Hand hygiene technique quality evaluation in nursing and medicine students of two academic courses (2024)

Abstract

Introduction

Hospital-acquired infections (HAIs) are one of the main causes for morbility andmortality in the health field, which constitute one of the main issues in global publichealth 1.

Health professionals' hands are one of the main transmission mechanisms for HAIs. Handwashing with water and antiseptic soap before and after patient contact is the mostefficient technique proven to prevent hospital-acquired infection 2.

However, in everyday clinical practice, hand hygiene (HH) is happening less often thandesired 3.

The World Health Organizations' (WHO) recommendations about enhancement strategies andbetter HH practice are considered as reference criteria, setting up several educationalinterventions targeting health professionals 4.

Both in Spain 5and in the Autonomous Community ofExtremadura 6, promotion and knowledge developmentas well as a culture of patient safety are being stressed among professionals andpatients in all health service levels. While performing its working lines on a localstage, the Complejo Hospitalario Universitario Infanta Cristina de Badajoz, the SociedadEspañola de Medicina Preventiva, Salud Pública e Higiene (SEMPSPH) planned educationalseminars and workshops about hand hygiene and its assessment.

Because they are health professionals, nursing and medical students' hands duringinternships can function as a transmission vehicle for hospital-acquired infections, andcan cause patient, object and surface contamination 7.

In this study we plan to assess the current state of HH in nursing and medicinestudents, enrolled to the Facultad de Medicina del Campus de Badajoz of the Universidadde Extremadura (UEX), who were doing an internship at the Complejo HospitalarioUniversitario Infanta Cristina de Badajoz (CHUICB).

Method

Our study was a descriptive, cross-sectional study that occurred in two periods of time,and a sample was limited by the UEX, namely the Medicine Campus where medicine (sixcourses) and nursing (four courses) undergraduate studies are available. Three hundredseventeen students were enrolled in the nursing degree 2012/13 class, and 294 studentsin the 2013/14 class. For the medicine degree, there were 877 students for the 2012/13class and 878 for the 2013/14 class.

The CHUICB is integrated with the Hospital Infanta

Cristina, Hospital Perpetuo Socorro, Hospital MaternoInfantil and the Specialty Center.This complex belongs to the Health Department of Badajoz, which served a populace of276, 154 people; it owned 831 beds, had a total of 40, 434 hospital admissions, 31, 533surgical procedures, 2,430 deliveries and the mean stay was 6.84 days 8.

No selection of the student' sample was conducted. All students attending preventivemedicine and public health classes of the biomedical sciences department and communitynursing I and II classes of the nursing department were included. Student participationwas voluntary.

Nursing and medical students from the Medicine Campus of Badajoz who participated in ourstudy were: nursing degree students in the second and third years, medicine degreestudents in second and fifth year, and medicine baccalaureate students in sixth year(last class of the old program).

The study occurred in two periods of time: Academic year 2012/213 and 2013/2014

The study was conducted by the same professionals in the preventive medicine and publichealth service, on several days and different schedules in order to study the wholesample of students. A one-hour theory lesson about the foundations of hand, object, andsurface contamination, epidemiology on the chain of bacteria transmission, and thedifferent kinds of HH (instructions, material and technique) were taught during theschool year of 2012/13 and 2013/14. The lesson focused on hygienic hand washing,antiseptic hand washing and hand rubbing with hydroalcoholic solutions. Likewise,instructions on applying HH, following the methodology of the "five moments of handhygiene" proposed by the WHO were stressed.

During practical teaching, nursing and medical students attended a simulated specialtymedical practice session. Small groups were established with five students. The reasonfor visit was explained (nausea) and students were asked to care for the patient (takingvital signs); asking them to perform a correct HH following WHO commendations. There wasno sink or water and soap for performance of the HH, only hydroalcoholic solution wasavailable which students had to use, applying knowledge acquired in the theoreticalclass.

Identifying variables included: date, center, academic course, nursing or medicine, sexand age.

An alcohol-based mix marked with fluorescence and an ultraviolet (UV) lamp (Dermalux(r),Derma LiteCheck by Dermalux - Training) were used to assess HH.

A visual assessment of the correct fluorescencemarked hydroalcoholic solution (HAS)distribution (categories yes/no) was performed. Five main sections were considered:palms, back of the hand, between the fingers, finger tips/nails separately for each hand(right and left) and for both hands.

