Handwashing Makes a Difference Margery Monsma, Rene Day, Sheri St. Arnaud
S
chool attendance, while important for all children, is critical for children with physical and sensory handicaps. Staff of the Pediatric Daypatient Program at Glenrose Rehabilitation Hospital in Edmonton, Alberta, noticed children with physical and sensory handicapping conditions seemed to have a higher frequency of colds, influenza, and other infections causing them to be absent or to seek medical assistance more than the average school-aged child. Handwashing, identified as a way of controlling the spread of infection,I4 was seen as a possible method of reducing the absenteeism and illness rate. Since the nurse’s role in treating handicapped children in school involves anticipating and preventing problems when possible,’ the nursing staff decided to plan and implement a pilot program for first grade students. A pilot program would enable health-related content to be added to the curriculum while providing an opportunity to evaluate the process and the outcomes during the implementation phase.
ASSESSING THE LEARNERS The average cognitive level of the 14 first grade children was age five, slightly lower than their chronological age. According to Piaget’s theory,6 these first grade students would be functioning in the preschool, preoperational period of cognitive development. Children at this level view the world through what they personally see or feel. Most are not able to read and few, if any, are able to draw a recognizable human figure or body part. The children remember things directly related to themselves and their needs and learn best in short sessions of 15 minutes, with frequent rehearsals and the use of several of their senses. From the perspective of teachers at Glenrose, instructional programs for handicapped children should be structured and concrete, with the material being repeated in a variety of ways. Positive reinforcement should be used for successful experiences and support used for failures.’ PLANNING THE PROGRAM Staff searched for an appropriate handwashing program to meet the needs of these children. A suitMargery Monsma, RN, MSN. Clinical Development and Special Projects Nurse, Glenrose Rehabilitation Hospital, when the research was conducted; Rene Day, RN, PhD, Nurse Researcher, Glenrose Rehabilitation Hospital. and Professor and Associate Dean, Undergraduate Education, Faculty of Nursing, 3-1 02 Clinical Sciences Bldg.. University of Alberta, Edmonton, Alberta, Canada T6J 2G3; and Sheri St. Arnaud, RN. BScN, Nursing Unit Supervisor, Pre-School/School Nursing Services, Glenrose Rehabilitation Hospital, 10230 111th Ave., Edmonton. Alberta, Canada TSG 087. This project was partially funded by the Alberta Foundation for Nursing Research. This article was submitted July IS, 1991. and revised and accepted for publication November 25. 1991.
able program was not available, necessitating development of one. A four-week program was planned in collaboration with first grade teachers (Figure 1). The program goal was to decrease student absenteeism and illness rates. Program objectives were 1) students would know how and when to wash their hands, and 2) students would understand the relationship between germs, handwashing, and wellness. Teachers agreed to provide classroom time for instruction and to support program objectives. In addition, nurses developed a workbook to reinforce the objectives. Nursing staff planned to teach the content, act as role models, and reward appropriate behavior. The concept of rewards to reinforce positive behavior was adapted from the “Scrubby Bear Handwashing Program,” now available from the American Red Cross, Orange County Chapter, 601 N. Golden Circle Drive, Santa Ana, CA 92705. Given that the best way to evaluate young children is to assess changes in behaviors,’ an observational checklist was developed to evaluate specific handwashing skills such as washing front, back, sides, thumb, and between fingers for 30 seconds, using soap and warm water, and turning taps off Figure 1 Glenrose Rehabilitation Hospital Handwashing Teaching Plan (Pilot Program) Weak 1 Describe program, obtain consents lrom parents and children - classroom. Assess current level of knowledge - informal questions - classroom. Assess current handwashing practice - independent evaluator and interviews - washroom. Teach handwashing song. Weak 2 Describe when it is appropriate to wash hands - classroom. Demonstrate handwashing technique - washroom. Have children return demonstration - washroom. At end of each day, have teachers give stickers lor appropriate handwashlng procedure - classroom. Reinforce appropriate times and techniques of handwashing - washroom, eating areas, etc. Weak 3 Agar Plates (24) Each child to have two plates, one to use before washing hands, one after. Review results of culture with children. With teacher, put on short play - classroom. At end of each day, give small stickers. Weak 4 Introduce coloring workbook - classroom Have teachers and family follow up . classroom and home. Ask children to help one another remember to wash hands - class room. At end of each day, ask teacher to give stickers for appropriate procedure. At end of week, evaluate handwashing times and technique -checklist. Give large sticker to children who did well. Final day give each child a button, and each class a stuffed animal classroom.
