R ESEARCH COR N ER
Assessing patient awareness of proper hand hygiene By Sunni R. Busby, BSN, RN, CMSRN; Bryan Kennedy, MS, RN, NEA-BC; Stephanie C. Davis, PhD, RN, FNP-BC; Heather A. Thompson, BA, ADN, RN, CMSRN; and Jan W. Jones, ADN, RN
Abstract Background: The authors hypothesized that patients may not understand the forms of effective hand hygiene employed in the hospital environment. Literature review: Multiple studies demonstrate the importance of hand hygiene in reducing healthcare-associated infections (HAIs). Extensive research about how to improve compliance has been conducted. Methodology: Patients’ perceptions of proper hand hygiene were evaluated when caregivers used soap and water, waterless hand cleaner, or a combination of these. Results: No significant differences were observed, but many patients reported they did not notice whether their providers cleaned their hands. Discussion: Educating patients and their caregivers about the protection afforded by proper, consistent hand hygiene practices is important. Implications for nursing practice: Engaging patients to monitor healthcare workers may increase compliance, reduce the spread of infection, and lead to better overall patient outcomes. Implications for research: This study revealed a need to investigate the effects of patient education on patient perceptions of hand hygiene. Conclusion: Results of this study appear to indicate a need to focus on patient education and the differences between soap and water versus alcohol-based hand sanitizers as part of proper hand hygiene. Researchers could be asking: “Why have patients not been engaged as members of the healthcare team who have the most to lose?” Background Hand hygiene is a simple but effective way of preventing the transmission of healthcare-associated infections (HAIs). The authors hypothesized that patients may not understand the forms of effective hand hygiene employed in the hospital environment. This misunderstanding can impede their ability to evaluate their safety. This study sought to identify patients’ perceptions of whether their “nurse and nursing assistant cleaned their hands” when these providers used only soap and water, only waterless alcohol-based hand cleaner, or a combination of both methods. Participants were randomly assigned to groups in which primary caregivers used one of the two methods or a combination. A survey was
administered at the end of the shift to assess patients’ perceptions of the frequency of hand hygiene. Although no significant differences were identified, many patients reported that they did not pay attention to whether their providers cleaned their hands. The authors discuss safety concerns and implications for further research about engaging patients to assist in safety monitoring. Literature review Most healthcare providers know this mantra: “Hand hygiene is the easiest way to prevent infection.” Multiple studies demonstrate the importance of hand hygiene in reducing HAIs.1,2 Extensive research has been conducted about how to improve compliance, including behavioral modifications,3,4 use of technology to
monitor alcohol-based hand rub dispenser use,5 and video surveillance.6 Value-based purchasing is a concept introduced by the Centers for Medicare and Medicaid Services in 2011. The program bases reimbursement partially on clinical indicators and patient satisfaction measures.7 Patients’ experiences are measured by their perceptions, including how well their pain was controlled, how responsive the staff was to their needs, and the cleanliness of the hospital.8 The current trend of factoring patient perception into reimbursement creates a new area of practice and the need for research to examine how well patients understand the concepts they are being asked to rate. Part of the standard admission process is education about the importance of hand hygiene, and a sign is posted in each room instructing patients to “Please ask healthcare providers if they have cleaned their hands.” Patients may not understand exactly what it means for healthcare workers to “clean” their hands. Despite studies that demonstrate alcohol-based hand sanitizers are equally effective compared with soap and water in most circumstances, the authors hypothesize that patients do not always understand the differences and similarities between cleaning with soap and water and cleaning with alcohol-based hand sanitizers.9,10 It is also important to consider The Society for Healthcare Epidemiology of America’s recommendation that soap and water and not alcohol-based hand sanitizers be used in the presence of a Clostridium difficile outbreak.11 May l Nursing2015 l 27
www.Nursing2015.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
R ESEARCH COR N ER
