Research.docx

Chapter 1 Introduction

Hospitals are designed to treat the sick and injured and to help patients heal and recover. This is the fundamental purpose for a hospitals existence. No one ever goes to a hospital with the intention of acquiring a disease and becoming ill or worse yet, dying! However, many people every year become infected with Hospital Acquired Infections (HAIs) and become sick, resulting in thousands of deaths per year. Pincock, Bernstein, Warthman, and Holst, 2012, report that “nearly 2 million HAIs and 100,000 HAI-related deaths occurring annually in the United States alone” (p. 18). Those are staggering statistics and are a major cause of preventable morbidity and mortality. The reason why so many HAIs are contracted every year and what can be done to solve the problem is of major concern for everyone that works at or is admitted into a hospital, which is nearly every single person in America at some point in their lives. Pincock, et al. 2012 state “Proper performance of hand hygiene at key moments during patient care is the most important means of preventing HAIs (p. 18). Hand hygiene is a complex issue nowadays. There are about 5378 articles of initial keyword about hand hygiene that had been studied (Aiello, Coulborn, Perez and Larson 2008, 1374). Despite of many proven studies, the hand hygiene compliance is still low in the field of healthcare setting (Boyce & Pittet 2002, 1-4; Aiello et al. 2008, 1379). Different campaigns and strategies used to improve the compliance of hand hygiene, but still the implementation of hand hygiene to the healthcare workers is very low. This is why a hand hygiene issue is captivating for

the healthcare workers and for the nursing students about their implementation towards the procedure. Most germs that cause serious infections in healthcare are spread by people’s actions. Hand hygiene is a great way to prevent infections. However, studies show that on average, healthcare providers clean their hands less than half of the times they should. This contributes to the spread of healthcare-associated infections that affect 1 in 25 hospital patients on any given day. Every patient is at risk of getting an infection while they are being treated for something else. Even healthcare providers are at risk of getting an infection while they are treating patients. Preventing the spread of germs is especially important in hospitals and other facilities such as dialysis centers and nursing homes (CDC, 2017) Hands of the Health Care Workers (HCWs) play a significant role in the transmission of nosocomial pathogens (Kampf & Kramer, 2004). Improper hand hygiene (HH) by HCWs is responsible for about 40% of nosocomial infections (Inwerebu, Dave, & Pittard, 2005). Health care–associated infections (HAIs) due to poor HH is a major cause of increasing morbidity, mortality, and health care costs among hospitalized patients worldwide (Sydnor & Perl, 2011; Trampuz & Widmer, 2004; World Health Organization [WHO], 2002). On average, health care providers clean their hands less than half of the times they should (Centre of Disease Control and Prevention, 2016). Hand Hygiene (HH) is an effective way of preventing the spread of infectious diseases and the spread of antimicrobial resistance (Anderson et al., 2008; WHO, 2009a, 2009b, 2009c). Improved compliance in HH, with proper use of alcohol-based hand rubs (ABHR) can reduce the nosocomial infection rate by as much as 40% (Kampf, Loffler, & Gastmeier, 2009). A systematic review study on HH in domestic settings showed that Hand Washing (HW) with soap reduces

diarrheal morbidity by 44% and respiratory infections by 23% (Curtis, Danquah, & Aunger, 2009). The spread of HAIs can be controlled if HCWs wash their hands properly before touching patients, before aseptic procedures, after body fluid exposure, after touching patients, and after touching patients surroundings, with soap and water or with ABHR (Bischoff, Reynolds, Sessler, Edmond, & Wenzel, 2000). HH is therefore the most important measure to avoid the transmission of harmful germs and prevent HAIs. Any person involved in direct or indirect patient care (HCWs, caregiver) therefore needs to be concerned about HH and should be able to perform it correctly at the right time (WHO, 2009c). Unfortunately, compliance with recommended HH procedures for HCWs has been poor, with mean baseline rates as low as 5% and an overall average of 38.7% (WHO, 2009c). Several factors are associated with poor compliance of HH (WHO, 2009c). These factors are lack of awareness and knowledge with regard to importance, techniques, methods and quality of HH, presence of individual towel/tissues, availability of HH agent, automated sinks, location of sinks, workload, or lack of institutional priorities (WHO, 2004). However, the reasons for low compliance with HH have not been defined in developing countries probably due to limited studies on HH (Karabay et al., 2005).

