Journal of Hospital Infection 89 (2015) 210e214 Available online at www.sciencedirect.com
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Association between students’ personality traits and hand hygiene compliance during objective standardized clinical examinations ¨ttpelz-Brauns a, U. Obertacke a, b, J. Kaden a, C.I. Hagl c, * K. Schu a
Department of Undergraduate Education and Educational Development, University Medicine Mannheim, Medical Faculty Mannheim at Heidelberg University, Mannheim, Germany b Department of Trauma Surgery, University Medicine Mannheim, Medical Faculty Mannheim at Heidelberg University, Mannheim, Germany c Clinic of Paediatric Surgery, Division of Research and Education, University Medicine Mannheim, Medical Faculty Mannheim at Heidelberg University, Mannheim, Germany
A R T I C L E
I N F O
Article history: Received 19 June 2014 Accepted 19 November 2014 Available online 26 December 2014 Keywords: Hand disinfection Hygiene Medical education
S U M M A R Y
Background: Although the need for hand hygiene (HH) is generally accepted, studies continue to document inadequate compliance. Medical students are taught about the importance of HH to prevent nosocomial infections, and receive training in the correct procedures for HH. However, personality traits (social orientation and achievement orientation) may influence HH compliance. People with high social orientation feel socially responsible and act cooperatively, and people with high achievement orientation are ambitious and competitive. Aim: To evaluate the relationship between HH compliance and personality traits of medical students. Methods: The HH compliance of 155 students was observed during objective standardized clinical examinations (OSCEs). Social orientation and achievement orientation were measured using the corresponding scales of the Freiburg Personality Inventory - Revised. Findings: Social orientation did not differ between students with high HH compliance and students with low HH compliance [F(1) ¼ 3.87, P ¼ 0.052, h2 ¼ 0.045]. For achievement orientation, a moderate effect was found between low and high HH compliance [F(1) ¼ 11.242, P ¼ 0.001, h2 ¼ 0.119], and students with high HH compliance were found to be more achievement orientated than students with low HH compliance. Conclusion: Achievement orientation plays a major role during OSCEs, while social orientation is less emphasized. To the authors’ knowledge, this is the first study to show that HH compliance is associated with achievement orientation in achievement situations. ª 2014 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Address: Department of Paediatric Surgery, University of Mannheim, Medical Faculty of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany. Tel.: þ49 (0) 621 383 3772; fax: þ49 (0) 621 383 1981. E-mail address: [email protected] (C.I. Hagl). http://dx.doi.org/10.1016/j.jhin.2014.11.014 0195-6701/ª 2014 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
K. Schu¨ttpelz-Brauns et al. / Journal of Hospital Infection 89 (2015) 210e214
Introduction
Methods
Since the work of Ignaz Semmelweis, hand hygiene (HH) has been recognized as the most effective method for the prevention of infection. HH diminishes the risk of infection for the patient, reduces the spread of infection and protects healthcare workers.1 As such, it should be standard practice in all aspects of health care. Sociocultural factors (e.g. social rules, codes of practice) and workplace/structural measures (e.g. accessible sinks, visible dispensers) influence everyday HH performance. Several other factors also influence hand hygiene behaviour, including sex (females are more likely to perform HH), role models (HH levels are higher when senior medical staff practice HH), HH habits acquired during childhood, social facilitation (increased handwashing in the presence of another person in the washbasin area), and emotions such as disgust.2e5 Surveys of medical staff have shown that HH does not depend on the actual risk of infection but on perception.6 A key element to increase HH is a user-centred concept such as ‘My five moments for hand hygiene’ by Sax et al.7 This describes reference points for hand hygiene during healthcare delivery, and facilitates understanding and appropriate performance.8 Implementation of HH using the ‘five moments’ concept led to improved HH compliance in all participating settings.9,10 Affective emotional components that drive HH could also support practical training during medical school. Ideally, this training would be modified according to personality traits of medical students. Social orientation and achievement orientation seem to influence HH compliance. Social orientation is closely associated with awareness of environmental needs. In general, healthcare professionals have pronounced social orientation, and it is the most commonly mentioned motivation among nurses.11 In the literature, nursing staff have been shown to have much better compliance with HH.12 People with high social orientation take more care, reflect on their behaviour more often and may therefore act more appropriately. Achievement orientation is mainly linked to careerpromoting attitudes. Reliable HH compliance has no influence on career prospects; indeed, senior staff often conform poorly with HH guidelines.13 Workload has been reported as a risk factor for non-compliance with HH,3 and common responses given in surveys to elucidate reasons for poor adherence to hygiene standards include ‘too much work’ or ‘no time to do so’. This study aimed to evaluate the relationship between HH compliance and social and achievement orientation. It was anticipated that people with high social orientation would demonstrate better HH compliance than people with low social orientation. Furthermore, it was hypothesized that people with high achievement orientation would show poorer HH compliance than people with low achievement orientation.