Journal of School Health
March 1992, Vol. 62, No. 3
109
with a towel. To objectively evaluate the children’s handwashing practices, two independent evaluators were trained to use the checklist. Evaluators observed the children prior to the teaching program, immediately after, and one, three, and six months following the program.
POSITIVE OUTCOMES Overall, the handwashing program was successful. Children in the program made 25% fewer visits to the physician, used 86% fewer medications, and were absent 22% less often than the previous year. General reaction of the children to the handwashing program was enthusiastic. They particularly enjoyed an experiment using Agar plates. In this exercise, they each touched a plate after purposely contaminating their hands in a variety of ways such as coughing, sneezing, or playing in dirt. After properly washing their hands, they each touched another plate. After 48 hours, they were able to observe that the “contaminated” plates grew many germs and the “clean” plates grew few, if any germs. This part of the program has been retained and has continued to be a success. It appeared that children in the program were using peer modeling9 to share their knowledge of handwashing with others. Children reminded each other to wash their hands to receive rewards, and encouraged children in the other grades t o wash their hands. Children in the program also insisted that teachers and nurses wash their hands after sneezing, before doing a procedure, or handling food. Some parents even reported the children were teaching their siblings how and when t o wash their hands. SYSTEM OF REWARDS The initial plan was t o use consistent and frequent reinforcement in the early weeks of the project. However, due to administrative changes at the Scrubby Bear Foundation, it was difficult to obtain an adequate supply of stickers, pins, and bears. This development forced the use of intermittent rewards which did not have the expected motivating effect for this group of children. To solve this problem, the hospital’s own bear mascot was reproduced as a hand stamp and was then used to reinforce appropriate technique immediately and consistently. This change correlated positively with an immediate and sustained improvement in appropriate handwashing skills (32% prior to teaching, 65% at one month post-teaching, and 70% at three months post-teaching). To ascertain if the children would continue their learned behaviors without a reward system, concrete rewards were discontinued after three months. Results at six months were disappointing (57%) but slightly better than those obtained by Williams and Buckles,Io who attributed their poor results to a failure to change attitudes and to increase motivation to wash hands frequently. A further problem was identifying what behavior actually was being rewarded. Pritchard and Hathaway,” in their patient handwashing model, identified 110
Journal of School Health
March 1992, Vol. 62, No. 3
the importance of looking at cues and triggers to action. Though staff believed they were rewarding and reinforcing, both the correct technique (how) and the correct reason (when and why) for handwashing, the children’s behavior demonstrated that they were consistently linking rewards to the technique only. Their cue for handwashing had become the presence of the nurse or evaluator rather than the fact that their hands were contaminated.
REVISIONS After evaluation, several program components were revised. For example, children were taught to sing a song lasting 30 seconds to ensure they washed their hands for an appropriate length of time. However, the song was too long for the children to remember and some words were too complex for children with language or learning disorders. The children coped by omitting the song. Because more recent literature12suggests 10 seconds of handwashing is adequate, it was decided that the song was no longer necessary. A skit presented by members of the nursing staff helped illustrate the relationships between germs, handwashing, and wellness. Though the children seemed to enjoy the skit (laughing, smiling, clapping), teachers indicated the use of familiar staff members as actors distracted the children and reduced the impact of the intended message. The skit was eliminated from subsequent teaching plan?. The workbook, so painstakingly developed, also needed some changes. After consulting with a primary reading specialist, the workbook content was revised to correlate more closely with the when, why, and how of handwashing. In addition, the print was enlarged and only one concept was presented per page. Nurses were concerned that teaching the theoretiFigure 2 Glsnross Rehabllltatlon Hospltal Revlsed Handwashing Teaching Plan Part A (one 20-mlnute rt::lon) Describe program. Assess children’s current knowledge. Describe when and why it is appropriate to wash hands. Agar plate exercise: Plate X1 - “contaminated” hands. Children wash their hands, staff coach and model correct method. Plate X2 “clean” hands. Staff teach lheory of germs and effects of handwashing. Distribute and review workbooks. (Children complete these during class lime over remainder of the week and then take workbooks home). Demonstrate handwashing technique. Children perform return demonstration. Ask children to remind each other to wash hands. ~
Part 8 (48 hwrr Irtsr) Review results of Agar plate cultures with children Reinlorce ‘why’ handwashing is important. hlt C (ongolnp) Reinforce correct handwashing technique with hand slamps. Continuously reward appropriate time/technique, as observed, for lour-six weeks. Intermittently reward children throughout remainder of the school year. Teachers and parents reinforce handwashing concepts through praise and use of the workbook.
