Evidence-Based Healthcare Practice - Essay Example

Topic:  An appraisal of a piece of research-based evidence relevant to healthcare practice: Barrett R & Randle J (2008) Hand hygiene practices: nursing students’ perceptions Journal of Clinical Nursing 17, 1851–1857. INTRODUCTION Evidence-based practice is defined as the incorporation of data and conclusions of documented research studies into clinical practice (Thomas 2002). Ongoing research studies in many diverse areas of clinical research may inform standards of practice in ways that reflect new developments in medicine and patient care. In this way, the practice of medicine and patient care is continually updated and subject to evaluation by accepted research standards. It is important to evaluate research pertinent to one’s area of clinical practice as the findings relate to specific care practices in regard to their relevance and potential to improvements in standard of care. The following appraisal evaluates a clinical research study and its potential applications to nursing practice. The main aims of this research study were to evaluate student nurses’ perceptions of hand hygiene practice compliance in order to explore ways of effectively incorporating best practice standards of hand hygiene compliance into nursing school curricula and training programmes. The impetus for this study was the documentation of increased incidence of health-care associated infections (HCAIs) and data that suggest that there are generally poor compliance rates for hand hygiene among healthcare workers (Creedon 2005). The rationale for the increased attention to hygiene compliance is that greater attention to hand hygiene practices among nurses, doctors and other healthcare workers may produce a decrease in the overall incidence of HCAIs among patients (Boyce & Pittet 2002). This is a very serious problem as noscomial infections are associated with higher mortality rates in critically ill patients, increased hospital stays and excessive antibiotic usage, all of which represent unwanted complications in patient care. A search strategy to obtain additional information on this topic could include search words such as: “hand hygiene”, “evidence-based practice hygiene”, “healthcare associated infections”, “prevention of HCAIs”, “nurses hand hygiene”. There are a number of excellent search engines that would be relevant to this type of search. These include the Cochrane Library Online, which is a website containing journal articles and research findings designed to meet the needs of nursing professionals. Another excellent website is the Centers for Disease Control website (CDC), a USA based database that contains the results of the latest research on infectious disease, and evidence-based practice research findings. Pubmed/medline is an online database that can be used in a search by topic mode to obtain the latest journal research articles on this subject. RESEARCH STUDY APPRAISAL The rationale for this research study involving nursing students’ perceptions of hand hygiene compliance was the demonstrated association between poor healthcare worker hygiene practices in patient care and the widespread occurrence of healthcare worker associated infections (HCAIs). HCAIs are defined as infections that are contracted by patients in a healthcare setting, during the course of diagnosis, treatment or recovery that are not associated with the patient’s primary medical condition (Polit & Beck 2004). The mechanism of infectious disease transmission under these circumstances may involve endogenous or exogenous spread, both of which may occur via healthcare worker contact with the patient. Moreover, the HCW’s hands are the primary vehicle of disease transmission under these circumstances (Polit & Beck 2004). For this reason, it is essential that hand hygiene practices of the highest standards be maintained at all times by healthcare personnel. The World Health Organisation (WHO) estimates that millions of cases of HCAI occur each year worldwide and that effective hand hygiene practices are the most important preventive approach to dealing with this important healthcare issue (Kampf 2004). Nevertheless, current estimates suggest that only 40% of HCWs engage in standard of practice levels of hand hygiene. Several reasons have been suggested to explain this lack of compliance by clinicians who should be aware of the significance of these healthcare practice standards in preventing or reducing the incidence of HCAIs . Among the stated reasons for the observed lack of compliance is the issue of compliance itself, which is considered to be a complex behaviour that is associated with a specific request and that may be influenced by one’s peers and surroundings (Polit & Beck 2004). The issue of compliance was the focus of this research study as it attempted to identify student nurses’ perceptions of the factors that could affect their personal compliance and the compliance of other HCWs in similar circumstances to this behavioural mandate. One reason why students were chosen to participate in this study is that this group is most amenable to intervention, as they are just beginning their clinical careers and may adopt hygienic practices that may become lifelong elements of their personal standards of hand hygiene in regard to patient care. Thus, the researchers felt it was important to identify those factors most relevant to this group to attain compliance with this important hygienic protocol. An extensive literature search by the authors of this study revealed that there was little data concerning the factors that affect hand hygiene practices and compliance among this important group of pre-registration nursing students. The majority of the research involved more general themes of infectious disease, noscomial infections and their prevention, which included evaluations of hand hygiene procedures and standards. For this reason, the authors decided to initiate a clinical research study designed to explore the viewpoints of student nurses on the issue of hand hygiene. Two