It is estimated that hospital-acquired infections (HAIs) prolong hospital stays, increase morbidity and mortality, and are associated with more than 99,000 deaths annually (World Health Organization [WHO], 2009). HAIs are most commonly caused by the transmission of organisms via person-to-person contact (Sickbert-Bennett, Weber, Gergen-Teague, & Rutala, 2004). Stopping the spread of HAIs is a major health care concern, with implications for patient outcomes and hospital reimbursement (WHO, 2009). Hand hygiene is an essential skill for nursing students to master to ensure both the practice of basic hygiene during patient care and to prevent the spread of potentially fatal organisms.
Traditionally, the teaching of infection control, specifically hand hygiene, has been conducted using a combination of (a) lecture, (b) practice in the skills laboratory, (c) hospital-based competency modules, and (d) reinforcement by individual clinical faculty. Jenner, Watson, Miller, Jones, and Scott (2002) described the complexity of influencing hand hygiene behaviors, suggesting that although traditional teaching methods are effective in the short term, they lack long-term effectiveness. Although no compliance rates were found for nursing students, studies have reported that the rate of hand hygiene among nurses was between 15% and 50% in observational studies (Hugonnet & Pittet, 2000; McArdle, Lee, Gibb, & Walsh, 2006; WHO, 2009). In addition, direct observation—the standard measure of hand washing practice—lacks concrete feedback related to hand hygiene behaviors and effectiveness (WHO, 2009).
Nursing students will be entering the complex health care system and are expected to deliver patient-centered care, with a focus on quality and safety (Armstrong, 2010). One facet of patient safety, the reduction of HAIs, can be achieved with proper, consistent hand hygiene (WHO, 2009). Nurse educators are charged with exploring innovative approaches to prepare students with the knowledge, skills, and attitudes to practice and promote a culture of safety in health care (QSEN Institute, 2009).
The current pilot study evaluated an innovative pedagogy by providing junior-level nursing students with direct feedback about hand microbe identification and counts while students were in direct contact with patients, pathogens, and hospital environments. In addition, the effectiveness of a real-time, critical thinking, computer-based exercise, providing patient outcomes based on the hand hygiene decisions presented in the exercise, was evaluated, as it was conducted concurrently with the hand microbe feedback. The study hypothesis was that with direct and real-time feedback on personal hand hygiene and safety, nursing students will be more effective and safer clinical practitioners.
This pilot study had a longitudinal within-subject design. The study sample was a convenience sample of all junior-level nursing students (n = 68) enrolled in the Adult Health I clinical course in the 2013 fall semester at Indiana University of Pennsylvania. The clinical sites were based in three community hospitals in Pennsylvania. Internal institutional review board approval was obtained from the university and the community hospitals prior to beginning this study.
Standard hand hygiene instruction was given to all students at an orientation session during the first week of the semester, prior to the start of their clinical experience. The students self-swabbed their hands during their clinical experience during weeks 1, 6, and 11. The swabs were then returned to the Indiana University of Pennsylvania campus for analyses. Students completed a hand swab self-reporting survey, in which they stated the time since they last used effective hand hygiene and whether they cared for a patient in isolation for known pathogens. E-mail feedback, containing only their hand swab microbial counts, was provided to each student. Faculty were given a general overview of the aggregate results.
In a group session at the end of the semester, all of the students were given a brief report of the aggregate results and the opportunity to ask questions of the researcher (L.K.O.) regarding the study results. After receiving the second hand swabs microbial counts (week 6), the students were directed to complete the Partnering to Heal (PTH) online training exercise within 1 week (U.S. Department of Health and Human Services, n.d.). The online exercise, located on the Department of Health and Human Services’ Web site ( http://www.health.gov), highlights effective infection control practices and the creation of a culture of safety in health care through HAI prevention decisions. In the exercise, the student assumes the identity of a nurse and makes decisions related to patient care. The online exercise is a decision tree that evolves the patient clinical experience according to the responses given by the student regarding infection control, including hand hygiene practices. Patient outcomes are determined by the actions of the student.