cal components of the program during a four-week period was too long. Concepts learned were often forgotten from one week to the next. Children needed to know the when and why of handwashing before they learned the how (technique). The program was revised to present the theory and the experiment with the Agar plates in one 20-minute session (Figure 2). Initial demonstration of the skill of handwashing is modeled immediately after this session. Appropriate application of all aspects of handwashing are continuously shaped and reinforced with immediate concrete rewards as they emerge during the next four to six weeks. Intermittent rewards are used throughout the school year as a method of consolidating the children's knowledge, maintaining their technique, and increasing their motivation.
CONCLUSION This pilot program was developed as a way of trying different teaching strategies and approaches to help first grade students with physical and sensory handicapping conditions learn about handwashing. Though the intended decrease in absenteeism and illess rates occurred, evaluation data indicated the children were inconsistent in how and when to wash. Many revisions to the current program resulted from the data obtained during the implementation stage. As a result, some strategies were retained while
others were modified or deleted. An improved handwashing program is now successfully in place and is offered to all children attending the school program. References 1. Albert R, Condie F. Handwashing patterns in medical intensive ;,ire units. N Engl J Med. 1981;304(24):1465-1466. 2. Center for Disease Control. Guidelines for the prevention and control of nonsocomial infections - guidelines for hand washing and hospital environment control. Am J frlfect Control. 1985;14(3):110-115. 3. Larson E. Current hand washing issues. Infect Control. 1984;5(1):15-17 4. Steere A, Mallison G. Hand washing practices for the prevention of nosocomial infections. Ann Intern Med. 1975;83(5): 683-690. 5 . Grindley J. The handicapped child in school. Holistic Nurs Pract. 1988;2(2):11-19. 6. Phillips J. The Origins of Intellect: Piagel's theory. San Francisco, Calif: WH Freeman and Co; 1985. 7. Strategies for Teaching Handicapped Children. Edmonton, Alberta, Canada; Glenrose Rehabilitation Hospital; 1975;6-13. 8. Mitchell J. Child Dev. Toronto, Ontario, Canada: Holt Rinehart and Winston; 1985. 9. Roberts M, Wurtele S, Boone R, Ginther L, Elkins P. Reduction of medical fears by use of a modelling: A preventative application in a general population of children. J Pediafr fsychol. 1981 ;6(3):293-300. 10. Williams E, Buckles A. A lack of motivation. Nurs Times. 1988;84(2):62-64. 11. Pritchard V, Hathaway C. Patient handwashing practice. Nun Times. 1988;84(36):68-72. 12. Gamer JS, Favero MS. Guidelines for handwashing and hospital environmental control. Am J f @ c t Control, 1986;l4(3): 110-129.
oordlnaPors
Attentlon AdmMsPraPors
Are You Meeting Your State's Health & Safety Codes On Infectious Diseases Including HIWAIDS Awareness & Prevention? HW/MDS A W m N E S S & PRE INSERWrn Developed In Cooperation With the California State Department of Education's Healthy Kids Professional Development Center
Complete Package Includes: A 30 Page Facilitator's Manual, A 20 Minute Video Presentation, 25 Staff Reference Cards, & A Program Test & Evaluation Form
lnservice Covers: Definitions, Modes of Transmission, Universal Precautions, Needs & Sensitivity, and Confidentiality & Laws. Because Of The Effectiveness And Affordability Of This Video lnservice Pro It Is Currently Being Used Throughout The State Of California By Regional Health Centers & Organizations, School Districts, And Private Corporations.
