Systematic qualitative literature review of health care workers' compliance with hand hygiene guidelines

A seesaw of equilibrium, midwives' experiences of infection prevention and control guideline adherence: A qualitative descriptive study

Background

Infection prevention and control guidelines play a key role in preventing infections which can impact mothers and their newborn's quality of life. Despite the presence of evidenced-based infection prevention and control guidelines, midwives' adherence can be suboptimal internationally. The identification of facilitators and barriers to infection prevention and control guidelines can support practice and facilitate midwifery care.

Aim

To understand midwives' experiences of the barriers and facilitators when adhering to infection prevention and control guidelines.

Methods

A qualitative descriptive study using semi-structured interviews with 10 midwives from February to March 2022. The interviews were audio recorded, transcribed verbatim, and analysed utilising Braun and Clarke's thematic analysis framework involving the six steps of becoming familiar with the data, generating initial codes, generating themes, reviewing themes, defining and naming the themes, and presenting themes.

Findings

Two themes developed; seesaw for equilibrium and back to basics: learning on your feet. Midwives experienced conflicting emotional motivators in the need for professional integrity towards infection prevention and control guideline adherence. The work environment impacts on midwives' ability to adhere to guidelines and communication and education have a vital role to play in infection prevention and control guideline adherence.

Conclusions

While midwives have a strong sense of protection of professional integrity, work conditions such as environment, organisational structures, and management systems affect midwives' adherence to infection prevention and control guidelines. Effective education, training, and communication are required to promote infection prevention and control guideline adherence.

Determinants of hand hygiene compliance among healthcare workers in intensive care units: a qualitative study

BACKGROUND

Practicing hand hygiene is a cost-effective method to decrease the occurrence of Healthcare-Associated Infections (HAIs). However, despite their simplicity, adhering to hand hygiene methods among healthcare workers (HCWs) can be highly challenging. We aim to examine the factors influencing hand hygiene compliance as perceived by HCWs working in the intensive care units (ICUs) at several major hospitals in Riyadh, Saudi Arabia.

METHOD

This qualitative study was conducted by adopting a content analysis to examine the interviews of HCWs who are currently working in the ICUs of various major hospitals located in the capital city of Riyadh, Saudi Arabia.

RESULTS

We interviewed 49 HCWs working in ICUs, with an average age of 38 and 8 years of experience. The HCWs comprised doctors (n = 12), anesthesiologists (n = 6), and nurses (n = 31). There were 34 females and 15 males among the participants. Our analysis revealed several factors that impact hand hygiene compliance, including individual, work/environment, team, task, patient, organizational, and management concerns. Several obstacles and possibilities for enhancement have been identified.

CONCLUSION

The results of this study would enhance our comprehension of hand hygiene practices and serve as a foundation for creating future strategies and assessment methods to enhance compliance with hand hygiene protocols in ICUs.

Mobile Applications for Learning Hand Hygiene: A Comparative Analysis

Infection control is crucial for high-quality patient care. One of the most effective and commonly used infection control procedures is hand hygiene which, it is known, requires repeated refresher training. There are many ways to educate healthcare professionals about hand hygiene, including the use of mobile applications (apps). Our aim is to review such hand hygiene apps, and to identify which have been available since 2021 and to assess their quality. We conducted a review using the PRISMA diagram to document our app selection process in the Google Play Store and Apple store in March 2024. For the evaluation of apps, we used the user version of the Mobile Application Rating Scale questionnaire (uMARS). Of 16 apps only five adhere to WHO hand hygiene guidelines. Timers were included in 12 of the 16 apps and reminders were included in 10 of 16 apps. The highest overall uMARS scoring app was Give Me 5-Hand Hygiene (4.31 ± 0.28), while Wash your hands! (1.17 ± 0.14) had the lowest score. We found that more than half of the apps were unavailable from the 2021 review. We believe that app-based education could effectively sustain hand hygiene knowledge in healthcare settings.

Process Evaluation of an Acute-Care Nurse-Centred Hand Hygiene Intervention in US Hospitals

This paper describes a process evaluation of a 'wise' intervention that took place in six acute care units in two medical-surgical teaching hospitals in the United States during 2016-2017. 'Wise' interventions are short, inexpensive interventions that depend on triggering specific psychological mechanisms to achieve behaviour change. This study sought to increase the hand hygiene compliance (HHC) rates before entering a patient's room among nurses. The intervention centred on the use of threat to professional identity to prompt improved HHC. Through questionnaires administered to intervention participants and the implementation facilitator, together with independent observation of intervention delivery, we examined whether the steps in the Theory of Change occurred as expected. We found that aspects of the implementation-including mode of delivery, use of incentives, and how nurses were recruited and complied with the intervention-affected reach and likely effectiveness. While components of the intervention's mechanisms of impact-such as the element of surprise-were successful, they ultimately did not translate into performance of the target behaviour. Performance was also not affected by use of an implementation intention as repeated performance of HHC over years of being a nurse has likely already established well-ingrained practices. Context did have an effect; the safety culture of the units, the involvement of the Nurse Managers, the level of accountability for HHC in each unit, and the hospitals themselves all influenced levels of engagement. These conclusions should have implications for those interested in the applicability of 'wise' interventions and those seeking to improve HHC in hospitals.

Barriers to radiographers' use of radiation safety principles: A qualitative perspective

INTRODUCTION

To minimise the risks associated with ionising radiation, it is necessary for all staff involved to employ specific techniques to reduce radiation exposure of the patient. These techniques include using compression during examinations of the pelvic region and lumbar spine, using a gonad shield, and asking women if they are pregnant. However, some staff do not use these techniques consistently. Increasing compliance requires determining why staff are non-compliant. Thus, this study aims to qualitatively investigate why radiographers do not use these techniques.

METHODS

This qualitative study is based on a cross-sectional electronic survey with open-ended questions. The data were analysed using an inductive qualitative content analysis with quantification of the findings. In total, 111 radiographers from 20 hospitals in Sweden participated.

RESULTS

Three categories appear related to barriers that could obstruct the radiographer from using compression, gonad shields and asking about pregnancy: patient characteristics, interaction between the patient and the radiographer and issues related to the situation and examination.

CONCLUSIONS

The barriers to not using radiation protection measures varied depending on the specific measure. However, the barriers were mainly related to the patient experiencing pain, communication difficulties and cultural reasons. In addition, the lack of adequate and user-friendly equipment was seen as a barrier to applying compression and using gonad shielding.

Hand hygiene perceptions, preferences, and practices among hospital staff in the Dominican Republic in the context of COVID-19: a qualitative study

Background

Proper hand hygiene (HH), which includes sanitizing with alcohol-based hand rub (ABHR) (or handwashing with soap and water if ABHR is unavailable), is key for preventing healthcare-associated infections (HCAI), including COVID-19. Understanding drivers of HH is key to improving adherence.