Statement of the Problem This study aims to determine the rate of nurses who practices hand hygiene compliance and the rate of nurses who do not practice hand hygiene compliance before and after handling their patient in A-MCB. Specifically, it seeks to answer the following questions: 1. What are the profile characteristics of the respondents in terms of:

a. Gender, b. Age, c. Station assigned, 2. What is the rate of nurses who practices hand hygiene compliance before and after handling their patient in A-MCB? 3. What is the rate of nurses who do not practice hand hygiene compliance before and after handling their patient in A-MCB 4. Is there a significant difference in the rate of nurses who practice hand hygiene compliance before and after handling their patient a. When grouped according to gender, age, station assigned? 5. Is there a significant difference in the rate of nurses who do not practice hand hygiene compliance before and after handling their patient a. When grouped according to gender, age, station assigned?

Statement of Hypothesis 1. There is no significant difference in the rate of nurses who practices hand hygiene compliance before and after handling their patient when grouped according to gender. 2. There is no significant difference in the rate of nurses who practices hand hygiene compliance before and after handling their patient when grouped according to age. 3. There is no significant difference in the rate of nurses who practices hand washing before and after handling their patient when grouped according to the station they are assigned.

4. There is no significant difference in the rate of nurses who do not practice hand hygiene compliance before and after handling their patient when grouped according to gender. 5. There is no significant difference in the rate of nurses who do not practice hand hygiene compliance before and after handling their patient when grouped according to age. 6. There is no significant difference in the rate of nurses who do not practice hand hygiene compliance before and after handling their patient when grouped according to the station they are assigned.

Scope and Limitation This study will focus on surveying the rate of hand hygiene compliance among nurses in Adventist Medical Center Bacolod. The respondent will be the nurses of A-MCB. The researcher will observe if nurses practices hand hygiene compliance or not, and answers the questionnaire prepared for each nurses. Survey dates will be within first to second weeks of June, 2019 which will be done by the researcher, research adviser, and research assistant. Survey will take place in A-MCB. In view of the financial and time constraints on the part of the researcher, only one (1) station will be selected. The result of the study will be more definitive and conclusive if it will cover more station in the hospital. Owing to the aforesaid constraints, findings are applicable only to the station that will be covered by the study.

Definition of Terms Compliance – Conceptually refers to the act of obeying an order, rule, or request (Cambridge Dictionary). Operationally it refers to the result of the survey done to the participant. Hand Hygiene – Conceptually it refers to a core element of patient safety for the prevention of healthcare-associated infections and spread of antimicrobial resistance (WHO, 2008). Operationally it is generally performed either by hand rubbing with an alcohol-based formulation or HW with plain or antimicrobial soap and water. Nurses – Conceptually refers to a person whose job is to care for people who are ill (Collins Dictionary). Operationally nurses are the participants of this study.

Chapter II Review of Related Literature A comprehensive literature review was conducted through multiple databases and search engines including Google Scholar, EBSCO Host, and CINAHL nursing database. The inclusive criteria for research collection included articles between 2012 and 2017. Search terms included “hand washing, prevention of illness, flu season, and hand washing compliance.” With infections today adapting and becoming stronger, the need for protection in the hospital setting is at an alltime high. Hand hygiene is an easy and very efficient way of preventing the spread of infections.

