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Running head: EXPLORING HAND HYGIENE COMPLIANCE IN NURSING 1

Exploring Hand Hygiene in Nursing and Identifying

Mechanisms for Improving Compliance Rates

William Erskine

Paige Hawkins

Alexis Hertz

Olivia Millsop

Youngstown State University


EXPLORING HAND HYGIENE COMPLIANCE IN NURSING 2

Abstract

This literature review aimed to define non-compliance of hand hygiene and identify mechanisms

to improve hand hygiene compliance in nurses by evaluating existing research studies. Non-

compliance includes, but is not limited to, not practicing hand hygiene or not maintaining the

minimum time requirement when performing hand hygiene in any of the following five moments

the World Health Organization recommends practicing hand hygiene. These are identified as (1)

before touching a patient; (2) before a clean/aseptic procedure; (3) after body fluid exposure risk;

(4) after touching a patient; (5) after touching the patients surroundings. We then explored

multiple options to identify effective ways to improve hand hygiene compliance. One of the

studies we reviewed utilized a badge that detected the use of alcohol based hand rubs upon

entering and exiting the room. Another study focused on the notion that hand hygiene

compliance is associated with a change of perception toward hand hygiene among medical

personnel. The last study discussed implemented ultrasound transmitters that monitored hand

hygiene compliance of nurses on specific units. They then cross referenced the data collected

with intermittent direct observation, ensuring their accuracy. All of these methods suggest that

there are tangible ways to improve hand hygiene compliance in nursing across all fields of health

care.
EXPLORING HAND HYGIENE COMPLIANCE IN NURSING 3

Exploring Hand Hygiene in Nursing and Identifying

Mechanisms for Improving Compliance Rates

Hand hygiene compliance in the medical field, specifically compliance among nurses, is

an important step in the process of reducing the amount of hospital acquired infections, which

can be devastating to the patient medically and emotionally, and the hospital or health care

setting financially and legally. Several different mechanisms can be used to improve compliance;

however, the first step to improving compliance begins with education and self-awareness. Five

different clinical moments are first identified, and then a follow-up on the state of compliance

must be completed to ensure medical personnel are remaining compliant. The mechanisms

identified in this literature review include: detection devices and campaigns to improve hand

hygiene compliance in medical based practices.

Literature Review

There are five different clinical moments of hand hygiene specified by the World Health

Organization (WHO). The WHO model was developed based on a pattern of hand transmission

of microbes, and elements of cognitive behavioral science and social marketing. These moments

are identified as (1) before touching a patient; (2) before a clean/aseptic procedure; (3) after body

fluid exposure risk; (4) after touching a patient; (5) after touching the patients surroundings (Lau

et al., 2014).
There was a cross-sectional observational study done between medical and nursing

students at a teaching university that looked at compliance across these five moments. These

students were given a hand hygiene lecture at the beginning of the year, but they were not

reassessed on their hand hygiene directly after. At the end of the students first year, they were

given a questionnaire in which each student rated their own compliance rate. They were supplied

with a five-point scale, which showed the number of times hand hygiene was performed at each
EXPLORING HAND HYGIENE COMPLIANCE IN NURSING 4

of the five clinical moments (Lau et al., 2014). The results reported an overall compliance rate of

83.0 percent. At each clinical moment, compliance rates were 71.4 percent at moment 1, 88.2

percent at moment 2, 95.4 percent at moment 3, 90.8 percent at moment 4, and 69.6 percent at

moment 5 (Lau et al., 2014). Compliance with hand hygiene was clearly the lowest right before

touching the patient and after touching the patients surroundings.


On the questionnaire, the students were also required to report some reasons for non-

compliance. The students described three main reasons for non-compliance. The four most

commonly reported reasons for non-compliance were: hand-washing agents cause skin irritation

and dryness, forgetfulness, being too busy, and hand-washing agents have a bad smell (Lau et al.,

2014).
It is evident that hand hygiene is important, though many medical personnel are not

aware of the five specific moments that it is most important to practice. Increasing education on

both parameters for hand hygiene as well as the defined moments in which hand hygiene is

required would improve compliance.

One way to increase hand hygiene compliance is to implement devices that can monitor

hand hygiene compliance without direct observation. According to Edmond (2010) there are

three methods to measure hand hygiene compliance; direct observation, self-reporting and

indirect measurement, with direct observation being the most accurate but also the most costly.

