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International Journal of Nursing Practice 2014; 20: 46–52
RESEARCH PAPER
Hand hygiene compliance among the nursing staff in freestanding nursing homes in Taiwan: A preliminary study Wen-I Liu PhD RN Associate Professor, School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
Shu-Yuan Liang PhD RN Associate Professor, School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
Shu-Fang Vivienne Wu PhD RN Associate Professor, School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
Yeu-Hui Chuang PhD RN Assistant Professor, School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
Accepted for publication October 2012 Liu W-I, Liang S-Y, Wu S-FV, Chuang Y-H. International Journal of Nursing Practice 2014; 20: 46–52 Hand hygiene compliance among the nursing staff in freestanding nursing homes in Taiwan: A preliminary study This study aimed to explore the hand hygiene compliance among the nursing staff in Taiwanese freestanding nursing homes. A descriptive observational research design was used. A total of 782 opportunities for hand hygiene were observed by one trained research assistant in two freestanding nursing homes. The hand-hygiene observation tool was used to assess hand hygiene practice. The overall hand hygiene compliance among nursing staff in nursing homes was only 11.3%. Results further showed that the compliance was greater after contact with body fluids (odds ratio = 6.9, confidence interval (CI) = 3.75–9.88, P = 0.000) and lower before the performance of aseptic procedures (odds ratio = 0.15, CI = 0.04–0.63, P = 0.003) when compared with other activities. Hand hygiene compliance was relatively low among the nursing staff in freestanding nursing homes in Taiwan. To comprehensively analyze this issue, further research involving a larger number of nursing homes and strategies to improve compliance with hand hygiene among the nursing staff at these institutions is needed. Key words: compliance, handwashing, nurses, nurses’ aides, nursing homes.
INTRODUCTION Health care-associated infection (HAI) is a serious problem that deeply impacts patient safety and is a major cause of
Correspondence: Yeu-Hui Chuang, School of Nursing, College of Nursing, Taipei Medical University, 250, Wu-Xing Street, Taipei, Taiwan 110. Email address: [email protected] © 2013 Wiley Publishing Asia Pty Ltd
patient morbidity and mortality. It also prolongs the length of stay in health-care settings and increases medical costs.1,2 Hand hygiene is an effective and important measure that reduces the frequency of pathogen transmission and prevents HAIs.3–6 However, the vast majority of studies have placed considerable emphasis on hand hygiene practice in acute care settings7–12 with less attention paid to the basic issue of hand hygiene in long-term care institutions.13 doi:10.1111/ijn.12120
Hand hygiene in freestanding nursing homes
A long-term care facility (LTCF) is not simply a healthcare setting. For most of the dependent older adults who reside in LTCFs, these facilities are also the places for them to stay in the rest of their lives. The residents often have physical disabilities and cognitive impairments that compromise their capacity to care for themselves. Aging may contribute to a decline in the function of the immune systems of older residents. Such a decline can lead to an increased vulnerability to disease.14,15 Consequently, there is an increased risk of acquiring and transmitting HAIs among older residents. Because of high infection rates in Taiwan’s LTCFs,16,17 the compliance with hand hygiene among the nursing staff needs to be assessed and evaluated. A statistical model has shown that a threshold adherence of greater than 50% was necessary to interrupt nosocomial transmission of pathogens.18 Unfortunately, hand hygiene compliance in LTCFs was shown to be as low as 14.7% in a Canadian study19 and as low as 17.5% in an Italian study.20 A French study revealed a better compliance with hand hygiene (61.5%) in eight health-care settings for the elderly including acute-care geriatric wards, skilled nursing facilities and long-term care facilities compared with other previous studies.21 A Taiwanese one-group intervention study found that the compliance of nursing assistants with hand hygiene was only 9.34% before the intervention. Even after the hand hygiene intervention, which included a 1-h lecture and 30 min of hands-on training, the rate of compliance was only 30.36%.22 However, this study did not include nurses who are also the major health-care providers in the nursing homes and perform invasive treatments and care frequently. Similarly, the Hong Kong study found that hand hygiene compliance of health-care workers in the LTCFs increased from 25.8% to 33.3% only after the interventions that included using pocketsized containers of alcohol-based hand rub, reminder materials and education.23 There are two types of nursing homes in Taiwan: as of January 2008, there were 142 hospital-based nursing homes and 168 free-standing nursing homes.24 Around 50% of nursing homes are freestanding nursing homes. The quality of care within freestanding nursing homes needs to be scrutinized. Unlike hospital-based nursing homes, which are supervised and operated by hospitals with a focus on infection control policy,16 freestanding nursing homes are usually run by individuals in the community and have fewer regulations, policies and resources. The study by Tsang et al.16 indicated that
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66.7% of hospital-based nursing homes had infection control committees, and none of the free-standing nursing homes had one. In addition, 83.3% of the hospital-based nursing homes had hand hygiene practice policy, but only 66.7% of the freestanding nursing homes had that policy. Handwashing behaviour is complex.25 It is a wellknown practice in health-care settings, but there is a significant inability to motivate health-care providers to comply with hand hygiene practices. Studies have revealed that nurses not only overestimate their personal compliance with hand hygiene26 but also show inconsistencies between what they say, what they know and what they do.5,27 Observed handwashing practice was found to be unrelated to the self-reported behaviours of health-care professionals.27 Accordingly, direct observation, although labour-intensive and time-consuming, is therefore considered the gold standard for the assessment of handwashing practices.28,29 The purpose of this study, then, was to explore the compliance with hand hygiene by the nursing staff in Taiwanese freestanding nursing homes using the method of direct observation.
METHODS Design The quantitative cross-sectional descriptive observational research design was used.
Research settings and access The query letters were sent to all (nine) freestanding nursing homes in Tainan city from a list of nursing homes registered with the Department of Health (DOH) in Taiwan. Following the query letters, phone calls were made to explain the purpose of the study and the process that would be implemented, as well as to answer any questions. Only two nursing homes were willing to participate in this study because of both the employed method of direct observation and sensitivity regarding the rate of compliance with hand hygiene among their health-care workers. The owners or directors of freestanding nursing homes could have concerns in reference to their reputation, and the potential drop in income from operating the institutions if subpar compliance rates were made public; however, confidentiality was assured. Before collecting data, the administrators of the two nursing homes introduced the study to the entire nursing staff, including nurses and nursing assistants. Each staff member was then approached individually and invited to © 2013 Wiley Publishing Asia Pty Ltd
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participate in the study on a voluntary basis. All nursing staff in the two nursing homes agreed to join the study.
