The Centers for Disease Control and Prevention (CDC) (2002a) estimates that 10% of all hospital admissions are complicated by hospital-acquired infections, which contribute to the death of approximately 90,000 patients each year. There is substantial evidence that proper hand hygiene is the most effective approach to preventing hospital-acquired infection (CDC, 2002a; Larson, 1999; Mears et al., 2009; Pittet et al., 2004; Smith & Lokhorst, 2009). However, adherence of health care workers to proper hand hygiene procedures remains low and compliance rates rarely exceed 50% (Creedon, 2005; McLaws, Pantle, Fitzpatrick, & Hughes, 2009; Pittet et al., 2000).
The CDC’s (2002a) “Guideline for Hand Hygiene in Healthcare Settings” was developed as an overall strategy to reduce infections in health care settings to promote patient safety. These guidelines conclude that “education is a cornerstone for improvement with hand hygiene practices” (p. 25) and recommend implementation of multifaceted, multidisciplinary programs to improve hand hygiene practice among health care workers. The guidelines also recommend the development of systems for measuring improvement in compliance rates.
Extensive research has been conducted regarding health care workers’ hand hygiene practices, along with barriers and programs to improve compliance with the CDC guidelines. Some of the barriers reported that most significantly contribute to noncompliance include inaccessible equipment (Harris et al., 2000; Smith & Lokhorst, 2009), lack of time (Pittet et al., 2000), and deleterious effects on the skin (Boyce, 2001). Other deterrents reported are misconceptions about hand hygiene practice, insufficient knowledge of the guidelines and indicators for hand hygiene during patient care, and attitudes of health care workers toward the hand hygiene guidelines. For example, health care workers who view the guidelines as unimportant are less likely to accept and adhere to the guidelines (Larson, 2004; Snow, White, Alder, & Stanford, 2006).
Substantial research has also been conducted on interventions to improve hand hygiene compliance in health care workers, including the use of automated sinks (Larson, Bryan, Adler, & Blane, 1997); electronic monitoring, direct observation, and computerized voice prompts (Swoboda, Earwsing, Strauss, Land, & Lipsett, 2004); memos and posters emphasizing the importance of handwashing (Pittet et al., 2000); role modeling; performance feedback; and use of focus groups to identify effective strategies (Erasmus et al., 2009; Thomas et al., 2005). Likewise, Ott and French (2009) stressed the importance of institutional commitment and rigor in improving compliance rates.
McGuckin, Waterman, and Govednik (2009) found that hand hygiene compliance increases when monitoring is combined with feedback. In a multicenter collaborative study in the United States, hand hygiene product use (soap and sanitizers) and the effect of feedback to health care workers on compliance were examined. After 12 months, hand hygiene compliance increased from 26% to 37% in intensive care units and from 36% to 51% in non-intensive care units.
Haas and Larson (2008) also supported multifaceted initiatives but indicated that the product use method does not identify specific individual use or areas of noncompliance. They emphasized three major methods for compliance measurement: “direct observation, measurement of product usage and self report” (p. 42).
Research has shown that hand hygiene behavior is complex, involving individual beliefs and attitudes and institutional commitment, and that health care workers’ hand hygiene compliance rates are difficult to change. No single intervention has been effective in improving hand hygiene practice, and interventions have resulted in only transient improvement in compliance (Beggs, Shepherd, & Kerr, 2009; CDC, 2002a; McLaws et al., 2009).
Hand hygiene monitoring and interventions to improve compliance should target not only health care workers, but also the many students who rotate daily through patient care facilities. Few studies focus on students in health care professions and their knowledge of infection control and hand hygiene practices. Calabro, Bright, and Kouzekanani (2000) found a lack of retention of knowledge of infection control content in fourth-year medical students 2 years after the initial lecture. McCarthy and Britton (2004) investigated compliance with infection control procedures of dental, medical, and nursing students during their final year and found that dental students performed more frequent handwashing prior to treating patients than did nursing and medical students. One study comparing nursing and medical students (Kim, Kim, Chung, & Kim, 2001) revealed a higher level of knowledge and practice of universal precautions among the nursing student group compared with the medical students, although nursing students still lacked understanding in some areas of infection control. Observations of handwashing practice in medical students during their final year clinical examination revealed that only 8.5% washed their hands after patient contact, which increased to only 18.3% when posters were placed in the area (Feather, Stone, Weissier, Boursicot, & Pratt, 2000). Mentoring, role modeling, and reinforcing (performance feedback) best practice behaviors have been moderately successful with student compliance. Snow et al. (2006) found that the mentor’s use of hand hygiene and glove use was associated with strong positive attitudes toward hand hygiene and increased compliance in a group of certified nursing assistant students. Cole (2009) found that nursing students overestimated their knowledge, skills, and compliance with proper hand hygiene and concluded that flawed self-assessments may be a barrier to improved performance if students view their compliance as better than it actually is.
