What is the purpose of hygienic hand washing?
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Effectiveness of Hygienic Hand Washing Training on Hand Washing Practices and Knowledge: A Nonrandomized Quasi-Experimental Design Mete Kagan Karaoglu, BSc, RN, MSc; and Semiha Akin, BSc, RN, MSc, PhD
Hygiene is considered as an integral part of hospital infection control. Hygiene refers to hand washing using antiseptic hand wash, antiseptic hand rub, or surgical hand antiseptics to reduce the spread of micro- organisms and infection. Hygiene includes the practices and precautions to prevent the spread of infectious diseases and microorganisms from one environment to another (World Health Organization [WHO], 2009). Although the hospital-acquired infection rate for inpatients is 5% to
10%, that rate exceeds 20% to 25% in intensive care units (Yurttaş, Kaya, & Engin, 2017). Compliance with hygiene practices and infection control precautions such as hand hy- giene reduces the incidence of hospital-acquired infections and financial burdens and prevents long-term disability (Koşucu, Göktaş, & Yıldız, 2015; WHO, 2009).
Guidelines published by the Centers for Disease Con- trol and Prevention (CDC) in 2002 and the WHO in 2009 emphasized that multidisciplinary hand hygiene promotion programs and alcohol-based hand rubs have been reported to improve hand hygiene practices of health care staff (CDC, 2002; WHO, 2009). Hospital workers’ hands are one of the most important sources of infections among patients (Yurttaş, Kaya, & Engin, 2017). With simple hygienic applications such as washing the hands with soap and water or alcohol-based hand rubs, many in- fectious diseases could be prevented (Deveci, Açık, Ercan, Ferdane, & Oğuzöncül, 2010). Although the importance of washing hands for infection prevention is well known, compliance with hand hygiene practices among health care staff continues to be a frequently encountered prob- lem (Sadeghi-Moghaddam, Arjmandnia, Shokrollahi, & Aghaali, 2015; WHO, 2009).
The WHO (2009) states that the assessment of hand hygiene indications and actions should be monitored to
Nurses undertake important responsibilities in patient care and the prevention of hospital-acquired infections. However, adherence to hand hygiene practices among nurses has been reported to be low. This study aims to evaluate the effectiveness of hygienic hand washing training on hand washing practices and knowledge. The study design was a nonrandomized, quasi-experimental study, with pretest–posttest for one group. Pre- and postobservations were also conducted using an observa- tion form on any 5 workdays to evaluate the effective- ness of hygienic hand washing training on hand washing practices. The study was conducted with 63 nurses work- ing at a hospital in Istanbul. Hand Hygiene Knowledge Form scores after hygienic hand washing training were higher than the pretraining scores. The number of the nurses’ hand hygiene actions after hand hygiene train- ing increased significantly compared with that before training. The results indicate that training in proper hand washing techniques and hygienic hand washing practices positively affects the knowledge level of nurses and their hand washing behavior. J Contin Educ Nurs. 2018;49(8):360-371.
Mr. Karaoglu is Faculty, Hematology/Oncology Ward, Florence Night- ingale Hospital, and Dr. Akin is Associate Professor, Faculty of Nursing, University of Health Sciences, Istanbul, Turkey.
The authors have disclosed no potential conflicts of interest, financial or otherwise.
Address correspondence to Semiha Akin, BSc, RN, MSc, PhD, Associ- ate Professor, Faculty of Nursing, University of Health Sciences, Mekteb-i Tıbbiye-i Sahane (Haydarpasa) Kulliyesi Selimiye Mahallesi, Tibbiye Cad. No:38, 34668 Uskudar, Istanbul, Turkey; e-mail: email@example.com.
Received: August 1, 2017; Accepted: April 12, 2018 doi:10.3928/00220124-20180718-07
361The Journal of Continuing Education in Nursing · Vol 49, No 8, 2018
improve approaches for the prevention of health care- associated infections and the transmission of microorgan- isms. Direct observation is still considered the gold stan- dard for monitoring compliance with hand hygiene and is a widely used assessment technique, providing more accu- rate and reliable data (CDC, 2002; WHO, 2009). Hand hygiene actions that health care staff should follow include washing hands (a) before patient contact, (b) before asep- tic tasks, (c) after body fluid exposure risk, (d) after patient contact, and (e) after contact with patient surroundings. Observational studies reported poor adherence to hand hygiene procedures among health care staff (CDC, 2002).