For the final quality assessment of the HH technique, some categories were established:"very good" if HAS was spread throughout all sections, "good", if four sections wereexposed, "fair" if two sections were not exposed, and "poor" if three or more regionswere left without HAS exposure (Likert-type scale with four categories). Subsequently,they were divided in two categories: "proper HH" when the right hand, left hand and bothhands obtained a "very good" or "good" notation; "inadequate HH" when the right hand,left hand or both hands obtained a "fair" or "poor" notation.

Limitations to the study included: lack of a randomized sample, as well as theconcomitant differences in year of education, which could bias the study.

A separate descriptive analysis of the variables was conducted, presenting the meancorresponding to the qualitative variables, and centralizing measures as well asdispersion of the quantitative variables.

A chi-square (χ2) was used for the bivariant analyses of the qualitative variables and aStudent t-test for the quantitative variables, considering as significative the valuesp>0.05.

Excel of Microsoft Office 2007 was used for the coding of the obtained data, and SPSSversion 15.0 for the statistical analysis.

Ethical factors: Participation of all subjects in the study was voluntary.Confidentiality of data (Organic Law 15/1999, of December 13, of the Protection ofPersonal Character Data) and statistics (group coding, analysis and results) were keptsecret at all times; likewise, the compliance was maintained with the Hospital InfantaCristina de Badajoz's (Spain) Ethics Committee's research protocols.

Results

A total of 546 students participated in the study, 403 (73.8%) of them were medicalstudents and 143 (26.2%) were nursing students; 216 (39.6%) students were from the2012/2013 class and 330 (60.4%) students were from the 2013/2014 class. Males accountedfor 30.45% (144), and 69.6% (380) were female. The mean age of the sample was 21.4 ±3.73 years of age.

In general, HAS distribution on the right hand was correct in 96.5% of cases on thepalm, 86.1% between the fingers, 72.7% on the back of the hand, 70.3% on the fingertips, and 56.9% on the thumbs. For the left hand: 95.2% on the palm, 82.6% between thefingers, 80.4% on the back of the hand, 68.7% on the finger tips, and 63% on the thumbs.Considering both hands, th eHAS covered: 92.9% on the palms, 78.02% between the fingers,65.2% on the finger tips, 64.2% on the back of the hand, and 55.1% on the thumbs.

Through direct observation, right hand, left hand and both hand HH technique quality wasobtained. It was noted that 34.1% performed HH on the right hand by spreading HAS onfive sections properly, 29.5% performed good HH, 21.7% achieved a fair score, and 14.6%achieved a poor score. For the left hand, 38.5% obtained a very good HH score, 30.9% hadone mistake a 19.9% had two mistakes, 20.4% had three or more mistakes. Thus, 24.7% inboth hands was very good, 29.8% was good, 25.1% was fair, and 20.3% was poor.

Category results were as follows: right hand HH was appropriate in 63.5%, 69.4% on lefthand and HH for both hands was accurate in 50.2% of the students.

In terms of bivariant analysis by sex, men spread HAS worse than women in between thefingers and the back of the hand, on both the right and left hand ((table 1). Observation for both hands showed that mendid not spread HAS to the thumbs and in between the fingers as often as women did.Likewise, it was the men who obtained a "fair" notation on the right hand and "poor" onboth hands, with significant differences versus women. These differences kept groupingthe evaluation into two HH categories, which were: inappropriate HH on the right hand,and both hands, for men ((table 1). There were nodifference in the men and women groups based on year, course or age.

Table 2shows that nursing students performedinappropriate HH on the right hand 2.2 times and on the left hand 1.7 times (p<0,05)more often than medical students. Future nurses obtained a "fair" and "poor" notation onthe right hand and "poor" on the left hand, with significant differences compared to themedical students. Hand sections most often left without HAS by nursing students versusmedical students were the palm, thumb and in between fingers of right hand; back of thehand and between the fingers on left hand, leaving back of hands, thumbs and in betweenfingers poorly washed on both hands ( Table 2,p<0,05).

Hand hygiene technique quality was significatively study or age ( Table 3). Table 3shows how alack of better for the 2013/14 class versus the previous class rubbing HAS in betweenthe fingers and thumbs stood and in women; there were no differences per year of out asa factor most involved in inappropriate HH.

Discussion

HH is recognized globally as a key factor in the reduction of hospital-acquiredinfection occurrence. The WHO recommends that research and publications focus on theestablishment of hydroalcoholic solution and assessment of its use via diversestrategies. Educational and awareness programs, workshops, reminder posters, directobservation to assess completion and

adherence stand out among them^{(7, 9)}, as well as indirect assessment viaproxy variables such as HAS use and hospital-acquired infection rates.