Aim

This study aims to explore drivers and barriers to HH practice at two hospitals in the Dominican Republic in the context of the COVID-19 pandemic to inform development of HH behaviour change interventions.

Methods

We conducted in-depth interviews with 20 hospital staff during September 2021. We used the COM-B (capability, opportunity, motivation, behaviour) model to explore HH experiences and preferences. Interviews were recorded, transcribed, coded, and analysed using a thematic approach.

Results

A total of 11 parent codes and 27 sub-codes were identified, and 1145 coded segments were analysed. Use of handwashing with soap and water and/or sanitizing with ABHR was reported by all participants; handwashing was generally preferred. Participants expressed knowledge of proper HH methods (capability), but inconsistent supplies and lack of time presented HH challenges (opportunity). Interviewees described practicing HH to protect themselves and their families from COVID-19 and other infections (reflective motivation) or out of habit (automatic motivation).

Discussion

By understanding and addressing underlying factors affecting HH, hospitals can decrease the risk of HCAIs. Our findings suggest that interventions implemented to improve HH in these hospitals should target motivation and opportunity. These findings informed a multimodal intervention to increase ABHR access and implement message-tested communications campaigns; end-point assessments will provide insights into the intervention's impact.

Central aspects when implementing an electronic monitoring system for assessing hand hygiene in clinical settings: A grounded theory study

Background

New technologies, such as electronic monitoring systems, have been developed to promote increased adherence to hand hygiene among healthcare workers. However, challenges when implementing these technologies in clinical settings have been identified.

Aim

The aim of this study was to explore healthcare workers' experiences when implementing an electronic monitoring system to assess hand hygiene in a clinical setting.

Method

Interviews with healthcare workers (registered nurses, nurse assistants and leaders) involved in the implementation process of an electronic monitoring system (n = 17) were conducted and data were analyzed according to the grounded theory methodology formulated by Strauss and Corbin.

Results

Healthcare workers' experiences were expressed in terms of leading and facilitating, participating and contributing, and knowing and confirming. These three aspects were merged together to form the core category of collaborating for progress. Leaders were positive and committed to the implementation of the electronic monitoring system, endeavouring to enable facilitation and support for their co-workers (registered nurses and nurse assistants). At the same time, co-workers were positive about the support they received and contributed by raising questions and demands for the product to be used in clinical settings. Moreover, leaders and co-workers were aware of the objective of implementing the electronic monitoring system.

Conclusion

We identified dynamic collective work between leaders and co-workers during the implementation of the electronic monitoring system. Leadership, participation and knowledge were central aspects of enhancing a collaborative process. We strongly recommend involving both ward leaders and users of new technologies to promote successful implementation.

Nurses' preferences for interventions to improve infection prevention and control behaviors based on systems engineering initiative to patient safety model: a discrete choice experiment

BACKGROUND

The evidence of preferences for infection prevention and control (IPC) intervention from system perspective was lacked. This study aimed to elicit nurses' preferences for the intervention designed to improve IPC behaviors based on the Systems Engineering Initiative to Patient Safety (SEIPS) model using Discrete Choice Experiment (DCE).

METHODS

A DCE was conducted among nurses who were on active duty and willing to participate from July 5th to 10th, 2021 in a tertiary hospital in Ganzhou City, Jiangxi Province, using convenience sampling. A self-administered questionnaire included scenarios formed by six attributes with varying levels based on SEIPS model: person, organization, tools and technology, tasks, internal environment and external environment. A conditional logit and latent class logit model were performed to analyze the data.

RESULTS

A total of 257 valid questionnaires were analyzed among nurses. The results from the latent class logit model show that nurses' preferences can be divided into three classes. For nurses in multifaceted-aspect-preferred class (41.9%), positive coefficients were obtained in those six attributes. For person-preferred class (19.7%), only person was positively significant. For environment-preferred class (36.4%), the most important attribute were tasks, tools and technology, internal environment and external environment.

CONCLUSIONS

This finding suggest that nurses have three latent-class preferences for interventions. Multifaceted interventions to improve IPC behaviors based on the SEIPS model are preferred by most nurses. Moreover, relevant measured should be performed targeted the latent class of person-preferred and external-environment-preferred nurses.

Effects of data-driven feedback on nurses' and physicians' hand hygiene in hospitals - a non-resource-intensive intervention in real-life clinical practice

Background

Hand hygiene (HH) by healthcare workers (HCWs) is one of the most important measures to prevent hospital-acquired infections. However, HCWs struggle to adhere to HH guidelines. We aimed to investigate the effect of a non-resource intensive intervention with group and individual feedback on HCWs HH in a real-life clinical practice during the COVID-19 pandemic.

Methods

In 2021, an 11-month prospective, interventional study was conducted in two inpatient departments at a Danish university hospital. An automated hand hygiene monitoring system (Sani Nudge™) was used to collect data. HH opportunities and alcohol-based hand rub events were measured. Data were provided as HH compliance (HHC) rates. We compared HHC across 1) a baseline period, 2) an intervention period with weekly feedback in groups, followed by 3) an intervention period with weekly individual feedback on emails, and 4) a follow-up period.

Results

We analyzed data from physicians (N=65) and nurses (N=109). In total, 231,022 hygiene opportunities were analyzed. Overall, we observed no significant effect of feedback, regardless of whether it was provided to the group or individuals. We found a trend toward a higher HHC in staff restrooms than in medication rooms and patient rooms. The lowest HHC was found in patient rooms.

Conclusions

The automated hand hygiene monitoring system enabled assessment of the interventions. We found no significant effect of group or individual feedback at the two departments. However, other factors may have influenced the results during the pandemic, such as time constraints, workplace culture, and the degree of leadership support.

Environmental approaches to controlling Clostridioides difficile infection in healthcare settings

As today's most prevalent and costly healthcare-associated infection, hospital-onset Clostridioides difficile infection (HO-CDI) represents a major threat to patient safety world-wide. This review will discuss how new insights into the epidemiology of CDI have quantified the prevalence of C. difficile (CD) spore contamination of the patient-zone as well as the role of asymptomatically colonized patients who unavoidable contaminate their near and distant environments with resilient spores. Clarification of the epidemiology of CD in parallel with the development of a new generation of sporicidal agents which can be used on a daily basis without damaging surfaces, equipment, or the environment, led to the research discussed in this review. These advances underscore the potential for significantly mitigating HO-CDI when combined with ongoing programs for optimizing the thoroughness of cleaning as well as disinfection. The consequence of this paradigm-shift in environmental hygiene practice, particularly when combined with advances in hand hygiene practice, has the potential for significantly improving patient safety in hospitals globally by mitigating the acquisition of CD spores and, quite plausibly, other environmentally transmitted healthcare-associated pathogens.