Sample
211
The Medical Faculty Mannheim offers an innovative curriculum, ‘Mannheim Reformed Curriculum Medicine’, approved by the federal state (Baden-Wu ¨rttemberg). The advanced clinical study period in the third year is structured into four six-week teaching units with an objective structured clinical examination (OSCE) following the ‘preparatory instruction’ unit. OSCEs measure skills and competencies using standardized patients and timed stations to assess the performance of different tasks.14 During their third year of medical education, the students are divided into cohorts. Skills training courses are held within integrated units, and cohorts pass through the units in differing orders. As such, students have differing knowledge throughout the study year, but should have equal knowledge and skills by the end of the year. As third-year students enter the clinical stage of their training, the focus of the curriculum is on practical clinical skills. The ‘preparatory instruction’ unit includes teaching students about physical examination of the cardiovascular system, lungs, abdomen, upper and lower limbs, basic inspection in otolaryngology and paediatrics, taking a blood sample with a cannula (injection and venepuncture part I and II), and medical counselling techniques. Small groups of six students train together to meet the learning objectives. Students have extra time to practice under supervision with a tutor. HH is part of all physical examinations but is not taught explicitly.
Materials HH was included as an additional item [‘HH occurred (yes) or not (no)’] in the checklist at each OSCE station, in accordance with the ‘five moments for hand hygiene’ concept.7 Social orientation and achievement orientation were measured using the corresponding scales of the Freiburg Personality Inventory Revised (FPI-R). The scales of the FPI-R are objective, valid, economical and reliable.15 A respondent agrees or disagrees with the statements. Cronbach’s alpha showed that the reliability of social orientation and achievement orientation on the FPI-R were moderate (Table I). To compare results with the norm, raw scores were transformed into nine standard scores (ST 1e9). ST 4e6 represents 54% of the norm within the age group, ST 7e9 (23% of the norm) represents a high level, and ST 1e3 reflects a low level. ST 4e6 is normal compared with the German population.
Table I Example questions in the Freiburg Personality Inventory e Revised showing the German question and its translation for each personality trait Questions (N)
Question in German
English translation
Cronbach’s a
Social orientation
12 12
I feel responsible for others, and not only for my family. I like difficult tasks that are challenging.
0.71
Achievement orientation
Ich fu ¨hle mich auch u ¨ber meine Familie hinaus fu ¨r andere Menschen verantwortlich. Ich habe Spaß an schwierigen Aufgaben, die mich herausfordern.
Personality trait
0.77
212
K. Schu¨ttpelz-Brauns et al. / Journal of Hospital Infection 89 (2015) 210e214
Procedure
*
The HH of students was documented during OSCEs between May 2008 and February 2010 for four consecutive cohorts. In these OSCEs, clinical skills such as taking blood or examining and treating standardized patients were tested. In the linear sequence of multiple stations, the students had to perform a physical examination of a standardized patient. Each examination room had an antiseptic dispenser that was clearly visible and filled. Students were allocated at random to one of the cohorts, and the results of HH did not affect the OSCE grading. During the OSCE, neither the examiner nor the students knew about the study. Two months after the last OSCE in February 2010, all students were informed about the study and asked to fill in the FPI-R.15 After signing an informed consent form, students completed the two scales of the FPI together with demographic data (date of birth and sex). Both sets of data were de-identified and used to combine observed HH and FPI results. The Ethics Committee of the Medical University considered this study to be exempt from requirements for formal ethical approval (Reference No.: 2010-211N).
