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Assessing hand hygiene in older people’s care settings

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BACKGROUND: The NHS is running a number of high-profile campaigns to promote better hand hygiene in healthcare establishments in order to reduce the rate of healthcare-associated infections.

AIM: To evaluate whether sufficient attention is paid to patient hand hygiene in older people’s care settings.

METHOD: We surveyed 114 staff in mental health care settings for older people – two mental health NHS inpatient units and five private care facilities in the North of England. An eight-item questionnaire designed specifically for the study was used.

RESULTS AND DISCUSSION: Staff believe that good patient hand hygiene is important but do not frequently assist patients experiencing physical and cognitive impairment to wash their hands either after visits to the toilet or before meals.

CONCLUSION: Staff did not routinely assist patients to wash their hands across a number of situations. Despite the study being set in the North of England, we found evidence that these findings could be generalised across the UK.


Mackenzie, L. et al (2008) Assessing hand hygiene in older people’s care settings. This is an extended version of the article published in Nursing Times; 104: 32, 30-31.


Lorna Mackenzie, Dip HE, RMN, is challenging behaviour nurse specialist; Ian Andrew James, PhD, MSc, BSc, CPsychol, is consultant clinical psychologist; Karin Smith, Dip HE, RMN, is challenging behaviour nurse specialist; Louise Barnard, D.Clin Psych, MPhil, BSc, CPsychol is senior clinical psychologist; all at Newcastle General Hospital; Damian Robinson, MA, MB, BcHIR, MRCPsych, FFPHM, is consultant old age psychiatrist, at Newcastle General Hospital, and associate director for public health, at Northumberland, Tyne and Wear NHS Trust.

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The incidence of healthcare-associated infections (HCAIs) has increased over recent years, and the Department of Health and NHS have responded with a host of campaigns and initiatives (NHS North East, 2008; DH, 2004). The problem of HCAIs is clearly not restricted to the NHS, as new proposals in the Health and Social Care Bill mean that the NHS Code of Practice is expected to apply to private healthcare providers in the future. This is relevant to elderly care facilities, which look after some of the most vulnerable residents and patients with respect to HCAIs.

Since the publication of the Chief Medical Officer’s Winning Ways report (DH, 2003), there has been a particular focus on meticillin-resistant staphylococcus aureus (MRSA) and clostridium difficile. As a result, MRSA and C. difficile targets have been set and statutory requirements laid out regarding cleanliness, infection prevention and control (DH, 2006). The Health Protection Agency has also set up a comprehensive surveillance system for the mapping of MRSA and C. difficile, and specialist teams have been established to coordinate NHS trusts’ responses (DH, 2006).

As part of the drive to reduce HCAIs, governments across the UK have been running national hand hygiene campaigns – ‘Clean your hands’ (National Patient Safety Agency, 2007) and Scotland’s ‘Wash your hands of them’ (Health Protection Scotland, 2007a). Particular emphasis has been placed on this issue because handwashing ‘is considered to be the single most important way to stop the spread of germs’ (Health Protection Scotland, 2007b). The latter audit highlights the importance of using a systematic approach to handwashing, emphasising that good hygiene is essential for staff and visitors, but also for patients too. Despite this rhetoric, the success of UK campaigns to date has tended to be measured only in relation to changes in staff behaviour.

Literature review

Around 9% of inpatients in England and Wales at any one time have an HCAI (equivalent to around 100,000 infections a year), with around 30% of these thought to be preventable (National Audit Office, 2000). Not surprisingly, the costs to society, the NHS and the individual are huge. Handwashing is widely believed to be the most important factor in preventing HCAIs (DH, 2004; 2003; 2000; NAO, 2000).

Existing research on hand hygiene falls into three main categories. First, the identification of effective hand hygiene techniques, that is, soap and water, alcohols, gels and so on. The second focuses on healthcare workers’ attitudes to hand hygiene and discrepancies between attitudes and actual practice. The third area focuses on barriers to hand hygiene, such as insufficient facilities, time or issues around prioritisation. An overwhelmingly obvious omission in all this research is the role of patient handwashing, including identification of methods for encouraging staff to support patients in washing their own hands.