Sampling The hand hygiene opportunity was the unit of analysis in this study. All hand hygiene opportunities were referred to as ‘the sample size’ and were defined as the points in time when the hands should have been washed, regardless of whether the hand washing actually occurred or what cleansing agent was chosen. The points in time for hand washing included: before contact with residents, before aseptic tasks, after contact with residents and their surroundings, and after body fluid exposure risk. The nursing staff were directly monitored during data collection by a trained observer. The number of hand hygiene opportunities for this study were calculated based on data from two previous studies conducted in long-term care facilities19,20 via the Sample Size Proportion Calculator.30 As a result, the study required at least 450 hand hygiene opportunities for a power of 90% and alpha level of 0.05.
Instrument The demographic data concerning the institutions and the nursing staff who were observed were collected. The hand hygiene observation tool (HHOT), which was developed by McAteer et al.,28 was used to assess hand hygiene practice. Permission to use the HHOT has been obtained from the authors. This tool has a set of precise standard operating procedures with clear instructions for use and data collection. The interobserver agreement for the HHOT was 92%, and the Kappa coefficient was 0.88 (95% confidence interval (CI) 0.78–0.98). To implement the HHOT, a resident care area of five to eight beds was defined. Hand hygiene opportunities and hand hygiene behaviours among the nursing staff were recorded by a trained observer. A hand hygiene opportunity was defined as hand hygiene practices that should occur before contact with residents, before aseptic tasks, after contact with residents and their surroundings, and after body fluid exposure risk. Hand hygiene behaviour was defined as whether or not the nursing staff washed their hands correctly at a given opportunity with either alcohol, or soap and water, took no action, or took unknown actions. Overall hand hygiene compliance was calculated as the number of times in which soap or an alcohol-based hand sanitizing agent was used correctly divided by the total hand hygiene opportunities with the result multiplied by 100%.31 The observer observed each © 2013 Wiley Publishing Asia Pty Ltd
resident care area for 20 min and then rotated to different resident care areas, so all residents could be covered in each observation day. The order of the rotation of resident care areas had been randomly assigned by the observer each day.
Data collection The observer received 20 h of training by the researcher before initiating data collection. The training program included information on how to use the HHOT, the definition of a resident care area and a hygiene opportunity, the correct procedures of hand hygiene practice, the difficulties that may arise for the observer and the strategies to counter them, role playing, and practice scenarios. The intra-rater reliability of the observer was 100% after training. The observer visited the facilities one week before data collection was initiated to allow the nursing staff to familiarize themselves with her to decrease the possibility of a Hawthorne effect. The observations were took place during the day shift, from 9:00 a.m. to 12:00 p.m., during the entire study (including weekdays and weekends) because these times are correlated with the highest level of resident contact. The observation was undertaken for one week at each facility.
Data analysis Analysis of the data was undertaken using the Statistical Package for the Social Sciences (SPSS version 18.0; SPSS, Inc., Chicago, IL, USA). The mean and percentage were used to describe the demographic data and the characteristics of the participants. The proportion was used to describe the overall compliance with hand hygiene among the nursing staff. The chi-square test was used to compare the differences between the compliance of nurses and nursing assistants. Odds ratios (ORs) with 95% CIs were used to examine the relationships between the various hand hygiene opportunities. A P value less than 0.05 was considered statistically significant.
Ethical considerations Ethical approval was obtained from the research ethics committee in one university. The two nursing homes do not have their own ethics committees; however, approval of the study was received from the participating facilities, and all the participants signed the informed consents. The rights of all participants were protected by abiding by the requirements of the research ethics committee. Participants were also informed about the withdrawal
Hand hygiene in freestanding nursing homes
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option and informed that if they chose not to participate, there would be no adverse effects on their careers, either now or in the future. All participants in the study were also assured of the privacy and anonymity of any information they provided.
RESULTS Two private freestanding nursing homes (A and B), which were supervised by the DOH, were recruited to this study. In facility A with 51 beds, there were 6 nurses and 11 nursing assistants. In facility B with 31 beds, there were four nurses and seven nursing assistants. Nursing managers of both facilities claimed that they offered the hand hygiene in-service programs and audited their members’ hand hygiene behaviours regularly. A total of 16 members of the nursing staff (seven nurses and nine nursing assistants) were observed during the data collection period and the final sample was composed of 57% of all nursing staff in these two nursing homes. Seven nurses with a mean age of 33.29 years (standard deviation (SD) = 10.56) had worked in the nursing home for 11.14 months (SD = 14.37), and nine nursing assistants with a mean age of 33.89 years (SD = 7.01) had worked in the nursing home for 13.11 months (SD = 18.47). The majority of the nursing staff was female (93.7%). Only one (6.3%) nursing assistant was male. Six nurses (85.7%) had bachelor degrees, and five nursing assistants (55.5%) had high school diplomas. One (6.3%) nurse in facility A claimed that she has not attended any hand hygiene training lecture and program. All nursing staff have ever been audited their hand hygiene behaviours in the facilities. During the observation period, a total of 782 hand hygiene opportunities (435 in facility A and 347 in facility B) were observed. There were 352 hand hygiene opportunities among nurses, but only 62 (17.6%) hand hygiene practices were performed. Furthermore, there were 430
hand hygiene opportunities among the nursing assistants, with only 26 (6.0%) hand hygiene practices undertaken. The overall compliance with hand hygiene among the nursing staff in the nursing homes was 11.3% (88/782). The study also found that nurses had better compliance with hand hygiene than nursing assistants (17.6 vs. 6.0%, respectively; P = 0.000) (Table 1). There were no differences on hand hygiene compliance between nurses and nursing assistants before resident contact (P = 0.334) and aseptic tasks (P = 0.472). However, nurses had better compliance than nursing assistants after contact with resident and resident surroundings (P = 0.000) and body fluid exposure risk (P = 0.006). The compliance with hand hygiene varied by hand hygiene opportunities including the time before resident contact, before aseptic tasks, after contact with a resident and the resident’s surroundings, and after body fluid exposure risk. Both nurses and nursing assistants had higher compliance with hand hygiene after body fluid exposure risk (41.56% and 15.79%, respectively). The lowest compliance occurred prior to the performance of aseptic tasks for both nurses and nursing assistants (2.67% and 0%, respectively). Adherence to hand hygiene guidelines among nursing staff was greater after contact with the body fluids of residents than before or after other activities (OR = 6.9, CI = 3.75–9.88, P = 0.000). In addition, compliance with hand hygiene was lower before the performance of aseptic procedures or treatments as compared with other activities (OR = 0.15, CI = 0.04– 0.63, P = 0.003) (Table 2).