Research supports the implementation of multifaceted, multidisciplinary programs that include cognitive, emotional, and behavioral components of interventions. Active involvement and participation in hand hygiene compliance programs is more likely to sustain improvement of health care workers’ compliance with the CDC guidelines (CDC, 2002a; Haas & Larson, 2008; Naikoba & Hayward, 2001). Therefore, research related to health care workers’ curricular intervention regarding hand hygiene is important.
The purpose of this study was to describe the effect that participation in hand hygiene monitoring of health care workers has on retention of knowledge of infection control principles, opinions about handwashing, and hand hygiene practices among baccalaureate nursing students.
This was a quantitative study using an exploratory descriptive survey design. The study was conducted at a southeastern United States academic medical center with a 722-bed tertiary care hospital. The study group consisted of 75 junior-level baccalaureate nursing students enrolled in a nursing research course who agreed to participate in the study. The study occurred over a 3-month period during their spring semester of study. The authors used three data collection tools that were administered to students following their participation in monitoring hand hygiene compliance of health care workers in patient care areas throughout the hospital.
Three self-report surveys were administered that were designed to elicit data about attitudes, beliefs, and knowledge regarding compliance with hand hygiene guidelines. The Hand Hygiene Knowledge survey was developed from the CDC’s “Hand Hygiene Guidelines Fact Sheet” (2002b) to illicit data regarding students’ retention of knowledge of hand hygiene and infection control. The survey consisted of 10 true-or-false items (Table 1). Validity and clarity of the instrument was obtained from 5 undergraduate and 5 graduate nursing faculty.
Table 1: Knowledge of Infection Control
Self-reported practices and opinions about handwashing were measured by the Hand Hygiene Opinion Survey and Handwashing Practice Survey developed by Larson et al. (1997) and used with the author’s permission (personal communication, January 7, 2006). For the original versions, Larson reported a correlation coefficient on test-retest for both scales at 0.81; Cronbach’s alpha (to test for internal consistency) was 0.87 for the opinion scale and 0.76 for the practice scale. The original scales were later updated to the current version used in this study to include universal precautions and eliminate redundant questions.
The Handwashing Opinions Survey consists of 21 statements, such as “Handwashing is effective in preventing the spread of AIDS” and “Handwashing takes too much time.” Each question was scored on a Likert rating (5 = strongly agree to 1 = strongly disagree) (Table 2). The Hand Hygiene Practice Survey (Table 3) contains 22 open-ended questions to illicit responses from participants on their hand hygiene practices. The survey contained statements such as “I wash my hands before caring for a wound” and “I wash my hands when a poster reminds me.” A Likert rating scale was used (1 = always to 4 = never).
Table 2: Handwashing Opinions Survey
Table 3: Hand Hygiene Practice Survey
Students were also surveyed on their perceptions of the value of the hand hygiene monitoring project. They were asked to rate the extent that participation in the monitoring activities influenced their own opinions and practices with hand hygiene compliance. In addition, they were asked whether the project influenced their understanding of the nurse’s role in research and the importance of evidence-based nursing practice.
Approval was obtained from the medical center institutional review board prior to initiation of the study. The study consisted of three sequential components: an educational session, a skills-training session, and hand hygiene monitoring sessions.
Educational Session. Infection Control Personnel (ICP) presented an educational session to the nursing students that included a slide presentation that gave an overview of the CDC’s “Guidelines for Hand Hygiene in Health-Care Settings” (2002a) and a Hand Hygiene Guidelines Fact sheet (2002b). Students were instructed in proper hand hygiene procedures using soap and water and alcohol-based hand rubs. The educational component was designed to increase the students’ knowledge of infection control and correct any misconceptions they may have had about hand hygiene practices.
Skills Training Session. The ICPs provided instructions on conducting hand hygiene surveillance through observations of hand hygiene practices and recording of observation compliance findings on a monitoring tool. The tool includes recording the data collected on the discipline observed, the number of hand hygiene opportunities observed, and the type of hand hygiene method used (if done). Disciplines were listed as nursing, physician, respiratory, radiology, phlebotomy, housekeeping, transport, food services, and other. The students were given advice on how to determine the service or department in which the employees worked. For example, different colors are worn by some departments, helping to differentiate the departments. Hand hygiene opportunities consisted of beginning/resuming care after completion of care/after removing gloves; before invasive procedures; after contact with non-intact skin, mucous membranes, and blood/body fluids; and after contact with patient equipment/surfaces. Each student was asked to observe a total of 10 hand hygiene opportunities and record their findings using the observation tool. Sessions for data collection were scheduled for students to complete their observations.