Healthcare Personnel Hand Hygiene Compliance: Are We There Yet?

Purpose of Review

Poor hand hygiene is well documented as a factor in healthcare-associated infections and excellent rates of hand hygiene remains elusive.

Recent Findings

There is increased use of universal or increased gloving to minimize hand contamination, but its use does not replace hand hygiene opportunities. There is significant interest in electronic hand hygiene monitoring systems, but they are not without their unique issues. Behavioral psychology remains a significant factor in motivating hand hygiene behaviors; even in COVID-19, hand hygiene rates initially improved but trended down back to baseline while still dealing with the pandemic.

Summary

More emphasis should be placed on the how to properly perform hand hygiene and why it is so important, as well as the role of gloves, is needed. Continued investment and awareness of their status as role models from both system leadership and senior healthcare providers are needed.

A Multifaceted Approach to the "Bare below the Elbow" Concept and Hand Hygiene Compliance among Healthcare Professionals-Multicenter Population-Based Study

Nosocomial infections remain an important issue for patient safety concerns. Since hospital infections are mainly connected with healthcare professionals' routines, an increase in hand hygiene effectiveness through compliance with the "bare below the elbow" (BBE) concept could reduce the number of nosocomial infections. Therefore, this study aims to evaluate hand hygiene and to investigate healthcare professionals' compliance with the BBE concept. We performed our study on a group of 7544 hospital professionals involved in patient care. During the national preventive action, questionnaires, demographic data, and hand hygiene preparations were recorded. Hand disinfection was verified by COUCOU BOX, containing a UV camera. We noted that 3932 (52.1%) persons complied with the BBE rules. Nurses and non-medical personnel were significantly more often classified as BBE rather than non-BBE (2025; 53.3% vs. 1776; 46.7%, respectively, p = 0.001 and 1220; 53.7% vs. 1057; 46.3%, p = 0.006). Different proportions were demonstrated for the groups of physicians-non-BBE (783; 53.3%) compared to BBE (687; 46.7%) (p = 0.041). Healthcare workers from the BBE group statistically more often disinfected their hands correctly (2875/3932; 73.1%) compared to the non-BBE group (2004/3612; 55.5%) (p < 0.0001). This study demonstrates the positive impact of compliance with the BBE concept on effective hand disinfection and patient safety. Therefore, education and infection-prevention actions should be popularized to improve the BBE policy's effectiveness as well.

Qualitative assessment of hand hygiene knowledge, attitudes and practices among healthcare workers prior to the implementation of the WHO Hand Hygiene Improvement Strategy at Faranah Regional Hospital, Guinea

Healthcare-associated infections are a serious burden globally. Few qualitative studies have explored healthcare workers' knowledge, attitudes and practices of hand hygiene. Prior to the implementation of the World Health Organization's Hand Hygiene Improvement Strategy at Faranah Regional Hospital in the Upper Region of Guinea in December 2018, we conducted a qualitative baseline assessment of knowledge, attitudes and practices of hand hygiene among healthcare workers to guide future hand hygiene interventions. The qualitative study consisted of direct observations, In-Depth Interviews (IDIs) and Focus Group Discussions (FGDs). We found that the 2013-16 Ebola outbreak had had a pivotal impact on healthcare workers' knowledge, attitudes and practices. The severity of the disease and the training provided for infection control were responsible for their knowledge acquisition and adoption of good attitudes and practices. However, negligence, resulting in poor hand hygiene practices, rose after the outbreak, once the "cue of fear" that had motivated workers for their own self-protection had waned. Our results suggest that local capacity building through training and availability of hand hygiene materials would be a sustainable approach to enhance hand hygiene culture at the hospital. Our study suggests that there is a need for a high and long-term commitment of authorities and healthcare workers at all levels for a sustainable hand hygiene culture.

Nurses' assessed self-efficacy levels to medical asepsis and their relation to structural empowerment, work engagement and work-related stress

BACKGROUND

Nurses' working conditions are important for their well-being at work and for their ability to provide patients with safe care. Self-efficacy can influence employees' behaviour at work. Therefore, it is valuable to study self-efficacy levels to medical asepsis in relation to working conditions.

OBJECTIVE

To investigate the relationship between nurses' assessed self-efficacy levels to medical asepsis in care situations and structural empowerment, work engagement and work-related stress.

METHODS

A cross-sectional study with a correlational design was conducted. A total of 417 registered nurses and licensed practical nurses at surgical and orthopaedic units responded to a questionnaire containing: the Infection Prevention Appraisal Scale, the Conditions of Work Effectiveness Questionnaire-II, the Utrecht Work Engagement Scale-9 and the Health & Safety Executive Management Standards Indicator Tool. Correlational analyses and group comparisons were performed.

RESULTS

The nurses rated high levels of self-efficacy to medical asepsis in care situations. The correlational analyses revealed that correlation coefficients between structural empowerment, work engagement, work-related stress and self-efficacy to medical asepsis were 0.254-0.268. Significant differences in self-efficacy were found in the grouped working conditions.

CONCLUSIONS

This study revealed that nurses rated high self-efficacy levels to medical asepsis and, to some extent, this seemed related to structural empowerment, work engagement and work-related stress. This valuable knowledge could enable improvements at the managerial and organisational levels, benefiting both nurses and patients in the long run.

Impact of COVID-19 pandemic waves on health-care worker hand hygiene activity in department of medicine and ICU as measured by an automated monitoring system

BACKGROUND

Hand hygiene (HH) compliance among health-care workers is important for preventing transmission of infectious diseases.

AIM

To describe health-care worker hand hygiene activity in ICU and non-ICU patients' rooms, using an automated monitoring system (AMS), before and after the onset of the COVID-19 pandemic.

METHODS

At the Intercommunal Hospital of Créteil, near Paris, France, alcohol-based hand sanitizer (ABHS) consumption in the Department of Medicine (DM) and ICU was recorded using an AMS during four periods: before, during, and after the first wave of the COVID-19 pandemic, and during its second wave.

FINDINGS

From 1st February to 30th November 2020, in the DM, the mean number of doses per patient-day for each of the four periods was, respectively, 5.7 (±0.3), 19.4 (±1.3), 17.6 (±0.7), and 7.9 (±0.2, P < 0.0001). In contrast, ICU ABHS consumption remained relatively constant. In the DM, during the pandemic waves, ABHS consumption was higher in rooms of COVID-19 patients than in other patients' rooms. Multivariate analysis showed ABHS consumption was associated with the period in the DM, and with the number of HCWs in the ICU.

CONCLUSION

An AMS allows real-time collection of ABHS consumption data that can be used to adapt training and prevention measures to specific hospital departments.