DISCUSSION The findings of this study highlight the relatively low hand hygiene compliance among the nursing staff at two Taiwanese freestanding nursing homes despite their awareness of the observer. The 11.3% compliance with hand hygiene
Table 1 The differences of hand hygiene compliance in different handwashing moments between nurses and nursing assistants Compliance with hand hygiene
Overall
Before resident contact Before aseptic tasks After contact with resident and resident surroundings After body fluid exposure risk Total
3.8% 2.1% 11.6% 33.0% 11.3%
Nurses (9/237) (2/94) (39/336) (38/115) (88/782)
5.3% 2.7% 21.9% 41.6% 17.6%
(5/95) (2/75) (23/105) (32/77) (62/352)
Nursing assistants
c2 (P value)
3.2% 0% 6.9% 15.8% 6.0%
0.93 0.52 15.79 7.64 25.93
(4/142) (0/19) (16/231) (6/38) (26/430)
(0.334) (0.472) (0.000)** (0.006)* (0.000)**
* P < 0.01; ** P < 0.001.
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Table 2 The comparison of hand hygiene compliance at different hand hygiene opportunities among nursing staff Hand hygiene opportunity
Compliance in this opportunity
Compliance in other opportunities
Odds ratio (95% CI)
Before resident contact Before aseptic tasks After contact with resident and the resident’s surroundings After body fluid exposure risk
3.8% 2.1% 11.6% 33.0%
14.5% 12.5% 11% 7.5%
0.23 0.15 1.06 6.09
(9/327) (2/94) (39/336) (38/115)
(79/545) (86/688) (49/446) (50/667)
(0.15 (0.04 (0.68 (3.75
P value
to to to to
0.47) 0.63) 1.67) 9.88)
0.000** 0.003* 0.79 0.000**
* P < 0.01; ** P < 0.001.
found in this study was even lower than the data shown in previous studies (14.7% and 17.5%, respectively).19,20 In addition, the hand hygiene compliance among nursing assistants was also lower (6.0%) than the findings of a study conducted in three Taiwanese LTCFs (9.34% before the training program in hand hygiene and 30.36% after the training).22 The length of nursing experiences in nursing homes among nursing staff was short in the present study, so there is possibility that lack of experience may have influences on the very low compliance of hand hygiene. In addition, the heavy workloads, busy schedule and no nearby sinks in these nursing homes may worsen the situation. One Flemish study reported that 81 LTCF healthcare workers’ average score on a hand hygiene quiz was 51%.32 The inadequate knowledge regarding hand hygiene among LTCF staff may be the cause of low compliance, but it needs to further examine the relationship between the two variables in the future study. The results of this study suggest that compliance with hand hygiene in Taiwanese nursing homes, especially in the freestanding nursing homes, should be improved immediately. The previous studies have also found that the compliance with hand hygiene varied according to staff position. In the present study, nurses had a higher compliance with hand hygiene than nursing assistants. The Italian study20 also revealed that nurses (20.1%) had a higher compliance than nursing assistants (10%). In addition, one large survey conducted in the USA found that nurses had better knowledge of the hand hygiene guidelines than nursing assistants and other professionals, such as physician, social workers and physical therapists in 17 LTCFs.33 In contrast, some studies found that nurses had lower compliance than nursing assistants in long-term care facilities.19,34 However, the most important point found in the present study, however, is that the compliance for both nurses and nursing assistants was very poor. © 2013 Wiley Publishing Asia Pty Ltd
The compliance was higher after contact with residents and lower before contact with residents when compared with other tasks in this study. Several studies had similar findings.20,35,36 Both Pan et al.,20 and Korniewicz and El-Masri35 suggested that hand hygiene was usually considered as a method to protect health-care workers rather than a method to protect patients. In addition, the compliance by the nursing staff regarding hand hygiene, following the performance of tasks, was higher after contact with the body fluids of residents as compared with other types of contact with residents or their surroundings. Richards and Russo,37 and Santana et al.38 in 2007 suggested that health-care workers were more likely to clean their hands when they perceived they were in a risky and possibly infectious situation. It is possible that the nursing staff noticed the visible stains or dirt on their hands after contact with the body fluids of residents and then remembered to wash their hands. They may also have believed that their hands were clean before patient contact.35 The other important finding in this study is that the compliance was lowest before the performance of aseptic tasks. These results are similar to those reported by the World Health Organization,39 whose research also showed a low compliance prior to the performance of an aseptic task. Similarly, a study found that the LTCF health-care workers scored less than 50% marks on both ‘hand hygiene before a clean/aseptic procedure’ and ‘hand hygiene after glove removal’ questions.32 It is possible that the nursing staff usually wore gloves during the performance of some aseptic procedures, which they may have believed was a substitute for hand hygiene. Additionally, the nursing staff may also have believed that their hands were clean enough before the performance of aseptic tasks. In contrast, Randle et al.7 found that healthcare professionals were fully compliant with hand washing prior to the performance of aseptic tasks; the study,
Hand hygiene in freestanding nursing homes
however, consisted of only three hand hygiene opportunities prior to aseptic tasks during a 24-h observation period in a hospital. Based on the findings of this study, the right time to clean hands especially before contact with residents and before the performance of aseptic tasks should be re-emphasized for the nursing staff. It is suggested that both nurses and nursing assistants should receive regular training on hand hygiene practice, have reminding materials, have adequate available hand hygiene agents and need more frequent ongoing audits on hand hygiene23 either by the institutions or by government-level officers. Because of the nature of observation, the possibility of a Hawthorne effect needs to be considered in this study. The real compliance with hand hygiene is potentially lower than the results found in this study. For minimizing the Hawthorne effect in this study, the observer spent 1 week in the participating nursing homes prior to the collection of data to allow the staff to become familiar with her presence. Another limitation of the study was that all observations were conducted during morning hours. These hours were chosen because major tasks and treatments