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Hand inspection cabinets as an aid to washing technique

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Aim: The study aimed to discover if self-assessment of handwashing techniques would help staff to improve practice.


VOL: 101, ISSUE: 31, PAGE NO: 38

Linda Bissett, BN, RN, SPQ Infection Control, is infection control nurse

Karen Craig RN, Dip Advanced Nursing Practice (Infection Control), is infection control adviser; both at Tayside Health Board Primary Care Division, Royal Dundee Liff Hospital, Dundee

Aim: The study aimed to discover if self-assessment of handwashing techniques would help staff to improve practice.



Method: A rolling programme of self-assessment of handwashing technique was carried out over a period of three months using hand inspection cabinets (glow-and-tell boxes). A simple questionnaire was then used to establish opinions on the glow-and-tell box as an aid to self-assessment in handwashing technique.



Results: In total 2,009 staff of all disciplines self-assessed their handwashing skills. The questionnaires identified that self-assessment had increased awareness of handwashing techniques and of the need to introduce regular handcare into regimes.



Conclusion: This programme allowed a large number of staff to be reached in a short time. It also raised self-awareness of handwashing techniques and allowed changes to practice where required. The glow-and-tell boxes also highlighted areas where skin was dry or damaged thereby encouraging good handcare among staff.



Health care-associated infections (HAIs) are infections that are neither present nor incubating when patients are admitted to hospitals or other health care settings but are acquired during their stay. It is estimated that nine per cent (more than 300,000) of hospital inpatients will contract an HAI at any one time (National Audit Office, 2000).



HAIs are estimated to cost the NHS £1bn per year in England and Wales (National Audit Office, 2000) and a further £186m in Scotland (NHS Scotland, 2004). This figure does not include infections contracted in other health care settings. Taylor et al (2002) estimate that 5,000 patients die each year after contracting an HAI.



There is a higher degree of morbidity among susceptible patients who develop an HAI, increasing their length of hospital stay. The cost to patients can include loss of earnings, lowered self-esteem, reduced mobility, psychological problems, confusion and, in some cases, death. Davie and Nathwani (1998) suggest that the effect on patients is not always considered in cost findings.



Literature review
Voss and Widmer (1997) and Horton (1995) identified hand hygiene as one of the simplest and most effective methods of reducing cross-infection. Hands are the principal route by which HAIs are transmitted (Elliot, 1992) and yet research indicates that conformity to handwashing guidelines rarely exceeds 40 per cent (Harding, 1996; Widmer, 2000). This finding is supported by Larson (1995), who identified hand hygiene as the most effective measure for preventing HAIs and confirmed that compliance to handwashing guidelines was poor.



Despite the efforts of infection control teams (ICTs) to encourage compliance with handwashing guidelines, increased compliance is not sustained in the long term (Graham, 1990; Tibballs, 1996).



Hugonnet and Pittet (2000) suggested a multidisciplinary approach to try to change behaviour that leads to non-compliance. They suggested encouragement of good practice by ward managers and infection control nurses (ICNs), and increased educational input for nurses, junior doctors and allied health professionals.



Elliot (1996) recognised the need for education and training in handwashing to promote safe practice. Until recently there were no national standards for hand hygiene but in 1998 the Infection Control Nurses Association (ICNA) published evidence-based guidelines to redress this situation.



Emphasis in hand hygiene education has been based on face-to-face teaching and demonstration of handwashing activities (Larson, 1999). Heenan (1992) and Sproat and Inglis (1994) suggested that ineffective communication and deficiencies in education played a part in poor handwashing technique. This may have been exacerbated by the lack of infection control nurses on health boards until recently and by the large geographical areas ICNs were required to cover, especially within primary care.



Bissett (2002) said, ‘Further research is indicated on the effect of changing education on handwashing and encouraging staff to take ownership of their training to promote safe practice in their area.’ Perhaps if staff education took the form of self-assessment of handwashing skills, this would emphasise staff responsibility and compliance to protocols and guidelines would be maintained.



Regardless of the cleaning product used, if it is not properly applied or hands are not washed using the six-step guide (ICNA, 1998), then decontamination may not be successful and skin can become damaged. Ayliffe et al (1988) confirmed that technique rather than product dictated the success of handwashing or decontamination.



Due to the geographical layout of Tayside Primary Care Division, demonstrating hand hygiene technique to all staff would prove a time-consuming process and might jeopardise the team’s ability to carry out other functions. For this reason they decided to carry out a programme of self-assessment of handwashing skills for all staff.



