Hospital acquired infections are increasing dramatically. Adherence to hand hygiene is the most important way of reducing infections in healthcare facilities. Despite evidence of benefit, hand hygiene compliance among healthcare workers remains low. Nursing leaders are forefront members of the healthcare team who undertake tremendous responsibility in the prevention and control of infections. Committed nursing leadership using multidisciplinary and proactive approach is essential in promoting and sustaining hand hygiene compliance to decrease the incidence of hospital acquired infections. Nursing leaders must support and positively reinforce hand hygiene practice among healthcare workers.
Hospital acquired infections are one of the most serious complications of healthcare. In the U.S., more than 1.7 million hospitalized patients are diagnosed with hospital acquired infections annually, and approximately 90,000 of them die each year.1 These infections impose a major cost burden on healthcare facilities and patients, and are the fifth leading cause of death in acute care hospitals.2 As a result of increasing numbers of hospital acquired infections, penalties are now on Medicare and Medicaid reimbursement to hospitals with high rates of infection. Hospitals now are required to make their hospital acquired infections statistics available to the public.
Most hospital acquired infections result from cross-infection from the hands of healthcare workers. Because hands of healthcare workers frequently serve as vectors for the transmission of organisms between patients, and are also a major reservoir for pathogens with antimicrobial resistance, hand hygiene is the most effective strategy to reduce hospital acquired infections.3 When healthcare workers care for, especially, immune-compromised patients, patients' decreased immune system place them at higher risk for infections requiring antibiotics.
Hand hygiene is the single most effective and cost efficient method for preventing and reducing the transmission of hospital acquired infections.4 However, the rates and outbreaks of hospital acquired infections continue to increase due to healthcare workers' poor hand hygiene compliance.
A nurse management study has found that poor leadership, low staffing levels and heavy workload are risk factors that affect infection control.5 Improper hand hygiene techniques and poor hand hygiene compliance can predispose immune-compromised patients to develop potentially life-threatening infections and increase the patients' length of stay in hospital, cost per patient day, and cost per episode of care. Many studies have found that healthcare workers neglect to wash their hands before and after patient contact. Barriers to compliance with hand hygiene are insufficient time for hand hygiene due to heavy workloads, inaccessible hand hygiene supplies, skin irritation caused by hand -hygiene products, forgetfulness and lack of knowledge of the guidelines.6 It is estimated that 15 percent to 30 percent of hospital acquired infections are preventable through improved hand hygiene.4 Although hand hygiene increases during the educational interventions and improves slightly thereafter, the changes in behaviors are not sustained beyond the period of the study interventions. Educational programs alone aimed at improving hand hygiene compliance have limited success and are not effective in the long-term.2 Successful continuing education for healthcare staff may be limited by staff shortages, lack of time, lack of appropriate follow-up and lack of sophisticated education materials.
Studies suggest that a multidisciplinary approach, including the use of feedback, education, the introduction of alcohol-based hand wash, and visual reminders, may increase adherence to hand-hygiene recommendations.7 In a multidisciplinary approach, committed nursing leadership and communication with team members is essential. There is evidence that the use of feedback may be the key to increasing adherence.
Audit and feedback is widely used as a strategy to improve many professional practice.8 The literature suggests that medical practitioners are more likely to change behavior if they receive feedback from a leader about their actual practices and process of care rather than about only clinical outcomes.8 Continuity in leadership and good teamwork has a direct impact on infection levels.5
Another consideration is work based on evidence. Although hand hygiene practices are poor among healthcare workers, increased hand hygiene compliance with an alcohol-based rub has been attributed to product placement in the environment, convenience of use and the minimal time required for use.9 Supported by the evidence-based research, nursing leaders can implement alcohol-based rub into multidisciplinary approach. Nursing leaders need to value research evidence and support healthcare worker's hand hygiene practice through products that are more readily available, less expensive and result in better skin integrity of the nurse
Motivating Healthcare Workers
A nurse leader can use the health belief model as theoretical framework to motivate and influence infection prevention behaviors of healthcare workers. The health belief model is a psychological model that helps predict health behaviors by focusing on the attitudes and beliefs of individuals. The health belief model has some key components of perceived susceptibility, perceived severity, perceived benefits and perceived barriers.
According to this theory, healthcare workers would adhere to hand hygiene if they believed that they were susceptible to infection if they did not wash their hands. Education on infection control may influence staff's perceived risk of contracting and spreading infection. Staff may perceive severity by understanding the serious consequences of infection caused by poor hand hygiene compliance, such as prolonged hospital stay, expensive medical cost, and increased morbidity. Staff may perceive benefits regarding the effectiveness of hand hygiene practice when it comes to decreasing infection among patients and thereby decreasing healthcare workers' heavy workload.
The major role of leaders is to move people and organizations from responsibility to accountability. Involvement of all members of staff is the key to their success in infection control. Leaders need to introduce ownership and accountability in the organization culture. To sustain hand hygiene compliance, education and role modeling at both the individual and organizational levels might be beneficial.
1. Klevens, R.M., et al. (2007). Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Reports, 122(2), 160-166.
2. Boyce, J. (2008, October 2). Hand hygiene compliance monitoring: Current perspectives from the USA. Journal of Hospital Infection, 70, 2-7.
3. Curry, V. & Cole, M. (2005). Applying social behavioral theory as a template in contracting and confining VRE. Critical Care Nurse Quarterly, 24,2 13-19.
4. Whitby, M., et al. (2008, June). Three successful interventions in health care workers that improve compliance with hand hygiene: Is sustained replication possible? American Journal of Infection Control, 36(5), 349-355.
5. Duffin C. (2008). Leadership and workload key to infection control. Nursing Standard, 22 (47): 7.
6. Aiello, A., et al. (2009, March). The influence of knowledge, perceptions, and beliefs, on hand hygiene practices in nursing homes. American Journal of Infection Control, 37(2), 164-167.
7. Maskerine, C., & Loeb, M. (2006). Improving adherence to hand hygiene among health care workers. Journal of Continuing Education in the Health Professions, 26(3), 244-251.
8. Berhe, M., et al. (2006, October). Measurement and feedback of infection control process measures in the intensive care unit: Impact on compliance. American Journal of Infection Control, 34(8), 537-539.
9. Hugonnet, S., et al. (2002). Alcohol-based handrub improves compliance with hand hygiene in intensive care units. Archives of Internal Medicine, 162(9), 1037-1043.
Min Jeong Seo is a team leader, Boston Dialysis Center, Boston.