VOL: 103, ISSUE: 3, PAGE NO: 32-33
Mark Cole, BA, RGN, Dip Infection Control
Lecturer in nursing, University of Nottingham.
Cole, M. (2007) Should nurses take a pragmatic approach to hand hygiene? www.nursingtimes.net
Background: It is frequently stated that hand hygiene is the single most effective measure to prevent healthcare-associated infection, yet numerous studies have reported that compliance among healthcare professionals is poor. There is often an assumption that poor compliance is a result of staff attitudes, behaviour and negligent acts.
Method: Literature on hand hygiene was reviewed to explore why healthcare professionals fail to practise effective hand hygiene and attempt to answer the question: is full compliance achievable or simply another example of the theory-practice gap?
Results: The literature suggests that as workload intensifies and care becomes increasingly complex, the amount of hand hygiene episodes required to achieve full compliance becomes aspirational rather than achievable. In addition, no evidence is available to distinguish between those patient care activities that result in a clinically significant transmission of bacteria and those that do not.
Conclusion: If this topic continues to be discussed in terms of the theory-practice gap, standards may decline further as infection control professionals become alienated from the staff that they wish to influence. By refocusing the debate and developing a pragmatic model based on a hierarchy of interventions and professional practice, the profession may find, paradoxically, an improvement in overall standards.
Hand hygiene remains the single most effective measure to prevent healthcare-associated infection (HCAI). However, the importance of this apparently simple and inexpensive procedure is not sufficiently recognised by healthcare professionals, and poor compliance has been documented repeatedly (Pittet et al, 2000). This article reviews the literature on hand hygiene to explore why healthcare professionals fail to practise effective hygiene and attempts to answer the question: is full compliance achievable or simply another example of the theory-practice gap?
The cause of infection
Commensal microorganisms constitute the normal flora of a healthy human body (Gould and Brooker, 2000). They live on the skin and the mucus membranes of the upper-respiratory tract, intestines and vagina and obtain nourishment from the body’s secretions and food residues (Greenwood et al, 2002). Bacteria are generally harmless but under certain circumstances may invade the tissues and cause disease as opportunistic pathogens (Greenwood et al, 2002). This may explain why the literature uses the term ‘risk assessment’ when examining the potential implications of medical interventions in relation to bacteria and infection (Larson and Aiello, 2006; Rayner, 2003; Curran, 2001; McCulloch, 1999). However, in discussing risk assessment the Health and Safety Executive (2006) illustrates the difference between a hazard and a risk. A hazard is defined as anything that may cause harm, such as bacteria, while a risk is the chance, high or low, that somebody could be harmed by the hazard - in the case of bacteria, an infection.
Although it is generally accepted that the risk posed by bacteria increases when they gain access to the body through invasive devices or procedures (Wilson, 2006), Kingsley (2001) demonstrates through the infection continuum how the body’s relationship with bacteria is in fine balance, with each part of the body defined as either sterile, contaminated, colonised, critically colonised or infected. The fact that these states are a continuum and at any point may transcend one another illustrates the importance of hand hygiene as a means of preventing the transmission of transient bacteria to vulnerable sites (Storr and Clayton-Kent, 2004). Nevertheless, recognising the pathogenic potential of the body’s normal commensal flora has implications for the way healthcare professionals use and interpret the terms ‘risk’ and ‘hazard’ within infection control.
What causes hand contamination?
Direct contact with and handling of patient secretions are generally accepted as factors that may result in significant contamination of the hands of healthcare professionals (Boyce and Pittet, 2002). However, as each person has been estimated to emit approximately one million skin squames into the environment each day (Storr and Clayton-Kent, 2004),social care and touching inanimate objects can also result in similar contamination (Boyce et al, 1997). This has been demonstrated by the recovery of healthcare-associated pathogens from colonised areas of normal, intact patient skin in addition to wounds, catheter urines and other invasive devices (Larson, 2000; Bonten et al, 1996; Sanderson and Weissler, 1992). This makes it difficult to distinguish which patient-care activities may result in a significant transmission of bacterial flora to the hands (Boyce and Pittet, 2002). As a result hand hygiene guidelines need to be comprehensive. The EPIC guidelines (Pratt et al, 2001), for example, state that ‘Hands must be decontaminated immediately before every episode of direct patient contact/care and after any activity that potentially results in hands becoming contaminated’. However, the fact that this statement is given a ‘category 3’ evidence grading, acknowledges that there is limited scientific evidence and an absence of directly applicable studies of good quality to support this recommendation. Indeed the lack of scientific information indicating a definitive impact of improved hand hygiene on healthcare-associated infection rates is reported as an additional barrier to adherence (Pittet et al, 1999). Of course, this does not mean the recommendation is unsound but serves to illustrate the difficulties of quantifying risk in any meaningful or practical way.