Sample Collection and Microbial Culture Analyses
Hand microbial cultures were obtained by the students by swabbing both of their hands, identifying whether the swabs were from their dominant or nondominant hand, at a random time after at least 4 hours of patient care in the hospital. Each swab was then placed in a transport medium that was labeled with the unique student identifier. The cultures were prepared and processed in the Indiana University of Pennsylvania infectious diseases research laboratory by one of the researchers (V.R.I.). The three groups of microbe population of interest for isolation were (a) general bacterial flora present on both hands as confirmation of general hand hygiene; (b) methicillin-resistant Staphylococcus aureus (MRSA), a gram-positive skin microbe that is becoming increasingly common in hospital and community settings; and (c) gastrointestinal tract vancomycin-resistant Enterococcus (VRE). Using aseptic techniques, the presence of all bacterial flora was tested by plating both the left and right hand swabs onto tryptic soy agar plates. Similarly, the presence of MRSA and VRE were tested by plating both the left and right hand swabs onto MRSA and VRE selective plates under aseptic conditions. The plates were incubated at 37°C under aerobic conditions for 24 to 48 hours. At the end of incubation period, individual plates were analyzed for the presence of skin or gastrointestinal tract microbes by counting the number of bacterial colonies (i.e., colony forming units) per plate. The growth of an increased number of skin and gastrointestinal tract microbes is an indicator of students’ poor hygiene in a health care setting.
All data analyses were performed using SPSS®, version 21 software. Data were analyzed via repeated-measures analysis of variance across three time points (study weeks 1, 6, and 11). The students’ hands (dominant and nondominant) were treated as a within-subject factor, whereas the hospital and the floor to which the student was assigned were treated as between-subject factors. Data were analyzed separately for tryptic soy agar plates, MRSA, VRE, and total colony forming units (i.e., tryptic soy agar plates+MRSA+VRE), as reported in the Results section. Colony counts did not vary systematically as a function of participant hand (dominant versus nondominant) among hospitals or floors within the hospitals; therefore, these variants were removed from final analyses.
When all of the data (including missing values and students who were not available for hand swabs on the clinical unit) across all participants were considered, mean skin flora numbers decreased over time (from 22.47 colony forming units at week 1 to 20.57 and 14.22 colony forming units at weeks 6 and 11, respectively); however, the difference was not statistically significant (Figure 1; F = 0.82). The increase in MRSA numbers was also not significant over the same time period, which averaged from 0.08 to 0.40 (Figure 2; F = 0.75), a change that was likely mediated by the few MRSA samples detected (<10% of samples).
Colonization of skin flora across hospitals over the 3-month study period. Note. CFUs = colony forming units; error bars denote 1 standard deviation.
Colonization of methicillin-resistant Staphylococcus aureus across hospitals over the 3-month study period. Note. CFUs = colony forming units; error bars denote 1 standard deviation.
When all of the data (including missing values) were considered, no significant between-hospital effects were noted for skin flora (Figure 1; F = 1.56) or MRSA (Figure 2; F = 1.34), and no effect of participants’ hands (dominant versus nondominant) was noted for skin flora (F = 2.70 [not significant]) or for MRSA (F = 0.51 [not significant]). Regarding VRE, too few VRE samples were encountered for analyses. Although some hospitals had at least 30% of participants missing during weeks 6 and 11 due to students being on alternate assignments off the hospital units, no difference in analyses results from the above was noted. Less than half of MRSA-positive students reported caring for an isolation patient on the days of the culture collection. Only 55% of the students completed the PTH online exercise. In a repeated measures analysis across the three sampling periods, those students who participated in the online exercise had significantly higher total colony forming unit counts than did students who did not view the online exercise (F[1,27] = 5.33, p = 0.029).