were most often performed during those times. However, by not observing the nursing staff at other times, the study may have missed some aspects of hand hygiene practice. In addition, the hand hygiene behaviours reflected only those nursing staff who were observed and might not be the representative of all nursing staff in the nursing homes. The strategy to overcome this issue was to stay in the nursing home for the whole week in order to observe different nursing staffs’ hand washing behaviours. Despite these limitations, the findings of this study still provide valuable information that calls immediate attention to the poor hand hygiene practice in freestanding nursing homes. In summary, this study revealed that the nurses and nursing assistants of freestanding nursing homes had very low compliance with hand hygiene. The results alert health-care professionals to make efforts on the infection control and hand hygiene practices in long-term care facilities. Further, this finding significantly suggests that immediate action should be taken to improve hand hygiene practice not only by the managers or the nursing staff of nursing homes but also by the lawmakers or supervisors of the DOH. The DOH should perhaps become responsible for a hand hygiene surveillance system to ensure the quality of care in freestanding nursing homes. Large-scale studies of hand hygiene practices in long-term care facilities should be conducted in the near future in
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Taiwan. Importantly, the effective and appropriate interventions should be immediately developed based on the information provided in this study.
ACKNOWLEDGEMENTS The authors gratefully acknowledge the two nursing homes and nursing staff for participating in the study. This study was supported by a research grant (TMU100-AE1B06) Taipei Medical University in Taiwan.
REFERENCES 1 Sheng W-H, Chie W-C, Chen Y-C, Huang C-C, Wang J-T, Chang S-C. Impact of nosocomial infections on medical costs, hospital stay, and outcome in hospitalized patients. Journal of the Formosan Medical Association 2005; 104: 318– 326. 2 Chen Y, Chou Y, Chou P. Impact of nosocomial infection on cost of illness and length of stay in intensive care units. Infection Control and Hospital Epidemiology 2005; 26: 281– 287. 3 Pittet D, Hugonnet S, Harbarth S et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. The Lancet 2000; 356: 1307–1312. 4 Trampuz A, Widmer A. Hand hygiene: A frequently missed life-saving opportunity during patient care. Mayo Clinic Proceedings 2004; 79: 109–116. 5 Creedon S. Healthcare workers’ hand decontamination practices: Compliance with recommended guidelines. Journal of Advanced Nursing 2005; 51: 208–216. 6 Rummukainen M, Jakobsson A, Karppi P, Kautiainen H, Lyytikäinen O. Promoting hand hygiene and prudent use of antimicrobials in long-term care facilities. American Journal of Infection Control 2009; 37: 168–171. 7 Randle J, Arthur A, Vaughan N. Twenty-four-hour observational study of hospital hand hygiene compliance. Journal of Hospital Infection 2010; 76: 252–255. 8 Polat S, Parlak Gurol A, Cevik U. Hand hygiene compliance of nurses: A 5-unit observational study in North-Eastern Anatolia. International Journal of Nurisng Practice 2011; 17: 435–440. 9 Chau JP, Thompson DR, Twinn S, Lee DT, Pang SW. An evaluation of hospital hand hygiene practice and glove use in Hong Kong. Journal of Clinical Nursing 2011; 20: 1319– 1328. 10 Lee A, Chalfine A, Daikos GL et al. Hand hygiene practices and adherence determinants in surgical wards across Europe and Israel: A multicenter observational study. American Journal of Infection Control 2011; 39: 517–520. 11 Naderi H, Sheybani F, Mostafavi I, Khosravi N. Compliance with hand hygiene and glove change in a general hospital, Mashhad, Iran: An observational study. American Journal of Infection Control 2012; 40: e221–e223. © 2013 Wiley Publishing Asia Pty Ltd
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12 Venkatesh AK, Pallin DJ, Kayden S, Schuur JD. Predictors of hand hygiene in the emergency department. Infection Control and Hospital Epidemiology 2011; 32: 1120–1123. 13 The Joint Commission. Measuring hand hygiene adherence: overcoming the challenge. 2009. Available from URL: http://www.jointcommission.org/Measuring_Hand_ Hygiene_Adherence_Overcoming_the_Challenges_/. Accessed 30 September 2011. 14 Eaton SM, Burns EM, Kusser K, Randall TD, Haynes L. Age-related defects in CD4 T cell cognate helper function lead to reductions in humoral responses. The Journal of Experimental Medicine 2004; 200: 1613–1622. 15 Castle S. Clinical relevance of age-related immune dysfunction. Clinical Infectious Diseases 2000; 31: 578–585. 16 Tsang L, Yang C, Huang L, Kuo I. Prevalence survey of infection and currents status of infection control in nursing homes. The Journal of Long-Term Care 2004; 8: 425–439. 17 Lee CM, Chen YL, Yang CL. Nosocomial infection in one long term care facility: A nursing home. Journal of Internal Medicine of Taiwan 2008; 19: 331–336. 18 Austin D, Bonton M, Weinstein R, Slaughter S, Anderson R. Vancomycin-resistant enterococci in intensive-care hospital settings: Transmission dynamics, persistence, and the impact of infection control programs. Proceedings of the National Academy of Sciences of the Untied States of America 1999; 96: 6908–6913. 19 Smith A, Carusone S, Loeb M. Hand hygiene practices of health care workers in long-term care facilities. American Journal of Infection Control 2008; 36: 492–494. 20 Pan A, Domenighini F, Signorini L et al. Adherence to hand hygiene in an Italian long-term care facility. American Journal of Infection Control 2008; 36: 495–497. 21 Eveillard M, Pradelle M, Lefrancq B et al. Measurement of hand hygiene compliance and gloving practices in different settings for the elderly considering the location of hand hygiene opportunities during patient care. American Journal of Infection Control 2011; 39: 339–341. 22 Huang TT, Wu SC. Evaluation of a training programme on knowledge and compliance of nurse asssitants’ hand hygiene in nursing homes. Journal of Hospital Infection 2008; 68: 164–170. 23 Yeung WK, Tam WS, Wong TW. Clustered randomized controlled trial of a hand hygiene intervention involving pocket-sized containers of alcohol-based hand rub for the control of infections in long-term care facilities. Infection Control and Hospital Epidemiology 2011; 32: 67–76. 24 Taiwanese Long-Term Care Association. The resources of long-term care facilities in Taiwanese area. 2008. Available from URL: http://www.ltcpa.org.tw/about/ aboutus-302.php. Accessed 20 June 2011. 25 Whitby M, McLaws M, Ross MW. Why healthcare workers don’t wash their hands: A behavioral explanation. Infection Control and Hospital Epidemiology 2006; 27: 484–492.
