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Knowledge - Involving patients in staff hand hygiene

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VOL: 102, ISSUE: 24, PAGE NO: 46

Linda Pearson, BSc, PhD, RN, PGCE(FE), is RCN Institute distance learning tutor and a freelance development facilitator. At the time of writing this article, she was a non-executive director of Selby and York PCT

Vivien Duncanson, MSc, RN, is senior nurse infection prevention and control, Northern Lincolnshire and Goole NHS Trust, Grimsby

The national 'cleanyourhands' campaign (National Patient Safety Agency, 2004), was introduced as a way of trying to...

The national 'cleanyourhands' campaign (National Patient Safety Agency, 2004), was introduced as a way of trying to reduce cross-infection and, as part of the campaign, patients are invited to ask healthcare staff 'Have you washed your hands?'

This aspect of the campaign was influenced by two studies that demonstrated a sustained improvement in hand hygiene practices with patient involvement (McGuckin et al, 2001; 1999). The studies investigated the effect of patient education on staff compliance with handwashing, using the patient as the intervention.

It is important that some of the professional issues associated with the 'cleanyourhands' campaign are discussed in order to raise staff awareness of its impact. This will equip them to introduce the campaign appropriately, so avoiding conflict with patients and colleagues.

Involving patients

Inviting patients to become 'partners' in their care may be an appropriate response to reports of the rising incidence of healthcare-associated infections (HCAIs) and the difficulties associated with ensuring healthcare staff wash their hands effectively and at appropriate times (Al-Damouk et al, 2004; Pittet, 2001). However, while some infection control professionals welcome the move, others reject it outright (Parkin and Jeanes, 2003).

An investigation by the National Patient Safety Agency (2004) into the extent to which patients wish to be partners in their care, and our own study (Duncanson and Pearson, 2005), found that the majority thought patients and the public should be involved in helping staff improve hand hygiene. However, implementing a campaign involving patients without regard to context, or to whether or not an organisation is prepared to embrace the concept, has the potential to affect the relationship between patients and health professionals and patients' experience of care.

In 2005 we published a survey of 150 patients who were about to be discharged from an acute hospital, the aim being to explore their opinions about being encouraged to ask staff if they had washed their hands before providing care, and to see what factors might influence those opinions.

Two questionnaires were used to collect information. The first was designed to obtain information about participants' previous experience of being in hospital, having an infection and what they thought and felt about asking different groups of staff to wash their hands before different aspects of their care. The second was used to obtain information about different dimensions of each participant's personality using a previously tested tool (Costa and McCrae, 1992).

The results revealed a number of important issues that may affect how patients experience the 'cleanyourhands' campaign (Box 1).

Encouraging involvement

A current government priority is to put people at the heart of all public services (DoH, 2004a). In the NHS this means that care must be built around the needs of the patient rather than the convenience of professionals. Staff are being asked to work in different and creative ways to facilitate this, while primary care and hospital trusts now have a statutory duty to engage with patient and public involvement (PPI) (DoH, 2003a).

Involving patients covers a broad range of activities, from providing information about health problems and services to the active involvement of users and communities in decision-making and service design. However, it is vital that the level and type of involvement is appropriate to the individual concerned.

One of the drivers of the PPI initiative was patients' expressed desire to be listened to and taken seriously by staff and decision-makers. In many instances, PPI involves changing the patient-staff relationship to one that is an equal partnership rather than being one in which passive patients are told what to do by health professionals (Pearson, 2003). However, some clinicians are reluctant to involve patients in their care because they feel unable to relinquish power or control over them (Cahill, 1996).

For many people, admission to hospital is an anxious, distressing and stressful experience. One way of increasing patients' feelings of security is to ensure they have confidence in healthcare staff. From the patients' perspective this appears to be at odds with inviting them to challenge staff about basic procedures such as hand hygiene, an activity that our study indicated would be very difficult for some patients. In addition, we may be doing some patients a serious disservice if they are left worrying that not to ask staff to wash their hands will result in their contracting an infection.


Some staff may find it difficult to accept being challenged by patients, which could have a negative effect on their relationships with them. Patients who are perceived as demanding, uncooperative and ungrateful or who make staff feel ineffective have been labelled as 'difficult' or 'bad' patients (Finlay, 1997), while 'good' patients are those who confirm the role of the nurse (Kelly and May, 1982).

There is a danger that these challenges and conflicts could have a negative impact on staff looking for new ways to involve patients in their care. Involvement can be achieved appropriately in many instances by actively listening to patients, explaining possibilities, giving them information and feedback, and asking open questions.

Future strategies

If healthcare staff are to retain the confidence and trust of patients, the public and of each other, we believe that hand hygiene should be their responsibility, and that this aspect of the 'cleanyourhands' campaign helps to focus our attention on it. There are a number of potentially supportive national strategies in place that could foster sustained improvement of handwashing by healthcare staff. For example, there is a move within the nursing profession to equip nurses with leadership skills so that they are able to contribute to, and influence, policy direction and its implementation (Scott and West, 2001).

Culture change within the NHS has already begun, albeit slowly. Infection control research communities are now looking at the models and theories of the behavioural sciences as a means of generating new ideas to enhance patient care in order to complement those methods that we know are effective (Pittet, 2004; Jenner et al, 2002).


The cleanyourhands campaign is a useful tool for increasing staff compliance with hand hygiene protocols but it will be most successfully implemented if it is patient-focused and sensitive to staff needs.

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

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

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