Recent research highlights the benefits of involving patients in hand hygiene improvement efforts from an infection prevention standpoint and the importance of engaging the patient as an active participant in monitoring.12,13 In a study by the National Patient Safety Agency in the United Kingdom, the authors surveyed inpatients, the general public, and healthcare workers to determine their opinions on patient engagement and the influence it had on compliance with hand hygiene. Surveys of the general public and of medical-surgical inpatients across five hospitals in the United Kingdom assessed their opinions about receiving small bottles of alcohol-based hand sanitizer and education about hand hygiene, and evaluated whether these actions affected their willingness to ask healthcare workers if they would clean their hands. The authors found that only about 30% of the public were “very likely” to ask their providers if they had cleaned their hands. Reasons they cited for their reluctance included assumptions the staff had already performed the cleaning, fears it would insult their caregiver’s professionalism, and concerns the question would annoy the provider. However, inpatients rated explanations by healthcare workers that it was okay to ask if they washed their hands as one of the most useful interventions to empower patients.14 In the study, healthcare workers were asked for their opinions about patients receiving a bottle of alcoholbased sanitizer and being encouraged to ask if their providers had cleaned their hands. Although 71% of the participants felt HAIs could be reduced with patient involvement in hand hygiene monitoring, 25% reported the patient monitoring would undermine their relationship
with the patient. Among the healthcare workers, only 37% reported that, if hospitalized, they would ask nurses if they had cleaned their hands.14 Ottum et al. surveyed patients with a history of or at high risk for antibiotic-resistant infections to assess their understanding of HAIs, including hand hygiene as a prevention strategy.15 The authors found that patients were more likely to ask providers if they had performed hand hygiene if the patient had done so on a previous encounter. Likewise, patients as well as their visitors who were healthcare professionals were more likely to question their physicians and nurses about whether they had performed hand hygiene upon or just prior to entering the room. These findings suggest the importance of both dialoguing with patients on how to ask about hand hygiene compliance and the importance of self- or visitor-advocacy in a patient safety initiative. Methodology Although many studies have assessed patients’ and providers’ willingness to discuss hand hygiene in the context of patient safety, limited research has studied patients’ understanding of what proper hand hygiene entails. In the study facility, Professional Research Consultants surveys patients upon discharge home about their hospital experiences, including hand hygiene.16 Because the survey asks patients to evaluate how often staff cleaned their hands, the authors performed a descriptive study designed to evaluate patient understanding of the concept “hand cleaning.” • Operational definition. For the purposes of this study, hand hygiene was defined as antiseptic handwash or antiseptic hand rub. Either activity or a combination of both consti-
tutes proper cleaning. Antiseptic handwash involves washing hands with soap and water containing an antimicrobial agent, and antiseptic hand rub requires application of a preparation containing at least 60% ethanol or isopropanol to all surfaces of the hands.17 Although other methods are approved, they were excluded from this study because they are not commonly used in the study facility. • Method. This study was conducted on a 25-bed inpatient unit admitting adult general medical patients. The unit is part of a 461-bed facility in the southeastern United States. Patients were surveyed after an 8-hour shift during which the nurse and nursing assistant used soap and water, waterless alcohol-based hand cleaner, or a combination of both methods for hand hygiene. The soap-and-water cleaning was performed at the sink in the patient’s room and the waterless hand cleaning was done at a dispenser inside the room next to the door. Both locations were within view of the patient. Thirty patients were selected for each of the three groups. Inclusion criteria were patients who were capable of observing the hand hygiene performance of their caregivers. Exclusion criteria were patients requiring transmission-based precautions and those with mental status changes that impaired their memory or perception. The patients were given a single question survey: “How often during this 8-hour shift did your nurse and nursing assistant clean their hands?” by checking always, usually, sometimes, or never. The survey was administered by the unit charge nurse, and comments related to hand washing were noted. Demographic data were noted after the response was collected, but the surveys were otherwise anonymous.