:OR INFORMATION OR MULTIPLE DISCOUNTS CALL
(714)653-6662 a
Journal of School Health
March 1992, Vol. 62, No. 3
111
S
chool attendance, while important for all children, is critical for children with physical and sensory handicaps. Staff of the Pediatric Daypatient Program at Glenrose Rehabilitation Hospital in Edmonton, Alberta, noticed children with physical and sensory handicapping conditions seemed to have a higher frequency of colds, influenza, and other infections causing them to be absent or to seek medical assistance more than the average school-aged child. Handwashing, identified as a way of controlling the spread of infection,I4 was seen as a possible method of reducing the absenteeism and illness rate. Since the nurse’s role in treating handicapped children in school involves anticipating and preventing problems when possible,’ the nursing staff decided to plan and implement a pilot program for first grade students. A pilot program would enable health-related content to be added to the curriculum while providing an opportunity to evaluate the process and the outcomes during the implementation phase.
ASSESSING THE LEARNERS The average cognitive level of the 14 first grade children was age five, slightly lower than their chronological age. According to Piaget’s theory,6 these first grade students would be functioning in the preschool, preoperational period of cognitive development. Children at this level view the world through what they personally see or feel. Most are not able to read and few, if any, are able to draw a recognizable human figure or body part. The children remember things directly related to themselves and their needs and learn best in short sessions of 15 minutes, with frequent rehearsals and the use of several of their senses. From the perspective of teachers at Glenrose, instructional programs for handicapped children should be structured and concrete, with the material being repeated in a variety of ways. Positive reinforcement should be used for successful experiences and support used for failures.’ PLANNING THE PROGRAM Staff searched for an appropriate handwashing program to meet the needs of these children. A suitMargery Monsma, RN, MSN. Clinical Development and Special Projects Nurse, Glenrose Rehabilitation Hospital, when the research was conducted; Rene Day, RN, PhD, Nurse Researcher, Glenrose Rehabilitation Hospital. and Professor and Associate Dean, Undergraduate Education, Faculty of Nursing, 3-1 02 Clinical Sciences Bldg.. University of Alberta, Edmonton, Alberta, Canada T6J 2G3; and Sheri St. Arnaud, RN. BScN, Nursing Unit Supervisor, Pre-School/School Nursing Services, Glenrose Rehabilitation Hospital, 10230 111th Ave., Edmonton. Alberta, Canada TSG 087. This project was partially funded by the Alberta Foundation for Nursing Research. This article was submitted July IS, 1991. and revised and accepted for publication November 25. 1991.
able program was not available, necessitating development of one. A four-week program was planned in collaboration with first grade teachers (Figure 1). The program goal was to decrease student absenteeism and illness rates. Program objectives were 1) students would know how and when to wash their hands, and 2) students would understand the relationship between germs, handwashing, and wellness. Teachers agreed to provide classroom time for instruction and to support program objectives. In addition, nurses developed a workbook to reinforce the objectives. Nursing staff planned to teach the content, act as role models, and reward appropriate behavior. The concept of rewards to reinforce positive behavior was adapted from the “Scrubby Bear Handwashing Program,” now available from the American Red Cross, Orange County Chapter, 601 N. Golden Circle Drive, Santa Ana, CA 92705. Given that the best way to evaluate young children is to assess changes in behaviors,’ an observational checklist was developed to evaluate specific handwashing skills such as washing front, back, sides, thumb, and between fingers for 30 seconds, using soap and warm water, and turning taps off Figure 1 Glenrose Rehabilitation Hospital Handwashing Teaching Plan (Pilot Program) Weak 1 Describe program, obtain consents lrom parents and children - classroom. Assess current level of knowledge - informal questions - classroom. Assess current handwashing practice - independent evaluator and interviews - washroom. Teach handwashing song. Weak 2 Describe when it is appropriate to wash hands - classroom. Demonstrate handwashing technique - washroom. Have children return demonstration - washroom. At end of each day, have teachers give stickers lor appropriate handwashlng procedure - classroom. Reinforce appropriate times and techniques of handwashing - washroom, eating areas, etc. Weak 3 Agar Plates (24) Each child to have two plates, one to use before washing hands, one after. Review results of culture with children. With teacher, put on short play - classroom. At end of each day, give small stickers. Weak 4 Introduce coloring workbook - classroom Have teachers and family follow up . classroom and home. Ask children to help one another remember to wash hands - class room. At end of each day, ask teacher to give stickers for appropriate procedure. At end of week, evaluate handwashing times and technique -checklist. Give large sticker to children who did well. Final day give each child a button, and each class a stuffed animal classroom.