The term hand hygiene refers to hand washing using soap and water, antiseptic hand wash, antiseptic hand rub, or surgical hand antiseptics. Alcohol-based hand rubs in- tended for use in hospitals (e.g., gels, foams) are available in the units. Both hand washing and alcohol-based hand rubbing are considered hand hygiene practices. Nurses are encouraged to use alcohol-based hand antiseptics and to wash their hands with soap and water when their hands are visibly dirty, before exposure to patients with infec- tious diseases, before eating, and after using the restroom.
Hand hygiene practices are influenced by personal and professional characteristics of the health care staff, type of hospital unit, workload, and perceptional, environmental, and organizational factors (Erkan, 2010; Joint Commis- sion, 2009; WHO, 2009). Education, motivation, regular direct or indirect monitoring and feedback, and behav- ioral and administrative measures may help address poor hand washing practices (WHO, 2009).
Multidisciplinary behavioral approaches and train- ing have been reported to improve hand hygiene com- pliance among nurses and other health care profession- als (Freeman et al., 2016; Rn, Jones, Martello, Biron, & Lavoie-Tremblay, 2017; Sadeghi-Moghaddam et al., 2015; Santosaningsih et al., 2017; von Lengerke et al., 2017). A randomized controlled trial showed that edu- cational interventions improved both compliance rate for proper hand hygiene practices and knowledge of effective hand hygiene practices (Santosaningsih et al., 2017). Sim- ilarly, a systematic review revealed that educational inter- ventions improved proper hand hygiene practices (Rn et al., 2017). Besides having positive effects on hand hygiene compliance rates, educational interventions on proper hand hygiene practices have also been shown to decrease (Sadeghi-Moghaddam et al., 2015). These findings sug- gest the importance of further implementing educational strategies to improve hand hygiene practices.
Nurses working in specialized units such as oncology wards, intensive care units, and transplant units must have sufficient knowledge about infection control and must adopt proper hand hygiene practices to prevent the
spread of hospital-acquired infections among patients. For hospital-acquired infections to be successfully controlled, nurses should be sensitive about hand hygiene and be sup- ported with regard to washing their hands. An assessment of hand hygiene practices among nurses and the need for improving their compliance with proper hand hygiene practices will help develop multidisciplinary (administra- tive staff, infection control nurse and physicians, pharma- cists) hand hygiene promotion strategies.
STUDY AIM This study was conducted to evaluate the extent to
which nurses’ knowledge levels and hand washing prac- tices are affected by training on proper hand washing tech- niques and hygienic hand washing practices. This was a nonrandomized quasi-experimental study, in which the pretest–posttest order for a single group was used. The study hypotheses were: l Hygienic hand washing training increases the level of
nurses’ knowledge of hand hygiene and proper hand washing techniques.
l Hygienic hand washing training positively affects nurs- es’ compliance with hand hygiene and practices regard- ing proper hand washing techniques.
METHOD Study Location
The study was conducted at a hospital’s hematology and oncology wards, chemotherapy unit, surgical inten- sive care unit, and transplant units.
Study Population and Sample The study population consisted of 88 nurses working
in the hospital’s hematology wards, oncology wards, che- motherapy unit, surgical intensive care unit, and trans- plant units. Nurses who (a) volunteered to participate in the study and (b) took primary responsibility for patient care were included in the sample (convenience sampling method). To determine the sample size, a power analysis was performed using the G*Power (v3.17) program. Ac- cording to Cohen’s effect size coefficients, and according to calculations made with the assumption that evaluations to be made between two dependent groups should have a large effect size (d = 0.44), the sample size of nurses was found to be at least 48. However, possible losses during the study were taken into consideration, and all 63 nurses were included in the study.
Ethical Considerations Ethical committee permission was obtained to conduct
the research. Institutional permission was granted by the hospital administration. Data were collected using three
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data collection tools. The permission for using Hand Washing Observation Tool was obtained from the tool’s
developer. The researchers prepared the Nurse Knowledge Form and the Hand Hygiene Knowledge Form.
The nurses were told that the study was being performed to assess their knowledge about hand hygiene. They were asked not to include any information that revealed their identity. Their verbal and written informed consent was obtained. Those who gave informed consent were includ- ed in the sample, and anonymity was preserved.
Data Collection Tools Data were collected using the data collection tools list-
ed below through questionnaires and direct observation. Nurse Knowledge Form. This form included questions
regarding the nurses’ sociodemographic characteristics and the characteristics of the units where they worked.