Statistical analysis At each OSCE station, HH was recorded as 0 when no hand disinfection was performed and as 1 when HH was performed before either patient contact or the physical examination. For each student, the scores for HH were summed and the percentage of HH was calculated. Students with the minimum score of 0 had not performed HH at any OSCE station, and those with the maximum score of 100 had performed HH at every OSCE station. An analysis of the missing results was undertaken. All stations except one had documented HH in >95% of cases. As 72% of results were missing at one station, this was excluded from the analysis in order to prevent bias.16 In total, the results of five stations were included in the analysis, namely lung auscultation, abdominal palpation with percussion of the liver, venepuncture and examination of upper and lower limbs. To compare HH between the cohorts, one-way analysis of variance with a post-hoc test (Newman-Keuls test) was conducted. The Newman-Keuls test examines differences in the means of subgroups, and groups them into subgroups with nonsignificant differences. The Newman-Keuls test is more powerful than the Tukey test which is often used for post-hoc testing.17 Groups with high HH compliance and low HH compliance were identified in order to compare social orientation and achievement orientation between these groups. All students were ranked with respect to their HH. The one-third of students with the highest scores for HH compliance were categorized as having high HH compliance (HH compliance at 80% of the stations), and the one-third of students with the lowest scores for HH compliance were categorized as having low HH compliance (HH compliance at 20% of the stations). The subgroup with high HH compliance contained 34 students, and the subgroup with low HH compliance contained 46 students. Means and standard deviations for social orientation and achievement orientation were computed for each subgroup of HH compliance. FPI scores were compared between the two groups using one-way analysis of variance. The effect size (h2) was also calculated, and classified as follows: small effect,
Mean (hand hygiene) [%]
0.8
0.6
0.4
0.2
0 I
II
III
IV
Cohort
Figure 1. Mean frequency of hand hygiene disinfection in the objective standardized clinical examination of four consecutive cohorts. *Cohorts I and II differed significantly from cohorts III and IV (analysis of variance, Newman-Keuls test). Error bars show 95% confidence intervals.
0.0099; moderate effect, 0.0588; and large effect, 0.1379.18
Results Of the 155 students that participated in the OSCEs, 127 students agreed to complete the questionnaire. Thirty-four questionnaires had missing data and were excluded, leaving 93 questionnaires for analysis. Mean HH increased between the cohorts (F(3) ¼ 14.01, P < 0.000, h2 ¼ 0.218). Newman-Keuls test showed that cohorts I and II had lower HH compliance than cohorts III and IV (Figure 1). However, even in the cohort with the highest HH compliance, only one-third (28%) of the students demonstrated correct HH behaviour (i.e. performed HH at each station). No relationship was found between type of OSCE station and HH compliance. The numbers of students who demonstrated low and high HH compliance are shown in Table II. The FPI scales in Table III show comparable social orientation and achievement orientation for medical students related to the age norm. Table II Total number of students that participated in the objective standardized clinical examination, and students with low or high hand hygiene (HH) compliance within each cohort Total no. of students Cohort Cohort Cohort Cohort Total a b
I II III IV
37 35 44 49 165
Low HH compliancea 33 24 16 11 84
(89%) (69%) (36%) (22%) (51%)
HH compliance at 20% of examination stations. HH compliance at 80% of examination stations.
High HH complianceb 1 (3%) 4 (11%) 15 (34%) 17 (35%) 37 (22%)
K. Schu¨ttpelz-Brauns et al. / Journal of Hospital Infection 89 (2015) 210e214
213
Table III Personality traits in groups of students with low and high hand hygiene (HH) compliance Personality trait Social orientation Achievement orientation
Low HH compliance Mean (SD)
High HH compliance Mean (SD)
Difference
6.02 (1.58) 4.80 (1.72)
6.71 (1.57) 5.97 (1.31)
F(1) ¼ 3.87, P ¼ 0.052, h2 ¼ 0.045a F(1) ¼ 11.242, P ¼ 0.001, h2 ¼ 0.119b
SD, standard deviation. a Small effect. b Moderate effect
Students with high HH compliance were similar in terms of social orientation compared with students with low HH compliance (Table III). For achievement orientation, a moderate effect was found between low and high HH compliance, and students with high HH compliance were found to be more achievement orientated than students with low HH compliance.