Hand-Hygiene Monitoring Sessions. Students were initially paired with one of the ICPs in the hospital to assure that they could accurately monitor health care workers’ compliance with hand hygiene and record their observations on the Hand Hygiene Observation tool. Students and ICPs separately recorded observations and compared their findings for accuracy. This typically required 2 to 4 observations. Once accuracy was assured, students were allowed to monitor hand hygiene compliance independently to obtain the allotted 10 observations. The observations took from 2 to 4 hours depending on the patient care unit or department to which they were assigned. Students assessed health care workers’ hand hygiene compliance rates on units and in departments through direct observation (either before or after treating a patient). Observations were random, occurring on different days and during mornings, evenings, and nights to enhance data representation.
Following completion of the hand hygiene surveillance, students completed the surveys of hand hygiene knowledge, opinions, and practices and influence of the study on their current practices. This was followed by focus group discussion sessions in which students were given the opportunity to further discuss their thoughts and feelings about participation in the study. Data analysis was performed on the three self-reported surveys using descriptive statistical (frequencies and mean/standard deviation) and nonparametric testing with SPSS version 18.0 software.
Seventy-five nursing students participated in the study and received classroom instruction on the CDC hand hygiene guidelines and training in monitoring and recording hand hygiene observations. Students observed and recorded approximately 900 health care workers’ hand hygiene opportunities throughout the medical center’s hospitals and clinics, representing 59 different patient care units and departments. This provided a much larger and more comprehensive survey for analysis of health care workers’ hand hygiene compliance rates than had ever been done by the Infection Control department for this length of time.
Hand Hygiene Knowledge Survey
Analysis of students’ responses on the Hand Hygiene Knowledge survey revealed that the group demonstrated a strong knowledge base of hand hygiene principles. All students correctly answered 4 of the 10 questions about specific guidelines of hand hygiene and infection control. Ninety-two percent of the students correctly identified handwashing as the single most effective factor in the prevention of infections. Thirty-six percent incorrectly responded to the amount of time for manual friction when washing hands, believing the correct answer was a shorter duration. A small number of students (approximately 18%) believed that alcohol-based hand rubs caused excessive skin irritation and dryness (Table 1).
Handwashing Opinions Survey
Table 2 summarizes the mean scores of student opinions and perceptions regarding handwashing behaviors. Sixty percent believed that washing hands could cause skin to become dry and wrinkled (mean = 3.27). Lack of clean facilities was found to be a deterrent to handwashing among 41% of the students. Most of the students reported that handwashing was effective in preventing disease. Interestingly, more than 40% reported that handwashing is effective in preventing the spread of AIDS. More than half of the class thought that the hand hygiene class and monitoring activities positively influenced their opinion about the importance of handwashing, whereas 24% of students were neutral about the experience.
Hand Hygiene Practice Survey
The findings as presented in Table 3 demonstrate the mean scores for actual practice characteristics of the nursing students. Students reported that posters were not particularly helpful in reminding them to wash their hands (mean = 2.38). More than 40% of students reported that they would seldom or never wash their hands when a poster reminded them. A high proportion of students indicated a positive attitude toward handwashing before or after patient care interactions, such as before (81.3%) or after (89.3%) caring for a wound, after direct contact with body fluids (100%), and after touching contaminated objects (85.3%). Forty percent indicated that they would seldom wash their hands after touching office objects. However, 65.3% of the students stated that the hand hygiene class and monitoring experience positively influenced their current hand hygiene practices (Table 3).
Focus group discussions were held with the students after completion of the hand hygiene monitoring project to obtain their feedback on the value of the project in helping them appreciate nursing research and evidence-based practice. Students reported that they enjoyed working with the ICPs and they enjoyed the monitoring session. Some reported that the project required too much time; others suggested that the project be done earlier in the curriculum. The majority of students (70%) agreed that the hand hygiene class activity research emphasized the accountability of registered nurses in clinical practice.
Increasing awareness of the importance of proper hand hygiene can be a positive influence on student opinions and practice compliance. Today’s nursing students will be tomorrow’s nursing leaders, and many will be in nursing education or clinical supervisory positions. These future nurses will be in positions to positively influence other health care workers by serving as role models in infection control and hand hygiene best practices. Developing a strong appreciation of the importance of hand hygiene while still a student is an important first step for future nurses in clinical practice.
