The Importance of Hand-washing - Term Paper Example

Continuous development of healthcare practices is essential for efficient and safe patient’s care in all settings. There is a wide gap between research findings and the actual scenario at the hospital settings. Being new to this field, I have experienced a lot of difference between theory and practice in various clinical practices. It is extremely difficult to assume that an individual or even a team could bring about changes in practices that have been followed for years but an attempt can certainly be made. Every healthcare practitioner has a professional responsibility to prevent and control infection and this should reflect in the daily practices. One such aspect which has come to my attention is hand washing by the nursing staff. Effective hand hygiene is considered to be one of the most important factors in controlling infections. This essay will discuss the importance of handwashing, why it is essential to address this issue, and under the ward settings whether it is feasible to bring about a change. The rationale for choosing this clinical practice is because despite the guidelines and the negative outcomes of poor hygiene available, the practice of handwashing is seldom adhered to. NHS has prioritized reduction of hospital acquired infection (HAI) and one of the control procedures has been identified as handwashing (Stone, 2001). According to DoH 2004, the first of the core standards is safety which emphasizes that healthcare organizations must have systems in place and ensure that risk is minimized to all concerned. Improving hand hygiene is a critical component of clinical governance (Storr & Clayton-Kent, 2004). Hand washing has been defined as a vigorous, brief rubbing together of all surfaces of lathered hands, followed by rinsing under a stream of water (Widmer, 2000). Hand washing mechanically removes the microorganisms by rinsing with water. Hand hygiene for safe care is not a new phenomenon but the compliance by health workers and by doctors in general is very poor. The guidelines are never adhered to. According to Grol and Gribshaw (2003) doctors have poor knowledge about the outcome of poor hygiene and perhaps they would comply better if they were well informed of the results. If the health workers experience a problem in practice they may be motivated to change. These are the cognitive theories. It is important to reflect on solutions and discuss difficulties. Behavioral theories suggest that external stimuli can assist in change like incentives, modeling and external reinforcement. Social theories suggest that someone should take the initiative or lead and others would automatically follow. There is lack of leadership in management that prevents others from following the guidelines. Organizational theories suggest that it is a system failure due to inadequately organized care processes. This problem is aggravated in the medical unit where I work, which has 22 patients as the staff lacks motivation and incentive to work. They usually work with a grudge and complain about just everything. The unit comprises of a senior sister as the leader and there is one nurse and one support worker for 11 patients. Students are often taken in and used as just ‘another hand’. The ward philosophy is to be with your self – just carry on with your duty and get away. There is no time for handwashing and staff is also wary about the after effects. Besides, the basins are a little away from the ward and staff just shrug their shoulders and walk away rather than walk to the basin to wash hands. To bring about a change in this situation is a Herculean task although not impossible. HAI affect the patients as well as the NHS in various ways. One tenth of the NHS patients are affected by HIA every year. As far as the patients are concerned, it delays discharge by up to 11 days. For the NHS it represents a loss of 3.6 million bed days with a projected cost of £1 billion a year (Winn & Barraclough, 2006). If the guidelines are adhered to, 10 to 50% reduction in infection can be achieved. Obstacles to change in clinical practice are largely dependent on leadership apart from other factors and this essay would concentrate on leadership as the obstacle to change in practices. Different settings would require different types of strategies and in the case of the acute neurological setting leadership can help to achieve the desired outcome. Understanding and implementation depends upon interpretation of individual staff within the ward. Perceptorship is an important part of the development of nurses. Change is difficult but not impossible what I as a freshly registered nurse observe. Section II Healthcare workers’ adherence to recommended hand hygiene practices is very low (Pittet, 2001). NHS guidelines state that hands should be decontaminated before and after each activity including putting of hand gloves (Winn & Barraclough, 2006). If soiled they have to be washed with liquid soap and water. For decontamination handrub with 70% alcohol base should be used between caring for different patients and also between different care activities for the same patient. Hands should become free from dirt and organic material. An effective decontaminated technique involves three stages – preparing, washing and rinsing and drying. Hands should be rubbed thoroughly before drying with paper towels. Hand cream should be applied at the end of the shift to protect the hands from the regular effects of regular hand decontamination. Barriers to effective implementation of handwashing ‘What is taught in the schools is not practiced on the wards’ implies the gap that exists between policy and practice. Nursing has been observed as task-centered and the approach is not based on total care of individual patients (Maben, Latter & Clark, 2006). Speed has been associated with nursing work and a ‘good’ nurse is a quick nurse. Nurses are constantly under pressure to rush with their tasks, to keep the ward tidy and not ask questions. Speed has been associated with efficiency and there is evidence that nursing workload has intensified in the past three decades. Public expectations of healthcare, importance of adhering to guidelines, emphasis on holistic, individualized and research-based care have added to the pressure on nurses. These pressures heighten professional and