Discussion This study had three main findings. HH compliance increased between the cohorts, but remained less than that required to prevent nosocomial infections. Students with high HH compliance were more achievement orientated than students with low HH compliance, while social orientation did not differ between the groups with high and low HH compliance. There are two possible explanations for the increase in HH compliance between the cohorts. Firstly, other teaching units as well as the ‘preparatory instruction’ unit deal with HH within the third year of study. Also, students start clinical training in the third year, and have regular contact with patients and attend ward rounds. On clinical rotations, HH is an integral part of everyday work, and awareness of HH compliance in clinic situations may influence students through role modelling. University Hospital Mannheim participated in the German national HH campaign ‘Aktion saubere Ha ¨nde’, which demonstrated an increase in HH compliance at participating institutions.9 Secondly, students may have learnt that HH was included in the OSCE checklists. More senior medical students are involved with teaching activities, tutorials and OSCE preparations, and it is possible that these tutors may have influenced students by demonstrating HH more intensively during their training sessions. However, it seems unlikely that this would have had a significant effect. The result related to social orientation was unexpected, as it was anticipated that social orientation would have a positive influence on HH compliance. The social orientation of the entire student cohort was above average for their age group.15 Reflecting on one’s own behaviour requires an analytical way of thinking and the ability to abstract, which may explain why HH compliance was higher in students with high achievement orientation. Students with high achievement orientation develop early learning strategies and expect to fulfill their own expectations.19 These learning strategies may also form useful routines to comply with their own high standards, and may lead to better HH compliance. OSCEs are achievement situations.20 Achievement orientation plays a major role during an OSCE, while social orientation is less emphasized. Students with high achievement orientation could see the OSCE situation as a whole, and therefore be more aware of HH compliance as an element of patient contact.
To the authors’ knowledge, this is the first study to show that HH compliance is associated with achievement orientation in achievement situations. Although HH compliance is an essential element of patient contact, HH compliance was not part of the grading and therefore may have been perceived as unimportant. This may explain the low rate of HH compliance (only 44% of the students were found to have good HH compliance). It is disappointing that medical students passed through the third year of study without HH being a requirement. Future strategies with earlier incorporation of HH training in the curriculum and more vigorous enforcement are necessary. One limitation of this study is that high HH compliance in an OSCE does not ensure high HH compliance in everyday work. For practical reasons, it was not possible to measure HH compliance before the teaching units, so it is not known whether or not HH compliance increases when students are taught about HH. In addition, long-term HH compliance was not investigated. When HH is part of an assessment, awareness of HH and its importance within medical education is enhanced. To increase HH compliance, there is a need to differentiate between achievement situations (e.g. assessment situations or surgery) and more social situations (e.g. clinical teaching with patient contact or ward rounds). Therefore, it is recommended that HH should be taught in undergraduate medical education and throughout clinical training, and should be made an integral part of all clinical assessments. To help facilitate this, further studies are needed to systematically investigate the effects of explicit teaching in achievement and social situations, as well as strategies for long-term effects of HH teaching.
Acknowledgement The authors wish to thank Jill Thistlethwaite for proof reading and commenting on the draft. Conflict of interest statement None declared. Funding source This study was supported by the Federal Ministry of Education and Research (BMBF Grant No.: 01PL12011C).
References 1. Kampf G, Loffler H, Gastmeier P. Hand hygiene for the prevention of nosocomial infections. Dtsch Arztebl Int 2009;106:649e655. 2. Guinan ME, McGuckin-Guinan M, Sevareid A. Who washes hands after using the bathroom? Am J Infect Control 1997;25:424e425.
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3. Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med 2004;141:1e8. 4. Drankiewicz D, Dundes L. Handwashing among female college students. Am J Infect Control 2003;31:67e71. 5. Porzig-Drummond R, Stevenson R, Case T, Oaten M. Can the emotion of disgust be harnessed to promote hand hygiene? Experimental and field-based tests. Soc Sci Med 2009;68:1006e1012. 6. Jackson C, Griffiths P. Dirt and disgust as key drivers in nurses’ infection control behaviours: an interpretative, qualitative study. J Hosp Infect 2014;87:71e76. 7. Sax H, Allegranzi B, Uckay I, Larson E, Boyce J, Pittet D. ‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect 2007;67:9e21. 8. Pittet D, Allegranzi B, Boyce J. The World Health Organization guidelines on hand hygiene in health care and their consensus recommendations. Infect Control Hosp Epidemiol 2009;30:611e622. 9. Reichardt C, Koniger D, Bunte-Schonberger K, et al. Three years of national hand hygiene campaign in Germany: what are the key conclusions for clinical practice? J Hosp Infect 2013;83(Suppl. 1): S11eS16. 10. Allegranzi B, Gayet-Ageron A, Damani N, et al. Global implementation of WHO’s multimodal strategy for improvement of hand hygiene: a quasi-experimental study. Lancet Infect Dis 2013;13:843e851. 11. Fitzpatrick JJ. What motivates idealistic young people as they plan their careers? Nurs Educ Perspect 2005;26:7.