28 l Nursing2015 l May
www.Nursing2015.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Results Data were collected from February 2 to April 27, 2013. (For responses, see Survey responses by intervention group.) Most patients in the hand washing-only and sanitizer-only groups (90.0% and 93.3%, respectively) indicated their caregivers always cleaned their hands. Some of the comments received from patients were as follows: • “Why are you washing your hands so much?” • “If you wash your hands any more, they’re going to fall off.” • “It’s a wonder you all have any skin left on your hands, as much as you wash them.” These questions suggest a lack of understanding of the importance of hand washing. Another troubling observation was that all of the patients who had no response reported that they did not notice whether staff members cleaned their hands. One of the patients who did not respond had been awakened by the nurse when she used the waterless cleanser dispenser. The nurse told the patient, “I’m sorry I scared you. The hand sanitizer wasn’t working, and I have to make sure my hands are clean.” Even so, this patient reported that he “did not notice if they cleaned their hands.” Demographic data including age, gender, and race revealed no significant differences in responses, including those patients who stated they did not notice whether their providers cleaned their hands. Discussion This study sought to explore patients’ perceptions of hand hygiene. The results do not support the hypothesis that patients perceive soap-and-water hand washing and waterless hand sanitizer differently. The number of patients who did not notice whether
Survey responses by intervention group* Always
Usually
Sometimes
Never
No response
Hand washing only (N=30)
90.0%
6.7%
0.0%
0.0%
3.3%
Sanitizer only (N=30)
93.3%
0.0%
0.0%
0.0%
6.7%
Combination (N=30)
80.0%
6.7%
6.7%
0.0%
6.7%
*Due to rounding, not all totals add up to 100%.
healthcare providers performed proper hand hygiene suggests that attempts to educate and empower patients to assist in monitoring their own safety have not been successful. Research has demonstrated the willingness of patients to promote hand hygiene as well as the belief of many healthcare workers that engaging patients would improve compliance with hand hygiene. Patients indicated that being asked by healthcare providers to assist in monitoring increased their likelihood of questioning the providers’ hand-cleaning practices. However, healthcare workers expressed concerns that empowering patients to question their caregivers would interfere with the professional relationship. Educating both patients and their caregivers about the protection afforded by proper, consistent hand hygiene practices is important. Due to the limited size of the unit, a convenience sample was used. The small sample represents a significant limitation and observations would require further research on a much larger scale to validate the findings. Implications for nursing practice The idea that appropriate and effective hand hygiene prevents spread and/or progression of infection and saves lives is a widely accepted principle. Increased compliance with hand
hygiene is well known to be urgently needed among healthcare workers. Engaging patients in monitoring healthcare workers may increase compliance, reduce spread of infection, and lead to better overall patient outcomes. Educating patients about proper hand hygiene and the need to monitor healthcare workers entering their rooms could be initiated during the hospital admission process. This would empower patients to monitor their own safety and risk. Implications for research Although this study does not indicate major differences in patients’ perceptions of hand hygiene using soap and water or alcohol-based hand sanitizers, the lack of patient observation is a matter of concern. Informed patients who can advocate for themselves have become a major focus of current research. This study revealed a need to investigate the effects of patient education on patient perceptions of hand hygiene. Informing patients of the significance of proper hand hygiene for infection control and prevention and educating healthcare workers about appropriate hand hygiene techniques may positively impact patient outcomes. Patients must be informed that it is appropriate, and even advised, to ask healthcare workers if they have performed hand hygiene. Further research to examine provider perceptions and May l Nursing2015 l 29
www.Nursing2015.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
R ESEARCH COR N ER
objections to patients questioning the quality of their hand hygiene would be useful for promoting change. Also, investigators should take into account the ongoing research of the efficacy of handwashing versus waterless hand cleaner use in the presence of C. difficile infection.11 Conclusion Results of this study appear to indicate a need to focus on patient education and the differences between soap and water versus alcohol-based hand sanitizers as part of proper hand hygiene. For too many years, researchers have been forced to ask, “Why is compliance with hand hygiene among providers not 100%?” However, the question that should be asked instead may be: “Why have patients not been engaged as members of the healthcare team who have the most to lose?” REFERENCES 1. Chen YC, Sheng WH, Wang JT, et al. Effectiveness and limitations of hand hygiene promotion on decreasing healthcare-associated infections. PLoS One. 2011;6(11):e27163.