bureaucratic work conflict. When the Department of Health published the handwashing guidance, the following reasons were cited as barriers to handwashing - lack of time, poor availability of sinks and soaps, skin sensitivity and lack of time (Stone). Skin irritation, inadequate supplies, insufficient number of sinks, workload, forgetfulness, wearing gloves, ignorance of the guidelines, and lack of information on the impact of lack of adherence to hand hygiene are some of the other reasons associated with low compliance of the guidelines (Pittet). Another strong reason that has been cited in the skin irritation caused due to frequent hand washing. Hand washing increases the skin pH, reduces lipid content, increase water loss from the epidermis and increases microbial shedding. Time constraints and allergies to antiseptic preparations have been identified as the main barriers to regular practice of handwashing. Various methods or interventions to increase handwashing have not resulted in any significant increase in the process. An alternative method or hand rubbing with alcohol (HRA) too did not take off well as clinicians were not convinced that an alcohol based waterless antiseptic can reduce bacterial contamination. Research evidences that HRA is more effective (83% against 58%) in reducing bacterial contamination. The time taken by both the processes is the same (approximately 30 seconds) while HRA is more effective than soap but Storr and Clayton-Kent cite that it takes 90 seconds for washing hands while hand rubbing takes 10 to 20 seconds and this time the nurse can spend communicating with the patient as she does not have to go to a basin to wash. Various complexities may arise in change process involved in implementing evidence based practice like handwashing. Most successful implementation occurs when evidence is high, say Harvey et al., (2002). The other factors that determine change are the receptive environment and strong leadership. Maben further states that very few newly qualified nurses have found role models in the senior nursing staffs that reinforce the message of patient care. Leadership theories and role model Despite all this information available, the practice of handwashing continues to be low in the ward. There is an obvious lack of interest, motivation and involvement. Neither the staff is involved nor the patients. This is where leadership becomes effective. Leadership need not necessarily be a senior sister or someone appointed by the authorities. Leadership is taken up one who possesses the attributes of a leader. A leader is one who is conscientious, extrovert and open to experience. In addition, for effective leadership, the person must possess the traits of humility and humor. Any group will look up to someone as a leader and follow her if she has emotional as well as task competence. A leader must also possess the power of collaboration and communication. Transformational leadership is required for the ward where the leader can induce the followers to act for certain goals (Stansfield, 2006), in this case handwashing. This according to Burns is a deep and powerful process where people engage with each other in such a way that leaders and followers raise each other to higher levels of motivation and morality. This kind of leadership would allow for sustained practice of handwashing having a long lasting effect. This is playing the role model for attainment of goals and requires charismatic communication style, implementing a vision, and communicating the vision. Prevention and control of healthcare associated infections require strong leadership at the highest levels (HCAI, 2005). The senior management has to foster a culture which must be supported at the organizational level. Such actions should become the performance indicators if the organization has to achieve success. It has also been suggested that for change to become effective, critical evidence of best practice must be embedded in everyday and routine activities. Unless this is imposed the necessary standards may not be achieved. The influence of role model has been found to be critical and elementary hygiene practice should be taught at medical schools (Stone). According to Doyle and Smith (2001), people who can take control of a crisis are leaders and in practice they become the role models. They have a vision what can and should be done and they can communicate this to others. Hence, to be role models transformational leadership is required. Leaders are those who can influence the action, beliefs and feelings of others. It is very essential that the ward members are influenced. Department of Health issued guidelines that say handwashing reflects attitudes, behaviors and beliefs (Stone). It is these attitudes and beliefs that a role model can help transform and induce handwashing. If nursing is to contribute to the improved care of clients nurses have to take a leadership role and must have the conviction and the necessary skills to effect the change. If the leaders are liked and respected they will receive the support of others in bringing about a change. Nursing leadership has to go beyond developing nursing practice. It has to be a process through which health policy may be influenced (Antrobus & Kitson, 1999). Nursing knowledge derived from nursing practice was essential for leadership philosophy. Leadership for any clinical practice is supposed to bridge the gap between the policy and practice. This is possible through transformational leadership where the leader raises the levels of consciousness and awareness of the significance and value of the policies and suggests ways to achieve them. Such leaders can help everyone to transcend their own self-interest for the sake of the patients and the hospital (Adam & Smith). Leaders may have formal authority but leadership is not concerned with power or authority. They command respect for their attributes and for their ability to persuade. Hence, in the ward it is possible that even without formal authority, freshly qualified nurse can take up the leadership if she satisfies all the other qualities essential to be a leader. It has been increasingly felt that “good clinical leadership is central to the delivery of the NHS plan” cite Hewison and Griffiths (2000) from Department of Health, 2000a. Leaders should be willing to embrace and drive