12. Sladek RM, Bond MJ, Phillips PA. Why don’t doctors wash their hands? A correlation study of thinking styles and hand hygiene. Am J Infect Control 2008;36:399e406. 13. Buffet-Bataillon S, Leray E, Poisson M, Michelet C, BonnaureMallet M, Cormier M. Influence of job seniority, hand hygiene education, and patient-to-nurse ratio on hand disinfection compliance. J Hosp Infect 2010;76:32e35. 14. Epstein RM. Assessment in medical education. N Engl J Med 2007;356:387e396. 15. Fahrenberg J, Selg H. FPI-R Freiburger Perso¨nlichkeitsinventar. Go ¨ttingen: Hogreve; 2010. ¨ ber das Problem fehlender Werte: Wie der Einfluss 16. Wirtz M. U fehlender Informationen auf Analyseergebnisse entdeckt und reduziert werden kann. [On the problem of missing data: how to identify and reduce the impact of missing data on findings of data analysis]. Die Rehabil 2004;43:109e115. 17. Abdi H, Williams LJ. Newman-Keuls test and Tukey test. Thousand Oaks, CA: Sage; 2010. 18. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988. 19. Stegers-Jager KM, Cohen-Schotanus J, Themmen AP. Motivation, learning strategies, participation and medical school performance. Med Educ 2012;46:678e688. 20. Turner JL, Dankoski ME. Objective structured clinical exams: a critical review. Fam Med 2008;40:574e578.
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Association between students’ personality traits and hand hygiene compliance during objective standardized clinical examinations ¨ttpelz-Brauns a, U. Obertacke a, b, J. Kaden a, C.I. Hagl c, * K. Schu a
Department of Undergraduate Education and Educational Development, University Medicine Mannheim, Medical Faculty Mannheim at Heidelberg University, Mannheim, Germany b Department of Trauma Surgery, University Medicine Mannheim, Medical Faculty Mannheim at Heidelberg University, Mannheim, Germany c Clinic of Paediatric Surgery, Division of Research and Education, University Medicine Mannheim, Medical Faculty Mannheim at Heidelberg University, Mannheim, Germany
A R T I C L E
I N F O
Article history: Received 19 June 2014 Accepted 19 November 2014 Available online 26 December 2014 Keywords: Hand disinfection Hygiene Medical education
S U M M A R Y
Background: Although the need for hand hygiene (HH) is generally accepted, studies continue to document inadequate compliance. Medical students are taught about the importance of HH to prevent nosocomial infections, and receive training in the correct procedures for HH. However, personality traits (social orientation and achievement orientation) may influence HH compliance. People with high social orientation feel socially responsible and act cooperatively, and people with high achievement orientation are ambitious and competitive. Aim: To evaluate the relationship between HH compliance and personality traits of medical students. Methods: The HH compliance of 155 students was observed during objective standardized clinical examinations (OSCEs). Social orientation and achievement orientation were measured using the corresponding scales of the Freiburg Personality Inventory - Revised. Findings: Social orientation did not differ between students with high HH compliance and students with low HH compliance [F(1) ¼ 3.87, P ¼ 0.052, h2 ¼ 0.045]. For achievement orientation, a moderate effect was found between low and high HH compliance [F(1) ¼ 11.242, P ¼ 0.001, h2 ¼ 0.119], and students with high HH compliance were found to be more achievement orientated than students with low HH compliance. Conclusion: Achievement orientation plays a major role during OSCEs, while social orientation is less emphasized. To the authors’ knowledge, this is the first study to show that HH compliance is associated with achievement orientation in achievement situations. ª 2014 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Address: Department of Paediatric Surgery, University of Mannheim, Medical Faculty of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany. Tel.: þ49 (0) 621 383 3772; fax: þ49 (0) 621 383 1981. E-mail address: [email protected] (C.I. Hagl). http://dx.doi.org/10.1016/j.jhin.2014.11.014 0195-6701/ª 2014 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
K. Schu¨ttpelz-Brauns et al. / Journal of Hospital Infection 89 (2015) 210e214
Introduction
Methods