2. Pincock T, Bernstein P, Warthman S, Holst E. Bundling hand hygiene interventions and measurement to decrease health care-associated infections. Am J Infect Control. 2012;40(4 suppl 1):S18-S27. 3. De Wandel D, Maes L, Labeau S, Vereecken C, Blot S. Behavioral determinants of hand hygiene compliance in intensive care units. Am J Crit Care. 2010;19(3):230-239. 4. Whitby M, Pessoa-Silva CL, McLaws ML, et al. Behavioural considerations for hand hygiene practices: the basic building blocks. J Hosp Infect. 2007; 65(1):1-8. 5. Levchenko AI, Boscart VM, Fernie GR. The feasibility of an automated monitoring system to improve nurses’ hand hygiene. Int J Med Inform. 2011;80(8):596-603. 6. Palmore TN, Henderson DK. Big brother is washing...Video surveillance for hand hygiene adherence, through the lenses of efficacy and privacy. Clin Infect Dis. 2012;54(1):8-9. 7. CMS Media Relations. CMS issues fi nal rule for first year of hospital valuebased purchasing program. 2011. http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2011-Fact-Sheets-Items/2011-04-29.html. 8. Centers for Medicare and Medicaid Services. HCAHPS Fact Sheet (CAHPS Hospital Survey). 2013. http://www.hcahpsonline.org/facts.aspx. 9. Larson EL, Cohen B, Baxter KA. Analysis of alcohol-based hand sanitizer delivery systems: efficacy of foam, gel, and wipes against influenza A (H1N1) virus on hands. Am J Infect Control. 2012;40(9):806-809. 10. Steinmann J, Paulmann D, Becker B, Bischoff B, Steinmann E, Steinmann J. Comparison of virucidal activity of alcohol-based hand sanitizers versus antimicrobial hand soaps in vitro and in vivo. J Hosp Infect. 2012;82(4):277-280. 11. Dubberke ER, Gerding DN. Rationale for hand hygiene recommendations after caring for a patient with Clostridium difficile infection. 2011. http://www. shea-online.org/Portals/0/CDI%20hand%20hygiene%20Update.pdf. 12. Landers T, Abusalem S, Coty MB, Bingham J. Patient-centered hand hygiene: the next step in infection prevention. Am J Infect Control. 2012;40(4 suppl 1):S11-S17. 13. McGuckin M, Storr J, Longtin Y, Allegranzi B, Pittet D. Patient empowerment and multimodal hand hygiene promotion: a win-win strategy. Am J Med Qual. 2011;26(1):10-17. 14. Pittet D, Panesar SS, Wilson K, et al. Involving the patient to ask about hospital hand hygiene: a National Patient Safety Agency feasibility study. J Hosp Infect. 2011;77(4):299-303. 15. Ottum A, Sethi AK, Jacobs EA, Zerbel S, Gaines ME, Safdar N. Do patients feel comfortable asking healthcare workers to wash their hands? Infect Control Hosp Epidemiol. 2012;33(12):1282-1284. 16. Professional Research Consultants, Inc. PRC Online. http://www.prconline. com. 17. Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/ IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002;51(RR-16):1-45. http://www.cdc. gov/mmwr/PDF/rr/rr5116.pdf. At AnMed Health in Anderson, S.C., Sunni R. Busby is nurse manager of the orthopedics unit, Bryan Kennedy is director of nursing in the medical-surgical division, and Heather A. Thompson is the acting nurse manager and Jan W. Jones is a staff nurse, both in the adult medical unit. Stephanie C. Davis is the graduate coordinator and an associate professor of nursing at Clemson University School of Nursing in Clemson, S.C. Research Corner is coordinated by Cheryl Dumont, PhD, RN, CRNI, director of nursing research and the vascular access team at Winchester Medical Center in Winchester, Va. Dr. Dumont is also a member of the Nursing2015 editorial board. The content in this article has received appropriate institutional review board and/ or administrative approval for publication. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NURSE.0000463667.76100.06
30 l Nursing2015 l May
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Assessing patient awareness of proper hand hygiene By Sunni R. Busby, BSN, RN, CMSRN; Bryan Kennedy, MS, RN, NEA-BC; Stephanie C. Davis, PhD, RN, FNP-BC; Heather A. Thompson, BA, ADN, RN, CMSRN; and Jan W. Jones, ADN, RN