successfully through the ever changing clinical practice environment. NHS requires leadership at all levels – national, regional and local levels. There is enough evidence to prove that development of leadership in the NHS has resulted in improved leadership capabilities of ward sisters and senior nurses, leading to better patient care. The healthcare professionals have to be equipped in a new way to survive in new environment. There is plenty of nursing leadership development activity going on which suggests that the need has been recognized. There are apprehensions about newly qualified staff nurses (NQSN) as being adequately equipped to handle management issues. A study revealed that they did display good analytical and decision-making abilities but there was a perceived practical skills deficit (Baillie, 1999). A leader as discussed above has inborn traits and to lead requires very little practical skills. Hence, even a freshly qualified nurse can take the leadership to induce handwashing. In the clinical setting, the leader would also need to apply Hersey and Blanchard’s situational approach. This approach would make the task easier for the leader as individual staff development level has to be identified before directing, coaching, supporting and delegating takes place in the chosen situation. There is no best leadership situation and successful leaders are those who can adapt to the demands of the situation (Schermerhorn, 2001). Communication in this approach is important as the leader would have to explain to each member of the staff as to why, when and how handwashing is to be done. Two-way communication is also essential because socio-emotional support, psychological strokes and facilitating behavior can be achieved. When these two forms of communication are applied, the readiness and willingness of the staff would increase for handwashing. As the readiness increases, the leader can gradually decrease the task behavior and concentrate on the relationship behavior to provide socio-emotional support. When the group reaches a moderate level of readiness, and has understood the importance of handwashing, the leader can even reduce the relationship behavior. Through this approach, gradually the entire ward would start responding and improve the clinical practice of handwashing. Section III Nursing involves creating ideas to shape the practice of nursing. There has to be a strong relation between theory and practice and it also becomes possible to determine the extent of autonomous practice. Theoretical knowledge has to be grounded in practical knowledge say Warne and McAndrew (n.d.). This requires that nurses not just understand and carry on with patient care but also be aware of the guidelines and policies concerning patient welfare. Being a freshly qualified nurse, I would be at a disadvantage of not having fully acquired the depth of understanding that can come only through experience. Leadership is the process of concentrating the efforts of groups or individuals in achieving common goals (Alarcon et al., 2002). The nursing leadership is made up of four components – deciding, relating, influencing and facilitating. Leadership is not an inborn attribute but is acquired through a learning process and there is no best model for leadership. This would depend upon the organizational environment, the personal circumstances and the change that is aimed at. As a leader personal attributes are essential like positive attitude, empathy towards the group members, interpersonal skills, and patient listening. Group dynamics is important to play the role model or to induce change. Team leaders should intentionally introduce roles and situations so that each member is allowed to express and experiences a sense of empowerment (Wood, 2005). This would require identification of the potential of each team member and should be centered in persons rather than the institution. Leaders should share their knowledge with the team and give incentives. They should also make each member recognize the fact that working together improves the working climate. This is the situational approach of Hersey and Blanchard. As a preceptor, I would serve as a role model and try to influence the others in the ward to induce handwashing. I fully understand that I am a fresher but I wish to do this with the specific purpose of improving the practice of handwashing. Access to the knowledge of the organization and clinical practice is invaluable to the newly qualified nurse say O’Malley, Cunliffe, Hunter, Breeze (2000). As a preceptor I expect to stimulate up to date practice in handwashing and thereby improve quality of patient care. This would also ease my transition from learner to practitioner. As a preceptor I am aware that I am responsible for planning and role modeling. It is essential that all take active part in the process. Leadership and communication skills, decision-making ability and interest in the change desired, for the benefit of all, is a prerequisite for a preceptor. I have the confidence and skill essential for this. I can also provide individualized learning experience. A preceptor is also required to create an environment of research-based practice and sufficient research and the outcome of handwashing has been studied. Difficulties may arise since I am a newly qualified nurse and acceptability by others in the department may not be high. I may also not find enough time along with the duties, to devote to change in the clinical practice. It will help demonstrate my ability to be flexible and impart individualized teaching as task behavior. Interpersonal and group skills are essential to bring about change in any setting. Facilitation is the process of enabling implementation of evidence into practice. This implies that an individual has to carry out a specific role with the aim to help others. This further implies that the individuals must have the necessary skills and knowledge to help individual and teams to apply evidence into practice. This ultimately boils down to situational leadership and application of socio-emotional task. Reflection always helps to enhance the learning process as reflection brings about self analysis and corrections. Changing practice culture is by no means an easy task. Individuals and teams should be encouraged to reflect and change their own attitudes, behavior and ways of