Non-Compliance to Hand Hygiene among Medical Practitioners - Essay Example

Task 2

Evidence Based Practice and Applied Nursing Research

Min Jung Song

Western Governors University

Non-compliance to Hand Hygiene among Medical Practitioners

The compliance to hand hygiene remains historically low averaging to about 40% across the globe. This non-compliance to hand hygiene pose a major challenge to all the healthcare stakeholders who include, the medical practitioner, the specific medical facilities and organizations, for example, hospitals and the world care organization respectively and even the communities, which include the patients. Different factors have resulted in these low levels of compliance to hand hygiene. These factors include the existing work cultures that differ from one healthcare organization to another, the diverse environments, the processes and task requirements and even low levels of awareness among the public.

Significance of the Problem

Healthcare-associated infections preventable through hand hygiene account for a lot of deaths across the world each year. Epidemiologic evidence from studies conducted over the past years supports that hand hygiene tends to reduce the transmission of many healthcare associated pathogens. With these organizations, such as world health organization and the center for disease control have devised strategies provide specific regulations to ensuring proper hand hygiene. Impacts of hand hygiene are not only limited to the different incidences of infections but also increased health care hospital costs. For example, a study conducted in 2007 showed that the costs used for treating associated healthcare infections preventable through hand hygiene ranged from 28 to 33 billion dollars. With the increased hand hygiene challenges over the years, including non-compliance, the costs for treating hand hygiene are still high.

Defined hand hygiene is the process of removing microorganism through the use of specific disinfecting agents such as soaps, alcohol, and water. Hand hygiene should be implemented at all levels to ensure a disease free society.

Current Practices Related to Hand Hygiene Non-compliance

Being the most simplest and the most effective measure for the prevention of nosocomial infections and other related infections, different practices have been adopted to help deal with non-compliance. These strategies primarily focus on ensuring that medical practitioners including the physicians and nurses comply with the existing rules on hand hygiene. As Salmon and McLaws indicate in their study, it is accepted by relevant governing bodies that all medical practitioners have a duty to care which includes hand hygiene.

Current practices focused on ensuring there is compliance towards hand hygiene differ with the different organizational levels. The relevant governance stakeholders, for example, the WHO and the CDC have been in the race to provide specific hand hygiene compliance recommendations and interventions. These interventions and recommendations have in turn influenced the other practices at other levels of ensuring the level of compliance to hand hygiene increase. The World health organization has recommended five key movements for healthcare practitioners. These key movements require proper hand hygiene before any patient contact, before conducting any aseptic task, after any bodily fluid exposure and after the contact with their patients and their surroundings.

The CDC, on the other hand, published a guideline, which revolves around the interactive training of medical practitioners and also provides suggestions of some applicable motivational and educational programs. The concepts as guided by these regulations indicate the rationale for the importance of hand hygiene, some of the existing hand hygiene techniques, the methods of maintaining skin health and the indicators to glove use. In the United States, the Institute for Healthcare Improvement, in collaborations with the Society for Healthcare Epidemiology of America, the Association for Professionals in Infection Control and Epidemiology and the CDC have also developed other guidelines to improving hand hygiene compliance. The guidelines in this include a multi-faceted approach, which aims at improving knowledge on hand hygiene, ensuring availability of gloves, and alcohol rub at the point of care, having workers demonstrate their knowledge on hand hygiene and ensuring verification, monitoring of compliance and identification of gaps in hand hygiene. The CDC, WHO and other relevant stakeholders’ regulations basically encourage the compliance of all medical practitioners to the five movement and the other existing hand hygiene rules within the facility.

At the facility level, the medical practitioners adhere to these guidelines as provided by the governing bodies. Under this, the medical practitioners employ both single and multi-level interventions from the guidelines provided. These interventions include the involvement of patients in hand hygiene education, provision of feedback initiatives, change of the existing cultural practices that may hinder proper hand hygiene and even organizational change.

Impacts of Hand Hygiene Non-compliance

The non-compliance to hand hygiene among medical practitioners has adverse impacts on both the organization and the patient. The principle role of a medical practitioner is ensuring he or she provides proper care to their patients; the prevention of infection is among this major roles. Non-compliance with the regulations increases the risk of infection to both the patient and the medical practitioner. Poor compliance also impacts on the values within the organizations, which all revolve around the medical practitioner's duty of providing care to their patients.