Hand Washing Observation Tool. Data were collected using the Hand Washing Observation Tool. This obser- vation tool was prepared by Çağlar in 2007 based on principles defined by the CDC’s 2002 guidelines for hand hygiene practices. This tool has been reviewed by experts in infection control. The Hand Washing Obser- vation Tool was tested in a pilot study in the research (Çağlar, 2007).
The Hand Washing Observation Tool assessed nurses’ hand washing practice at the start (entry into the unit) of the shift. The tool also assessed nurses’ hand washing opportuni- ties and hand hygiene compliance during the shift. Those who washed their hands in line with hand washing indications were assessed with respect to proper hand hygiene techniques, the product used for hand washing, and the amount of time spent rubbing the hands together vigorously (Çağlar, 2007).
The Hand Washing Observation Tool is based on prin- ciples defined by CDC’s 2002 guidelines for hand hygiene practices (Çağlar, 2007). The hand washing observation tool was created based on terms found in the CDC’s 2002 guidelines, such as “improper hand washing technique,” “proper hand washing technique,” and “partially prop- er” hand washing techniques. The terms of “improper,” “proper,” and “partially proper” techniques have been de- fined based on definitions in the Guideline for Hand Hy- giene in Health-Care Settings (Çağlar, 2007).
Washing hands for at least 2 minutes and following the CDC’s (2002) recommendations for hand-washing tech- niques were the criteria used to define the proper hand washing technique. Hand washing for less than 2 minutes, while following the other recommendations of the CDC’s 2002 guidelines for hand washing techniques, was the criteria used to define the partially proper hand washing technique. Those who did not follow the CDC recom- mendations for hand washing technique regardless of the time spent hand washing were categorized as those who practiced an improper hand washing technique.
Figure. Study design and data collection.
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Hand Hygiene Knowledge Form. The Hand Hygiene Knowledge Form included multiple choice questions about the nurses’ knowledge levels regarding hand hy- giene. The Nurse Knowledge Form was prepared by the researchers (the authors) of the current study. The first sec- tion consists of 15 questions for a minimum of 0 and a maximum of 15 points. The second section consists of 13 questions. Items are answered as either correct, incorrect, or I don’t know. Each correct answer is scored as 1 point and each incorrect answer or I don’t know answer is scored as 0 points, for a minimum of 0 and a maximum of 13 points.
Procedure Data were collected between March 3, 2017, and April 7,
2017. The phases of data collection are shown in the Figure. Pilot Study. For our study, the infection control nurse
of the hospital trained one of the researchers (M.K.K.) on hand-washing techniques using the Hand Washing Observation Tool. Following this training, the researcher and the infection control nurses independently conducted pilot observations. The infection control nurse and the other researcher compared the results of both observa- tions. There were no significant differences between the researcher’s observations and the infection control nurse’s observations. Before the current study, a pilot investiga- tion of five nurses was conducted to assess the utility of the Hand Washing Observation Tool. This investigation revealed that the tool is easy to use and applicable.
Observation of Hand Washing Practices Before Training (First Observation). Observation was performed using an observation form on any five workdays between the hours of 8:00 a.m. and 4:00 p.m. when patient care efforts were most active. Each nurse was watched for 4 hours without knowing they were being observed (a total of 252 hours for the first observation). There was a sufficient number of sinks in each unit that were easily accessible for nurses to use during clinical shifts. The nurses were also followed into restrooms to observe their hand washing techniques.
Evaluation of Knowledge Levels Before the Hygienic Hand Washing Training (Pretest). The knowledge levels of the nurses regarding hygienic hand washing were evaluated using the Hand Hygiene Knowledge Form.
Hygienic Hand Washing Training. The researchers gave the hygienic hand washing training. This training was done for approximately 20 minutes for 12 times in groups of five to seven nurses.
Observation of Hand Washing Practices After the Train- ing (Second Observation). After the hygienic hand washing training, for a minimum of 2 weeks and a maximum of 4 weeks, the nurses’ hand washing behavior was observed for the second time using the Hand Washing Observation Tool. Each nurse was observed for 4 hours.
Evaluation of Knowledge After Hygienic Hand Washing Training (Posttest). After the hygienic hand washing train- ing, for a minimum of 2 and a maximum of 4 weeks, the posttest was applied (Hand Hygiene Knowledge Form).