Causes of poor compliance
Although there are difficulties associated with quantifying infection risk, public confidence in the NHS is based on the premise that healthcare is scientific and ethical, and has financial standards, transparent decision-making processes, a clear allocation of responsibilities and robust monitoring arrangements (Department of Health, 2001). Moreover, NICE (2004) suggests that clinical audit is a way to establish the confidence and trust upon which the NHS is founded. Audit systems are well established within the discipline of infection control (Infection Control Nurses Association, 2004; Ward et al?], 1995; Milward et al, 1993), as are observational studies examining hand hygiene compliance. Examining the findings of 26 observational studies, Boyce and Pittet (2002) reported poor compliance, with baseline rates of between 5-81% and an overall average of 40%. The reasons given for poor compliance commonly include: lack of time, knowledge deficit, poor facilities and materials, drying of skin, forgetfulness and disagreement with guidelines (Rickard, 2004; Boyce and Pittet, 2002; Pittet et al, 2000; Harris et al, 2000; Larson, 1995; Heenan, 1992). Lack of time appears to be a recurring theme in the literature, with some writers suggesting that 100% compliance with handwashing guidelines is impractical, unsustainable and would interfere with essential care (Stone et al, 2001; Weeks, 1999; Voss and Widmer, 1997).
However, according to Larsen (1995) an effective handwashing technique takes only 10-15 seconds, and for some it is an act of such simplicity that it may be deemed insulting or embarrassing to mention to advanced practitioners. This may suggest that it is the frequency of the activity rather than the activity itself that has a greater impact on behaviour. Hospital surveillance of hand hygiene reveals that the average number of episodes requiring handwashing varies markedly between hospital departments.These include up to 30 episodes across a range of clinical environments (Boyce and Pittet, 2002), eight episodes an hour in a paediatric setting and 20 episodes per hour in an ICU (Pittet et al, 1999). Ojajarvi (1977) reported that to attain full compliance staff would have had to decontaminate their hands in over 100 times in a single shift and Gould (2004) observed that one seriously ill patient generated 70 contacts in two hours.
Although some authors question whether these numbers represent a realistic view of compliance (Stone et al, 2001; Weeks, 1999; Voss and Widmer, 1997), it is perhaps surprising how rarely such sentiments are expressed within the literature. Rather, there seems to be an acceptance of the topic’s importance and an intention to do better (Creedon, 2005). However, intention to practise and reported compliance do not predict actual, observed behaviour (O’Boyle et al, 2001). A common theme to emerge from the literature is that estimates in self-reporting exceed observed performance (Rickard, 2004; O’Boyle et al, 2001; Ronk and Girard, 1994). This may suggest that while staff understand the importance of the activity and have good intentions, activity levels impact upon behaviour (Robert, 2000; Pittet et al, 1999).
To address issues of time, alcohol-based handrubs are increasingly being provided in ward areas (Storr and Clayton-Kent, 2004) as they take less than a quarter of the time to apply compared with traditional soap and water (Boyce and Pittet, 2002). Indeed a recent study demonstrated improved compliance of 20%, by using feedback and encouragingthe use of alcohol handrubs (Pittet et al, 2000).
In addition to the time benefits and convenience associated with alcohol handrubs, some authors argue that they have superior efficacy in reducing bacterial contamination compared with traditional methods (Girou et al, 2002). However, they should not be seen as a panacea. Alcohol handrubs are not always popular with staff due to a tendency to cause skin irritation and dryness and cannot replace conventional methods when hands look dirty or have debris visible to the naked eye (Storr and Clayton-Kent, 2004). Moreover, while Pittet et al (2000) achieved excellent results in improving compliance by 20% there remained a non-compliance rate of 32%. Anecdotally staff often favour traditional washing with soap and water and argue that their hands do not feel clean when handrubs are used in isolation. In addition, Gould (2004) reported that much of the behaviour she observed defied logic or rationale and concluded that many gestures that resulted in contamination were made unconsciously and were thus beyond the individual’s control.