PICO question

The PICO question for this study is: What are the causes of non-compliance to hand hygiene among medical practitioners, the impacts of education, motivation and system change, the better understanding of regulations and availability of resources in reducing the infections related to poor hand hygiene?

Search Strategies

The search strategy for this paper was guided by the key words as guided by the problem statement (the non-compliance to hand hygiene among healthcare professionals). The keywords for the search include:

• Hand hygiene
• Hand hygiene compliance
• Hand hygiene non-compliance

The keywords for the search resulted in seven scholarly articles which were later used in this study to analyze non-compliance of hand hygiene, the impacts it has on healthcare and the intervention measures for the problem. Five of the articles used were research evidence articles while two of the rest were non-research evidence (provided the basic information on the non-compliance to hand hygiene). In the five research articles, three were qualitative based while two were quantitative in nature. The articles, as identified in the evidence matrix were based on the quality (ABC) of the research, the information provided and their importance in this study. Among this, three were of quality class A that also belong in level I, one was of quality class B, which belong to level II, while the last was of class C that belong to level III. Two non-research articles were also used for the study. These articles provide the basic information on hand hygiene ranging from the definitions to policies and even the importance of hand hygiene.

The two primary research based articles used for this study were, “Qualitative findings from focus group discussions on hand hygiene compliance among health care workers in Vietnam” by Salmon and McLaws and “Improving Hand Hygiene at Eight Hospitals in the United States by Targeting Specific Causes of Noncompliance” by Chasing, Mayer and Nether. The researchers from these articles used qualitative and quantitative research methodologies respectively to arrive at their conclusions. The results from salmon and McLaws study show that the compliance to hand hygiene is greatly influenced by the working environment, the lack of enough resources and the existence of complicated hand hygiene guidelines. This article suits this study as it provides some of the challenges faced in less developed countries in relation to hand hygiene. The research by Chassin, Mayer, and Nether on the other hand through the use of quantitative research methodology show the average levels of compliance to hand hygiene in hospitals. The authors in the article also identify some of the reasons for non-compliance to hand hygiene and also some of the most important interventions for this challenges. The study methodology employed in the study was effective from the fact that it allowed the involved facilities customize specific improvements relating to hand hygiene.

The primary non-research based articles, on the other hand, include, “Interventions to Improve Hand Hygiene Compliance: Brief Update Review” by Pfoh, Sidney, and Engineer and “Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene” by Ellingson, Haas, and Aiello. These two articles provide the information on what is hand hygiene, the poor compliance to hand hygiene and the possible interventions to hand hygiene. Pfoh provides the interventions aimed at improving the compliance to hand hygiene including the lessons learned in hand hygiene. This article also comprises information on the specific stakeholders and their roles in the provision of regulations aimed at improving compliance to hand hygiene among medical practitioner. The article by Ellingson et al. on the other hand provides information on the guidelines for improving the adherence to hand hygiene in hospital settings. In these, the author mentions the impacts of improved hand hygiene and some strategies for improvement.

Recommended Practice Change

The practice change for the problem of non-compliance evident in both the research and the non-research articles as identified in the PICO question table is proper education, motivation, and system change. The specifics of this intervention may seem independent from one another; however, the latter implies just education as motivation while the former two (education and motivation) necessitate primarily as a system change. This practice change as an intervention is both a single and a multi-level intervention that engages all the relevant stakeholders in the provision of healthcare. As evident in the research articles, the primary factors that contribute to non-compliance to hand hygiene are the lack of proper training, ineffective education, the lack of resources and at times the condition of emergency situations (in cases where non-compliance happens in emergency situations).

Education, motivation, and system change plays a crucial role in improving the compliance levels of medical practitioners. Evident in the study conducted by salmon and McLaws, and that conducted by Chassin, Mayer, and Nether, some of the hand hygiene guidelines are viewed to be complicated by many medical practitioners and even the communities as a stakeholder in hand hygiene. An important element in this is the fact that with this intervention the involved stakeholders properly understand the underlying meanings of the guidelines for hand hygiene.

Improvement in infection control practices for hand hygiene requires stakeholders, specifically the medical practitioners and the public to question their basic beliefs, to continuously assess the stages of behavioral changes, to support the individual and group creativity and also question the interventions with appropriate strategies to change. The framework for change, in this case, should include specific parameters for the promotion of hand hygiene together with all the levels for applying these changes, which are: education level, motivational level, and the system.