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26 Jenner E, Fletcher E, Watson B, Jones F, Miller L, Scott G. Discrepancy between self-reported and observed hand hygiene behaviour in healthcare professionals. Journal of Hospital Infection 2006; 63: 418–422. 27 O’Boyle CA, Henly SJ, Larson E. Understanding adherence to hand hygiene recommendations: The theory of planned behavior. American Journal of Infection Control 2001; 29: 352– 360. 28 McAteer J, Stone S, Fuller C et al. Development of an observational measure of healthcare worker hand-hygiene behaviour: The hand-hygiene observation tool (HHOT). Journal of Hospital Infection 2008; 68: 222–229. 29 World Health Organization. WHO guidelines on hand hygiene in health care (advanced draft). 2008. Available from URL: http://www.who.int/patientsafety/information_ centre/ghhad_download_link/en/. Accessed 14 October 2011. 30 Dimension Research. Sample size for proportion calculator. 2009. Available from URL: http://www.dimensionsintl. com/ARCHIVE/sample_calculator.html. Accessed 14 October 2011. 31 Infectious Disease Research Network. NOSEC: national observation study of the effectiveness of the cleanyourhands campaign. 2008. Available from URL: http://www.idrn. org/nosec.php. Accessed 14 October 2011. 32 Wandel DD, Vogelaers D, Blot S. Hand hygiene knowledge in long-term care facilities (LTCFS): a multicentre pilot study. BMC Proceedings 2011; 5: 63. 33 Ashraf M, Hussain S, Agarwal N et al. Hand hygiene in long-term care facilities: a multicenter study of knowledge, attitudes, practices, and barriers. Infection Control and Hospital Epidemiology 2010; 31: 758–762. 34 Aiello AE, Malinis M, Knapp JK, Mody L. The influence of knowledge, perceptions, and beliefs, on hand hygiene practices in nursing homes. American Journal of Infection Control 2009; 37: 164–167. 35 Korniewicz DM, El-Masri M. Exploring the factors associated with hand hygiene compliance of nurses during routine clinical practice. Applied Nursing Research 2010; 23: 86–90. 36 Akyol AD. Hand hygiene among nurses in Turkey: Opinions and practices. Journal of Clinical Nursing 2007; 16: 431–437. 37 Richards MJ, Russo PL. Surveillance of hospital-acquired infections in Australia—One nation, many states. Journal of Hospital Infection 2007; 65: 174–181. 38 Santana SL, Furtado GH, Coutinho AP, Medeiros EA. Assessment of healthcare professionals’ adherence to hand hygiene after alcohol-based hand rub introduction at an intensive care unit in Sao Paulo, Brazil. Infection Control and Hospital Epidemiology 2007; 28: 365–367. 39 World Health Organization. Guidelindes on Hand Hygiene in Health Care. First Global Patient Safety Challenge: Clean Care is Safer Care. Geneva, Switzerland: World Health Organization, 2009.
International Journal of Nursing Practice 2014; 20: 46–52
RESEARCH PAPER
Hand hygiene compliance among the nursing staff in freestanding nursing homes in Taiwan: A preliminary study Wen-I Liu PhD RN Associate Professor, School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
Shu-Yuan Liang PhD RN Associate Professor, School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
Shu-Fang Vivienne Wu PhD RN Associate Professor, School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
Yeu-Hui Chuang PhD RN Assistant Professor, School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
Accepted for publication October 2012 Liu W-I, Liang S-Y, Wu S-FV, Chuang Y-H. International Journal of Nursing Practice 2014; 20: 46–52 Hand hygiene compliance among the nursing staff in freestanding nursing homes in Taiwan: A preliminary study This study aimed to explore the hand hygiene compliance among the nursing staff in Taiwanese freestanding nursing homes. A descriptive observational research design was used. A total of 782 opportunities for hand hygiene were observed by one trained research assistant in two freestanding nursing homes. The hand-hygiene observation tool was used to assess hand hygiene practice. The overall hand hygiene compliance among nursing staff in nursing homes was only 11.3%. Results further showed that the compliance was greater after contact with body fluids (odds ratio = 6.9, confidence interval (CI) = 3.75–9.88, P = 0.000) and lower before the performance of aseptic procedures (odds ratio = 0.15, CI = 0.04–0.63, P = 0.003) when compared with other activities. Hand hygiene compliance was relatively low among the nursing staff in freestanding nursing homes in Taiwan. To comprehensively analyze this issue, further research involving a larger number of nursing homes and strategies to improve compliance with hand hygiene among the nursing staff at these institutions is needed. Key words: compliance, handwashing, nurses, nurses’ aides, nursing homes.