Abstract Background: The authors hypothesized that patients may not understand the forms of effective hand hygiene employed in the hospital environment. Literature review: Multiple studies demonstrate the importance of hand hygiene in reducing healthcare-associated infections (HAIs). Extensive research about how to improve compliance has been conducted. Methodology: Patients’ perceptions of proper hand hygiene were evaluated when caregivers used soap and water, waterless hand cleaner, or a combination of these. Results: No significant differences were observed, but many patients reported they did not notice whether their providers cleaned their hands. Discussion: Educating patients and their caregivers about the protection afforded by proper, consistent hand hygiene practices is important. Implications for nursing practice: Engaging patients to monitor healthcare workers may increase compliance, reduce the spread of infection, and lead to better overall patient outcomes. Implications for research: This study revealed a need to investigate the effects of patient education on patient perceptions of hand hygiene. Conclusion: Results of this study appear to indicate a need to focus on patient education and the differences between soap and water versus alcohol-based hand sanitizers as part of proper hand hygiene. Researchers could be asking: “Why have patients not been engaged as members of the healthcare team who have the most to lose?” Background Hand hygiene is a simple but effective way of preventing the transmission of healthcare-associated infections (HAIs). The authors hypothesized that patients may not understand the forms of effective hand hygiene employed in the hospital environment. This misunderstanding can impede their ability to evaluate their safety. This study sought to identify patients’ perceptions of whether their “nurse and nursing assistant cleaned their hands” when these providers used only soap and water, only waterless alcohol-based hand cleaner, or a combination of both methods. Participants were randomly assigned to groups in which primary caregivers used one of the two methods or a combination. A survey was
administered at the end of the shift to assess patients’ perceptions of the frequency of hand hygiene. Although no significant differences were identified, many patients reported that they did not pay attention to whether their providers cleaned their hands. The authors discuss safety concerns and implications for further research about engaging patients to assist in safety monitoring. Literature review Most healthcare providers know this mantra: “Hand hygiene is the easiest way to prevent infection.” Multiple studies demonstrate the importance of hand hygiene in reducing HAIs.1,2 Extensive research has been conducted about how to improve compliance, including behavioral modifications,3,4 use of technology to
monitor alcohol-based hand rub dispenser use,5 and video surveillance.6 Value-based purchasing is a concept introduced by the Centers for Medicare and Medicaid Services in 2011. The program bases reimbursement partially on clinical indicators and patient satisfaction measures.7 Patients’ experiences are measured by their perceptions, including how well their pain was controlled, how responsive the staff was to their needs, and the cleanliness of the hospital.8 The current trend of factoring patient perception into reimbursement creates a new area of practice and the need for research to examine how well patients understand the concepts they are being asked to rate. Part of the standard admission process is education about the importance of hand hygiene, and a sign is posted in each room instructing patients to “Please ask healthcare providers if they have cleaned their hands.” Patients may not understand exactly what it means for healthcare workers to “clean” their hands. Despite studies that demonstrate alcohol-based hand sanitizers are equally effective compared with soap and water in most circumstances, the authors hypothesize that patients do not always understand the differences and similarities between cleaning with soap and water and cleaning with alcohol-based hand sanitizers.9,10 It is also important to consider The Society for Healthcare Epidemiology of America’s recommendation that soap and water and not alcohol-based hand sanitizers be used in the presence of a Clostridium difficile outbreak.11 May l Nursing2015 l 27
www.Nursing2015.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
R ESEARCH COR N ER
