Improving adherence to hand hygiene practice | nursing times

Approaches to educate health professionals on hand hygiene practice must take into account “human factors” to ensure long-term adherence ABSTRACT Hand hygiene compliance rates continue to

vary between healthcare settings and individual professionals. This article looks at how a multimodal approach to infection prevention and control, using expertise from other disciplines,

can increase compliance with hand hygiene practices. CITATION: STORR J, KILPATRICK C (2013) Improving adherence to hand hygiene practice. _Nursing Times_; 109: 38: 12-13. AUTHORS: Julie

Storr is president and Claire Kilpatrick is communications team leader, Infection Prevention Society; both are independent patient safety and infection prevention consultants. * This article

has been double-blind peer reviewed * Scroll down to read the article or download a print-friendly PDF, including any tables and figures INTRODUCTION Infection prevention and control teams

work with staff in complex socio-technical systems to help them play their part in preventing infections. This aspect of the role can be particularly challenging. Vincent (2010) describes

patient safety as “a tough problem” in cultural, technical, clinical and psychological terms. Infection prevention and control - particularly hand hygiene compliance - is a key component to

maintaining patient safety; however, bridging the gap between evidence and practice, and engaging health professionals and senior management in evidence-based infection-control practices

remains an ongoing challenge. Recent evidence has shown the effectiveness of clinical interventions in controlling the spread of infection - for example the work of Berenholtz et al (2004)

in reducing catheter-related bloodstream infections in intensive care units. The impact of such interventions can be enhanced if we look beyond conventional approaches to other disciplines,

such as psychology, neurosciences and ergonomics. Integrating other disciplines in approaches to hand hygiene, particularly the social sciences, has been successful to date but hand hygiene

compliance is still not being sustained at an acceptable level. This multifactorial approach to improving hand hygiene is grounded in behavioural science. It has been pioneered by the World

Health Organization (2009), from whose website a toolkit of implementation resources is available. WHY IS HAND HYGIENE MISSED? Hand hygiene is relatively simple to perform. However,

embedding it as a habitual behaviour in healthcare, which is performed at the right times as an automatic activity, is far more complex for a number of reasons (Kilpatrick et al, 2013; WHO,

2006). Anderson et al (2010) give five common reasons for hand hygiene behaviours not being adequately adhered to (Table 1); these provide a solid starting point to explain the complexity of

hand hygiene. This research challenges the belief that infection prevention and control and hand hygiene are a matter of common sense, and encourages those working in this area to consider

human factors when developing approaches to educate health professionals. These approaches are more likely to improve compliance with guidelines and recommendations. USING A MULTIMODAL

APPROACH Considering the factors summarised in Table 1, it is clear that a single-focused approach is unlikely to work, especially as it is well established that hand hygiene compliance

rates are variable. An approach that focuses solely on education and training, without taking into account constraints that affect appropriate placement of hand-cleansing solutions, beliefs

and perceptions of health professionals, and the real-life context, is unlikely to be effective. To avoid single-focused approaches, WHO has listed five inter-related parts of the WHO hand

hygiene improvement strategy (Box 1). BOX 1. WHO MULTIMODAL IMPROVEMENT STRATEGY  * Change the system * Train the staff * Monitor and audit practices * Promote clean hands * Get the culture

right Source: World Health Organization (2009) The WHO Hand Hygiene Self-assessment Framework (WHO, 2010) can act as a useful starting point in guiding hand hygiene improvement efforts.

Based around the five parts of a multimodal strategy, it helps to measure hand hygiene improvement, allowing healthcare settings to identify where they are on the framework and to plan

targeted next steps on the improvement continuum. Allegranzi et al (2013) looked at the impact of the WHO’s improvement strategy in six pilot sites across five countries and found that it

can significantly improve hand hygiene knowledge and compliance in health professionals worldwide. A four-year research study into the multimodal “cleanyourhands” campaign, organised in

England by the National Patient Safety, found it highly successful. The study highlighted a link between the availability of alcohol handrub and soap, and declining rates of MRSA and C

difficile (Stone et al, 2012). ROLE OF NURSES Nurses play a key role in promoting many elements of hand hygiene, including: * Motivating other staff to perform hand hygiene during clinical

activities as recommended in Five Moments for Hand Hygiene (WHO, 2006); * Helping design and place reminders to prompt professionals to perform hand hygiene during clinical activities; *

Providing information on the flow of patient care to advise where alcohol handrub would be best placed; * Being willing and committed to revisiting, relearning and gaining understanding of

the need for hand hygiene at the right times to prevent infection and save lives, and cascading this information to colleagues. CONCLUSION It is important to draw on available resources and

solutions to improve our approach to infection prevention. Reviewing where an organisation sits on the hand hygiene improvement continuum using WHO’s self-assessment framework is an

essential starting point. The implementation of a targeted multimodal improvement strategy has been shown to reduce unnecessary patient harm and increase patient safety. Nurses have the

knowledge and experience to play a key role in ensuring ongoing hand hygiene action and can act as vital links between other disciplines. KEY POINTS * Engaging health professionals in

infection prevention practices is one of the biggest challenges for infection prevention and control teams * Infection preventionand control is key to maintaining patient safety * Using

other disciplines to support a multimodal approach can help change long-term behaviour * Hand cleansing is sometimes considered to be inconvenient * Nurses are well placed to promote hand

hygiene in practice and to advise on where improvements can be made ALLEGRANZI B ET AL (2013) Global implementation of WHO’s multimodal strategy for improvement of hand hygiene: a

quasi-experimental study. The Lancet Infectious Diseases; Early online publication: doi:10.1016/S1473-3099(13)70163-4. ANDERSON J ET AL (2010) Using human factors engineering to improve the

effectiveness of infection prevention and control. _Critical Care Medicine_; 38: 8 (Suppl): S269-2681. BERENHOLTZ SM et al (2004) Eliminating catheter-related bloodstream infections in the

intensive care unit. _Critical Care Medicine_; 32: 10, 2014-2020. KILPATRICK C ET AL (2013) Hand hygiene - when and how should it be done? _Nursing Times_; 109: 38, 16-18. STONE S ET AL

(2012) Evaluation of the national Cleanyourhands campaign to reduce Staphylococcus aureus bacteraemia and Clostridium difficile infection in hospitals in England and Wales by improved hand

hygiene: four year, prospective, ecological, interrupted time series study. _British Medical Journal_; 3: 344: e3005. doi: 10.1136/bmj.e3005. VINCENT C (2010) Patient Safety. Chichester:

Wiley-Blackwell. WORLD HEALTH ORGANIZATION (2010) Hand Hygiene Self-assessment Framework 2010. Geneva: WHO. WORLD HEALTH ORGANIZATION (2009) A Guide to the Implementation of the WHO

Multimodal Hand Hygiene Improvement Strategy. Geneva: WHO. WORLD HEALTH ORGANIZATION (2006) Five Moments for Hand Hygiene. Geneva: WHO.