. 61). The nurse can fulfill this

10 NURSES ROLE IN HAND HYGIENE standard of practice by ensuring proper hand hygiene is consciously being followed 100% of the time. Patrick and Van Wicklin (2012) discuss how lack of appropriate hand hygiene is considered the leading cause of hospital acquired infections from transmission of bacteria. Yet, less than 50% of health care professionals adhere to proper hand hygiene practices at a given time. A given floor or unit in a hospital should ideally see a reduction in the number of hospital acquired infections over a 6 month period if staff members are abiding by the hand washing protocols and procedures at all times. As described in the QSEN quality and improvement competency, data can be monitored and outcomes can be measured (QSEN Institute, 2014). If hospital acquired infections continued to rise over a six month time period, a change in protocol or policy would have to be evaluated with changes made to improve quality of care. Patrick and Van Wicklin describe an effective approach to maintaining hand hygiene by developing policies that fit the needs of the patients and monitoring compliance to policies on an ongoing basis making changes when necessary (2012). Safety and optimal health are priority issues when caring for patients as a nurse. The QSEN competency of safety is to minimize the risk of harm to patients through an effective collaboration between systematic and individual actions (QSEN Institute, 2014). Being said, a sole nurse may not think that her actions will influence the risk of infection, when in reality, if all health care providers thought this way, infection rates would radically increase every day. Numerous research articles have been published implicating hand hygiene compliance in minimizing infection in the health care environment. Although articles similarly stress the importance of proper hand hygiene, there is a variance in study designs as how to meet the desired outcome (reduction in number of hospital acquired infections). Gould et al. (2011) postulated through a Cochrane systematic review that there is still not enough evidence to show

11 NURSES ROLE IN HAND HYGIENE what strategies improve hand hygiene associated with patient care. The use of hand sanitizer accompanied by ongoing education, is not making enough of an impact in reducing the number of HAI. It is theorized through including staff in planning activities or applying social marketing strategies will increase compliance; the article suggests more evidence is needed to formulate effective interventions that can be closely monitored for at least 12 months. Vogel (2011) discusses the long-term implementations of hand sanitizer use. With current research bringing possible consequences of hand sanitizer use to light, it can be conjectured that recommendations against hand sanitizer use may decrease hand hygiene compliance even further. Additional research is also needed on recommendations as to how often to wash hands with soap and water after using ABHS. The University of Michigan recommends washing hands with soap and water when a build-up of emollients is felt on hands (University of Michigan Health System, 2014) whereas the CDC recommends washing with soap and water after 4-5 times of using ABHS (CDC, 2013). As identified by the Joint Commissions monograph, through identifying barriers contributing the hand hygiene adherence, an organization is able to develop interventions or strategies to increase compliance amongst workers. The process to identify barriers may come at a cost as monitoring is often resource intensive through time, energy and money invested (Joint Commission, 2009). However, if adequate resources are invested the quality and safety related to the patient outcome of decreased infections would be well worth the investment. In order to improve quality and safety the nurse can incorporate numerous concepts into practice as recommended by research to increase compliance with hand washing. The nurse can engage self in ongoing education related to organization policies and procedures as well as remaining knowledgeable on evidence base best practice. Recognizing own barriers as well

12 NURSES ROLE IN HAND HYGIENE potential barriers of co-workers is key to establishing proper interventions to entire team of health-care workers compliance to hand hygiene. However, as discussed throughout the paper, compliance continues to be an issue regardless of recommendations from research related to this topic. With continuing advances in technology, it can be hoped that a means to better detect hand hygiene compliance is in the works. For example, if hospital rooms were equipped with a UV light source indicating that a health care professional had not washed their hands prior to entering the room, a higher sense of accountably may be held by providers as they do not want to seem incompetent of such a simple task. Regardless of interventions completed by the nurse, hand hygiene compliance continues to be an ongoing issue that must be addressed at all times in order to maintain patient safety and quality of care. Further research is needed in order to establish the best means necessary for hand hygiene compliance amongst health care workers. Conclusion Based on the findings throughout this paper, nurses play a vital role in preventing the spread of hospital acquired infections in the hospital setting through compliance of hand washing policies and procedures. Through recognition of barriers, holding self and others accountable, continuing education on best practice, and developing strategies to increase hand hygiene compliance, nurses can lead the initiative to drastically reduce the number or hospital acquired infections through proper hand washing.

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