INTRODUCTION Health care-associated infection (HAI) is a serious problem that deeply impacts patient safety and is a major cause of
Correspondence: Yeu-Hui Chuang, School of Nursing, College of Nursing, Taipei Medical University, 250, Wu-Xing Street, Taipei, Taiwan 110. Email address: [email protected] © 2013 Wiley Publishing Asia Pty Ltd
patient morbidity and mortality. It also prolongs the length of stay in health-care settings and increases medical costs.1,2 Hand hygiene is an effective and important measure that reduces the frequency of pathogen transmission and prevents HAIs.3–6 However, the vast majority of studies have placed considerable emphasis on hand hygiene practice in acute care settings7–12 with less attention paid to the basic issue of hand hygiene in long-term care institutions.13 doi:10.1111/ijn.12120
Hand hygiene in freestanding nursing homes
A long-term care facility (LTCF) is not simply a healthcare setting. For most of the dependent older adults who reside in LTCFs, these facilities are also the places for them to stay in the rest of their lives. The residents often have physical disabilities and cognitive impairments that compromise their capacity to care for themselves. Aging may contribute to a decline in the function of the immune systems of older residents. Such a decline can lead to an increased vulnerability to disease.14,15 Consequently, there is an increased risk of acquiring and transmitting HAIs among older residents. Because of high infection rates in Taiwan’s LTCFs,16,17 the compliance with hand hygiene among the nursing staff needs to be assessed and evaluated. A statistical model has shown that a threshold adherence of greater than 50% was necessary to interrupt nosocomial transmission of pathogens.18 Unfortunately, hand hygiene compliance in LTCFs was shown to be as low as 14.7% in a Canadian study19 and as low as 17.5% in an Italian study.20 A French study revealed a better compliance with hand hygiene (61.5%) in eight health-care settings for the elderly including acute-care geriatric wards, skilled nursing facilities and long-term care facilities compared with other previous studies.21 A Taiwanese one-group intervention study found that the compliance of nursing assistants with hand hygiene was only 9.34% before the intervention. Even after the hand hygiene intervention, which included a 1-h lecture and 30 min of hands-on training, the rate of compliance was only 30.36%.22 However, this study did not include nurses who are also the major health-care providers in the nursing homes and perform invasive treatments and care frequently. Similarly, the Hong Kong study found that hand hygiene compliance of health-care workers in the LTCFs increased from 25.8% to 33.3% only after the interventions that included using pocketsized containers of alcohol-based hand rub, reminder materials and education.23 There are two types of nursing homes in Taiwan: as of January 2008, there were 142 hospital-based nursing homes and 168 free-standing nursing homes.24 Around 50% of nursing homes are freestanding nursing homes. The quality of care within freestanding nursing homes needs to be scrutinized. Unlike hospital-based nursing homes, which are supervised and operated by hospitals with a focus on infection control policy,16 freestanding nursing homes are usually run by individuals in the community and have fewer regulations, policies and resources. The study by Tsang et al.16 indicated that
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66.7% of hospital-based nursing homes had infection control committees, and none of the free-standing nursing homes had one. In addition, 83.3% of the hospital-based nursing homes had hand hygiene practice policy, but only 66.7% of the freestanding nursing homes had that policy. Handwashing behaviour is complex.25 It is a wellknown practice in health-care settings, but there is a significant inability to motivate health-care providers to comply with hand hygiene practices. Studies have revealed that nurses not only overestimate their personal compliance with hand hygiene26 but also show inconsistencies between what they say, what they know and what they do.5,27 Observed handwashing practice was found to be unrelated to the self-reported behaviours of health-care professionals.27 Accordingly, direct observation, although labour-intensive and time-consuming, is therefore considered the gold standard for the assessment of handwashing practices.28,29 The purpose of this study, then, was to explore the compliance with hand hygiene by the nursing staff in Taiwanese freestanding nursing homes using the method of direct observation.
METHODS Design The quantitative cross-sectional descriptive observational research design was used.
Research settings and access The query letters were sent to all (nine) freestanding nursing homes in Tainan city from a list of nursing homes registered with the Department of Health (DOH) in Taiwan. Following the query letters, phone calls were made to explain the purpose of the study and the process that would be implemented, as well as to answer any questions. Only two nursing homes were willing to participate in this study because of both the employed method of direct observation and sensitivity regarding the rate of compliance with hand hygiene among their health-care workers. The owners or directors of freestanding nursing homes could have concerns in reference to their reputation, and the potential drop in income from operating the institutions if subpar compliance rates were made public; however, confidentiality was assured. Before collecting data, the administrators of the two nursing homes introduced the study to the entire nursing staff, including nurses and nursing assistants. Each staff member was then approached individually and invited to © 2013 Wiley Publishing Asia Pty Ltd
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participate in the study on a voluntary basis. All nursing staff in the two nursing homes agreed to join the study.
Sampling The hand hygiene opportunity was the unit of analysis in this study. All hand hygiene opportunities were referred to as ‘the sample size’ and were defined as the points in time when the hands should have been washed, regardless of whether the hand washing actually occurred or what cleansing agent was chosen. The points in time for hand washing included: before contact with residents, before aseptic tasks, after contact with residents and their surroundings, and after body fluid exposure risk. The nursing staff were directly monitored during data collection by a trained observer. The number of hand hygiene opportunities for this study were calculated based on data from two previous studies conducted in long-term care facilities19,20 via the Sample Size Proportion Calculator.30 As a result, the study required at least 450 hand hygiene opportunities for a power of 90% and alpha level of 0.05.
Instrument The demographic data concerning the institutions and the nursing staff who were observed were collected. The hand hygiene observation tool (HHOT), which was developed by McAteer et al.,28 was used to assess hand hygiene practice. Permission to use the HHOT has been obtained from the authors. This tool has a set of precise standard operating procedures with clear instructions for use and data collection. The interobserver agreement for the HHOT was 92%, and the Kappa coefficient was 0.88 (95% confidence interval (CI) 0.78–0.98). To implement the HHOT, a resident care area of five to eight beds was defined. Hand hygiene opportunities and hand hygiene behaviours among the nursing staff were recorded by a trained observer. A hand hygiene opportunity was defined as hand hygiene practices that should occur before contact with residents, before aseptic tasks, after contact with residents and their surroundings, and after body fluid exposure risk. Hand hygiene behaviour was defined as whether or not the nursing staff washed their hands correctly at a given opportunity with either alcohol, or soap and water, took no action, or took unknown actions. Overall hand hygiene compliance was calculated as the number of times in which soap or an alcohol-based hand sanitizing agent was used correctly divided by the total hand hygiene opportunities with the result multiplied by 100%.31 The observer observed each © 2013 Wiley Publishing Asia Pty Ltd
resident care area for 20 min and then rotated to different resident care areas, so all residents could be covered in each observation day. The order of the rotation of resident care areas had been randomly assigned by the observer each day.