We have been unable to identify any research exploring staff support of patient hand hygiene in social care settings but we did identify one research article based in a healthcare setting (Burnett et al, 2008). These researchers directly observed handwashing opportunities for patients who needed assistance (after toileting, before mealtimes, after vomiting and expectoration of sputum). They rated whether nursing staff supported them in maintaining adequate hand hygiene. Burnett et al (2008) found that staff almost never offered support for hand hygiene; amazingly, out of a total of 75 observed handwashing opportunities, handwashing facilities were only offered once. Despite this, in an anonymous questionnaire, 64% of nurses indicated they had offered patients facilities for hand hygiene. Over half of patients indicated they did not think that staff felt patient hand hygiene was important, with 55% saying they had not been offered the opportunity to wash their hands at all during their hospital admission. These figures were obtained despite all nursing staff involved in the study indicating they believed patient hand hygiene to be important. The low rate (1%) of actually offering hand hygiene support in this study is surprising, given that nursing staff were aware of the reason they were being observed. This highlights that purely observing practice is unlikely to be sufficient to change practice. The authors concluded that healthcare organisations should ensure all patients are able to decontaminate their hands when necessary and that further research should be conducted in this neglected area.

This issue has also been neglected by policymakers. We have been unable to find references on the importance of supporting patients to maintain appropriate levels of hand hygiene in recent government documents. For example, the DH (2004; 2003) and the NAO (2000) made no mention of the role of patient hand hygiene in tackling HCAIs. Similarly, the Code of Practice for the Prevention and Control of Health Care Associated Infections (DH, 2006) made brief reference to visitor handwashing but, again, makes no reference to patient hand hygiene.

This clearly leaves a gap in the hygiene strategy, failing to emphasise the importance of good patient handwashing. It is this apparent failure that is the topic of this research study.

We are particularly interested in hand hygiene in elderly mental health care settings, especially in relation to patients with organic and affective difficulties. Indeed, it is suggested that these patients are most vulnerable to HCAIs, due to the fact their cognitive difficulties may lead to both poor self-care and forgetfulness regarding washing. In such elderly settings, it is therefore reasonable to assume that nurses and carers routinely encourage patients to wash their hands after going to the toilet and before meals. This study examines these two issues.


This study aimed to test the following two assumptions about hand hygiene in elderly care settings: that staff frequently encourage patients to wash their hands after going to the toilet and before meals.



Questionnaires were completed by 114 participants from two elderly inpatient units and five private care homes. Of those providing demographic details, 50 (44%) were qualified mental health nurses (RMNs) and 53 (46%) unqualified staff (care workers, domestic staff). Due to concerns about anonymity, demographic details were kept to a minimum.

All the facilities studied in this survey cared for elderly people with a mixed range of cognitive, physical and mental health difficulties. This group of people, owing to motivational and memory problems, was generally considered at risk of not following regular hygiene routines and thus were in need of regular prompts regarding hand hygiene.


The survey was carried out by two of the authors (Lorna Mackenzie and Karin Smith). As hospital mental health nurses, we routinely work in NHS wards and care homes in the North of England. We visited elderly wards and care homes. Participants were recruited through ward and care home managers, who gave permission for staff to receive the questionnaires. Completed questionnaires were returned anonymously in sealed envelopes. The overall return rate was 83% (114 out of 137 questionnaires given out).


The questionnaire contained eight questions, one of which was qualitative. The key quantitative questions were rated on a five-point Likert scale (1-never, 2-rarely, 3-occasionally, 4-frequently, 5-always). Means, modes and standard deviations are presented in Table 1.


The project was registered as a service development project with Northumberland, Tyne and Wear NHS Trust.


The vast majority (n=112, 98%) of participants viewed handwashing as an important feature in the control of infection. Fifty people (44%) stated they were aware of guidelines about patient handwashing, but only 19 of these (38%) could give specific details about such guidance.

The findings indicate that staff believe they encourage patients to wash hands more often than their colleagues. Furthermore, staff think that both they and their colleagues are more likely to encourage handwashing after a visit to the toilet than before a meal. The degree of encouragement varied with respect to each condition, with the highest frequency occurring for ‘self encouragement of handwashing after the toilet’ (x=3.73, sd=1.06). This corresponded to a descriptor score between ‘occasionally and frequently’, and a modal score of 3 (occasionally). The least encouragement of handwashing occurred in the ‘colleagues before meals’ condition (x=2.42, sd=1.28); this corresponded to a descriptor score between ‘rarely and occasionally’ and a modal score of 2 (rarely).

When asked about obstacles preventing handwashing, it was evident that lack of washing facilities was not an issue (x=4.53, sd=0.88). The sorts of obstacles mentioned by staff in order of frequency were: lack of time; low staffing levels; patient resistance to washing; communication problems with patient; issues relating to height, size of washbasins, patient mobility and dexterity problems; and forgetfulness by staff. One member of staff stated there was no need to wash patients’ hands as they did not come into contact with urine/faeces due to help from staff.