Hand Hygiene: Past to Present Ignaz Semmelweis was a Hungarian physician of ethnic-German ancestry, known as the “father of hand hygiene”. Semmelweis along with other colleagues established that hospital acquired infections were transmitted through the hands during activities with patients. In 1847, Semmelweis discovered this after witnessing an alarmingly high number of mortality rates from puerperal fever at an obstetric clinic in which he held the position house officer. Semmelweis proposed all healthcare professionals wash their hands with a chlorinated lime solution before all patient contact and as a result the mortality rate at the obstetrics clinic fell to dramatically to three percent and subsequently remained low. Since Semmelweis initial hand hygiene implementation, hundreds of studies and investigations have been conducted to provide evidence based practice recommendations on hand hygiene and the prevention of hospital acquired infections. In the 1980’s the first national guidelines for hand hygiene were published and in 1995 and 1996, the Center for Disease Control (CDC)/Healthcare Infection Control Practices Advisory Committee (HICPAC) recommended either antimicrobial soap or a waterless antiseptic agent to be used for cleansing hands for all healthcare professionals entering and exiting patient rooms to decrease the spread of multidrug-resistant pathogens. In 2002, HICPAC released guidelines that define alcohol-based hand rubbing, as the standard of care for hand hygiene practices in healthcare settings and that hand washing is reserved for specific situations only. The current CDC recommendations for hand hygiene in healthcare settings include decontaminating hands with healthcare facility approved antiseptics when hands are visibly soiled, routinely, before direct contact with a patient, before donning gloves and after removing gloves and when performing any healthcare related procedure on a patient. Hand Hygiene Barriers

Although, 100% hand hygiene compliance may seem like a straightforward and effortless task, a variety of challenges have been recognized as hindrances to accomplishing this objective. WHO presented common barriers of hand hygiene including “skin irritation caused by hand hygiene agents, inaccessible hand hygiene supplies, interference with HCW [health care worker]– patient relationships, patient needs perceived as a priority over hand hygiene, wearing of gloves, forgetfulness, lack of knowledge of guidelines, insufficient time for hand hygiene, high workload and understaffing, among other issues. Kirk et al. performed a crosssectional examination of health care workers utilizing a survey to inquire about one’s knowledge, attitude, and self-reported practice of point of care hand hygiene. A convenience sample of 200 health care providers in the United States and 150 health care providers in Canada were chosen for the study. Half of the respondents were physicians and half were nurses. Forty-one percent of the respondents listed “dispensers/sinks not in a convenient location”, 36% reported “being busy”, and 32% reported “products dry our hands” as barriers. Increased workload and crowding was recognized as a main factor to low hand hygiene compliance in an observational study performed over 22- months in a 40-bed emergency department located in Toronto, Ontario, Canada. Although this study is limited to a single emergency department with potential bias of an observational study, the theme of increased workload as a barrier to hand hygiene is valid. In a society involving technology in all facets of the health care system, it’s very important to comment on the use of mobile phones and the potential barrier to proper hand hygiene. A study performed by Mark et al., at a hospital in Northern Ireland, involved swabbing 50 mobile phones for bacterial growth and simultaneously administering a questionnaire investigating cell phone usage among staff. Sixty percent of the phones yielded bacterial growth. The results from the questionnaire found 45% of the participants never wash their hands after cell phone usage and 63% report never decontaminating their phone.

In addition, 57% stated that if their phone was proven to be contaminated, this would change their hand hygiene practice when using their device. Despite these barriers, is it possible to educate hospital staff about the overwhelming importance of proper hand hygiene to result in increased hand hygiene compliance? Hand Hygiene in Healthcare Nurses’ hands come into close contact with patients and are frequently contaminated during routine patient care: e.g. auscultation and palpation or while touching contaminated surfaces, devices or materials such as changing of dressing [19]. Therefore, hand hygiene is considered an essential, cheap and most effective means of preventing cross. This method is designed to save lives and provide a safe treatment atmosphere for all patients and HCWs, regardless of the setting [20]. use different terms for hand hygiene, such as hand antisepsis, disinfection, degerming, decontamination or sanitising, in this paper hand hygiene refers to either hand washing with antimicrobial soap or hand disinfecting with an alcohol-based hand-rub. The aim of hand hygiene is to remove dirt and limit the microbial counts on the skin, to prevent cross transmission of pathogens between patients [21]. Since nurses are present 24 hours a day, 7 days a week in the healthcare setting, it is essential to comply with hand hygiene policy and maintain patient safety. Furthermore, nurses are obliged by regulatory registration councils, such as in the U.K’s Nursing and Midwifery Council (NMC), to safeguard patients and to act as the patient advocate. Nurses are professionally and ethically accountable for their actions. The NMC’s ‘Code of Standards and Conduct’ requires nurses and midwives to ‘provide a high standard of practice and care at all times’ (NMC 2008, 2). Yet, despite the momentum for hand hygiene, some nurses are still presenting with low compliance because they perceive it as not their problem, that it is something to do with infection control staff and they have to deal with it [22]. Furthermore,