Data collection The observer received 20 h of training by the researcher before initiating data collection. The training program included information on how to use the HHOT, the definition of a resident care area and a hygiene opportunity, the correct procedures of hand hygiene practice, the difficulties that may arise for the observer and the strategies to counter them, role playing, and practice scenarios. The intra-rater reliability of the observer was 100% after training. The observer visited the facilities one week before data collection was initiated to allow the nursing staff to familiarize themselves with her to decrease the possibility of a Hawthorne effect. The observations were took place during the day shift, from 9:00 a.m. to 12:00 p.m., during the entire study (including weekdays and weekends) because these times are correlated with the highest level of resident contact. The observation was undertaken for one week at each facility.
Data analysis Analysis of the data was undertaken using the Statistical Package for the Social Sciences (SPSS version 18.0; SPSS, Inc., Chicago, IL, USA). The mean and percentage were used to describe the demographic data and the characteristics of the participants. The proportion was used to describe the overall compliance with hand hygiene among the nursing staff. The chi-square test was used to compare the differences between the compliance of nurses and nursing assistants. Odds ratios (ORs) with 95% CIs were used to examine the relationships between the various hand hygiene opportunities. A P value less than 0.05 was considered statistically significant.
Ethical considerations Ethical approval was obtained from the research ethics committee in one university. The two nursing homes do not have their own ethics committees; however, approval of the study was received from the participating facilities, and all the participants signed the informed consents. The rights of all participants were protected by abiding by the requirements of the research ethics committee. Participants were also informed about the withdrawal
Hand hygiene in freestanding nursing homes
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option and informed that if they chose not to participate, there would be no adverse effects on their careers, either now or in the future. All participants in the study were also assured of the privacy and anonymity of any information they provided.
RESULTS Two private freestanding nursing homes (A and B), which were supervised by the DOH, were recruited to this study. In facility A with 51 beds, there were 6 nurses and 11 nursing assistants. In facility B with 31 beds, there were four nurses and seven nursing assistants. Nursing managers of both facilities claimed that they offered the hand hygiene in-service programs and audited their members’ hand hygiene behaviours regularly. A total of 16 members of the nursing staff (seven nurses and nine nursing assistants) were observed during the data collection period and the final sample was composed of 57% of all nursing staff in these two nursing homes. Seven nurses with a mean age of 33.29 years (standard deviation (SD) = 10.56) had worked in the nursing home for 11.14 months (SD = 14.37), and nine nursing assistants with a mean age of 33.89 years (SD = 7.01) had worked in the nursing home for 13.11 months (SD = 18.47). The majority of the nursing staff was female (93.7%). Only one (6.3%) nursing assistant was male. Six nurses (85.7%) had bachelor degrees, and five nursing assistants (55.5%) had high school diplomas. One (6.3%) nurse in facility A claimed that she has not attended any hand hygiene training lecture and program. All nursing staff have ever been audited their hand hygiene behaviours in the facilities. During the observation period, a total of 782 hand hygiene opportunities (435 in facility A and 347 in facility B) were observed. There were 352 hand hygiene opportunities among nurses, but only 62 (17.6%) hand hygiene practices were performed. Furthermore, there were 430
hand hygiene opportunities among the nursing assistants, with only 26 (6.0%) hand hygiene practices undertaken. The overall compliance with hand hygiene among the nursing staff in the nursing homes was 11.3% (88/782). The study also found that nurses had better compliance with hand hygiene than nursing assistants (17.6 vs. 6.0%, respectively; P = 0.000) (Table 1). There were no differences on hand hygiene compliance between nurses and nursing assistants before resident contact (P = 0.334) and aseptic tasks (P = 0.472). However, nurses had better compliance than nursing assistants after contact with resident and resident surroundings (P = 0.000) and body fluid exposure risk (P = 0.006). The compliance with hand hygiene varied by hand hygiene opportunities including the time before resident contact, before aseptic tasks, after contact with a resident and the resident’s surroundings, and after body fluid exposure risk. Both nurses and nursing assistants had higher compliance with hand hygiene after body fluid exposure risk (41.56% and 15.79%, respectively). The lowest compliance occurred prior to the performance of aseptic tasks for both nurses and nursing assistants (2.67% and 0%, respectively). Adherence to hand hygiene guidelines among nursing staff was greater after contact with the body fluids of residents than before or after other activities (OR = 6.9, CI = 3.75–9.88, P = 0.000). In addition, compliance with hand hygiene was lower before the performance of aseptic procedures or treatments as compared with other activities (OR = 0.15, CI = 0.04– 0.63, P = 0.003) (Table 2).
DISCUSSION The findings of this study highlight the relatively low hand hygiene compliance among the nursing staff at two Taiwanese freestanding nursing homes despite their awareness of the observer. The 11.3% compliance with hand hygiene
Table 1 The differences of hand hygiene compliance in different handwashing moments between nurses and nursing assistants Compliance with hand hygiene
Overall
Before resident contact Before aseptic tasks After contact with resident and resident surroundings After body fluid exposure risk Total
3.8% 2.1% 11.6% 33.0% 11.3%
Nurses (9/237) (2/94) (39/336) (38/115) (88/782)
5.3% 2.7% 21.9% 41.6% 17.6%
(5/95) (2/75) (23/105) (32/77) (62/352)
Nursing assistants
c2 (P value)
3.2% 0% 6.9% 15.8% 6.0%
0.93 0.52 15.79 7.64 25.93
(4/142) (0/19) (16/231) (6/38) (26/430)
(0.334) (0.472) (0.000)** (0.006)* (0.000)**
* P < 0.01; ** P < 0.001.