Recent research highlights the benefits of involving patients in hand hygiene improvement efforts from an infection prevention standpoint and the importance of engaging the patient as an active participant in monitoring.12,13 In a study by the National Patient Safety Agency in the United Kingdom, the authors surveyed inpatients, the general public, and healthcare workers to determine their opinions on patient engagement and the influence it had on compliance with hand hygiene. Surveys of the general public and of medical-surgical inpatients across five hospitals in the United Kingdom assessed their opinions about receiving small bottles of alcohol-based hand sanitizer and education about hand hygiene, and evaluated whether these actions affected their willingness to ask healthcare workers if they would clean their hands. The authors found that only about 30% of the public were “very likely” to ask their providers if they had cleaned their hands. Reasons they cited for their reluctance included assumptions the staff had already performed the cleaning, fears it would insult their caregiver’s professionalism, and concerns the question would annoy the provider. However, inpatients rated explanations by healthcare workers that it was okay to ask if they washed their hands as one of the most useful interventions to empower patients.14 In the study, healthcare workers were asked for their opinions about patients receiving a bottle of alcoholbased sanitizer and being encouraged to ask if their providers had cleaned their hands. Although 71% of the participants felt HAIs could be reduced with patient involvement in hand hygiene monitoring, 25% reported the patient monitoring would undermine their relationship
with the patient. Among the healthcare workers, only 37% reported that, if hospitalized, they would ask nurses if they had cleaned their hands.14 Ottum et al. surveyed patients with a history of or at high risk for antibiotic-resistant infections to assess their understanding of HAIs, including hand hygiene as a prevention strategy.15 The authors found that patients were more likely to ask providers if they had performed hand hygiene if the patient had done so on a previous encounter. Likewise, patients as well as their visitors who were healthcare professionals were more likely to question their physicians and nurses about whether they had performed hand hygiene upon or just prior to entering the room. These findings suggest the importance of both dialoguing with patients on how to ask about hand hygiene compliance and the importance of self- or visitor-advocacy in a patient safety initiative. Methodology Although many studies have assessed patients’ and providers’ willingness to discuss hand hygiene in the context of patient safety, limited research has studied patients’ understanding of what proper hand hygiene entails. In the study facility, Professional Research Consultants surveys patients upon discharge home about their hospital experiences, including hand hygiene.16 Because the survey asks patients to evaluate how often staff cleaned their hands, the authors performed a descriptive study designed to evaluate patient understanding of the concept “hand cleaning.” • Operational definition. For the purposes of this study, hand hygiene was defined as antiseptic handwash or antiseptic hand rub. Either activity or a combination of both consti-
tutes proper cleaning. Antiseptic handwash involves washing hands with soap and water containing an antimicrobial agent, and antiseptic hand rub requires application of a preparation containing at least 60% ethanol or isopropanol to all surfaces of the hands.17 Although other methods are approved, they were excluded from this study because they are not commonly used in the study facility. • Method. This study was conducted on a 25-bed inpatient unit admitting adult general medical patients. The unit is part of a 461-bed facility in the southeastern United States. Patients were surveyed after an 8-hour shift during which the nurse and nursing assistant used soap and water, waterless alcohol-based hand cleaner, or a combination of both methods for hand hygiene. The soap-and-water cleaning was performed at the sink in the patient’s room and the waterless hand cleaning was done at a dispenser inside the room next to the door. Both locations were within view of the patient. Thirty patients were selected for each of the three groups. Inclusion criteria were patients who were capable of observing the hand hygiene performance of their caregivers. Exclusion criteria were patients requiring transmission-based precautions and those with mental status changes that impaired their memory or perception. The patients were given a single question survey: “How often during this 8-hour shift did your nurse and nursing assistant clean their hands?” by checking always, usually, sometimes, or never. The survey was administered by the unit charge nurse, and comments related to hand washing were noted. Demographic data were noted after the response was collected, but the surveys were otherwise anonymous.