The intervention of education, motivation, and system change is aimed at ensuring there is an improvement in the compliance to hand hygiene through enhancing the interaction of practice and behavioral change. The interdependence of factors such as environmental constraints and the facilities climate in these are considered in the development of hand hygiene through the change of specific behavior or attitude. A complex dynamic change in specific behaviors, in this case, revolves through a combination of research, education, and training (motivation, education, and system change).

When implemented appropriately the intervention influences the hand hygiene behavior in relation to the practitioner's intentions, attitudes towards a specific behavior, the perceived behavioral control, the perceived social norm, the habits of hand hygiene practices and the perceived risks of infection, perceived knowledge and motivation and the perceived model roles. As evident in the research-based articles the most important factors in need of immediate change, include the dissatisfaction with the existing situations within the facilities, the perception of alternations at both individuals and institutional level and the level of ability and the potential to change.

The reasons reported in the studies that contribute to poor compliance and non-compliance are closely related to the facility or the institution, which in this case is the system. Some of these reasons include the lack of facility priority for hand hygiene, the lack of an institutional environment that encourages safety and the need for administrative sanctions for non-compliance. Whereas, the reasons require a system change, the reason for lack of an institutional environment that focuses and encourages safety would require visible safety programs, tolerant, and supportive attitudes towards the reported problems within the facility, the belief in the efficacy of the preventive strategies and acceptable levels of work stress. This calls for the need for proper education, motivation, and even training.

As a practice change, institutions should also ensure there exist proper resources that promote hand hygiene. As identified in the study by salmon and McLaws, a major challenge towards the compliance to hand hygiene revolves around the work environment and the existing resources. In these, the authors indicate that all groups used for the study emphasized on the lack of appropriate resources for ensuring there exists proper practices of hand hygiene. For example, the group identified the lack of sinks and solutions for hand hygiene. The second article by McLaws and other authors, (Farahangiz, Palenik, and Askarian) also identified the influences of the lack of proper resources in the compliance to hand hygiene in different hospital settings.

As evident in both the research and the non-research articles, a major practice change to improve the compliance to hand hygiene regulations is education motivation and a system change. This practice change would positively influence the level of compliance and the attitudes the medical practitioners have on the importance of hand hygiene.

Process for Implementing the Recommendation

The most relevant stakeholders for the process of implementation discussed in this section includes the federal government together with other relevant organization such as the CDC, and the WHO, the institutions including the management and the staff members (physicians and nurses), and the public (patients). In order to improve the compliance levels, these stakeholders should work together to reduce infections caused by poor hand hygiene. The federal government through its specific departments such as the ministry and specific organizations is responsible for all the existing rules and regulations, ensuring compliance, as well as providing funds to the facilities. Among the major complaints includes the lack of resources and complexity of the existing regulations. The federal government in this plays a major role in the provision of resources through funding the facilities as well as the organizations within the health sector, which in turn have a role in the creation of awareness, training, and even checking the levels of compliance within the specific facilities..

The institutions should understand the relevance of practices that promote hand hygiene. In this, they should ensure that their staff is well educated and well trained on the practices that ensure proper hand hygiene, for example, adopting the key movements by the WHO. The patients are at the center of health care as they are the receivers of care. Patients should be alert on the way they are treated by physicians and how their nurses attend to them. The patients can also receive information on hand hygiene through education or other techniques of awareness creation.

Within the application of practice changes, there are specific barriers that may arise. These barriers include the lack of resources such as limited resources and ignorance. Both barriers are common in all the research articles and tend to present a major challenge in the implementation of regulations towards ensuring proper hand hygiene. Limited resources, in this case, includes insufficient funding and even the lack of proper equipment in the medical facilities. Ignorance, on the other hand, includes the specific reasons provided by medical practitioners as to why they do follow specific regulations towards hand hygiene.

Resolving these challenges should start with the collaboration of all the relevant stakeholders. For example, the barrier on lack of resources should be a responsibility of the federal government. Ignorance can be solved through motivation; medical practitioners should also understand that they have a duty to care for their patients and that hand hygiene is one of the methodologies of delivering care to their patients.

An effective indicator identifying the outcomes related to the recommendation would be a reduced number of infections related to hand hygiene. Implemented properly, the recommendation would reduce complaints from both the medical practitioners as well as their patients. The recommendation would ensure that the needed resources to ensure hand compliance are available, the medical practitioners understand the existing regulations, the consequences of non-compliance, and also ensure that the patients understand the level of care they are supposed to receive from their physicians and care providers. This would, in turn, reduce the number of infections resulting from poor hand hygiene.