Journal of School Health
March 1992, Vol. 62, No. 3
109
with a towel. To objectively evaluate the children’s handwashing practices, two independent evaluators were trained to use the checklist. Evaluators observed the children prior to the teaching program, immediately after, and one, three, and six months following the program.
POSITIVE OUTCOMES Overall, the handwashing program was successful. Children in the program made 25% fewer visits to the physician, used 86% fewer medications, and were absent 22% less often than the previous year. General reaction of the children to the handwashing program was enthusiastic. They particularly enjoyed an experiment using Agar plates. In this exercise, they each touched a plate after purposely contaminating their hands in a variety of ways such as coughing, sneezing, or playing in dirt. After properly washing their hands, they each touched another plate. After 48 hours, they were able to observe that the “contaminated” plates grew many germs and the “clean” plates grew few, if any germs. This part of the program has been retained and has continued to be a success. It appeared that children in the program were using peer modeling9 to share their knowledge of handwashing with others. Children reminded each other to wash their hands to receive rewards, and encouraged children in the other grades t o wash their hands. Children in the program also insisted that teachers and nurses wash their hands after sneezing, before doing a procedure, or handling food. Some parents even reported the children were teaching their siblings how and when t o wash their hands. SYSTEM OF REWARDS The initial plan was t o use consistent and frequent reinforcement in the early weeks of the project. However, due to administrative changes at the Scrubby Bear Foundation, it was difficult to obtain an adequate supply of stickers, pins, and bears. This development forced the use of intermittent rewards which did not have the expected motivating effect for this group of children. To solve this problem, the hospital’s own bear mascot was reproduced as a hand stamp and was then used to reinforce appropriate technique immediately and consistently. This change correlated positively with an immediate and sustained improvement in appropriate handwashing skills (32% prior to teaching, 65% at one month post-teaching, and 70% at three months post-teaching). To ascertain if the children would continue their learned behaviors without a reward system, concrete rewards were discontinued after three months. Results at six months were disappointing (57%) but slightly better than those obtained by Williams and Buckles,Io who attributed their poor results to a failure to change attitudes and to increase motivation to wash hands frequently. A further problem was identifying what behavior actually was being rewarded. Pritchard and Hathaway,” in their patient handwashing model, identified 110
Journal of School Health
March 1992, Vol. 62, No. 3
the importance of looking at cues and triggers to action. Though staff believed they were rewarding and reinforcing, both the correct technique (how) and the correct reason (when and why) for handwashing, the children’s behavior demonstrated that they were consistently linking rewards to the technique only. Their cue for handwashing had become the presence of the nurse or evaluator rather than the fact that their hands were contaminated.
REVISIONS After evaluation, several program components were revised. For example, children were taught to sing a song lasting 30 seconds to ensure they washed their hands for an appropriate length of time. However, the song was too long for the children to remember and some words were too complex for children with language or learning disorders. The children coped by omitting the song. Because more recent literature12suggests 10 seconds of handwashing is adequate, it was decided that the song was no longer necessary. A skit presented by members of the nursing staff helped illustrate the relationships between germs, handwashing, and wellness. Though the children seemed to enjoy the skit (laughing, smiling, clapping), teachers indicated the use of familiar staff members as actors distracted the children and reduced the impact of the intended message. The skit was eliminated from subsequent teaching plan?. The workbook, so painstakingly developed, also needed some changes. After consulting with a primary reading specialist, the workbook content was revised to correlate more closely with the when, why, and how of handwashing. In addition, the print was enlarged and only one concept was presented per page. Nurses were concerned that teaching the theoretiFigure 2 Glsnross Rehabllltatlon Hospltal Revlsed Handwashing Teaching Plan Part A (one 20-mlnute rt::lon) Describe program. Assess children’s current knowledge. Describe when and why it is appropriate to wash hands. Agar plate exercise: Plate X1 - “contaminated” hands. Children wash their hands, staff coach and model correct method. Plate X2 “clean” hands. Staff teach lheory of germs and effects of handwashing. Distribute and review workbooks. (Children complete these during class lime over remainder of the week and then take workbooks home). Demonstrate handwashing technique. Children perform return demonstration. Ask children to remind each other to wash hands. ~
Part 8 (48 hwrr Irtsr) Review results of Agar plate cultures with children Reinlorce ‘why’ handwashing is important. hlt C (ongolnp) Reinforce correct handwashing technique with hand slamps. Continuously reward appropriate time/technique, as observed, for lour-six weeks. Intermittently reward children throughout remainder of the school year. Teachers and parents reinforce handwashing concepts through praise and use of the workbook.