Since the work of Ignaz Semmelweis, hand hygiene (HH) has been recognized as the most effective method for the prevention of infection. HH diminishes the risk of infection for the patient, reduces the spread of infection and protects healthcare workers.1 As such, it should be standard practice in all aspects of health care. Sociocultural factors (e.g. social rules, codes of practice) and workplace/structural measures (e.g. accessible sinks, visible dispensers) influence everyday HH performance. Several other factors also influence hand hygiene behaviour, including sex (females are more likely to perform HH), role models (HH levels are higher when senior medical staff practice HH), HH habits acquired during childhood, social facilitation (increased handwashing in the presence of another person in the washbasin area), and emotions such as disgust.2e5 Surveys of medical staff have shown that HH does not depend on the actual risk of infection but on perception.6 A key element to increase HH is a user-centred concept such as ‘My five moments for hand hygiene’ by Sax et al.7 This describes reference points for hand hygiene during healthcare delivery, and facilitates understanding and appropriate performance.8 Implementation of HH using the ‘five moments’ concept led to improved HH compliance in all participating settings.9,10 Affective emotional components that drive HH could also support practical training during medical school. Ideally, this training would be modified according to personality traits of medical students. Social orientation and achievement orientation seem to influence HH compliance. Social orientation is closely associated with awareness of environmental needs. In general, healthcare professionals have pronounced social orientation, and it is the most commonly mentioned motivation among nurses.11 In the literature, nursing staff have been shown to have much better compliance with HH.12 People with high social orientation take more care, reflect on their behaviour more often and may therefore act more appropriately. Achievement orientation is mainly linked to careerpromoting attitudes. Reliable HH compliance has no influence on career prospects; indeed, senior staff often conform poorly with HH guidelines.13 Workload has been reported as a risk factor for non-compliance with HH,3 and common responses given in surveys to elucidate reasons for poor adherence to hygiene standards include ‘too much work’ or ‘no time to do so’. This study aimed to evaluate the relationship between HH compliance and social and achievement orientation. It was anticipated that people with high social orientation would demonstrate better HH compliance than people with low social orientation. Furthermore, it was hypothesized that people with high achievement orientation would show poorer HH compliance than people with low achievement orientation.
Sample
211
The Medical Faculty Mannheim offers an innovative curriculum, ‘Mannheim Reformed Curriculum Medicine’, approved by the federal state (Baden-Wu ¨rttemberg). The advanced clinical study period in the third year is structured into four six-week teaching units with an objective structured clinical examination (OSCE) following the ‘preparatory instruction’ unit. OSCEs measure skills and competencies using standardized patients and timed stations to assess the performance of different tasks.14 During their third year of medical education, the students are divided into cohorts. Skills training courses are held within integrated units, and cohorts pass through the units in differing orders. As such, students have differing knowledge throughout the study year, but should have equal knowledge and skills by the end of the year. As third-year students enter the clinical stage of their training, the focus of the curriculum is on practical clinical skills. The ‘preparatory instruction’ unit includes teaching students about physical examination of the cardiovascular system, lungs, abdomen, upper and lower limbs, basic inspection in otolaryngology and paediatrics, taking a blood sample with a cannula (injection and venepuncture part I and II), and medical counselling techniques. Small groups of six students train together to meet the learning objectives. Students have extra time to practice under supervision with a tutor. HH is part of all physical examinations but is not taught explicitly.
Materials HH was included as an additional item [‘HH occurred (yes) or not (no)’] in the checklist at each OSCE station, in accordance with the ‘five moments for hand hygiene’ concept.7 Social orientation and achievement orientation were measured using the corresponding scales of the Freiburg Personality Inventory Revised (FPI-R). The scales of the FPI-R are objective, valid, economical and reliable.15 A respondent agrees or disagrees with the statements. Cronbach’s alpha showed that the reliability of social orientation and achievement orientation on the FPI-R were moderate (Table I). To compare results with the norm, raw scores were transformed into nine standard scores (ST 1e9). ST 4e6 represents 54% of the norm within the age group, ST 7e9 (23% of the norm) represents a high level, and ST 1e3 reflects a low level. ST 4e6 is normal compared with the German population.
Table I Example questions in the Freiburg Personality Inventory e Revised showing the German question and its translation for each personality trait Questions (N)
Question in German
English translation
Cronbach’s a
Social orientation
12 12
I feel responsible for others, and not only for my family. I like difficult tasks that are challenging.