However, routine checking 10of methodologyquality to improve HH adherence in order to reduce hospital-acquired infection is stillinadequate to prove the efficiency of this approach; in addition to maintaining thebiases in this type of study 11.

Currently, the use of a motivational tool named positive deviation is suggested. Thistool identifies groups of individuals that solve problems better than others withoutadditional resources, which in a study conducted by Mara AR et al. 12obtained an improvement, although no conclusive results wereobtained in another routine revision 13.

In another HH compliance study 14with interns ina Brazilian hospital, 50% lower adherence was obtained, but this is no guarantee ofperformed handwashing efficiency via verification/assessment of proper HH technique.Likewise, nursing students had their internship in different hospitals, which preventeda follow-up; the introduction of this assessment in an undergraduate program becomesjustified along with the five-step HH proposed by the WHO, complete with adherencestudies during the clinical internship and career.

There are few studies that assess the HH technique via marked HAS spreading. This isprobably due to the HH guide provided by the WHO and other institutions that describethe solutions, their efficiency, and application sequence, but which do not providestatements about quality assessment.

Macdonald 15assessed marked-HAS distribution inthree sections (fingers, palms and thumbs) in trained staff, but the study does notdetail the percentage of the sample who rubbed each individual section properly. Inanother study by the same author, the surface of a practice workshop was assessed beforeand after in the traumatology service, providing an estimate of the palm and back of thehand sections.

Widmer 16found a great improvement andcorrelation between HAS covered areas scores and hand

colony-forming units (CFUs), before and after specific training, which was compulsoryfor the staff.

Hautmaniere 17and Sutter 18performed a beforeafter assessment of specific HH trainingprograms for medical students, improving sections covered with HAS and CFU spreading;they concluded that this tool is easy and trustworthy for gauging the HH technique.

Kampf 19found that 53% of subjects studied leftout at least one section during HH, using the reference technique in the EN1500 norm;although the sample was small (55 people) and had many comparisons (16 variables).

Via a compulsory educational course, Szilágy 20obtained an assessment of 67-72% from 4642 participants with a "good"notation; in that study, the sections forgotten most frequently were the top section ofthe fingers close to the nails, the thenar eminence, and the wrist. These results aresimilar to the present study, although this last one was performed on students and wasvoluntarily.

In Spain, only the study conducted by RamonCanton 21assessed HH technique in healthcare professionals at their work post, withno previous compulsory workshop. The results showed that 95.2% of people assessed leftat least one section unclean, and the sections with the worst scores were the thumbs andfingers. In our study, the same assumption gives a result of 75.27% with at least onesection of the hand left unclean, and the sections with worst scoring were the thumbsand in between the fingers.

Other studies^{(17, 22)} involving medical and nursing students obtained arating of inadequate HAS HH of 78.5% and 81.5%, much higher than our study (49.82%).

Furthermore, 26.6% of the students were observed to have attended the practicum withlong nails, with nail polish or artificial nails, watches or bracelets; thesecircumstances complicate correct HH performance, and were not taken into account inother studies.

It is important to point out that the right hand on its own was better cleaned with HASthan the left one, except the thumb; considering that most of the human population isright-handed, this entails that the dominant hand is washed less properly. Therefore,emphasis should be placed on raising awareness and training the non-dominant hand onHH.

Likewise, comments and questions of the students attending were heeded, this helpedidentify the fact that they had difficulty in recognizing the opportunities for HHaccording to the different procedures that form their usual clinical practice. All theseelements must be taken into account and incorporated into cross-disciplinary educationduring undergraduate studies.

Knowledge that health care students must have about hand, object and surfacecontamination and HH issues in hospital-acquired infection prevention and control is keyto improve HH quality and adherence ^(23-24) to provide safe healthservices.

Conclusions

All staff in a health institution, and specially heath care professionals, includingstudents during their internship, must deliver safe health services that preventhospital-acquired infection in their everyday practice.

Therefore, proper education and training in proper HH technique performance and regularcreation of campaigns and workshops remains a priority.

Moreover, effectiveness of HH also depends on quality technique, and we believe thatregular practicum and assessment using this immediate feedback method could provide asimple, quick tool with large effect in students and professionals; it can ascertain HHtechnique quality at an individual level, after a course/workshop or at their place ofwork, giving them the necessary skills and knowledge as well as awareness and betteradherence, which need improvement.

Hand hygiene improvement must be a priority for healthcare authorities in all levels, beit undergraduate, graduate studies or ongoing training, where there is an individualresponsibility for each healthcare professional. All HH programs must include differentactions, such as alcoholic solution introduction, staff education and motivation, aswell as assessment and counselling in HH technique quality.

Footnotes

References