Students who participated in the online exercise had total colony forming units counts at weeks 1 and 11 that were not different from the students who did not view the PTH (Figure 3; F[1,57] = 0.33 and F[1,46] = 0.01, respectively; both of which were not significant). At week 6, students who participated in the online exercise had higher total colony forming unit hand counts than did those who did not view the PTH (Figure 3; F[1,46] = 3.24, p = 0.078).
General bacterial totals are divided according to participation (Yes/No) in the Partnering to Heal online training program. Note. CFUs = colony forming units.
Discussion, Limitations, and Conclusions
Despite nonstatistically significant results, a decreasing trend in normal flora during the current study suggested that students were more aware of hand hygiene. The online exercise was not a course mandated and carried neither a penalty for noncompletion nor a grade for completion. Therefore, students freely chose to complete the online exercise. However, the resulting bacterial colony counts may have motivated students’ to participate in the online exercise. Students who completed the online exercise (55%) showed a trend toward higher colony counts during weeks 1 and 6, suggesting that a heightened awareness of their hand microbial counts may have influenced their behaviors to seek more information on hand hygiene.
During the hand swab self-reporting survey, students reported whether they were assigned to a patient in isolation or whether they assisted another student or nurse in the care of patient in isolation. Given that less than half of the students with positive MRSA cultures reported having cared for a patient in isolation, hand contamination with MRSA is possibly occurring outside the MRSA patient isolation units. The awareness that MRSA colonies were transferred to the students’ hands outside the patient care areas or from a yet to be identified patient carrier of MRSA was disconcerting to the students and generated discussion at the end of the semester. The students’ inquiry regarding their results, the antidotal observations of the students, their reflections on the online exercise, and their questions concerning MRSA-positive cultures on their hands demonstrated to the faculty and researchers that the students were critically thinking about hand hygiene.
During this 3-month hand hygiene study, variations across three regional hospitals, as well as the different clinical groups, were noted. Students performing their own hand swabs could have added to this variation, as the nondominant hand bacterial counts were always higher than the dominant hand counts, although they were not statistically significant. Although missing values were considered during the statistical analyses, it is important to note that at least 30% of the students were missing during weeks 6 and 11 across hospitals due to students being on alternate assignments off the hospital units.
The current study is a work in progress to change hand hygiene behaviors in a hospital setting. All of the data results and observations from this pilot study informed the next step of the study, initiated in fall 2014. The study hypothesis—with direct and real-time feedback on personal hand hygiene and safety, nursing students will be more effective and safe clinical practitioners—has not been fully explored. On the basis of student data, it is clear that in addition to providing direct and real-time feedback on personal student hand hygiene and safety, the use of a mixed methods approach is warranted to further investigate nursing student hand hygiene behaviors, with the ultimate goal of educating more effective and safe clinical practitioners.
A mixed-methods approach will be used in the next step of the study (fall 2014). The authors will repeat this pilot study, with some improvements to the methodology. Given that there was no significant difference between the hand microbe counts during weeks 1 and 6, hand swabs will be obtained twice—once before and once after the PTH online exercise. This will decrease the costs to conduct the study and decrease the burden on students and faculty. To decrease variability among the students’ swabbing technique, the researchers will obtain the swabs instead of having the student self-swab. Communication will be improved with clinical faculty to decrease the numbers of missing students from the analyses. The swab results will be e-mailed, as in the current study, with the addition of visual feedback (pictures of bacterial colonies on respective plates), which will provide definite proof of swab culture results to the students. In addition, the students lived experiences and attitudes regarding the spread of infection in the hospital setting will be explored in two formats: (a) a PTH online exercise will be conducted, with reflective student feedback; and (b) a focus group of randomly chosen study participants at week 12 to better inform and prepare entry-level nurses regarding microbial safety.
- Armstrong, G. (2010) Quality and safety education for nurses update. NCSBN Leader to Leader, Fall, 1–2.
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