A controlled before-and-after study of a multi-modal intervention to improve hand hygiene during the peri-natal period in Cambodia

Adequate hand hygiene practices throughout the continuum of care of maternal and newborn health are essential for infection prevention. However, the hand hygiene compliance of facility-based birth attendants, parents and other caregivers along this continuum is low and behavioural-science informed interventions targeting the range of caregivers in both the healthcare facility and home environments are scarce. We assessed the limited efficacy of a novel multimodal behaviour change intervention, delivered at the facility, to improve the hand hygiene practices among midwives and caregivers during childbirth through the return to the home environment. The 6-month intervention was implemented in 4 of 8 purposively selected facilities and included environmental restructuring, hand hygiene infrastructure provision, cues and reminders, and participatory training. In this controlled before-and-after study, the hand hygiene practices of all caregivers present along the care continuum of 99 women and newborns were directly observed. Direct observations took place during three time periods; labour, delivery and immediate aftercare in the facility delivery room, postnatal care in the facility ward and in the home environment within the first 48 h following discharge. Multilevel logistic regression models, adjusted for baseline measures, assessed differences in hand hygiene practices between intervention and control facilities. The intervention was associated with increased odds of improved practice of birth attendants during birth and newborn care in the delivery room (Adjusted odds ratio [AOR] = 4.7; 95% confidence interval [CI] = 2.7, 7.7), and that of parental and non-parental caregivers prior to newborn care in the post-natal care ward (AOR = 9.2; CI = 1.3, 66.2); however, the absolute magnitude of improvements was limited. Intervention effects were not presented for the home environment due COVID-19 related restrictions on observation duration at endline which resulted in too low observation numbers to warrant testing. Our results suggest the potential of a facility-based multimodal behaviour change intervention to improve hand hygiene practices that are critical to maternal and neonatal infection along the continuum of care.

Hand hygiene improvement of individual healthcare workers: results of the multicentre PROHIBIT study

BACKGROUND

Traditionally, hand hygiene (HH) interventions do not identify the observed healthcare workers (HWCs) and therefore, reflect HH compliance only at population level. Intensive care units (ICUs) in seven European hospitals participating in the "Prevention of Hospital Infections by Intervention and Training" (PROHIBIT) study provided individual HH compliance levels. We analysed these to understand the determinants and dynamics of individual change in relation to the overall intervention effect.

METHODS

We included HCWs who contributed at least two observation sessions before and after intervention. Improving, non-changing, and worsening HCWs were defined with a threshold of 20% compliance change. We used multivariable linear regression and spearman's rank correlation to estimate determinants for the individual response to the intervention and correlation to overall change. Swarm graphs visualized ICU-specific patterns.

RESULTS

In total 280 HCWs contributed 17,748 HH opportunities during 2677 observation sessions. Overall, pooled HH compliance increased from 43.1 to 58.7%. The proportion of improving HCWs ranged from 33 to 95% among ICUs. The median HH increase per improving HCW ranged from 16 to 34 percentage points. ICU wide improvement correlated significantly with both the proportion of improving HCWs (ρ = 0.82 [95% CI 0.18-0.97], and their median HH increase (ρ = 0.79 [0.08-0.97]). Multilevel regression demonstrated that individual improvement was significantly associated with nurse profession, lower activity index, higher nurse-to-patient ratio, and lower baseline compliance.

CONCLUSIONS

Both the proportion of improving HCWs and their median individual improvement differed substantially among ICUs but correlated with the ICUs' overall HH improvement. With comparable overall means the range in individual HH varied considerably between some hospitals, implying different transmission risks. Greater insight into improvement dynamics might help to design more effective HH interventions in the future.

Understanding Hand Hygiene Behavior in a Public Hospital in Benin Using the Theoretical Domain Frameworks: The First Step for Designing Appropriate Interventions

Background: Hand Hygiene (HH) is widely recognized to be one of the most successful and cost-effective measures for reducing the incidence of healthcare-associated infections (HAIs). The hand hygiene behavior of hospital healthcare workers (HCWs) is not well-documented in Benin. Therefore, Theoretical Domains Framework (TDF) was used to identify the behavioral determinants that may impact HCWs’ hand-hygiene compliance in a public hospital. Methods: A qualitative design comprising face-to-face semi-structured interviews with nine HCWs. The interviews included questions on transmission of infections, hand-hygiene practices, problems with their implementation; and ways to improve hand hygiene compliance. Two pharmacists independently coded interviews into behavioral domains using the TDF and then subdivided them into several themes. Interview transcripts were analyzed following 3-steps approach: coding, generation of specific beliefs, and identification of relevant domains. Results: Almost all interviewees have cited the environmental context and resources (such as lack of water) as a barrier to HH practice. They also believed that role models had a significant impact on the good practices of others HCWs. Fortunately, they were confident of their capabilities to perform appropriate HH behaviors. The majority (7/9) reported having the necessary knowledge and skills and believed they could carry out appropriate HH behavior. In all cases, the participants were motivated to carry out HH behavior, and it was recognized that HH remains the cornerstone to reduce health care associated infections. Conclusion: This study identified several behavioral constructs aligned with the TDF that can be targeted and help for the development of new hand-hygiene interventions. These may increase the likelihood of a successful intervention, thereby improving HH compliance and patient safety, especially in hospitals.

Healthcare worker mental models of patient care tasks in the context of infection prevention and control

OBJECTIVE

Understanding the cognitive determinants of healthcare worker (HCW) behavior is important for improving the use of infection prevention and control (IPC) practices. Given a patient requiring only standard precautions, we examined the dimensions along which different populations of HCWs cognitively organize patient care tasks (ie, their mental models).

DESIGN

HCWs read a description of a patient and then rated the similarities of 25 patient care tasks from an infection prevention perspective. Using multidimensional scaling, we identified the dimensions (ie, characteristics of tasks) underlying these ratings and the salience of each dimension to HCWs.

SETTING

Adult inpatient hospitals across an academic hospital network.

PARTICIPANTS

In total, 40 HCWs, comprising infection preventionists and nurses from intensive care units, emergency departments, and medical-surgical floors rated the similarity of tasks. To identify the meaning of each dimension, another 6 nurses rated each task in terms of specific characteristics of tasks.

RESULTS

Each HCW population perceived patient care tasks to vary along 3 common dimensions; most salient was the perceived magnitude of infection risk to the patient in a task, followed by the perceived dirtiness and risk of HCW exposure to body fluids, and lastly, the relative importance of a task for preventing versus controlling an infection in a patient.

CONCLUSIONS

For a patient requiring only standard precautions, different populations of HCWs have similar mental models of how various patient care tasks relate to IPC. Techniques for eliciting mental models open new avenues for understanding and ultimately modifying the cognitive determinants of IPC behaviors.