Collaborative projects between education and service, such as the one described here, can be valuable methods to influence student knowledge, attitudes, and practice. Active involvement of students in evidence-based practice activities, such as this hand hygiene surveillance project, can be effective in helping students understand and value the link between research and best practices in the clinical area. The described model could be adopted for use by other programs and ICPs to identify interventions to improve practice and to help students value the importance of hand hygiene in preventing infection. It is also important that we continue to collect data on hand hygiene compliance rates in patient care settings and examine these data in relation to hospital-acquired infection rates to address patient safety and quality improvement issues in our health care settings.
Hand hygiene behavior is complex. There are multiple recommendations about what strategies may improve hand hygiene compliance. However, none have been proven to significantly enhance or change practice. The overlying consensus supports multidimensional and multidisciplinary strategies that include educational and motivational components along with reflections on practice and the ethics of care.
Faculty must incorporate hand hygiene principles into the curriculum and clinical performance assessments throughout the student’s course of study while modeling positive behaviors. In particular, self-assessment through reflection may help students engage in an open communication about behavioral methods to gain insight into their performance and perceptions. Students may commit to acquiring enhanced clinical reasoning skills and a higher level of practice when presented with multidimensional and even multidisciplinary strategies such as those presented here.
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Knowledge of Infection Control
|Question||Correct Response (%)|
|Handwashing is the single most effective factor in prevention of infections.||92|
|Gloves can be used as a substitute for hand hygiene.||100|
|Hands should be washed after touching sources that are likely to be contaminated.||100|
|Alcohol-based hand rubs are better at reducing bacterial count than antimicrobial soap.||88|
|In an 8-hour shift, an estimated hour of a nurse’s time is spent washing his or her hands.||86.7|
|The most common mode of transmission of pathogens is by the hands.||100|
|A nosocomial infection is a hospital acquired infection.||100|
|It is not necessary to change gloves between patients.||98.7|
|Alcohol-based hand rubs cause excessive skin irritation and dryness.||82.7|
|When washing hands, provide manual friction for 8 seconds.||64|
Handwashing Opinions Survey
|Washing hands can make them look dry and wrinkled.||3.27||1.32|
|Washing hands can help to make them smell appealing.||3.72||1.21|
|Washing hands can make them feel bad to touch.||2.53||1.31|
|Washing hands can make my fingernail polish chip.||2.84||1.29|
|Washing hands can be a reason for people around me to make negative comments.||1.43||0.94|
|Handwashing is not effective in protecting my health and preventing disease.||1.38||1.12|
|Handwashing slows down building resistance and immunity to disease.||1.92||1.36|
|Washing hands can cause skin to become dry, cracked, and wrinkled.||3.51||1.38|
|Handwashing is inconvenient.||2.31||1.12|
|Handwashing takes too much time.||2.13||1.09|
|Dirty restrooms or sink areas can be a reason for not washing hands.||2.95||1.51|
|Lack of a nearby sink can be a reason for not washing hands.||3.11||1.32|
|Lack of an acceptable soap product can be a reason for not washing hands.||2.93||1.31|
|Washing hands after caring for a scratch, cut, or wound can protect from infections.||4.38||1.17|
|Washing hands when preparing food can be effective in preventing foodborne disease.||4.47||1.08|
|Washing hands before eating can reduce the risk of getting sick.||4.44||1.07|
|Washing hands after urinating is effective in preventing disease.||4.51||1.08|
|Washing hands after a bowel movement is effective in preventing disease.||4.41||1.22|
|Handwashing is effective in preventing the spread of AIDS.||3.10||1.59|
|If I wear gloves, handwashing is unnecessary.||1.52||1.56|
|The hand hygiene class and monitoring activities positively influenced my opinion about the importance of handwashing.||3.71||1.25|
Hand Hygiene Practice Survey
|I Wash My Hands:||Mean||SD|
|Before food preparation.||1.24||0.46|
|After a bowel movement.||1.05||0.28|
|Before caring for a wound.||1.17||0.45|
|After caring for a wound.||1.08||0.32|
|After touching contaminated objects.||1.12||0.37|
|If they look dirty.||1.03||0.23|
|If they feel dirty.||1.12||0.40|
|When a poster reminds me.||2.38||0.99|
|When there is a rule for washing hands.||1.43||0.72|
|When others are watching.||1.60||0.89|
|After minimum patient contact.||1.50||0.60|
|After contact with blood and body fluids.||1.00||0.00|
|After contact with infected patient.||1.00||0.00|
|After contact with material soiled with feces.||1.00||0.00|
|After contact with material soiled with secretions.||1.00||0.00|
|After touching office objects.||2.20||0.78|
|After touching patient objects not contaminated.||1.70||0.68|
|After direct contact with secretions of infected patient.||1.00||0.00|
|After touching material soiled with patient urine.||1.00||0.00|
|After contact with blood.||1.00||0.00|