28 l Nursing2015 l May
www.Nursing2015.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Results Data were collected from February 2 to April 27, 2013. (For responses, see Survey responses by intervention group.) Most patients in the hand washing-only and sanitizer-only groups (90.0% and 93.3%, respectively) indicated their caregivers always cleaned their hands. Some of the comments received from patients were as follows: • “Why are you washing your hands so much?” • “If you wash your hands any more, they’re going to fall off.” • “It’s a wonder you all have any skin left on your hands, as much as you wash them.” These questions suggest a lack of understanding of the importance of hand washing. Another troubling observation was that all of the patients who had no response reported that they did not notice whether staff members cleaned their hands. One of the patients who did not respond had been awakened by the nurse when she used the waterless cleanser dispenser. The nurse told the patient, “I’m sorry I scared you. The hand sanitizer wasn’t working, and I have to make sure my hands are clean.” Even so, this patient reported that he “did not notice if they cleaned their hands.” Demographic data including age, gender, and race revealed no significant differences in responses, including those patients who stated they did not notice whether their providers cleaned their hands. Discussion This study sought to explore patients’ perceptions of hand hygiene. The results do not support the hypothesis that patients perceive soap-and-water hand washing and waterless hand sanitizer differently. The number of patients who did not notice whether
Survey responses by intervention group* Always
Usually
Sometimes
Never
No response
Hand washing only (N=30)
90.0%
6.7%
0.0%
0.0%
3.3%
Sanitizer only (N=30)
93.3%
0.0%
0.0%
0.0%
6.7%
Combination (N=30)
80.0%
6.7%
6.7%
0.0%
6.7%
*Due to rounding, not all totals add up to 100%.
healthcare providers performed proper hand hygiene suggests that attempts to educate and empower patients to assist in monitoring their own safety have not been successful. Research has demonstrated the willingness of patients to promote hand hygiene as well as the belief of many healthcare workers that engaging patients would improve compliance with hand hygiene. Patients indicated that being asked by healthcare providers to assist in monitoring increased their likelihood of questioning the providers’ hand-cleaning practices. However, healthcare workers expressed concerns that empowering patients to question their caregivers would interfere with the professional relationship. Educating both patients and their caregivers about the protection afforded by proper, consistent hand hygiene practices is important. Due to the limited size of the unit, a convenience sample was used. The small sample represents a significant limitation and observations would require further research on a much larger scale to validate the findings. Implications for nursing practice The idea that appropriate and effective hand hygiene prevents spread and/or progression of infection and saves lives is a widely accepted principle. Increased compliance with hand
hygiene is well known to be urgently needed among healthcare workers. Engaging patients in monitoring healthcare workers may increase compliance, reduce spread of infection, and lead to better overall patient outcomes. Educating patients about proper hand hygiene and the need to monitor healthcare workers entering their rooms could be initiated during the hospital admission process. This would empower patients to monitor their own safety and risk. Implications for research Although this study does not indicate major differences in patients’ perceptions of hand hygiene using soap and water or alcohol-based hand sanitizers, the lack of patient observation is a matter of concern. Informed patients who can advocate for themselves have become a major focus of current research. This study revealed a need to investigate the effects of patient education on patient perceptions of hand hygiene. Informing patients of the significance of proper hand hygiene for infection control and prevention and educating healthcare workers about appropriate hand hygiene techniques may positively impact patient outcomes. Patients must be informed that it is appropriate, and even advised, to ask healthcare workers if they have performed hand hygiene. Further research to examine provider perceptions and May l Nursing2015 l 29
www.Nursing2015.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
R ESEARCH COR N ER
objections to patients questioning the quality of their hand hygiene would be useful for promoting change. Also, investigators should take into account the ongoing research of the efficacy of handwashing versus waterless hand cleaner use in the presence of C. difficile infection.11 Conclusion Results of this study appear to indicate a need to focus on patient education and the differences between soap and water versus alcohol-based hand sanitizers as part of proper hand hygiene. For too many years, researchers have been forced to ask, “Why is compliance with hand hygiene among providers not 100%?” However, the question that should be asked instead may be: “Why have patients not been engaged as members of the healthcare team who have the most to lose?” REFERENCES 1. Chen YC, Sheng WH, Wang JT, et al. Effectiveness and limitations of hand hygiene promotion on decreasing healthcare-associated infections. PLoS One. 2011;6(11):e27163.