Nazarko (2009) [23] indicates that nurses often fail to practise hand hygiene because they are busy and they feel hand hygiene takes up precious time. In addition, nurses often perceive that gloves can be used as an alternative to hand hygiene. They usually tend to remove the gloves without washing their hands or use the same gloves to deliver intended care to multiple patients. Even when they remove their gloves, only 20% of nurses actually clean their hands while study claim that nurses avoid hand hygiene because they are frightened that skin problems such as dermatitis could develop, especially with alcohol hand-rubs [23]. According to Collins [24] hand hygiene should be considered before invasive procedures, after contact with contaminated devices or materials, and with high risk, infectious patients. Moreover, Kampf claim that hand hygiene should be advocated before beginning work, at the end of work, and after visiting the rest room (toilet). However, Canham[25] argues that hand hygiene requirements depend on the type of procedure, the degree of contamination and the persistence of antimicrobial action on the skin. Even when nurses spend a longer time on hand hygiene, their technique is often poor compared to other HCWs in terms of leaving large areas unwashed effectively, i.e. wrists, thumbs, nail beds and between fingers. Collins claims that physicians generally have excellent hand hygiene skills compared to nurses. Karabay note that hand hygiene compliance is seen more in junior nurses and newly recruited staff, and Akyol claims that hand hygiene compliance is higher among nurses compared to physicians and other HCWs. Ott& French suggest that the attitudes and behaviour towards hand hygiene is a complex issue, involving the perception of its effectiveness, staff’s values and beliefs and existing barriers. In order to achieve high compliance rates with hand hygiene, Cambell (2010) suggests that the defaulters should be disciplined as though they have violated hospital policy, starting with personal counselling to verbal warning and eventually to a written warning placed in

their file. Hand hygiene is not only the nurses’ responsibility, it is a shared responsibility between hospital administration, key leaders, patients and others stakeholders. Effective Hand Hygiene Techniques Effective hand hygiene involves the removal of visible soiling and the reduction of microbial colonisation of the skin. Healthcare workers’ hands can be contaminated by two types of pathogens: transient (contaminating) and resident (normal or colonising) microorganisms (Mani et al. 2010). Resident flora colonise deeper skin layers and, compared to transient flora, is difficult to remove mechanically, i.e. by hand washing. Fortunately, resident flora tends to be less aggressive and is, therefore, less likely to cause serious infection. Negative staphylococci and Corynebacteria are examples of this group. These bacteria tend to grow in hair follicles and remain relatively inactive over time [25]. Transient flora, on the other hand, colonise the superficial skin layers for a short time. The hands of HCWs are often contaminated with transient flora by direct contact during daily patient care activities, environments or equipments. However, these micro-organisms are easily removed by mechanical methods, such as friction in hand washing. Staphylococcus aurous and Candida species are examples of transient flora. These bacteria have the ability to induce HAI among patients and HCWs [25. Taking into consideration the above information regarding transient and resident bacteria, effective hand hygiene, either by hand washing with antimicrobial soap or alcohol based hand-rub, is evidently the way to minimise the cross infection risk. Effective hand washing is the application of a plain (non-antimicrobial) or antiseptic (antimicrobial) soap onto wet hands; then vigorous rubbing together of both hands to form a lather, covering all the surface of the palms, tops of the hands, base of the fingers, between the fingers, back of the fingers, fingers tips, fingernails, thumb and wrists for one minute Equally important is that fingernails should be

