Nurses are well placed to promote good hand hygiene techniques in practice and should use this to influence culture change in their organisations
Nurses are well known and respected for championing practices that contribute to high standards of patient care, save lives, and help to influence other disciplines to do the same. Hand hygiene is one such practice. This article discusses the role nurses play in championing hand hygiene and explores how senior managers can support them in this.
Citation: Hart T (2013) Promoting hand hygiene in clinical practice. Nursing Times; 109: 38, 14-15.
Author: Tricia Hart is chief executive officer, South Tees Foundation Trust and patron of the Infection Prevention Society.
- 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
Failure to attend to hand hygiene has serious consequences: it has a negative effect on patient safety and the quality of patients’ lives as well as on their confidence in healthcare delivery. However, the prevalence of hand hygiene omission has been, and is still, high (World Health Organization, 2009).
Until recently, this topic was a significant factor in national policies, standards, guidance and campaigning throughout the UK, resulting in action to tackle hand-hygiene compliance at all levels in healthcare. Many wards and units still feature their hand hygiene compliance results on noticeboards, but we need to be sure hand hygiene is practised at the right time, every time.
Improving hand hygiene has the potential to prevent infections and harm, thereby reducing healthcare time and costs, which is particularly important with the current efficiency-saving targets for the NHS. Hand hygiene is a cost-effective intervention that can save lives (WHO, 2009); it is a vital element of nursing practice, but nurses also play an important role in influencing other professionals to comply with hand hygiene recommendations. However, the executive teams of healthcare providers, starting with chief executives and directors of nursing, also have a significant role to play in building on what has gone before and supporting health professionals to sustain patient care practices that are of a high standard.
During the last 12 months numerous national events and reports have highlighted the need for enhanced infection prevention action as part of a patient safety approach, including the report into care failings at Mid Staffordshire Foundation Trust (Francis, 2013) and the Keogh review of some hospital trusts in England (Keogh, 2013). This has served as a reminder of the importance of an organisational culture that reflects a healthy workplace for patients and staff to ensure the best, and most sustained, outcomes.
Culture is framed by the organisations we work in and leaders, including nurses, are in a privileged position to influence and enhance the culture of patient safety every day (Leonard and Frankel, 2012).
At a local level, culture is something of which we should be proud; we should embrace the promotion of high standards of care - the standard you walk past is the standard you accept. We must keep this in mind every day and support a culture that gives all employees the opportunity to advise colleagues about the right thing to do, especially when omissions do occur. We need to be bold and we need to make major culture changes now, wherever they are needed.
A Promise to Learn - A Commitment to Act: Improving the Safety of Patients in England was recently published by the National Advisory Group on the Safety of Patients in England (2013) highlighted a number of key points. Patients were placed at the centre of these - the report stressed a need to listen to and truly understand patient feedback, and reflect on this feedback and opinion in everything we do.
The NHS cares for millions of patients every year and, while this may seem like a lot of people to listen to, there are processes in place to help you understand how your patients feel, such as the Friends and Family Test (Department of Health, 2013). By stopping and listening, nurses can ensure patients are confident in the hand hygiene actions practised within their settings and address any concerns.
Fraser (2002) explains that “what gets talked about, gets done”, so habits can be reinforced by vocalising them. For example, before touching a patient, it is a good idea for nurses to mention that they have just cleaned their hands; this is one of the World Health Organization’s Five Moments for Hand Hygiene (Moment 1 - before touching a patient, as outlined by Sax et al, 2007).
Patients and the public want uneventful experiences of healthcare and good outcomes; infection prevention and control contribute hugely to these, even though they may appear to be a relatively small part of the patient journey. Although small, these are significant and each nurse has the potential and the responsibility to influence change and make a difference to patients’ lives.
The NHS complaints system is currently undergoing a nationwide review to provide new direction on effective management of complaints. Publications are being issued to advise on the handling and reduction of complaints (Parliamentary and Health Service Ombudsman, 2013). Hand hygiene omissions can result in complaints about avoidable infections and the failure of members of staff to undertake hand hygiene practices, which can be seen as life-saving actions. As such, as a profession, nurses should take a lead on ensuring such complaints do not need to be made by making sure that they comply with hand hygiene recommendations and encourage their colleagues to do the same.
Social media can be used effectively to influence compliance with hand hygiene recommendations. They allow health professionals in all specialties and settings to learn from experts such as those in the Infection Prevention Society (@IPS_Infection on Twitter), and to see nursing teams demonstrating their commitment to, and passion for, a topic such as hand hygiene through impactful messaging.
Social media also give us the opportunity to discuss our practice and share practical ideas within the nursing community. Many trusts and other health organisations use appropriate social media activities to engage, inform and listen to staff and the public, including potential patients or those seen in the past.
Supporting hand hygiene
Support for hand hygiene as a cornerstone of evidence-based practice from trust chief executives and senior managers is crucial. Hand hygiene is a critical intervention that should be undertaken at the right times and in the right way by all members of staff who touch patients. Ensuring that all staff achieve this depends on both knowledge and evidence being translated into practice in a reliable way, including through up-to-date training and education sessions, and through building competence. While infection prevention and control teams play an important role in this, infection prevention is not the responsibility of these teams alone - it should be the responsibility of everyone in healthcare.
Manning (2010) explained that the care and treatment of patients becomes more complicated as the healthcare environment becomes more complex. Emerging infections, new technologies, multiple treatment protocols, multiple providers and varied healthcare settings all contribute to a complex environment and increased risk of infection. However, they can also all contribute to a concentrated effort to improve infection prevention and hand hygiene in a reliable way if used and applied appropriately - nurses have the knowledge and expertise to take a lead in this area.
All staff working for healthcare providers, including senior management and chief executives, need to support the move towards greater integration of infection prevention, starting with the practice of hand hygiene. Infection prevention and control should be integrated into every aspect of healthcare through, for example:
- How we manage devices;
- Surveillance of infections;
- Monitoring of, and feedback on, hand hygiene compliance; and
- The way we train our staff, including undergraduates of all disciplines.
We need committed people to change and improve healthcare, and nurses should realise their influence on this crucial aspect of patient care.
- How can you engage your team in hand hygiene?
- Do you follow the Five Moments of Hand Hygiene?
- What can senior management do to inspire staff to action hand hygiene?
- How can messages be communicated effectively with members of staff?
- Why is hand hygiene missed so frequently?
Fraser SW (2002) Accelerating the Spread of Better Practice: A Workbook for Healthcare. West Sussex: Kingsham Press.
Department of Health (2013) The NHS Friends and Family Test: Publication Guidance. London: DH.
Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: Stationery Office.
Leonard M, Frankel A (2012) How Can Leaders Influence a Safety Culture? London: Health Foundation.
Manning ML (2010) Expanding infection preventionists’ influence in the 21st century: looking back to move forward. American Journal of Infection Control; 38: 778-783.
National Advisory Group on the Safety of Patients in England (2013) A Promise to Learn - A Commitment to Act: Improving the Safety of Patients in England. London: DH.
Parliamentary and Health Service Ombudsman (2013) Designing Good Together: Transforming Hospital Complaint Handling. London: PHSO.
Sax H et al (2007) “My five moments for hand hygiene”: a user-centered design approach to understand, train, monitor and report hand hygiene. Journal of Hospital Infection; 67: 9-21.
World Health Organization (2009) WHO Guidelines for Hand Hygiene in Health Care: A Summary. First Global Patient Safety Challenge: Clean Care is Safer Care. WHO: Geneva.