2. Pincock T, Bernstein P, Warthman S, Holst E. Bundling hand hygiene interventions and measurement to decrease health care-associated infections. Am J Infect Control. 2012;40(4 suppl 1):S18-S27. 3. De Wandel D, Maes L, Labeau S, Vereecken C, Blot S. Behavioral determinants of hand hygiene compliance in intensive care units. Am J Crit Care. 2010;19(3):230-239. 4. Whitby M, Pessoa-Silva CL, McLaws ML, et al. Behavioural considerations for hand hygiene practices: the basic building blocks. J Hosp Infect. 2007; 65(1):1-8. 5. Levchenko AI, Boscart VM, Fernie GR. The feasibility of an automated monitoring system to improve nurses’ hand hygiene. Int J Med Inform. 2011;80(8):596-603. 6. Palmore TN, Henderson DK. Big brother is washing...Video surveillance for hand hygiene adherence, through the lenses of efficacy and privacy. Clin Infect Dis. 2012;54(1):8-9. 7. CMS Media Relations. CMS issues fi nal rule for first year of hospital valuebased purchasing program. 2011. http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2011-Fact-Sheets-Items/2011-04-29.html. 8. Centers for Medicare and Medicaid Services. HCAHPS Fact Sheet (CAHPS Hospital Survey). 2013. http://www.hcahpsonline.org/facts.aspx. 9. Larson EL, Cohen B, Baxter KA. Analysis of alcohol-based hand sanitizer delivery systems: efficacy of foam, gel, and wipes against influenza A (H1N1) virus on hands. Am J Infect Control. 2012;40(9):806-809. 10. Steinmann J, Paulmann D, Becker B, Bischoff B, Steinmann E, Steinmann J. Comparison of virucidal activity of alcohol-based hand sanitizers versus antimicrobial hand soaps in vitro and in vivo. J Hosp Infect. 2012;82(4):277-280. 11. Dubberke ER, Gerding DN. Rationale for hand hygiene recommendations after caring for a patient with Clostridium difficile infection. 2011. http://www. shea-online.org/Portals/0/CDI%20hand%20hygiene%20Update.pdf. 12. Landers T, Abusalem S, Coty MB, Bingham J. Patient-centered hand hygiene: the next step in infection prevention. Am J Infect Control. 2012;40(4 suppl 1):S11-S17. 13. McGuckin M, Storr J, Longtin Y, Allegranzi B, Pittet D. Patient empowerment and multimodal hand hygiene promotion: a win-win strategy. Am J Med Qual. 2011;26(1):10-17. 14. Pittet D, Panesar SS, Wilson K, et al. Involving the patient to ask about hospital hand hygiene: a National Patient Safety Agency feasibility study. J Hosp Infect. 2011;77(4):299-303. 15. Ottum A, Sethi AK, Jacobs EA, Zerbel S, Gaines ME, Safdar N. Do patients feel comfortable asking healthcare workers to wash their hands? Infect Control Hosp Epidemiol. 2012;33(12):1282-1284. 16. Professional Research Consultants, Inc. PRC Online. http://www.prconline. com. 17. Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/ IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002;51(RR-16):1-45. http://www.cdc. gov/mmwr/PDF/rr/rr5116.pdf. At AnMed Health in Anderson, S.C., Sunni R. Busby is nurse manager of the orthopedics unit, Bryan Kennedy is director of nursing in the medical-surgical division, and Heather A. Thompson is the acting nurse manager and Jan W. Jones is a staff nurse, both in the adult medical unit. Stephanie C. Davis is the graduate coordinator and an associate professor of nursing at Clemson University School of Nursing in Clemson, S.C. Research Corner is coordinated by Cheryl Dumont, PhD, RN, CRNI, director of nursing research and the vascular access team at Winchester Medical Center in Winchester, Va. Dr. Dumont is also a member of the Nursing2015 editorial board. The content in this article has received appropriate institutional review board and/ or administrative approval for publication. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NURSE.0000463667.76100.06
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