cal components of the program during a four-week period was too long. Concepts learned were often forgotten from one week to the next. Children needed to know the when and why of handwashing before they learned the how (technique). The program was revised to present the theory and the experiment with the Agar plates in one 20-minute session (Figure 2). Initial demonstration of the skill of handwashing is modeled immediately after this session. Appropriate application of all aspects of handwashing are continuously shaped and reinforced with immediate concrete rewards as they emerge during the next four to six weeks. Intermittent rewards are used throughout the school year as a method of consolidating the children's knowledge, maintaining their technique, and increasing their motivation.
CONCLUSION This pilot program was developed as a way of trying different teaching strategies and approaches to help first grade students with physical and sensory handicapping conditions learn about handwashing. Though the intended decrease in absenteeism and illess rates occurred, evaluation data indicated the children were inconsistent in how and when to wash. Many revisions to the current program resulted from the data obtained during the implementation stage. As a result, some strategies were retained while
others were modified or deleted. An improved handwashing program is now successfully in place and is offered to all children attending the school program. References 1. Albert R, Condie F. Handwashing patterns in medical intensive ;,ire units. N Engl J Med. 1981;304(24):1465-1466. 2. Center for Disease Control. Guidelines for the prevention and control of nonsocomial infections - guidelines for hand washing and hospital environment control. Am J frlfect Control. 1985;14(3):110-115. 3. Larson E. Current hand washing issues. Infect Control. 1984;5(1):15-17 4. Steere A, Mallison G. Hand washing practices for the prevention of nosocomial infections. Ann Intern Med. 1975;83(5): 683-690. 5 . Grindley J. The handicapped child in school. Holistic Nurs Pract. 1988;2(2):11-19. 6. Phillips J. The Origins of Intellect: Piagel's theory. San Francisco, Calif: WH Freeman and Co; 1985. 7. Strategies for Teaching Handicapped Children. Edmonton, Alberta, Canada; Glenrose Rehabilitation Hospital; 1975;6-13. 8. Mitchell J. Child Dev. Toronto, Ontario, Canada: Holt Rinehart and Winston; 1985. 9. Roberts M, Wurtele S, Boone R, Ginther L, Elkins P. Reduction of medical fears by use of a modelling: A preventative application in a general population of children. J Pediafr fsychol. 1981 ;6(3):293-300. 10. Williams E, Buckles A. A lack of motivation. Nurs Times. 1988;84(2):62-64. 11. Pritchard V, Hathaway C. Patient handwashing practice. Nun Times. 1988;84(36):68-72. 12. Gamer JS, Favero MS. Guidelines for handwashing and hospital environmental control. Am J f @ c t Control, 1986;l4(3): 110-129.
oordlnaPors
Attentlon AdmMsPraPors
Are You Meeting Your State's Health & Safety Codes On Infectious Diseases Including HIWAIDS Awareness & Prevention? HW/MDS A W m N E S S & PRE INSERWrn Developed In Cooperation With the California State Department of Education's Healthy Kids Professional Development Center
Complete Package Includes: A 30 Page Facilitator's Manual, A 20 Minute Video Presentation, 25 Staff Reference Cards, & A Program Test & Evaluation Form
lnservice Covers: Definitions, Modes of Transmission, Universal Precautions, Needs & Sensitivity, and Confidentiality & Laws. Because Of The Effectiveness And Affordability Of This Video lnservice Pro It Is Currently Being Used Throughout The State Of California By Regional Health Centers & Organizations, School Districts, And Private Corporations.
:OR INFORMATION OR MULTIPLE DISCOUNTS CALL
(714)653-6662 a
Journal of School Health
March 1992, Vol. 62, No. 3
111