Hand Hygiene in the Intensive Care Unit: Knowledge, Compliance and Factors Influencing Nursing Adherence, a Descriptive Study

Background:

Nosocomial infections are particularly common among hospitalized patients who undergo resuscitation compared with other types of care. Hand hygiene remains the simplest and most effective measure to prevent and control the risk of infection.

Objective:

The main objectives are to evaluate hand hygiene compliance among nursing staff in the different intensive care units and to identify the factors influencing the adherence of nursing staff to the practice.

Methods:

It was a quantitative descriptive study using a questionnaire and an observation grid with all the nursing staff working in all the intensive care units of our university hospital.

Results:

The study showed a hand contamination rate of (80%), a hand hygiene compliance rate of (21.3%), it also showed the different factors explaining non-adherence, these are not necessarily related to training, nor to the availability of material resources but related to hidden reasons, non-apparent factors, which are often more important. (Workload and work environment)

Conclusion:

This study examined hand hygiene in the ICU setting, obtained data on overall compliance, which remains poor, and the various factors influencing nurses' adherence to the practice.

Capability, Opportunity, Motivation, and Hand Hygiene Behavior in Healthcare Workers: A Structural Equation Modeling

Background

Hand hygiene among healthcare workers is the leading measure to reduce healthcare-associated infections. However, hand hygiene behavior is complex and not readily understood. This study aimed to identify the determinants and the underlying mechanism of hand hygiene behavior based on the capability, opportunity, motivation-behavior model.

Methods

A self-constructed questionnaire survey was conducted among healthcare workers in Chongqing, China. Capability, opportunity, and motivation were designed as independent variables, and hand hygiene behavior was measured as a dependent variable. Internal consistency reliability analysis and confirmatory factor analysis were applied to examine the reliability and validity of the questionnaire. Structural equation modeling was performed to explore the relationships among capability, opportunity, motivation, and hand hygiene behavior.

Results

Four hundred and ninety-nine physicians and nurses were investigated. The Cronbach's α coefficients were above 0.764. Confirmatory factor analysis was confirmed with good data fitness. The structural equation modeling had a good fit (root mean square error of approximation=0.070, comparative fit index=0.960, Tucker-Lewis index=0.956). Both opportunity (β=0.265, p<0.05) and motivation (β=0.333, p<0.05) directly affected hand hygiene behavior. Both capability (β=0.194, p<0.001) and opportunity (β=0.719, p<0.001) were indirectly linked to hand hygiene behavior through motivation.

Conclusion

To improve hand hygiene behavior, more efforts need to be focused on resource provision and motivation enhancement in the future compared to training.

Nursing care for patients carrying multi-drug resistant organisms: Experiences, intention to use protective equipment and ability to comply with measures

AIMS

The aims of the study were to explore the impact of caring for patients carrying multi-drug resistant organisms on nursing staff and identify factors predicting their intention to use personal protective equipment and their ability to comply with advised infection prevention and control measures.

BACKGROUND

Carriage of multi-drug resistant organisms and corresponding infection prevention and control measures have a major impact on patients. Limited research has been done to investigate the impact of caring for these patients on nursing staff.

DESIGN

A cross-sectional design.

METHODS

Online survey among Dutch nursing staff in various healthcare settings. Prediction analyses were conducted using random forest. The STROBE checklist was used preparing the manuscript.

RESULTS

974 respondents were included. The majority of nursing staff reported to have experience in caring for patients carrying multi-drug resistant organisms. Relevant dilemmas in daily practice were identified. Important predictors of the intention to use protective equipment were practicing hand hygiene, usable protocols, favourable attitudes and perceptions, as well as knowledge. Important predictors of the ability to comply with advised measures were usable and findable protocols, a suitable work environment and practicing hand hygiene.

CONCLUSION

We have gained comprehensive insight into experiences, attitudes, perceptions, knowledge and dilemmas in daily practice of nursing staff caring for patients carrying multi-drug resistant organisms. To enhance their intention to use protective equipment and their ability to comply with advised measures, activities should focus on improving hand hygiene and the usability of protocols. Additionally, efforts are needed to improve knowledge, provide better resources and a more supportive work environment. All of which need to be specifically tailored to each healthcare setting.

RELEVANCE TO CLINICAL PRACTICE

The results can be used in the development of interventions to improve nursing care while reducing the unfavourable impact on nursing staff and supporting adherence to advised measures.

Hand hygiene compliance among healthcare workers before and during the COVID-19 pandemic

BACKGROUND

Healthcare workers' (HCWs) adherence to hand hygiene is vital in combatting COVID-19 in hospitals. We aimed to investigate HCWs hand hygiene compliance before and during the COVID-19 pandemic and hypothesised that hand hygiene compliance would increase during the pandemic.

METHODS

We conducted a prospective observational study in three medical departments at the Regional Hospital of West Jutland, Denmark from April 2019 to August 2020. A total of 150 HCWs participated before the COVID-19 pandemic and 136 during the pandemic. Hand hygiene observations were assessed using an automated hand hygiene monitoring system. Students unpaired t-test was used to assess differences in hand hygiene compliance rates in each department.

RESULTS

Comparison analyses showed, that hand hygiene compliance in department A and B was significantly higher before the COVID-19 pandemic than during the pandemic; a 7% difference in department A and a 5% difference in department B. For department C, the total hand hygiene compliance was unchanged during the pandemic compared to before.

CONCLUSION

The COVID-19 pandemic did not raise hand hygiene compliance. Further studies are needed to verify these findings and further identify barriers to hand hygiene compliance among HCWs.

Evaluating methods for the use and decontamination of needleless connectors: A qualitative inquiry

BACKGROUND

Needleless connectors (NCs) are essential devices designed to provide safe, needle-free connection between venous access devices, syringes and infusions. There is a variety of designs, and associated decontamination products and practices; the resulting confusion can cause detrimental patient outcomes. This study aimed to explore nurses' attitudes, techniques, and practices around the use and decontamination of NCs in clinical practice.

METHODS

Qualitative inquiry was conducted with seven focus groups of 4-6 participants each in the cancer and surgical units of a large tertiary hospital in Australia between January and March 2019. Participants comprised nurses who had taken part in a recent clinical trial of NC decontamination. Focus group sessions were recorded, transcribed and synthesised using content analysis.

RESULTS

Seven focus groups were conducted (total, N = 30 participants), lasting 16-20 min. Six major themes were identified surrounding needleless connector use and decontamination: 'safety and utility'; 'terminology and technological understanding'; 'clinical practice determinants'; 'decontamination procedures and influencers'; 'education and culture'; and 'research and innovation'.

CONCLUSION

The participants articulated positive attitudes towards needleless connector use for needle-stick and infection prevention, however rationales for care and maintenance practices demonstrated limited understanding of guidelines (e.g., disinfection time) and specific NC function (e.g., positive, negative pressure). The findings indicated the need for targeted, standardised needleless connector education, to enhance staff confidence, improve consistency of care and ensure patient safety.