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Table 2 The comparison of hand hygiene compliance at different hand hygiene opportunities among nursing staff Hand hygiene opportunity
Compliance in this opportunity
Compliance in other opportunities
Odds ratio (95% CI)
Before resident contact Before aseptic tasks After contact with resident and the resident’s surroundings After body fluid exposure risk
3.8% 2.1% 11.6% 33.0%
14.5% 12.5% 11% 7.5%
0.23 0.15 1.06 6.09
(9/327) (2/94) (39/336) (38/115)
(79/545) (86/688) (49/446) (50/667)
(0.15 (0.04 (0.68 (3.75
P value
to to to to
0.47) 0.63) 1.67) 9.88)
0.000** 0.003* 0.79 0.000**
* P < 0.01; ** P < 0.001.
found in this study was even lower than the data shown in previous studies (14.7% and 17.5%, respectively).19,20 In addition, the hand hygiene compliance among nursing assistants was also lower (6.0%) than the findings of a study conducted in three Taiwanese LTCFs (9.34% before the training program in hand hygiene and 30.36% after the training).22 The length of nursing experiences in nursing homes among nursing staff was short in the present study, so there is possibility that lack of experience may have influences on the very low compliance of hand hygiene. In addition, the heavy workloads, busy schedule and no nearby sinks in these nursing homes may worsen the situation. One Flemish study reported that 81 LTCF healthcare workers’ average score on a hand hygiene quiz was 51%.32 The inadequate knowledge regarding hand hygiene among LTCF staff may be the cause of low compliance, but it needs to further examine the relationship between the two variables in the future study. The results of this study suggest that compliance with hand hygiene in Taiwanese nursing homes, especially in the freestanding nursing homes, should be improved immediately. The previous studies have also found that the compliance with hand hygiene varied according to staff position. In the present study, nurses had a higher compliance with hand hygiene than nursing assistants. The Italian study20 also revealed that nurses (20.1%) had a higher compliance than nursing assistants (10%). In addition, one large survey conducted in the USA found that nurses had better knowledge of the hand hygiene guidelines than nursing assistants and other professionals, such as physician, social workers and physical therapists in 17 LTCFs.33 In contrast, some studies found that nurses had lower compliance than nursing assistants in long-term care facilities.19,34 However, the most important point found in the present study, however, is that the compliance for both nurses and nursing assistants was very poor. © 2013 Wiley Publishing Asia Pty Ltd
The compliance was higher after contact with residents and lower before contact with residents when compared with other tasks in this study. Several studies had similar findings.20,35,36 Both Pan et al.,20 and Korniewicz and El-Masri35 suggested that hand hygiene was usually considered as a method to protect health-care workers rather than a method to protect patients. In addition, the compliance by the nursing staff regarding hand hygiene, following the performance of tasks, was higher after contact with the body fluids of residents as compared with other types of contact with residents or their surroundings. Richards and Russo,37 and Santana et al.38 in 2007 suggested that health-care workers were more likely to clean their hands when they perceived they were in a risky and possibly infectious situation. It is possible that the nursing staff noticed the visible stains or dirt on their hands after contact with the body fluids of residents and then remembered to wash their hands. They may also have believed that their hands were clean before patient contact.35 The other important finding in this study is that the compliance was lowest before the performance of aseptic tasks. These results are similar to those reported by the World Health Organization,39 whose research also showed a low compliance prior to the performance of an aseptic task. Similarly, a study found that the LTCF health-care workers scored less than 50% marks on both ‘hand hygiene before a clean/aseptic procedure’ and ‘hand hygiene after glove removal’ questions.32 It is possible that the nursing staff usually wore gloves during the performance of some aseptic procedures, which they may have believed was a substitute for hand hygiene. Additionally, the nursing staff may also have believed that their hands were clean enough before the performance of aseptic tasks. In contrast, Randle et al.7 found that healthcare professionals were fully compliant with hand washing prior to the performance of aseptic tasks; the study,
Hand hygiene in freestanding nursing homes
however, consisted of only three hand hygiene opportunities prior to aseptic tasks during a 24-h observation period in a hospital. Based on the findings of this study, the right time to clean hands especially before contact with residents and before the performance of aseptic tasks should be re-emphasized for the nursing staff. It is suggested that both nurses and nursing assistants should receive regular training on hand hygiene practice, have reminding materials, have adequate available hand hygiene agents and need more frequent ongoing audits on hand hygiene23 either by the institutions or by government-level officers. Because of the nature of observation, the possibility of a Hawthorne effect needs to be considered in this study. The real compliance with hand hygiene is potentially lower than the results found in this study. For minimizing the Hawthorne effect in this study, the observer spent 1 week in the participating nursing homes prior to the collection of data to allow the staff to become familiar with her presence. Another limitation of the study was that all observations were conducted during morning hours. These hours were chosen because major tasks and treatments were most often performed during those times. However, by not observing the nursing staff at other times, the study may have missed some aspects of hand hygiene practice. In addition, the hand hygiene behaviours reflected only those nursing staff who were observed and might not be the representative of all nursing staff in the nursing homes. The strategy to overcome this issue was to stay in the nursing home for the whole week in order to observe different nursing staffs’ hand washing behaviours. Despite these limitations, the findings of this study still provide valuable information that calls immediate attention to the poor hand hygiene practice in freestanding nursing homes. In summary, this study revealed that the nurses and nursing assistants of freestanding nursing homes had very low compliance with hand hygiene. The results alert health-care professionals to make efforts on the infection control and hand hygiene practices in long-term care facilities. Further, this finding significantly suggests that immediate action should be taken to improve hand hygiene practice not only by the managers or the nursing staff of nursing homes but also by the lawmakers or supervisors of the DOH. The DOH should perhaps become responsible for a hand hygiene surveillance system to ensure the quality of care in freestanding nursing homes. Large-scale studies of hand hygiene practices in long-term care facilities should be conducted in the near future in
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Taiwan. Importantly, the effective and appropriate interventions should be immediately developed based on the information provided in this study.
ACKNOWLEDGEMENTS The authors gratefully acknowledge the two nursing homes and nursing staff for participating in the study. This study was supported by a research grant (TMU100-AE1B06) Taipei Medical University in Taiwan.
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