Wider survey

To determine whether the findings of the above survey were merely a reflection of local practices, 20 members of a UK-wide dementia research network were contacted and asked to comment on the results. The response rate was 80%. Participants were mainly nurses (69%) and care home managers (19%). The replies came from all over the UK, including areas such as Guernsey, Cornwall, Devon, and the Highlands. Participants were provided with a copy of the questionnaire and the findings, and asked to indicate whether a similar survey conducted in their clinical setting would yield similar results in relation to handwashing after going to the toilet or before meals. They were asked to use a five-point Likert scale to indicate whether their setting would score either better or worse (1=much worse, 2=worse, 3=same, 4=better, 5=much better).

The findings of this secondary survey produced a mean of 3.07 (sd=0.59) in relation to after going to the toilet, and 2.93 (sd=0.80) in relation to meal times. This indicates that our findings could be generalised across care settings in the UK.


This survey indicates that staff, as a group, do not frequently encourage patients/residents to wash hands before or after activities for which they might be expected to. We feel that some of the most telling findings in the data-set were the percentages for the ‘never to occasional’ categories (see Table 1). Such relatively high values indicate that on many occasions vulnerable people are simply not encouraged to be hygienic. The additional survey conducted among a network of workers in dementia care suggested that our findings could be generalised across other parts of the UK.

Table 1. Means, mode and standard deviations for Likert quantitative data

Questions regarding hand washing Mean (SD)
(1 never –5 always)
Mode % scoring 1-3 (never to occasionally)
Do YOU encourage patients to wash hands after using the toilet? 3.73 (1.06) 3 46.5
Do YOU encourage patients to wash their hands before meals? 2.61 (1.35) 2 73.7
Do COLLEAGUES encourage patients after using toilet? 3.27 (1.23) 4 54.1
Do COLLEAGUES encourage patients before meals? 2.42 (1.28) 2 78.8
Degree to which facilities are available in care setting? 4.53 (0.88) 5 14.2

These results are of particular concern because older people, especially older men, are the most vulnerable to death resulting from HCAIs. One way of attempting to rectify the situation is to deal with obstacles noted by staff in the survey. The greatest obstacle, according to workers, was lack of time and low staffing levels. For example, they highlighted the following issues: ‘You don’t remember to wash residents’ hands during meal times and there is not enough time or staff to ensure this is done’ and ‘Time factor. Staffing levels’.

Staff also mentioned that sometimes handwashing could not be carried out due to patient resistance. For example, participants wrote: ‘Violent and aggressive patients’ and ‘Confusion, dysphasia, patients can refuse.’

Participants suggested solutions to some of the issues raised above in their qualitative responses. For example, in the case of aggressive patients: ‘Encourage them to wash their hands when they are more approachable.’ Some participants suggested the use of some form of wipes: ‘Maybe use wet cloth with cleaning stuff on to wipe their hands.’ Environmental changes were also suggested, particularly in the case of wheelchair users: ‘Lower basins, an increase in their size. Basin can be too small and the temperature fluctuates.’

We believe that the present survey has raised an important issue, but it is relevant to acknowledge that the study only assessed practices within one locality. Despite the figures obtained from the secondary survey in other parts of the UK, it still may not be possible to draw general conclusions from these results. Furthermore, it is important to acknowledge that up to this point, national hand hygiene campaigns have focused on acute hospital settings. However, this will soon change, as in July 2008 more attention was due to be paid to mental health care settings. Hence, it would be of interest to revisit this issue following the reinvigorated campaigns targeting psychiatric settings.


Poor patient hand hygiene has obvious relevance to the NHS’s HCAI strategy. Indeed, it has the potential to undermine the much-vaunted ‘deep cleaning’ and ‘decluttering’ campaigns, as well as other features in the UK government’s £50m package to deal with infection control. This survey suggests that staff should be made more aware of the need for good patient hygiene. In addition, they should receive particular training in how to deal with those patients reluctant to wash their hands. The above situation is of concern, yet it may well improve over the forthcoming months due to the recent launch of the ‘Scrub-up’ campaign (NHS North East, 2008) in the north east of England.

Therefore, it would be worthwhile revisiting the issue in 12 months’ time – particularly in light of some of the worrying comments made by participants: ‘Many times as in the past and occasionally now, I see residents putting their hands in some pretty inappropriate places – hands they then use to pick their food up.’

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