Translating a theory-based positive deviance approach into an applied tool: Mitigating barriers among health professionals (HPs) regarding infection prevention and control (IPC) guidelines

Background

Although a wide range of intervention programs and methods have been implemented to increase health professionals’ (HPs) adherence with infection prevention and control (IPC) guidelines and decrease the incidence of healthcare associated infections (HAIs), a significant discrepancy remains between the guidelines and their implementation in practice.

Objectives

This study proposes an applied tool based on the integrated theoretical framework of the positive deviance (PD) approach for developing more effective interventions to mitigate this discrepancy.

Methods

A qualitative study guided by the PD approach based on data from two sources: (1) in-depth archival analysis of systematic review articles, and (2) integration and synthesis of findings based on an extensive empirical study we conducted, involving 250 HPs (nurses, physicians, support staff and cleaning staff) from three governmental hospitals in Israel, over 35 months (January 2017 to November 2020).

Results

The barriers faced by HPs were classified into four main categories: (1) individual-motivational, (2) social-cultural, (3) organizational, and (4) work environment and resource-centered. For each barrier, we constructed a set of questions based on the PD approach. For each question, we adapted and applied methodological tools (e.g., in-depth interviews, focus groups, social network maps, video clips and simulations) to help solve the problem.

Conclusion

Translating a theory-based approach into an applied tool that offers step-by-step actions can help researchers and practitioners adopt and implement the approach within intervention programs to mitigate barriers.

Electronic hand hygiene monitoring systems can be well-tolerated by health workers: Findings of a qualitative study

Background:

Electronic hand hygiene monitoring overcomes limitations associated with manual audit but acceptability to health workers varies and may depend on culture of the ward and the nature of the system.

Objectives:

Evaluate the acceptability of a new fifth type electronic monitoring system to frontline health workers in a National Health Service trust in the UK.

Methods:

Qualitative interviews with 11 informants following 12 months experience using an electronic monitoring system.

Results:

Informants recognised the importance of hand hygiene and embraced technology to improve adherence. Barriers to hand hygiene adherence included heavy workload, dealing with emergencies and ergonomic factors related to placement of alcohol dispensers. Opinions about the validity of the automated readings were conflicting. Some health workers thought they were accurate. Others reported problems associated with differences in the intelligence of the system and their own clinical decisions. Opinions about feedback were diverse. Some health workers thought the system increased personal accountability for hand hygiene. Others ignored feedback on suboptimal performance or ignored the data altogether. It was hard for health workers to understand why the system registered some instances of poor performance because feedback did not allow omissions in hand hygiene to be related to the context of care.

Conclusion:

Electronic monitoring can be very well tolerated despite some limitations. Further research needs to explore different reactions to feedback and how often clinical emergencies arise. Electronic and manual audit have complementary strengths.

Adherence to protective measures among healthcare workers in the UK: a cross-sectional study

BACKGROUND

Healthcare workers (HCWs) are frontline responders to emergency infectious disease outbreaks such as COVID-19. To avoid the rapid spread of disease, adherence to protective measures is paramount. We investigated rates of correct use of personal protective equipment (PPE), hand hygiene and physical distancing in UK HCWs who had been to their workplace at the start of the COVID-19 pandemic and factors associated with adherence.

METHODS

We used an online cross-sectional survey of 1035 UK healthcare professionals (data collected 12-16 June 2020). We excluded those who had not been to their workplace in the previous 6 weeks, leaving us with a sample size of 831. Respondents were asked about their use of PPE, hand hygiene and physical distancing in the workplace. Frequency of uptake was reported descriptively; adjusted logistic regressions were used to separately investigate factors associated with adherence to use of PPE, maintaining good hand hygiene and physical distancing from colleagues.

RESULTS

Adherence to personal protective measures was suboptimal (PPE use: 80.0%, 95% CI 77.3 to 82.8; hand hygiene: 67.8%, 95% CI 64.6 to 71.0; coming into close contact with colleagues: 74.7%, 95% CI 71.7 to 77.7). Adherence to PPE use was associated with having received training about health and safety in the workplace for COVID-19, greater perceived social pressure to adopt the behaviour and availability of PPE. Non-adherence was associated with fatalism about COVID-19 and greater perceived difficulty of adopting protective measures. Workplace design using markings to facilitate distancing was associated with adherence to physical distancing.

CONCLUSIONS

Uptake of personal protective behaviours among UK HCWs at the start of the pandemic was variable. Factors associated with adherence provide insight into ways to support HCWs to adopt personal protective behaviours, such as ensuring that adequate PPE is available and designing workplaces to facilitate physical distancing.

Health Care Environmental Hygiene: New Insights and Centers for Disease Control and Prevention Guidance

Recent research has significantly clarified the impact of optimizing patient-zone environmental hygiene. New insights into the environmental microbial epidemiology of many hospital-associated pathogens, especially Clostridioides difficile, have clarified and quantified the role of ongoing occult pathogen transmission from the near-patient environment. The recent development of safe, broadly effective surface chemical disinfectants has led to new opportunities to broadly enhance environmental hygiene in all health care settings. The Centers for Disease Control and Prevention has recently developed a detailed guidance to assist all health care settings in implementing optimized programs to mitigate health care-associated pathogen transmission from the near-patient surfaces.

Hand hygiene compliance of healthcare workers before and during the COVID-19 pandemic: A long-term follow-up study

Background

Information about the long-term effects of hand hygiene (HH) interventions is needed. We aimed to investigate the change in HH compliance (HHC) of healthcare workers (HCWs) once a data-driven feedback intervention was stopped, and to assess if the COVID-19 pandemic influenced the HH behavior.

Methods

We conducted an observational, extension trial in a surgical department between January 2019–December 2020. Doctors (n = 19) and nurses (n = 53) were included and their HHC was measured using an electronic HH monitoring system (EHHMS). We compared the changes in HHC during 3 phases: (1) Intervention (data presentation meetings), (2) Prepandemic follow-up and (3) Follow-up during COVID-19.

Results

The HHC during phase 1 (intervention), phase 2 (prepandemic follow-up) and phase 3 (follow-up during COVID-19) was 58%, 46%, and 34%, respectively. Comparison analyses revealed that the HHC was significantly lower in the prepandemic follow-up period (46% vs 58%, P < .0001) and in the follow-up period during COVID-19 (34% vs 58%, P < .0001) compared with the intervention period (phase 1).

Conclusions

Despite the COVID-19 pandemic, the HHC of the HCWs significantly decreased over time once the data presentation meetings from management stopped. This study demonstrates that HCWs fall back into old HH routines once improvement initiatives are stopped.