Is compliance achievable?
The factors discussed above inevitably pose the question whether compliance as it is currently measured and assessed is aspirational rather than achievable. In addition, rather than motivating and enhancing practice, continual exposure and criticism of healthcare professionals’ failure to achieve the recommended standard of hand hygiene demoralises staff, creates a culture of fatalism and becomes, in the long term, detrimental to the desired outcome. This is not to suggest the topic is not important, or dispute the relationship between hand hygiene, HCAIs and morbidity and mortality. However, when standards of practice are developed and expected of healthcare professionals, should there not be a reasonable expectation that they can achieve them?
There is continuing debate about whether or not it is physically possible for healthcare professionals to engage in up to 100 hand hygiene episodes each day, over a sustained period of time. However, in addition to the physical and environmental constraints, it needs to be considered whether in terms of behaviour and motivation it is emotionally or psychologically possible. Ajzen’s (1988) theory of planned behaviour proposes that intention to perform a behaviour - in this instance handwashing - is formed by certain determinants:
- Attitude (the value of performing a behaviour);
- Subjective norms (perceived social pressures);
- Behavioural control (an individual’s perception of the ease or difficulty of performing the targeted behaviour).
These determinants are formed by individual beliefs. As a general rule, the more favourable the attitude and subjective norm, and the greater the perceived control, the stronger should be the person’s intention to perform the behaviour.
Although, there may be irrefutable evidence that hand hygiene reduces incidence of HCAI (Teare et al, 2001), microorganisms cannot be seen by the naked eye (Rickard, 2004). Contaminated hands and the transfer of bacteria to patients and their multiplication on a vulnerable site are therefore unlikely to be pinpointed to a particular time, occasion or event. This may be significant in terms of compliance, as behavioural psychology suggests that staff need to see the rewards of their behaviour, for that behaviour to be re-enforced (Quinn, 2001). Many staff may not have the imagination or inclination to make the causal link between contamination and infection and see this as a theoretical concept (Storr and Clayton-Kent, 2004). In addition, some staff may find it difficult to comprehend and quantify the likelihood of a single omission of hand hygiene by a single member of staff leading to the spread of microbes that could cause infection (Storr and Clayton-Kent, 2004). For some, the principle of altruism, aligned to an understanding of hand hygiene, may in itself be sufficient reward to undertake handwashing. The nursing profession is well schooled in the notion of altruism, indeed the NMC’s (2004) Code of Professional Conductrequires nurses, midwives and health visitors to act to identify and minimise risks to patients and clients. However, it could be argued that altruism, like anything else, has its limitations and that compliance rates of 68% (Pittet et al, 2000) already demonstrates significant altruism and commitment.
Ajzen’s (1988) second determinant is the power of the subjective norm, which is the perceived social pressures on healthcare professionals to comply. Hand hygiene receives significant attention within healthcare itself (Pratt et al, 2001) and from the DH (2003; 2002) and the media, and nurses report a good understanding of its importance (Creedon, 2005). Despite this, the reporting of practice remains overwhelmingly one of poor-compliance (Creedon, 2005; Boyce and Pittet, 2002; Pittet et al, 2000). It is debatable whether the continuous coverage of hand hygiene and associated reports of non-compliance increases the power of the subjective norm, and motivates staff, or merely illustrates that compliance as determined by the current model is theoretical and unachievable. However, Callaghan (2003) suggested that nurses who are overworked and under-appreciated have low morale and this leads to a decrease in work performance (Castledine, 1998; 1997). Perhaps, within a culture where reporting of poor practice becomes common and ‘good’ practice is seen as unachievable, underperforming may be accepted and poor compliance become the norm.