0.71
Achievement orientation
Ich fu ¨hle mich auch u ¨ber meine Familie hinaus fu ¨r andere Menschen verantwortlich. Ich habe Spaß an schwierigen Aufgaben, die mich herausfordern.
Personality trait
0.77
212
K. Schu¨ttpelz-Brauns et al. / Journal of Hospital Infection 89 (2015) 210e214
Procedure
*
The HH of students was documented during OSCEs between May 2008 and February 2010 for four consecutive cohorts. In these OSCEs, clinical skills such as taking blood or examining and treating standardized patients were tested. In the linear sequence of multiple stations, the students had to perform a physical examination of a standardized patient. Each examination room had an antiseptic dispenser that was clearly visible and filled. Students were allocated at random to one of the cohorts, and the results of HH did not affect the OSCE grading. During the OSCE, neither the examiner nor the students knew about the study. Two months after the last OSCE in February 2010, all students were informed about the study and asked to fill in the FPI-R.15 After signing an informed consent form, students completed the two scales of the FPI together with demographic data (date of birth and sex). Both sets of data were de-identified and used to combine observed HH and FPI results. The Ethics Committee of the Medical University considered this study to be exempt from requirements for formal ethical approval (Reference No.: 2010-211N).
Statistical analysis At each OSCE station, HH was recorded as 0 when no hand disinfection was performed and as 1 when HH was performed before either patient contact or the physical examination. For each student, the scores for HH were summed and the percentage of HH was calculated. Students with the minimum score of 0 had not performed HH at any OSCE station, and those with the maximum score of 100 had performed HH at every OSCE station. An analysis of the missing results was undertaken. All stations except one had documented HH in >95% of cases. As 72% of results were missing at one station, this was excluded from the analysis in order to prevent bias.16 In total, the results of five stations were included in the analysis, namely lung auscultation, abdominal palpation with percussion of the liver, venepuncture and examination of upper and lower limbs. To compare HH between the cohorts, one-way analysis of variance with a post-hoc test (Newman-Keuls test) was conducted. The Newman-Keuls test examines differences in the means of subgroups, and groups them into subgroups with nonsignificant differences. The Newman-Keuls test is more powerful than the Tukey test which is often used for post-hoc testing.17 Groups with high HH compliance and low HH compliance were identified in order to compare social orientation and achievement orientation between these groups. All students were ranked with respect to their HH. The one-third of students with the highest scores for HH compliance were categorized as having high HH compliance (HH compliance at 80% of the stations), and the one-third of students with the lowest scores for HH compliance were categorized as having low HH compliance (HH compliance at 20% of the stations). The subgroup with high HH compliance contained 34 students, and the subgroup with low HH compliance contained 46 students. Means and standard deviations for social orientation and achievement orientation were computed for each subgroup of HH compliance. FPI scores were compared between the two groups using one-way analysis of variance. The effect size (h2) was also calculated, and classified as follows: small effect,
Mean (hand hygiene) [%]
0.8
0.6
0.4
0.2
0 I
II
III
IV
Cohort
Figure 1. Mean frequency of hand hygiene disinfection in the objective standardized clinical examination of four consecutive cohorts. *Cohorts I and II differed significantly from cohorts III and IV (analysis of variance, Newman-Keuls test). Error bars show 95% confidence intervals.
0.0099; moderate effect, 0.0588; and large effect, 0.1379.18
Results Of the 155 students that participated in the OSCEs, 127 students agreed to complete the questionnaire. Thirty-four questionnaires had missing data and were excluded, leaving 93 questionnaires for analysis. Mean HH increased between the cohorts (F(3) ¼ 14.01, P < 0.000, h2 ¼ 0.218). Newman-Keuls test showed that cohorts I and II had lower HH compliance than cohorts III and IV (Figure 1). However, even in the cohort with the highest HH compliance, only one-third (28%) of the students demonstrated correct HH behaviour (i.e. performed HH at each station). No relationship was found between type of OSCE station and HH compliance. The numbers of students who demonstrated low and high HH compliance are shown in Table II. The FPI scales in Table III show comparable social orientation and achievement orientation for medical students related to the age norm. Table II Total number of students that participated in the objective standardized clinical examination, and students with low or high hand hygiene (HH) compliance within each cohort Total no. of students Cohort Cohort Cohort Cohort Total a b
I II III IV
37 35 44 49 165
Low HH compliancea 33 24 16 11 84
(89%) (69%) (36%) (22%) (51%)
HH compliance at 20% of examination stations. HH compliance at 80% of examination stations.