stated goals of this research endeavour were to identify factors that might affect hand hygiene compliance in this group of students and to extrapolate data relevant to making recommendations for nursing courses and standard of practice protocols. The design of this research study involved a qualitative, interpretive design. This type of research study makes use of personal interviews and explores individual responses to specific questions relevant to the topic. This type of study is suitable for use in small subject design with limited participant enrolment, as it is time consuming and must be assessed qualitatively on an individual basis (Fossey et al 2002). This type of study also relies on the interpretation of responses by the principal investigators, who must be trained to evaluate issues relevant to the topic under study. The authors of this study chose this research tool as they were attempting to explore the complex behaviour of compliance, which is difficult to assess as a purely quantitative parameter. Recruitment of study participants was limited to students who were engaged in either a Masters of Nursing Science Degree or a Diploma of Nursing. All clinical specialties were considered for enrolment and the subjects ultimately selected were involved in diverse clinical disciplines. The participants were selected from a pool of applicants who responded to a request for research study interview that was announced publicly at several nursing schools in the UK. Inclusion criteria were that all study participants must be enrolled as pre-registration nursing students who must have completed at least one clinical course and signed ethical consent forms provided by the university. There were no other criteria for study participation. Only ten applicants who fulfilled these requirements were enrolled in the research study, due to lack of follow-up on the part of other potential applicants. The students’ names were kept anonymous, their statements confidential and they were fully informed of all aspects of the assessment before proceeding further with the research study. The study method involved individual interviews with each of the study participants that included a series of open-ended questions, based on appropriate themes obtained by the study authors from the literature review. The questions were pre-tested in a small, separate pilot study and slightly modified for the research study. The interviews were audio-taped to facilitate further assessment and accurate evaluation of responses. The purpose of the interpretive, qualitative open-ended design of the questionnaire was to facilitate the assessment of data to identify general themes and data categories characteristic of responses. The data were therefore extensively categorised prior to interpretation in order to elucidate general themes and construct a model for understanding and interpreting the responses of individual study participants. Moreover, the principal investigators were nurses, which may have aided them in interpreting the context of respondents’ answers. The interpretive, qualitative design of this research study is more difficult to analyse than a straightforward quantitative assessment (Fossey et al 2002). In quantitative studies, the data are analysed using statistical methods that allow relevant inferences to be made regarding the observations based on theoretical expectations (Tobin & Begley 2004). A qualitative study does not involve numerical data; moreover, this study did not even include nominal data that might be considered using non-parametric statistical tests (Randle, Clarke & Storr 2006). For example, the study questionnaire might have included questions such as: “How many times a day do you wash you hands when in clinic?” “How many patients do you see on a typical day in the clinic?” These answers would provide the potential to assess the degree of compliance in a more statistically relevant way. It certainly would be appropriate to address the degree of compliance as part of assessing students’ perceptions of factors affecting compliance. Moreover, a more structured questionnaire may have provided better data in regard to relative importance of factors that may affect compliance. For example: “Which is the most important factor that affects how frequently you follow hand-washing protocol in the clinic: a. hand-washing behaviour of other HCWs with whom I am working; b. number of patients in my care; c. condition of my hands: soreness, etc.” This attempt to prioritise among a number of possible reasons could provide the basis for a more relevant and accurate assessment of respondents’ viewpoints. The strength of the open-ended questionnaire is that it allows for the respondents’ answers to direct the establishment of categories and conditions relevant to the study. The study authors made clear that they used the data they obtained in this manner. However, they did not publish the questions, nor did they indicate the number or percentage of individuals who responded similarly to a specific question. These represent important omissions by the study authors as it forces the reader to rely on brief excerpts of study responses and the judgment of the principal investigators in interpreting the data in order to make any conclusions regarding its significance. Moreover, a major weakness of the study questionnaire is that there was no intrinsic hierarchy of responses and no attempt to provide a quantitative assessment of the issue under study (Horsburgh 2003). Most importantly, the number of study participants in this research study was so small that the relevance of the findings must be considered, at best, preliminary and requiring further assessment in a larger group of participants. DISCUSSION AND APPLICATIONS OF RESEARCH STUDY The results of this study indicated that there are several important factors identified by the nursing students that affect compliance with hand-washing hygiene protocols. One factor involves the type of clinical procedure. Some procedures (such as wound dressing) were