Ajzen’s (1988) third determinant was the behavioural control a person perceives they have in achieving the targeted behaviour. The body’s delicate relationship with bacteria and the transient state of the infection continuum may be reasons why the science underpinning infection control has difficulties in establishing, with any certainty, the significance of different patient care activities in relation to cross infection. As a result the EPIC guidelines (Pratt et al, 2001) include all patient-contact activities in relation hand hygiene requirements. The impact of this all-inclusive approach is that some healthcare professionals are required to decontaminate their hands up to 100 times in a single shift (Boyce and Pittet, 2000). The so-called theory-practice gap is a global phenomenon and has been repeatedly debated within nursing (Maben et al, 2006). Gallagher (2004) described it as a mismatch between nursing as taught and nursing as practised. Mead and Moseley (2000) argued that it derives from an antipathy and anti-intellectual bias held by many clinicians, who see educationalists and nurse researchers as a professional elite divorced from practice and operating from ‘ivory towers’. By employing measurements that appear to be, to most clinicians, unrealistic and unachievable, infection control professionals perhaps risk adding handwashing to the theory-practice gap debate.
The theory of planned behaviour is based on the assumptions that human beings are rational, make systematic use of available information, and consider the implications of their actions before engaging in behaviour (Ajzen, 1988). Healthcare professionals may consider that if the current compliance standards are unachievable they have no control over their behaviour in terms of compliance. Of course some may argue that 100% compliance is indeed a reasonable and realistic objective, however, as no study to date, has been able to demonstrate this, a moderate amount of scepticism seems well placed.
Achievable or aspirational?
Does it matter whether compliance standards are aspirational rather than strictly achievable? There is evidence that nursing workload within modern healthcare has intensified with increased patient throughput and turnover, shorter patient stays in hospital, increasing use of technology and increased acuity of illness (Maben et al, 2006). Moreover, demanding patient contacts, time pressure, and work overload lead to increasing stress and in some cases burnout (Demerouti et al, 2000). The relationship between motivation and burnout is equally well recognised (Schaufeli and Enzmann, 1998) and the importance of motivation in relation to hand hygiene compliance is well documented (Cole, 2006; O’Boyle et al, 2001). Herzberg et al’s (1959) two-factor theory of motivation proposes that motivators such as achievement, recognition and responsibility lead to satisfaction. When they are not adequately present in an organisation, employees develop a neutral and indifferent attitude towards their work. In short, if staff are continually confronted with failure, in terms of non-compliance, their performance will probably deteriorate further. Boyce and Pittet (2002) found that compliance rates among healthcare professionals varied widely (5-81%). Is such marked variation a symptom of staff adopting their own standards as they reject the recommended standards as being theoretical? If this is the case the control and rigor of the audit process has become lost.
Compliance studies rarely specify the type of episodes where healthcare professionals adhere to guidelines and those where they do not. For example, is compliance good when handling body fluids and accessing invasive devices, but poor when staff move rapidly between patients to deliver social care? Indeed does the discipline of infection control acknowledge that there is a difference? Is a failure to decontaminate hands before accessing a patient’s invasive device a professionally negligent act, while failure to decontaminate before taking a patient’s pulse, regrettable, but understandable when placed in the context of workload and hand hygiene demands?
This article has not sought to deny the importance of hand hygiene, call for a reduction in standards or criticise the excellent work of infection control professionals. However, no major study has demonstrated compliance with current standards, which raises the question whether this is an achievable or a theoretical model. In addition the frustration and demoralisation that invariably follows the reporting of compliance studies risks alienating infection control professionals from the staff that they wish to influence and motivate. An approach based on encouraging practice development may be more effective.
Quantitative microbial risk assessment has been used for some time in the US, Canada, and the UK as a tool for making risk-management decisions based on the probabilities of infection (Larson and Aiello, 2006). Perhaps the discipline needs to consider creating a hierarchy of interactions, based upon risk, reasonable expectations and professional practice. Although this may be an uncomfortable move for many, it could be empirically attractive for pragmatists, but also liberating for staff as their excellence in some areas is acknowledged, while highlighting development opportunities in others. Since mathematical modelling has predicted that very small increases in hand hygiene could bring endemic organisms under control (Cooper et al, 1999) the rewards could paradoxically be very high. To paraphrase Weinstein (2004) we have been prodding, cajoling, educating, observing and surveying healthcare professionals for 150 years, and adherence rates to hand hygiene remain poor. If we do not refocus the debate, we may well spend the next 150 years having the same discussion.
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