Edmond, Goodell, Zuelzer, Sango Elam, and Bearman came up with the idea to test hand

hygiene compliance using a credit card sized vapor detector to monitor hand hygiene

compliance. Nineteen nurses volunteered to wear a detector for a two week period. The detector

would activate at the doorway and the nurse would have eight seconds to put their hand near the

badge so it would detect if an alcohol based wash was used. If the nurse had completed hand

hygiene the badge would ding and a light would turn green. The badge would also activate upon
EXPLORING HAND HYGIENE COMPLIANCE IN NURSING 5

exiting the room, and the nurse would then have eight seconds to use an alcohol base wash.

Prior to the study, overall hand hygiene compliance was at 66%, and following the

implementation of the vapor sensors hand hygiene compliance increased to 93% (Edmond,

Goodell, Zulzer, Sango, Elam, and Bearman, 2010).

Following the end of the study a post-test was given, and showed the nurses felt that the

badge increased their hand hygiene compliance. This study shows evidence that an electronic

monitor does affect hand hygiene compliance in a positive manner. However, these devices can

be rather costly and not all hospitals may see it as a cost effective solution to the ongoing issue of

non-compliance in hand hygiene across all health care settings.

There are more cost effective solutions that have also been proven to have a positive

effect on hand hygiene compliance health care. One study conducted in a hospital in South Korea

argued that hand hygiene compliance rates improved with a change in perception toward hand

hygiene among medical personnel. The goal of this study was to determine if hand hygiene

would improve if perceptions toward hand hygiene shifted during the time of education and hand

hygiene promotion. The campaign to improve compliance rates included promotional programs

such as a poster campaign, monitoring and performance feedback, and education with special

attention to perceived subjective norms. According to Seung Soon Lee et al.s (2014) study, hand

hygiene compliance among medical personnel such as physicians and nurses improved from

2009 when the campaign was initiated to 2012. Rates specific to nurses rose from 52.3%

compliance to 91.2% (Lee et al., 2014). This study also focused on physicians becoming role

models of hand hygiene to continue to improve compliance rates. Data collection included direct

observation and a self-report questionnaire.


EXPLORING HAND HYGIENE COMPLIANCE IN NURSING 6

The mechanisms to improve compliance rates previously mentioned are cost effective

and relatively easy to implement. The posters included in the study represented a visual reminder

to medical personnel focused on the proper technique for hand hygiene and the importance of

hand hygiene. The posters were positioned in high traffic areas of the hospital to ensure the

posters were able to be seen (Lee et al., 2014). Educational seminars were held twice a year and

focused on the perceived subjective norm to become a role model advocating for hand hygiene

compliance. These educational sessions urged physicians to correct their compliance and

becoming a leading example for hand hygiene compliance.

The perception that hand hygiene is an important step in preventing hospital acquired

infections was improved during the time these mechanisms were applied. These perceptions

included: when to perform proper hand hygiene according to the situation and which method to

use, intention to comply with proper hand hygiene, perception of being a role model for others,

barriers in adhering to hand hygiene, and perception toward the campaign to improve compliance

rates (Lee et al., 2014). Because the medical personnel were educated on when to perform proper

hand hygiene to reduce the risk of spreading or transmitting an infection, such as before touching

a patient or an aseptic task, hand hygiene compliance continued to improve.

In summation, hand hygiene compliance is suggested to improve if certain perceptions

regarding hand hygiene are established in the workplace. The poster campaign, education

sessions, and monitoring feedback improved rates for compliance by changing the perception of

the medical personnel providing care for patients. The CDC has also published guidelines for

hand hygiene that includes educational resources and materials. The goal is to improve

knowledge of when hand hygiene is required, proper hand hygiene techniques, attitude toward
EXPLORING HAND HYGIENE COMPLIANCE IN NURSING 7

hand hygiene, and the perceived importance of hand hygiene and its role in prevention of

health-care associated infections (Pfoh, Dy, and Engineer, 2013).

Although the final study we reviewed was not quite as cost effective, we found it very

important to discuss due to the expanded secondary goals of the study. The primary focus of this

study, which took place in Singapore across three different wards, was to clinically validate an

electronic monitoring system for measuring hand hygiene compliance. Secondarily, the

objectives were to test the monitors as an intervention tool for providing reminder beeps and

individual performance reviews on individual Health Care Worker (HCW) hand hygiene

compliance (Fisher et. al, 2013). Discussing validity of mechanisms is extremely important when

making recommendations on ways to improve hand hygiene compliance in the clinical setting.