short. Artificial fingernails or extenders are potential traps for bacteria and should be avoided. New nail polish on natural nails does not aggravate microbial load; however, chipped nail polish can harbour bacteria . Wearing jewellery, such as rings or hand watches, could lead to the bacterial colonisation on the skin underneath them. After soaping and rubbing, hands should be rinsed thoroughly to remove all the lather. Rinsing with hot water should be avoided, because it could cause skin dryness [19. Study reports that hand position (hands up, hands down, hands lateral) during hand washing procedure and water flow showed no difference in microbial counts. Hand drying is equally important to prevent cross infection, because microorganisms thrive in a damp environment. Moreover, proper hand drying is required before wearing gloves, as trapped moisture under gloves can cause skin irritation and increase the harbouring of bacteria. Paper towels are effective for drying hands plus the friction created by their use enhances organism removal from the skin. Taps should not be touched again by freshly washed hands; a paper towel can be used instead to turn the water off. Although a hand dryer is as good as hand towels, paper disposable hand towels are quicker and more effective . The friction generated by vigorous hand rubbing with soap and hand drying with paper towels removes dirt and loosely adherent flora, i.e. most transient flora and a small portion of resident flora from hands. Alcohol based hand-rub is recommended for hand decontamination in all clinical settings apart from visibly soiled hands. Alcohol hand-rub uses alcohol instead of water. In contrast to the mechanical (friction) removal of flora in hand washing, alcohol works by killing the flora. Alcohol hand-rub differs from hand washing because it acts on the microorganisms by denaturing their proteins and thus has the ability to eradicate all transient flora and most resident flora .It also takes less time than hand washing, between 15 to 30 seconds. The process of alcohol hand-rub starts by applying a sufficient amount of the alcohol based hand-rub product (liquid, gel or foam) according to the

manufacturer’s recommendation. (Usually between 3 to 5 ml), and spreading it all over the hands, especially the areas between fingers, thumbs and fingernails. The effective concentration of alcohol should be 60% to 95%; concentrations of greater than 95% are not recommended because they have less water which is essential for the protein denaturation of microorganisms, thus making them less potent. HCWs should adopt either procedure for hand hygiene, either alcohol hand-rub or hand washing with antimicrobial or non-antimicrobial soap, but use the latter if hands are visibly soiled. Using both procedures simultaneously is not recommended, as it doubles both cost and time. Trampuz argue that using alcohol hand-rub immediately before or after hand washing could cause dermatitis and further recommend wearing powder-less gloves to avoid possible alcohol reaction with residual powder. However, Kampf& Loffler (2010) maintain that using alcohol hand-rub after hand washing could reduce irritation caused by hand washing detergents, since this method also removes detergent from the skin. Clearly, skin irritation and dermatitis are a professional hazard. Unfortunately, damaged skin can harbour bacteria and may contribute to cross infection further claim that hand washing removes lipids from the skin, while alcohol hand-rub only redistributes them. However, both procedures can induce skin dryness. Additionally, Collins [24] argue that frequent hand washing, hot water, harsh soap and rough hand paper towels are precipitating factors in skin dryness and subsequent skin infection. Therefore, skin protection products, such as hand lotions or creams, should be considered and used regularly in order to reduce dryness and promote regeneration of the skin cells.

Chapter III Methodology The research methodology indicates the general pattern to valid and reliable data for the problem under investigation. Research Approach A quantitative approach is used in the study to assess the Compliance of Hand Hygiene among Nursing Staff at A-MCB. Research Design The research design used in the study is a cross sectional design. Research Setting The study was conducted at Adventist Medical Center Bacolod. Population: The population selection for the study is staff nurses from Adventist Medical Center Bacolod. Sample Size: The 20 samples selected was a staff nurse from Adventist Medical Center Bacolod. Sample Technique: Convenient sampling technique was used. Sampling Criteria:

Inclusion criteria: 1. Staff Nurses. 2. Staff nurses who are willing to participate in the study. 3. Staff nurse who are available during the period of data collection. Exclusion Criteria: Who are not willing to participate in the study. Data Collection Tool Knowledge was assessed using WHO’s hand hygiene questionnaire for health care workers. This proforma of 25 questions includes multiple choice and “yes” or “no” questions. Attitude and practice were assessed using another self-structured questionnaire which consists of 10 and 25questions, respectively. Respondents were given the option to select on a 1- to 7-point scale between strongly agree and strongly disagree. A score of 0 was given for negative attitudes and puny practices. 1 point was given for each correct response to positive attitudes and good practices so that maximum score for attitude is 10 and for practice it is 25. A score of more than 75% was considered good, 50-74% moderate, and less than 50% was taken as poor. Data was analyzed using SPSS version software. Descriptive statistics was used to calculate percentages for each of the responses given. Z test was used to compare the percentage of correct responses between nursing staff and students. A P value less than 0.05 was considered significant.