The Journal of Continuing Education in Nursing

Original Article 

Use of World Health Organization Guidelines to Improve Hand Washing Efficacy

Kristin E. Fries, MSN, RN; Anna M. Figueroa, MSN, RN; Heather Pickerign, MSN, RN; Karen Breda, PhD, RN; Susan Eichar, EdD, APRN

Abstract

Background:

Hand washing continues to be the number one most effective way to prevent the spread of germs. This quality improvement project examines whether a hands-on soap and water hand washing tutorial increases the quality of hand washing technique.

Method:

The Glow Team developed and presented an evidence-based hands-on teaching tutorial demonstrating proper hand washing technique as recommended by the World Health Organization to 100 emergency department health care workers. The efficacy of the technique was evaluated by applying black light–sensitive lotion. Participants washed their hands before and after the education session. Participants completed a posttest to evaluate their gained knowledge of hand washing.

Results:

Hand washing efficacy improved from 60% preeducation to 82% posteducation. Each individual step noted improvement posteducation.

Conclusion:

Of 100 participants, 98 reported this education was helpful and suggested yearly competencies, posted fliers, and repeated demonstrations to improve compliance among self and peers. [J Contin Educ Nurs. 2020;51(10):453–456.]

Abstract

Background:

Hand washing continues to be the number one most effective way to prevent the spread of germs. This quality improvement project examines whether a hands-on soap and water hand washing tutorial increases the quality of hand washing technique.

Method:

The Glow Team developed and presented an evidence-based hands-on teaching tutorial demonstrating proper hand washing technique as recommended by the World Health Organization to 100 emergency department health care workers. The efficacy of the technique was evaluated by applying black light–sensitive lotion. Participants washed their hands before and after the education session. Participants completed a posttest to evaluate their gained knowledge of hand washing.

Results:

Hand washing efficacy improved from 60% preeducation to 82% posteducation. Each individual step noted improvement posteducation.

Conclusion:

Of 100 participants, 98 reported this education was helpful and suggested yearly competencies, posted fliers, and repeated demonstrations to improve compliance among self and peers. [J Contin Educ Nurs. 2020;51(10):453–456.]

Ongoing noncompliance with hand washing guidelines as specified by the World Health Organization (WHO) continues to lead to the unnecessary and preventable spread of pathogens. Proper hand hygiene can prevent the transmission of germs carried on the hands (WHO, 2009). Since the time of Florence Nightingale, nurses have been at the forefront of promoting hand hygiene as the most effective action to prevent the spread of disease. Despite overwhelming evidence, public awareness, hand washing initiatives, audits, and campaigns consistent with hand washing, compliance continues to be a challenge in the health care setting. Hand hygiene can be in the form of soap and water hand washing or alcohol-based gels or foams. This project will specifically address the use of soap and water hand washing technique following WHO guidelines in accordance with the participating facility's policies and specifically the following questions: With the increased use of alcohol-based gels and foams for hand hygiene, have health care workers maintained the quality and timeliness of soap and water hand washing technique? How can infection control measures engage staff in improving the quality of soap and water hand washing?

Glow Team Goal

The goal of this evidence-based quality improvement project was to educate hospital staff on proper soap and water hand washing techniques as recommended by the WHO. The project's driving question is as follows: Would health care workers present in the emergency department benefit from a hands-on tutorial regarding proper hand washing techniques with the aid of a black light germ detector pre- and posttutorial to improve hand hygiene compliance per facility policy within a 30-day trial? The project focused on the Glow Team assessing participants for:

  • Thoroughness of hand washing technique before and after education
  • Gained knowledge of when hand washing is required
  • Gained knowledge of circumstances when soap and water hand washing are required
  • Recommendations by staff for ongoing education and compliance evaluation

The Evidence

The statistics on noncompliance with hand hygiene in health care is overwhelming (Duarte de Oliveira Ribeiro et al., 2017). Hand washing is inexpensive and effective (Cavnar et al., 2017; Luciano et al., 2017). Proper and timely hand hygiene saves thousands of lives and millions of health care dollars (Cavnar et al., 2017). However, despite all the evidence and reinforcement, effective and timely hand washing continues to be a challenge. Cavnar et al. (2017) reported that in the United States, 99,000 deaths related to health care associated infections occur annually. Health care acquired infections can cost $28.4 to $45 billion annually. Hand hygiene needs to be taught and practiced as a critical part of health care practice (Cavnar et al., 2017). Implementing improved hand hygiene practices can help to lower health care associated infections. Ellis (2012) noted that 30% of health care associated infections are avoidable.

Anderson et al. (2015) noted that despite hospital staff receiving ongoing education regarding health care acquired infections, knowledge deficits persist. Chassin et al. (2015) reported that generic strategies do not promote compliance. Leadership is often aware of such noncompliance but lacks accountability tactics to discipline offenders (Chassin et al., 2015). Creating a new program can be beneficial. By reworking the hand hygiene policy to include education, practice, visual cuing, and dedicated ongoing checks, an improvement in compliance should lead to a decrease in health care–associated infections.

Project Details

The Glow Team consisted of three RNs offering educational and hands-on hand washing sessions. This project was conducted in an urban hospital's emergency department. One hundred health care workers (25 physicians, 25 nurses, 25 patient technicians, and 25 ancillary staff) participated in the 15-minute project. Staff were asked to come to a nonpatient care area on the unit during their shift when staffing allowed. The steps of the project were:

  • Apply black light–sensitive lotion to all areas of hands.
  • Wash hands.
  • Examine hands under a black light for presence or absence of lotion by a Glow Team member.
  • Watch a 3-minute video highlighting the problem of hospital infections due to poor hand hygiene, recommendations for timing of hand hygiene, and situations in which soap and water hand washing is required.
  • Reapply black light–sensitive lotion.
  • Wash hands again, this time following along with a 1-minute live video demonstration of WHO soap and water hand washing technique.
  • A Glow Team member reexamines hands under black light for presence or absence of lotion.
  • Complete a posttest including questions on mechanics and hand washing techniques along with participant's recommendations for increasing hand washing compliance (Figure 1).