considered to require careful attention to hand hygiene, whereas other routine procedures were considered less important in regard to hand hygiene. Another factor involves the use of gloves in regard to a lack of knowledge of appropriate hand hygiene protocol. Some students were not informed as to the duration of hand washing necessary for appropriate hygiene. Also, some students used gloves as a substitute for hand washing or did not wash hands when changing gloves between patients (Girou et al 2004). Another important issue relates to the lack of time due very busy schedules. Some students acknowledged that they did not wash hand between patients due to lack of time. Students associated increased scheduling demands with a lesser focus on hand hygiene regimens. The students also noted that continual hand washing can cause rashes and other painful skin conditions, which caused a general reluctance to wash hands unless essential (Flynn et al 2005). However, the most commonly cited factor identified by the student nurses was the desire to conform to the behaviour of senior staff in regard to hygiene practices involving patient care. The students explained that they felt compelled to adopt the hand hygiene practices of upper level staff with whom they worked in order to be accepted as part of the group. Thus the hand-hygiene practices of healthcare workers and instructors appeared to be among the most important factors in determining the standards of hygiene adopted by student nurses during their training. This research study identified a number of practical reasons why students may not comply with standard practice hand-hygiene in their daily patient care routines. Lack of time associated with very busy schedules falls into this category. Problems with skin lesions associated with hand washing protocols also comprised a very practical reason why hand-washing regimens may not be followed appropriately. The study also identified more pervasive reasons for a failure to adhere to hand hygiene protocols in patient care. Among these was the observation that many experienced nurses and HCWs do not adhere to correct hand-washing practices. This observation appeared to undermine the importance of this hygienic protocol in beginning student nurses. This attitude was also reflected in the selective adherence to hand washing hygiene only under circumstances that the students felt necessary rather than as a standard procedure to followed at all times. The main findings of this research study support previous findings that suggested that the most important factor in determining hand hygiene practices among student nurses was the behaviour of their instructors and role models. The desire to conform to these practice standards was seen as a critical factor in shaping beginning nurses’ views of hygiene practices as applied to patient care. The authors referred to an important aspect of the learning process that involves “professional socialisation”, which refers to the social aspects of learning in the context of a professional working environment (Ring et al 2005). The authors identify the teachers and supervisors of nurses-in-training as powerful role models who have the capacity to instill appropriate attitudes and practices related to hygienic healthcare practices (Kampf 2004). The study authors cite several useful areas that could be easily incorporated into clinical practice. The most important of these is the designation of an infection-control nurse (ICN) who is in charge of ensuring that hygienic practices are carried out according to protocol by all staff and trainees (Dawson 2003). The role of this coordinator could also include monitoring of patient cases of HCIA in order to focus attention on this important from within the context of the clinical setting (Storr, Topley & Privett 2005). It is important that hand care hygienic standards of practice be taught not only in the classroom but actively incorporated into daily routines in the clinic from the earliest stages of clinical nursing training (Hughes 2002). The results of this small study suggest that this may represent an important approach to the issue of compliance to these critical hygienic practices in the clinical setting. This approach falls under the description of practice development, in which educational practices are directly incorporated into the clinical setting, largely by way of example and ongoing instructional reinforcement (Garbett & McCormack 2002). CONCLUSION In summary, this research study involved a very small, descriptive questionnaire that attempted to define some of broad categories of attitudes and perceptions among pre-registration nursing students that may affect compliance with hand care hygiene protocols in clinical settings. The study size was too small, and the data obtained too descriptive to allow a generalised conclusion regarding the origins of the compliance issue. However, the responses obtained were consistent with other larger scale studies that addressed this area with other groups of respondents. Moreover, the study involved a very important group of individuals who have been the focus of little research attention in this area: student nurses. In this regard, the study has opened the door as a preliminary assessment that could be followed up in many important ways to develop more consistent adherence to hand hygienic practices in primary healthcare workers. REFERENCES Barrett R & Randle J (2008) Hand hygiene practices: nursing students’ perceptions Journal of Clinical Nursing 17, 1851–1857. Boyce J & Pittet D (2002) Guideline for hand hygiene in health care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA hand hygiene task force. American Journal of Infection Control 30, 1–46. Creedon SI (2005) Healthcare workers’ hand decontamination practices: compliance with recommended guidelines. Journal of Advanced Nursing 51, 208–216. Dawson SJ (2003) The role of the infection control link nurse. Journal of Hospital Infection 54, 251–257. 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