Data Evaluation and Statistical Analysis For statistical analyses, the Number Cruncher Statisti-
cal System program was used. During the evaluation of the
PERSONAL CHARACTERISTICS OF NURSES (N = 63)
Variable Min-Max (Median) Mean 6 SD
Age (years) 19 to 44 (24) 24.73 6 4.84
Length of employment as nurse (months)
1 to 312 (34) 42.59 6 50.83
Length of employment at the current hospital ward (months)
1 to 228 (18) 28.81 6 33.71
Number of patients given daily care
2 to 30 (7) 8.05 6 5.50
Variable n %
Female 56 88.9
Male 7 11.1
Vocational nursing school graduates
Associate’s degree 5 7.9
Bachelor’s degree 41 65.1
Master’s degree 5 7.9
Single 56 88.9
Married 7 11.1
Hospital unit or ward
Oncology wards 7 11.1
Hematology ward 10 15.9
Intensive care unit 7 11.1
Hematopoietic stem cell transplantation unit
Liver transplantation unit 9 14.3
Chemotherapy unit 7 11.1
Renal transplantation unit 8 12.7
Obtaining education about infection control
No 14 22.2
Yes 49 77.8
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study data, in addition to using descriptive statistical meth- ods (mean values, standard deviation, medians, frequencies, percentages, minimums, and maximums), the compliance of quantitative data to a normal distribution was tested us- ing the Shapiro–Wilk test and graphical examinations. The Mann–Whitney U test was used to compare quantitative data that did not exhibit normal distribution between two groups.
The Kruskal–Wallis test was used to compare quantita- tive data that did not show normal distribution between more than two groups, and if there were differences, the Dunn–Bonferroni test was used for the two-way evalua- tion. The Wilcoxon signed-rank test was used to compare quantitative data that did not exhibit normal distribution within groups. The marginal homogeneity test was used to compare qualitative data within groups. The Spear- man correlation analysis was used to evaluate relationships between quantitative variables. Statistical significance (p) was .05.
RESULTS Nurses’ Personal Characteristics
During the data collection period, 63 of 88 nurses met the inclusion criteria. Twenty-five nurses were not included because they were either too busy to complete the knowl- edge form, could not be reached, or were not accessible (e.g., on sick or annual leave). Among the participants, 65.1% had a bachelor’s degree in nursing, and the mean age was 24.73 6 4.84. Nearly one-quarter of the nurses (23.8%) worked at the hematopoietic stem cell transplanta- tion unit (Table 1).
Nurses’ Knowledge Regarding Hand Hygiene The Hand Hygiene Knowledge Form’s correct answer
rates increased significantly after the hand washing train- ing. Across all the nurses, the changes observed in the Hand Hygiene Knowledge Form total scores after the training compared with before were statistically signifi- cant (p , .001) (Table 2). The knowledge scores after the training were found to be significantly higher than those before hand washing training (Table 3).
The current study did not find any statistically signifi- cant relationship between the Hand Hygiene Knowledge Form total scores at the pretraining and posttraining pe- riod and length of time working as a nurse (p . .05). No statistically significant relationship was found between the Hand Hygiene Knowledge Form total scores obtained at the pretraining and posttraining period with regard to the nurses’ length of employment on the current hospital ward (p . .05).
A statistically significant increase in posttraining scores was detected between the Hand Hygiene Knowledge Form scores with regard to variables such as marital status, gender, clinical unit where the nurses worked, and status of receiving infection control training (p , .05) (Table 4).
Nurses’ Hand Washing Rates Before and After Training
The rate of observed hand washing episodes increased after hand washing training; however, hand hygiene compliance rates were still low both before and after hand washing training (Table 2). Pretraining hand hy- giene rates were between 0% and 2.3%. Hand hygiene
COMPARISON OF HAND HYGIENE KNOWLEDGE FORM TOTAL SCORES BEFORE AND AFTER HYGIENIC HAND WASHING TRAINING (N = 63)
Hand Hygiene Knowledge Form Total Scores
Knowledge Median (Q1, Q3) Mean 6 SD pa
Before hygienic hand washing training 15 (12, 18) 14.70 6 4.14 , .001**
After hygienic hand washing training 27 (25, 28) 25.79 6 2.64
Difference (after training versus before training) 11 (8, 14) 11.10 6 5.02
Hand Washing Rates Using Proper Technique
Hand Washing Rates Median (Q1, Q3) Mean 6 SD pa
Before hygienic hand washing training 0 (0, 0) 1.08 6 3.46 , .001**
After hygienic hand washing training 10 (0, 20) 13.33 6 11.94
Difference (after training versus before training) 10 (0, 20) 12.25 6 12.59
Note. Q1 = quartile 1; Q3 = quartile 3. a Wilcoxon signed-rank test. **p , .01.