Water, sanitation and hygiene (WASH) behaviour change research: why an analysis of contingencies of reinforcement is needed

Diarrheal disease associated with poor water, sanitation and hygiene (WASH) kills more than one million people every year. Safe WASH practices have the potential to greatly reduce these statistics but behaviour change interventions in the field have yielded little success to date. Currently, there is an emphasis on addressing cognitive processes to bring about changes in behaviour. In this review, a case is made for the benefits of a contingency-based perspective, focusing on the contextual antecedents and consequences of behaviour. The role of contingencies of reinforcement, not explored in previous WASH literature, is discussed as an explanatory framework for designing behaviour change strategies. A proper use of contrived reinforcers is recommended to counterbalance the natural reinforcers of convenience associated with risk practices. Recognising the role of consequences in the acquisition and maintenance of behaviour is an important step in the search for the answers urgently needed in the WASH field.

Identifying drivers for user preference and acceptability of different hydro-alcoholic hand rub formulations

BACKGROUND

In the current era, the importance of proper hand hygiene to reduce the transmission of infectious diseases has become difficult to debate. Yet, compliance rates remain low and are affected by many factors, amongst which is user acceptability of hand hygiene products.

AIM

The present study aimed at investigating drivers of preference towards different hand hygiene formulations.

METHODS

Three different formulations (liquid, foam and gel) of the same brand were randomly and blindly evaluated by 54 participants based on the WHO Protocol for Evaluation of Tolerability and Acceptability of Alcohol-based Handrubs.

RESULTS

The majority (76%) of respondents indicated that the product formulation impacted their level of compliance with hand hygiene protocols. The preferred formulation was liquid, with 50% of participants ranking it as first choice. General product satisfaction, the product texture, the drying speed and the ease of application, were the statistically significant drivers for participants to rank a formulation as their first choice vs not ranking it as their first choice.

CONCLUSIONS

When designing alcohol formulations and implementing hand hygiene protocols, understanding drivers of preference for formulations may enhance product user acceptability and therefore compliance with hand hygiene.

Healthcare personnel's working conditions in relation to risk behaviours for organism transmission: A mixed-methods study

AIMS AND OBJECTIVES

To investigate healthcare personnel's working conditions in relation to risk behaviours for organism transmission.

BACKGROUND

Healthcare personnel's behaviour is often influenced by working conditions that in turn can impact the development of healthcare-associated infections. Observational studies are scarce, and further understanding of working conditions in relation to behaviour is essential for the benefit of the healthcare personnel and the safety of the patients.

DESIGN

A mixed-methods convergent design.

METHODS

Data were collected during 104 h of observation at eight hospital units. All 79 observed healthcare personnel were interviewed. Structured interviews covering aspects of working conditions were performed with the respective first-line manager. The qualitative and quantitative data were collected concurrently and given equal priority. Data were analysed separately and then merged. The study follows the GRAMMS guidelines for reporting mixed-methods research.

RESULTS

Regardless of measurable and perceived working conditions, risk behaviours frequently occurred especially missed hand disinfection. Healthcare personnel described staffing levels, patient-level workload, physical factors and interruptions as important conditions that influence infection prevention behaviours. The statistical analyses confirmed that interruptions increase the frequency of risk behaviours. Significantly higher frequencies of risk behaviours also occurred in activities where healthcare personnel worked together, which in the interviews was described as a consequence of caring for high-need patients.

CONCLUSIONS

These mixed-methods findings illustrate that healthcare personnel's perceptions do not always correspond to the observed results since risk behaviours frequently occurred regardless of the observed and perceived working conditions. Facilitating the possibility for healthcare personnel to work undisturbed when needed is essential for their benefit and for patient safety.

RELEVANCE FOR CLINICAL PRACTICE

The results can be used to enlighten healthcare personnel and managers and when designing future infection prevention work.

Hand hygiene during facility-based childbirth in Cambodia: a theory-driven, mixed-methods observational study

Background

Despite current efforts to improve hand hygiene in health care facilities, compliance among birth attendants remains low. Current improvement strategies are inadequate, largely focusing on a limited set of known behavioural determinants or addressing hand hygiene as part of a generalized set of hygiene behaviours. To inform the design of a facility –based hand hygiene behaviour change intervention in Kampong Chhnang, Cambodia, a theory-driven formative research study was conducted to investigate the context specific behaviours and determinants of handwashing during labour and delivery among birth attendants.

Methods

This formative mixed-methods research followed a sequential explanatory design and was conducted across eight healthcare facilities. The hand hygiene practices of all birth attendants present during the labour and delivery of 45 women were directly observed and compliance with hand hygiene protocols assessed in analysis. Semi-structured, interactive interviews were subsequently conducted with 20 key healthcare workers to explore the corresponding cognitive, emotional, and environmental drivers of hand hygiene behaviours.

Results

Birth attendants’ compliance with hand hygiene protocol was 18% prior to performing labour, delivery and newborn aftercare procedures. Hand hygiene compliance did not differ by facility type or attendants’ qualification, but differed by shift with adequate hand hygiene less likely to be observed during the night shift (p = 0.03). The midwives’ hand hygiene practices were influenced by cognitive, psychological, environmental and contextual factors including habits, gloving norms, time, workload, inadequate knowledge and infection risk perception.

Conclusion

The resulting insights from formative research suggest a multi-component improvement intervention that addresses the different key behaviour determinants to be designed for the labour and delivery room. A combination of disruption of the physical environment via nudges and cues, participatory education to the midwives and the promotion of new norms using social influence and affiliation may increase the birth attendants’ hand hygiene compliance in our study settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03901-7.

Knowledge of infection prevention and control among healthcare workers and factors influencing compliance: a systematic review

BACKGROUND

Knowledge of infection prevention and control (IPC) procedures among healthcare workers (HCWs) is crucial for effective IPC. Compliance with IPC measures has critical implications for HCWs safety, patient protection and the care environment.

AIMS

To discuss the body of available literature regarding HCWs' knowledge of IPC and highlight potential factors that may influence compliance to IPC precautions.

DESIGN

A systematic review. A protocol was developed based on the Preferred Reporting Items for Systematic reviews and Meta-Analysis [PRISMA] statement.

DATA SOURCES

Electronic databases (PubMed, CINAHL, Embase, Proquest, Wiley online library, Medline, and Nature) were searched from 1 January 2006 to 31 January 2021 in the English language using the following keywords alone or in combination: knowledge, awareness, healthcare workers, infection, compliance, comply, control, prevention, factors. 3417 papers were identified and 30 papers were included in the review.

RESULTS

Overall, the level of HCW knowledge of IPC appears to be adequate, good, and/or high concerning standard precautions, hand hygiene, and care pertaining to urinary catheters. Acceptable levels of knowledge were also detected in regards to IPC measures for specific diseases including TB, MRSA, MERS-CoV, COVID-19 and Ebola. However, gaps were identified in several HCWs' knowledge concerning occupational vaccinations, the modes of transmission of infectious diseases, and the risk of infection from needle stick and sharps injuries. Several factors for noncompliance surrounding IPC guidelines are discussed, as are recommendations for improving adherence to those guidelines.