The study was performed on wards with specific zones placed around patient beds and

surroundings. The HCW had a preset amount of time to use an Alcohol Based Hand Rub

(ABHR) upon entry and exit before it would be noted as a moment of non-compliance. The setup

was done as a double blind experiment to further the validity of the results. The study was then

broken into three phases. During the first phase, participants performed hand hygiene as usual,

with monitoring occurring through all shifts and opportunities. During the second phase, the

intervention group was given real-time reminders through an audible beep emitted from the

sensor when recognizing a missed opportunity. In the third phase, each member in the

intervention group received weekly confidential reports providing results of their hand hygiene

compliance while continuing to receive the audible reminders. The control group was continually

monitored while no intervention was provided (Fisher et. al, 2013). The compliance rates were

taken from the data collected through the monitors which obtained more than one million
EXPLORING HAND HYGIENE COMPLIANCE IN NURSING 8

opportunities for hand hygiene use; however, direct observation audits were also performed

periodically to ensure the results were remaining valid.

As one would expect, there was no difference in the compliance rates between the control

and intervention groups during phase one. Compliance in phase two was increased in the

intervention group (univariate analysis showed a 2.9% increase on entry, and a 5.8% increase

when exiting) when comparing to the control group but was attenuated during phase three of the

study. With exclusion of the baseline on multivariate analysis the margin of difference in

compliance between the two groups was 8.7%, however, progression to phase three showed

lower compliances in both groups when compared to phase two (Fisher et. al, 2013). Even

though phase three saw a decrease from phase two in the intervention group, it still had higher

compliance rates than that of the control group, which saw a consistent decrease in compliance

upon both entering and exiting during all three phases.

It was noted that the electronic monitoring underestimated the number of opportunities by

an approximate 10%, which is on par with similar studies utilizing electronic monitoring ranging

from 2%-14% underestimation. Furthermore, electronic monitoring during this study

underestimated compliance by an average of 5.2%, which is again comparable to other data

reporting miscalculation within a range of 5%-7% (Fisher et. al, 2013).

After reviewing a plethora of literature it has become evident that there are multiple

options for health care agencies to pursue, regardless of financial availability, to increase hand

hygiene compliance among their employees. One of the vital pieces of information that is

required, regardless of what approach is taken to increase compliance, is making employees

aware of the guidelines for when hand hygiene is required. Education is an extremely important

component of increasing compliance, as seen by multiple articles noted in this literature review.
EXPLORING HAND HYGIENE COMPLIANCE IN NURSING 9

There are multiple examples provided in this review which assess the effectiveness of indirect

monitors. One of these articles showed extreme improvement with compliance, improving from

66% to 93%. Although the latter, which utilized the use of ultrasound transmitters, may not have

shown as significant of results, it did shed light on the validity of these types of monitors. This

allows an agency to understand that they may save financially through utilizing electronic

monitor techniques rather than direct observation to provide accurate data regarding hand

hygiene compliance. It seems that the best way to attack the ongoing issue of non-compliance

with hand hygiene among health care workers is to utilize a monitoring system while also

implementing extensive educational intervention for a combination approach to elicit a positive

response from health care employees and decrease the ill effects that are associated with non-

compliance with hand hygiene procedures.


EXPLORING HAND HYGIENE COMPLIANCE IN NURSING 10

References

Edmond, M.B., Goodell, A., Zuelzer, W., Sanogo, K., Elam, K., Bearman, G., ( 2010,
September). Successful use of alcohol sensor technology to monitor and report hand
hygiene compliance. Journal of Hospital Infection, 76(4), 364-365.
http://dx.doi.org/10.1016/j.jhin.2010.07.006

Fisher, D. A., Seetoh, T., May-Lin, H. O., Viswanathan, S., Toh, Y., Yin, W. C., Dempsey, M.
(2013). Automated Measures of Hand Hygiene Compliance among Healthcare Workers
Using Ultrasound: Validation and a Randomized Controlled Trial. Infection control &
Hospital Epidemiology, 34(9), 919-928. doi: 10.1086/671738

Lau, T., Tang G., Mak, K., & Leung, G. (2014). Moment-specific compliance with hand hygiene.
The Clinical Teacher 2014; 11: 159-164. doi: 10.1111/tct.12088

Lee, S. S., Park, S. J., Chung, M. J., Lee, J. H., Kang H. J., Lee, J., & Kim, Y. K. (2014).
Improved hand hygiene compliance is associated with the change of perception toward
hand hygiene among medical personnel. Infection & Chemotherapy, 46(3), 165-171. Doi:
10.3947/ic.2014.46.3.165

Pfoh, E., Dy, S., Engineer, C. (2013). Interventions to improve hand hygiene compliance: brief
update review. Making Health Care Safer II: An Updated Critical Analysis of the
Evidence for Patient Safety Practices (Chapter 8). Rockville, MD: Agency for
Healthcare Research and Quality (US).
http://www.ncbi.nlm.nih.gov/books/NBK133371/#ch8.s1

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