To build excitement for the project, the Glow Team gave out rubber bracelets with the slogan “Do you WHO or Glow Blue” after completion of the education. The Glow Team also presented a poster highlighting the project on World Hand Washing Day on October 15th.

Results

The Glow Team conducted the project over 5 days. The average score for thoroughness of hand washing preeducation was 60%. The average score increased to 82% posteducation. The fingertips/nail bed/cuticle areas (step 5) showed the most improvement, increasing 58%—from 24% compliance to 82% (Figure 2). It can be noted that the quality of hand washing technique preeducation was not significantly different when separated by practice specialty (RN, MD, patient technician, or ancillary staff), years of service, age, or gender identity. Eighty-seven percent of participants correctly identified situations that required hand washing, and 95% correctly identified when soap and water hand washing is specifically indicated. Most participants correctly identified the correct length of soap and water washing as 40 to 60 seconds. In addition to the visual rubber bracelets, recommendations by participants included flyers by hand washing areas and yearly competencies to maintain continued compliance. Frequent discussions persist among the unit staff regarding personal focus on specific techniques identified as poor during their individual education session.

Pre- and posteducation scores of hand washing observation steps. Note. WHO step descriptions obtained from World Health Organization (2009). Adapted from Hand hygiene: Why, how & when?https://www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and_When_Brochure.pdf

Figure 2.

Pre- and posteducation scores of hand washing observation steps. Note. WHO step descriptions obtained from World Health Organization (2009). Adapted from Hand hygiene: Why, how & when?https://www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and_When_Brochure.pdf

The majority of staff reported the project was efficient and quick enough to complete as a yearly competency or even as a routine spot check. Ongoing hand hygiene education and accountability are essential to a safe patient environment. Ongoing reinforcement may include eye-catching visuals (e.g., blue hands, WHO logo) by sinks, unscheduled spot-check technique reviews, and yearly competencies. World Hand Washing Day can be used to promote best practices with present education and awareness on a yearly basis. Use of the black light–sensitive lotion can also be used to assist underperformers to visualize the deficit in their technique.

Possible Pitfall

Due to the need to apply black light–sensitive lotion before the preeducation hand washing, participants were aware that their initial hand washing technique was being observed and it is likely that they were more thorough because of it. As participants were observing the video while washing the second time and focusing on the movements, it is possible they did not use adequate friction.

Conclusions

Participants responded positively to the project. Many participants were surprised to see that their current hand washing techniques were not thorough, and the results showed that all staff gained knowledge of hand washing. This project was successful in improving current practices. All participants benefited from practicing their soap and water technique. Discovering new and inventive ways to engage staff in performance improvement in hand washing can increase compliance, save money, and most importantly, save lives.

References

  • Anderson, N., Johnson, D. & Wendt, L. (2015). Use of a novel teaching method to increase knowledge and adherence to isolation procedures. Medsurg Nursing, 24(3), 159–164 PMID:26285370
  • Cavnar, K., Van Der Like, J. & Hobby-Burns, L. (2017). Promoting patient safety through interprofessional education simulation. Clinical Laboratory Science, 30(4), 228–232 doi:10.29074/ascls.30.4.228 [CrossRef]
  • Chassin, M. R., Mayer, C. & Nether, K. (2015). Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance. Joint Commission Journal on Quality and Patient Safety, 41(1), 4–12 doi:10.1016/S1553-7250(15)41002-5 [CrossRef] PMID:25976719
  • Duarte de Oliveira Ribeiro, F., Almeida de Souza, M., Oliveira de Paula, A., Gomes da Silva, A. & de Oliveira, A. C. (2017). Logical strategy for improving health hygienic practices among health professionals. Journal of Nursing UFPE/Revista de Enfermagem UFPE, 11(10), 3971–3979. doi:10.5205/reuol.12834-30982-1-SM.1110201735 [CrossRef]
  • Ellis, S. (2012). Role of emergency nurses in controlling infection. Emergency Nurse, 20(8), 16–21 doi:10.7748/en2012.12.20.8.16.c9479 [CrossRef] PMID:23488068
  • Luciano, M. N., Nascimento, B.B., Nunes, E. M., Oliveira, L. F. M., Davim, R. M. B. & César Alves, E. S. (2017). Adherence to hand hygiene (sic) by health professionals in an intensive care unit. Journal of Nursing UFPE Online, 11(10). 3764–3770. doi:10.5205/reuol.12834-30982-1-SM.1110201709 [CrossRef]
  • World Health Organization. (2009). Hand hygiene: Why, how & when? https://www.WHOint/gpsc/5may/Hand_Hygiene_Why_How_and_When_Brochure.pdf
Authors

Ms. Fries is Emergency Department Clinical Resource Specialist, and Ms. Figueroa is Emergency Department Leader, Trinity Health of New England, Saint Francis Hospital, Hartford, Ms. Pickerign is Lactation Consultant, Griffin Hospital, Derby. Dr. Breda is Associate Professor of Nursing, and Dr. Eichar is Associate Professor of Nursing, University of Hartford, West Hartford, Connecticut.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Kristin E. Fries, MSN, RN, Emergency Department Clinical Resource Specialist, Trinity Health of New England, 70 Hunter Road, Tolland, CT 06084; email: K.Fries714@yahoo.com.

Received: November 18, 2019
Accepted: May 04, 2020

10.3928/00220124-20200914-06

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