To facilitate the programme the ICT purchased 10 hand inspection (glow-and-tell) boxes. The box’s ultraviolet light causes a special handcream to glow. Staff are instructed to rub the cream into their hands using their usual handwashing technique. They then wash their hands in their normal manner and examine them under the light in the box. Areas that have been missed during the handwashing process glow in the light and indicate where alteration in washing technique is required. Dry skin can also make it difficult to remove the cream during washing and if areas continue to glow after further washing this may indicate dry or damaged skin that requires increased handcare using an aqueous-based handcream.



The purchase of the boxes enabled the ICT to set up a rolling programme of self-assessment of handwashing skills for all health care personnel within hospitals in their area of responsibility.



Before the programme started posters depicting the six steps required for effective handwashing were distributed to all hospitals in Tayside Primary Care Division. They were positioned above every handwashing sink in each facility.



Letters were sent to all clinical and ward managers in the ICT area of responsibility informing them of the distribution of the glow-and-tell boxes and the purpose behind this. Information on the use of the boxes, posters indicating the most frequently missed areas when washing hands and the six steps to good handwashing guidelines, in pictorial form, were laminated and inserted in the boxes before they were circulated to each area. A distribution list was included in each box to enable staff to identify the next ward, department or hospital to receive the box.



Each area received an evaluation form for staff to complete. This asked staff to list their name, designation, ward and hospital and also required their signature. The staff were asked to comment on the usefulness of the exercise. In this way the ICTs were able to identify the numbers, the disciplines and the skill mix of the staff who had completed the self-assessment. Managers returned the evaluation forms to the ICT to enable them to evaluate the effectiveness of the programme.



Arrangements for transportation of the boxes to distant areas and between sites was organised using the ICT personnel and the trust transport service. To guarantee that every area would receive the boxes each ward had the responsibility of ensuring that the box was passed to the next ward or hospital on their distribution list. It was therefore essential to obtain the cooperation of all clinical and ward managers and the board’s transport services to ensure that this would happen.



The Watt Report (2002) states that all health care staff including night staff must be included in infection control education and handwashing audit. It is not always possible for ICT members to be available during night-duty hours and this can lead to night staff being neglected in regard to in-service education. To ensure all staff had the opportunity to assess their own handwashing skills each ward or department kept the box for one week to allow staff of all disciplines and on every shift to participate in the programme.



The target area consisted of 18 hospitals. In total 2,009 staff self-assessed their handwashing skills within a three-month period. (Table 1, p39).



Following the exercise 200 members of staff were asked to complete a simple questionnaire to establish their opinion of the glow-and-tell boxes as an aid to self-assessment (Table 2).



The distribution of the boxes was not without its problems. In the outlying areas where boxes had to be passed from one hospital to another the process ran remarkably smoothly with only one box briefly going astray. It was in the larger hospitals where the box had to be passed between wards that the system fell down. Some boxes went adrift for more than a week at a time. Despite this all areas included in the distribution list did receive the boxes and were able to participate in the programme.



The staff who completed the questionnaires stated that they had been surprised by the result of their own self-assessment. Having considered their handwashing skills to be of a high standard 85 per cent now felt that there was room for improvement. The 93 per cent of staff who commented on their skin condition were surprised to find it was not as good as they had thought prior to the exercise.



Staff thought that self-assessment using the boxes had increased their awareness of their own handwashing technique and of the need to introduce regular handcare into their regime. Of the staff who completed the questionnaire 92 per cent considered it a good exercise to repeat annually.



Encouraging the staff to make any changes required to their own handwashing technique has given them ownership of the change and it is therefore more likely to succeed. Adair (1993) refers to this as strategic leadership as it allows staff to formulate methods of change.



This rolling programme has helped staff of all disciplines to become more aware of their handwashing technique. The number of staff who participated in the exercise exceeded the number that the ICT would have been able to assess within the same time frame. It is thought that distributing the boxes on a rolling programme basis helped highlight to staff the importance of the technique used to decontaminate the hands during handwashing. It also allowed a large number of staff to be reached in a short period of time.



By encouraging staff to assess their own handwashing skills the ICT has given them ownership of their own training. Adair (1997) refers to this as transformational leadership and suggests that it encourages staff to alter their practice.



This programme is to continue and plans are under way to extend it to GP practices and clinics. Organising this will take thought and time but it is felt that the outcome makes the exercise worthwhile. Meanwhile, glow-and-tell boxes are now available to staff at all education sessions and are lent out to clinics and GP surgeries on request.



- This article has been double-blind peer-reviewed.



For related articles on this subject and links to relevant websites see

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