CHAPTER I

THE PROBLEM AND ITS SETTING

Hand washing is associated with voluntary individualistic behavior. Dean David Holyoake

Is proper hand hygiene achievable in all healthcare settings? The researchers know that the reaction to this question from many people would be a resounding, Yes. However, the group suspects that the vast majority of those who believe it is possible to maintain proper hand hygiene in all types of locales, have thought of the question was just simple. Hence, the researchers has to admit that they initially thought it was a little simplistic to be discussing hand hygiene within their group of studentnurses; yet the group then started to think about it and realized just how complex and interesting hand hygiene is. The single act of hand washing has such a massive impact on not only our patients but also wider public health. Hand hygiene, defined as the act of washing ones hands with soap and water or disinfecting them with an antiseptic agent, is the single most successful and cost-effective means of preventing healthcare-associated infections, as well as an effective means of preventing illness in the community that may lead to hospitalization. Hand hygiene, before and after all patient or patient environment contact, before aseptic procedure, and/or after bodily fluid exposure, is recommended in all published infection control and public health guidelines and is considered the standard of care for all HCWs. Yet many studies document that HCWs compliance with hand hygiene recommendations is consistently less than 50%, with compliance among physicians routinely lower than that of other HCWs. Health care providers around the world are currently trying to safeguard the health of the patients in need and one of the interventions they could least do is hand washing. In one study of 2,834 observed opportunities for hand hygiene, researchers found the average adherence rate was a shockingly 48%. Adherence was highest among nurses during weekends and in pediatric units. Non adherence was higher in intensive-care units, during procedures that carried a high risk of bacterial contamination, and when the intensity of patient care was high. In other words, the higher the need for hand hygiene, the lower the adherence. The lowest adherence rate (36%) was found in intensive care units locally in some hospitals in the Indonesia, where indications for hand hygiene were typically more frequent. The highest adherence

rate (59%) was observed in pediatrics wards, where the average intensity of patient care was lower in other hospital areas. This study indicates the much need to be done to improve adherence to hand hygiene practices (Pittet, 2011). Furthermore, according to the Center for Disease Control and Infection CDC (2009) nurses have hands-on daily contact with their patients and therefore play a vital role in patient safety and infection control. Appropriate hand hygiene is a leading measure to reduce the transmission of healthcareassociated infection. Despite evidence for the efficacy of hand hygiene, multiple studies have demonstrated low levels of compliance, with average baseline rates of 40% (Boyce and Pittet, 2002). Contributing factors include a lack of education, high workload, lack of a role model from key staff and lack of administrative leadership (Pittet and Boyce, 2001). Some reasons for health care workers non-adherence to hand hygiene guidelines have been identied. Various studies have reported that environmental factors can effectively constitute barriers to performing the behaviour, such as harsh hand washing agents (Zimakoff et al.,1992) and paper towels (Heenan, 1992) and inaccessibility or insuf. cient numbers of sinks (Kaplan & McGuckin, 1986). Another barrier is health care workers perceptions about a lack of time to wash their hands. The ideal duration for hand washing is not known and it is worth noting the difference in the lengths of time promulgated by various countries. For example, in the UK, the technique most commonly advocated takes 60 seconds and is based on a test procedure described by Ayliffe et al. (1978). In the USA, however, the guidelines produced by the Centers for Disease Control recommend that this behaviour can be performed in ten seconds (Garner & Favero, 1985). However, despite this quicker technique, health care workers still claim that they do not have time (Larson & Killien, 1982). Time constraints therefore would appear to be an important consideration, and Voss and Widmer (1997) ask whether we can afford 100% compliance. Using a mathematical model, they calculated that in a 14-bed intensive therapy unit, with 12 staff each working eight hours, it would take 16 hours, or two full-time nurse equivalents a day, to achieve 100% compliance with hand washing. Weeks (1999) estimates that by not washing his hands between each of the 60 touch contacts he has every day with obstetric patients, he saves on average one or two hours , equivalent to 15% extra staffing that would be needed to cover the extra time. In an attempt to address health care workers perceptions about a lack of time, several types of alcohol-based products have now been marketed, including wipes (Butz et al., 1990) and gel (Newman & Seitz, 1990), in addition to hand rubs (Mackintosh & Hoffman, 1984). These can be applied and rubbed to dryness in five seconds whilst moving between patients. However, such products should only be used for decontaminating hands that are not visibly soiled; hence hand washing is still indicated under certain

circumstances. Voss and Widmer (1997) calculated that in an Intensive therapy unit, if hands were decontaminated with alcohol dispensed from containers on every bedside locker, it would take only four hours per day to achieve 100% compliance. It was to be hoped that the introduction of alcohol-based products would improve adherence, but unfortunately Gould (1994) found this not to be the case. It would appear therefore that the primary problem with hand hygiene is not a paucity of good products, but rather the laxity of practice (Larson, 1995 p. 259).

The researchers developed this study because research tells us that hand hygiene will vary from hospital to hospital, between different wards and departments and also according to the role of different practitioners. They were trying to identify the factors that influence hand hygiene. The aim of the study was to identify psychological constructs predictive of 2nd year and 3rd year nursing students hand hygiene behavioral intentions in order to determine ways to improve practice.