working. The leader has to enable reflective learning and encourage critical thinking (Harvey et al). The various methods that can be used to promote handwashing include education, distribution of information leaflets, workshops, lectures, and then I would also ask for a performance feedback on compliance. There is sufficient evidence to support that educational interventions like training sessions, newsletters, classes and videos have short-term impact while posters, labels and signs had slightly better effect. Education has to be interactive and continuous. There should be discussion of evidence. Research evidences that no single intervention has consistently improved compliance. According to Semmelweis normal handwashing does not always reduce infection and disinfection is a better alternative (Pittet). Evidence suggests that alcohol has the most rapid bactericidal action of all antiseptics and should be the preferred agents for hygienic hand rubs. Storr and Clayto-Kent also confirm that alcohol is superior to soap and water in its ability to reduce bacterial contamination but alcohol cannot replace the need for soap and water wash. Action has to be taken at the institutional level and role model would help change the clinical practice. Behavioral theories are insufficient to effect sustained change. Interventions have to be based on various levels of behavior interaction. The institutional climate, the individual characteristics and the environment are all interdependent and have to be integrated for a strategic planning to bring about sustained change in the practice of handwashing. Noncompliance with the guidelines are not just specific to the individual but is related to the group as well as the unit. Lack of encouragement, downsizing and understaffing are all factors related to noncompliance. There is lack of administrative leadership, rewards and support. Education, motivation and system change can bring about some effect to the purpose. Change has to take place both at the individual level as well as the institutional level because the individual may change jobs within months or years. What becomes a part of the institution should subsequently be passed on to others who join. The culture once embedded would influence all to follow and the same effort need not be exerted again. Strategies require that individual nursing should be motivated to question the belief that they have been following. This requires a holistic approach or transformational leadership and there should be a continuous assessment of the stage of behavioral change. It is important that the practitioners should reflect on why, when and how to keep hands clean. Handwashing or hand hygiene should be a way of life. To bring about a sustainable change, discipline for hand hygiene should spring from within because no external or imposed discipline can have long-lasting effect. Observing others is another good practice which is where the role model becomes important. Constant reminders to the self to maintain hand hygiene should be practiced. As per Storr and Clayton-Kent’s suggestion, I would urge the staff nurses in the ward to keep mentioning hand hygiene at every stage. For instance, I will just be back after cleaning my hands …or I shall attend to this as soon as I clean my hands. Posters demonstrating which microbes can be spread on the hand, which normally live on the body of the healthy people, the infections they are capable of causing and the extent of damage that can result, will be put all over the ward. I would also recommend changing the posters regularly, highlighting different aspects related to hand hygiene so that seeing the same posters for a long time does not cause monotony. Monotony can cause staff to ignore or overlook but the interest would be sustained if the posters are changed from time to time, which is evidenced by a study cited by Storr and Clayton-Kent. Awareness should be made to the staff of the policy guidelines, the deviation and statistics of non-adherence, and the outcome. Hand hygiene is dependent on the internal motivation of the staff and the resources available to carry out the task. I would also arrange a talk on the subject once a fortnight and involve each member of the ward in turn to explain what steps have been taken to improve compliance or what else can be incorporated. The challenges that I face is that I am a freshly qualified staff and the other ward members may not be willing to comply with my requests. Persuasion is a big challenge. I would like to instill the fact that we are all members of a team or group and hence all are leaders. We are individually and collectively responsible to bring a change in the attitude and culture. The success of hand hygiene cannot be documented or quantified but teams or groups can provide a feedback that hand hygiene has improved or occurred. This could be through observation of the ward staff or the consumption of the soap and alcohol. Alcohol rubs should be placed near the patients so that nurses can utilize the rubbing time to communicate with patients and perhaps even discuss the importance of hand hygiene. Nothing can work in isolation. It has to be an integrated approach and I as a newly qualified nurse in the ward can help to bring about a change but the involvement of top management is critical for a sustained organizational change. Compliance is known to have increased in switching from hand wash to hand rub but hand wash cannot be done away with. Bringing about a change in the clinical setting is not as easy task as a survey revealed that for some individuals workplace impedes them making the changes they would like to make and they reported various difficulties in applying change into practice (Williams, 2004). Due to work overload and time constraints the nurses do not find time to reflect on their work and clinical practices. I have the confidence to develop the necessary skills required to be a leader. It is possible to bring transformational change although to demonstrate results it may take several years. I would be able to bring about a positive attitude in my colleagues and ward members. I would help them to develop the self and apply critical thinking. Change, as mentioned, is difficult but not impossible and may take several years before it is realized. 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