High HH complianceb 1 (3%) 4 (11%) 15 (34%) 17 (35%) 37 (22%)
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213
Table III Personality traits in groups of students with low and high hand hygiene (HH) compliance Personality trait Social orientation Achievement orientation
Low HH compliance Mean (SD)
High HH compliance Mean (SD)
Difference
6.02 (1.58) 4.80 (1.72)
6.71 (1.57) 5.97 (1.31)
F(1) ¼ 3.87, P ¼ 0.052, h2 ¼ 0.045a F(1) ¼ 11.242, P ¼ 0.001, h2 ¼ 0.119b
SD, standard deviation. a Small effect. b Moderate effect
Students with high HH compliance were similar in terms of social orientation compared with students with low HH compliance (Table III). For achievement orientation, a moderate effect was found between low and high HH compliance, and students with high HH compliance were found to be more achievement orientated than students with low HH compliance.
Discussion This study had three main findings. HH compliance increased between the cohorts, but remained less than that required to prevent nosocomial infections. Students with high HH compliance were more achievement orientated than students with low HH compliance, while social orientation did not differ between the groups with high and low HH compliance. There are two possible explanations for the increase in HH compliance between the cohorts. Firstly, other teaching units as well as the ‘preparatory instruction’ unit deal with HH within the third year of study. Also, students start clinical training in the third year, and have regular contact with patients and attend ward rounds. On clinical rotations, HH is an integral part of everyday work, and awareness of HH compliance in clinic situations may influence students through role modelling. University Hospital Mannheim participated in the German national HH campaign ‘Aktion saubere Ha ¨nde’, which demonstrated an increase in HH compliance at participating institutions.9 Secondly, students may have learnt that HH was included in the OSCE checklists. More senior medical students are involved with teaching activities, tutorials and OSCE preparations, and it is possible that these tutors may have influenced students by demonstrating HH more intensively during their training sessions. However, it seems unlikely that this would have had a significant effect. The result related to social orientation was unexpected, as it was anticipated that social orientation would have a positive influence on HH compliance. The social orientation of the entire student cohort was above average for their age group.15 Reflecting on one’s own behaviour requires an analytical way of thinking and the ability to abstract, which may explain why HH compliance was higher in students with high achievement orientation. Students with high achievement orientation develop early learning strategies and expect to fulfill their own expectations.19 These learning strategies may also form useful routines to comply with their own high standards, and may lead to better HH compliance. OSCEs are achievement situations.20 Achievement orientation plays a major role during an OSCE, while social orientation is less emphasized. Students with high achievement orientation could see the OSCE situation as a whole, and therefore be more aware of HH compliance as an element of patient contact.
To the authors’ knowledge, this is the first study to show that HH compliance is associated with achievement orientation in achievement situations. Although HH compliance is an essential element of patient contact, HH compliance was not part of the grading and therefore may have been perceived as unimportant. This may explain the low rate of HH compliance (only 44% of the students were found to have good HH compliance). It is disappointing that medical students passed through the third year of study without HH being a requirement. Future strategies with earlier incorporation of HH training in the curriculum and more vigorous enforcement are necessary. One limitation of this study is that high HH compliance in an OSCE does not ensure high HH compliance in everyday work. For practical reasons, it was not possible to measure HH compliance before the teaching units, so it is not known whether or not HH compliance increases when students are taught about HH. In addition, long-term HH compliance was not investigated. When HH is part of an assessment, awareness of HH and its importance within medical education is enhanced. To increase HH compliance, there is a need to differentiate between achievement situations (e.g. assessment situations or surgery) and more social situations (e.g. clinical teaching with patient contact or ward rounds). Therefore, it is recommended that HH should be taught in undergraduate medical education and throughout clinical training, and should be made an integral part of all clinical assessments. To help facilitate this, further studies are needed to systematically investigate the effects of explicit teaching in achievement and social situations, as well as strategies for long-term effects of HH teaching.
Acknowledgement The authors wish to thank Jill Thistlethwaite for proof reading and commenting on the draft. Conflict of interest statement None declared. Funding source This study was supported by the Federal Ministry of Education and Research (BMBF Grant No.: 01PL12011C).
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