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CORRECT ANSWERS TO THE HAND HYGIENE KNOWLEDGE FORM BEFORE AND AFTER HYGIENIC HAND WASHING TRAINING (N = 63)
Hygienic Hand Washing Training
First Part of the Questionnaire Before, n (%) After, n (%)
1. What is the purpose of hygienic hand washing? 42 (66.7) 54 (85.7)
2. Why is it important to apply hand hygiene in the best manner? 40 (63.5) 58 (92.1)
3. Your hand has been contaminated with blood or bodily fluids. In this case, what is the best method to remove pathogen bacteria from your hands?
26 (41.3) 62 (98.4)
4. In which of the cases below, the hands do not need to be washed? 2 (3.2) 59 (93.7)
5. Read the situations listed below. In which of those is a hand wash not completely necessary? 30 (47.6) 58 (92.1)
6. Which of the below is the most effective hand washing method? 13 (20.6) 59 (93.7)
7. How long should a hygienic hand wash take? 32 (50.8) 62 (98.4)
8. In the hand washing process using an antiseptic solution, how many seconds should the hands be rubbed?
18 (28.6) 61 (96.8)
9. Which is the most appropriate way to dry hands? 36 (57.1) 60 (95.2)
10. Which of the items below is more resistant to antiseptic solutions? 25 (39.7) 59 (93.7)
11. How long should the natural nails be of health workers responsible for the care of high-risk patients?
26 (41.3) 61 (96.8)
12. Which one is not a factor that may disrupt hand hygiene? 44 (69.8) 61 (96.8)
13. When there are suspected spore bacteria, which is the most effective hand washing method? 21 (33.3) 59 (93.7)
14. Where are the locations often overlooked during washing hands? 4 (6.3) 59 (93.7)
15. What should be the temperature of water suggested for effective and appropriate hand washing?
50 (79.4) 61 (96.8)
Hygienic Hand Washing Training
Second Part of the Questionnaire Before, n (%) After, n (%)
1. Hands should be washed before contact with patients. 56 (88.9) 60 (95.2)
2. After the gloves are removed, the hands do not need to be decontaminated. 41 (65.1) 53 (84.1)
3. Hands should be washed before aseptic processes. 57 (90.5) 62 (98.4)
4. Hands should be washed after contamination with bodily fluids. 58 (92.1) 62 (98.4)
5. Hands should be washed after contact with patients (measuring pulse or blood pressure, lifting the patient up, etc.).
55 (87.3) 61 (96.8)
6. Hands should be washed after contact with the patient environment. 52 (82.5) 61 (96.8)
7. During patient care, while going from clean body parts to contaminated body parts, hands should be decontaminated.
20 (31.7) 45 (71.4)
8. Immediately after contact with inanimate matter (including medical tools), hands should be decontaminated.
38 (60.3) 56 (88.9)
9. If the hands are not visibly contaminated, it is suggested that the hands should be rubbed with an alcohol-based solution for routine decontamination.
29 (46) 52 (82.5)
10. Alcohol-based antiseptics are not effective against most hospital-based microorganisms. 23 (36.5) 50 (79.4)
11. Wet wipes with antimicrobials can be used instead of the process of washing hands with non- antimicrobial soap and water.
33 (52.4) 59 (93.7)
12. If there is suspected or certain contact with Bacillus anthracis, hands should be washed with soap and water.
46 (73) 59 (93.7)
13. Alcohol, chlorhexidine, iodophors, and other antiseptic agents are very effective against spores. 9 (14.3) 52 (82.5)
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compliance rates posttraining varied between 0% and 42% (Table 5).
Hand washing rates were examined before and after training. After the training, compared with before, a widely varying amount of increase between 0% and 50% was seen in hand washing rates. This result showed that, despite hand hygiene training, hand washing rates were still low and there was a need for improvement (Table 5).
The distributions regarding hand washing techniques and hand washing according to hand washing indications are shown in Table 6. The increase was seen in proper hand washing rates across the nurses’ posttraining and was statistically significant (p , .001).
After the training, situations that required hand washing were fulfilled at 25.6% after glove removal, 23% after contact or care with patients, 22.9% be- fore contact or care with patients, 7.3% after contact
COMPARISON OF HAND HYGIENE KNOWLEDGE SCORES ACCORDING TO PERSONAL CHARACTERISTICS (N = 63)
Hand Hygiene Knowledge Form Total Scores
Before Hygienic Hand Washing Training, Median
After Hygienic Hand Washing Training, Median
Difference (After Training Versus Before Training),