CONCLUSION

Embracing a multifaceted approach towards improving IPC-intervention strategies is highly suggested. The goal being to improve compliance among HCWs with IPC measures is necessary.

Comparing infection control and ward nurses' views of the omission of infection control activities using the Missed Nursing Care Infection Prevention and Control (MNCIPC) Survey

Aim

To compare the perceptions of nurses with infection control expertise and ward nurses as to what infection control activities are missed and the reasons why these activities are omitted.

Background

Infection prevention activities are viewed as important for reducing health care‐acquired infections (HAIs) but are often poorly performed.

Methods

Data were collected through the Missed Nursing Care Infection Prevention and Control (MNCIPC) Survey delivered to 500 Australian nurses prior to COVID‐19.

Results

Significant differences were found on the mean scores between infection control and other nurses on ten items. In eight cases, five relating to hand hygiene, infection control specialists viewed the activity as more likely to be missed. Factors viewed as having greater contribution to omission of infection control prevention were as follows: 'Patients have to share bathrooms', 'Urgent patient situation' and 'Unexpected rise in patient volume and/or acuity on the ward/unit'. Infection control nurses were more likely to highlight the role of organisational and management factors in preventing effective infection control.

Conclusions

Differences in response between nurses suggest that the extent of omission of infection control precautions may be under‐estimated by ward nurses.

Implications for Nursing Management

Infection control specialists are more likely to identify organisational barriers to effective infection control than other nurses. Work demands arising from pandemic management may contribute to infection control precautions being missed.

Le rapport aux règles d’hygiène auprès d’étudiants en soins infirmiers : une approche éthogénique

Introduction&#160;: Compliance with hygiene rules constitutes a central element of care practices in general and nursing training in particular. This study seeks to comprehend the behaviors associated with adherence to rules of hygiene based on the discourse of students in nursing training. The theoretical frame of reference is ethogenic and aims to explain the behaviors through the social conventions, culture and environment of care professionals.Method&#160;: 159 students in training were interviewed in focus groups to evoke the themes of violation of and adherence to hygiene rules.Results&#160;: The participants&#8217; comments collected illustrate that behaviors depend upon the perception of the contexts of care, skills and recognition within an in-training professional care work group.Conclusion&#160;: The results emphasize the importance of developing rules-based education on hygiene, while avoiding the establishment of resistance associated with the application of rules of hygiene in the workplace.

The impact of COVID-19 pandemic on hand hygiene performance in hospitals

Background

Achieving high levels of hand hygiene compliance of health care personnel has been an ongoing challenge. The objective of this study was to examine the impact of the COVID-19 pandemic on hand hygiene performance (HHP) rates in acute care hospitals.

Methods

HHP rates were estimated using an automated hand hygiene monitoring system installed in 74 adult inpatient units in 7 hospitals and 10 pediatric inpatient units in 2 children's hospitals. A segmented regression model was used to estimate the trajectory of HHP rates in the 10 weeks leading up to a COVID-19-related milestone event (eg, school closures) and for 10 weeks after.

Results

Three effects emerged, all of which were significant at P < .01. Average HHP rates increased from 46% to 56% in the months preceding pandemic-related school closures. This was followed by a 6% upward shift at the time school closures occurred. HHP rates remained over 60% for 4 weeks before declining to 54% at the end of the study period.

Conclusions

Data from an automated hand hygiene monitoring system indicated that HHP shifted in multiple directions during the early stages of the pandemic. We discuss possible reasons why HHP first increased as the pandemic began and then decreased as it progressed.

Barriers and facilitators to infection prevention and control in a neonatal unit in Zimbabwe - a theory-driven qualitative study to inform design of a behaviour change intervention

BACKGROUND

Hospital-acquired infection (HAI) is an increasing cause of neonatal morbidity/mortality in low-income settings. Hospital staff behaviours (e.g., hand hygiene) are key contributors to HAI. Understanding the drivers of these can inform interventions to improve infection prevention and control (IPC).

AIM

To explore barriers/facilitators to IPC in a neonatal unit in Harare, Zimbabwe.

METHODS

Interviews were conducted with 15 staff members of neonatal and maternity units alongside ethnographic observations. The interview guide and data analysis were informed by the COM-B (Capability, Opportunity, Motivation-Behaviour) model and explored individual, socio-cultural, and organizational barriers/facilitators to IPC. Potential interventions were identified using the Behaviour-Change Wheel.

FINDINGS

Enablers within Capability included awareness of IPC, and within Motivation beliefs that IPC was crucial to one's role, and concerns about consequences of poor IPC. Staff were optimistic that IPC could improve, contingent upon resource availability (Opportunity). Barriers included: limited knowledge of guidelines, no formal feedback on performance (Capability), lack of resources (Opportunity), often leading to improvization and poor habit formation. Further barriers included the unit's hierarchy, e.g., low engagement of cleaners and mothers in IPC, and staff witnessing implementation of poor practices by other team members (Opportunity). Potential interventions could include role-modelling, engaging mothers and staff across cadres, audit and feedback and flexible protocols (adaptable to water/handrub availability).

CONCLUSIONS

Most barriers to IPC fell within Opportunity, whilst most enablers fell under Capability and Motivation. Theory-based investigation provides the basis for systematically identifying and developing interventions to address barriers and enablers to IPC in low-income settings.

Obstetric Healthcare Workers' Adherence to Hand Hygiene Recommendations during the COVID-19 Pandemic: Observations and Social-Cognitive Determinants

Background

Hand hygiene is crucial to avoid healthcare‐associated infections and the transmission of COVID‐19. Although the WHO has issued global hand hygiene recommendations for healthcare, adherence remains challenging. Considering social‐cognitive theories such as the health action process approach (HAPA) can help to improve healthcare workers’ adherence. This study aimed to observe adherence and to assess determinants in obstetric hospitals during and after the onset of the COVID‐19 pandemic.

Methods

In all, 267 observations of behaviour were conducted in two German obstetric university hospitals over three time periods (pre‐COVID‐19 pandemic, heightened awareness, and strict precautions). In addition, 115 healthcare workers answered questionnaires regarding social‐cognitive determinants of hand hygiene behaviour. Multiple regression and multiple mediation analyses were used to analyse associations.

Results

Adherence to hand hygiene recommendations increased from 47 per cent pre‐COVID‐19 pandemic to 95 per cent just before lockdown while simple measures against the pandemic were taken. Self‐efficacy was associated with the intention to sanitise hands (β = .397, p < .001). Coping self‐efficacy mediated the association of intention with hand hygiene adherence.

Conclusions

Obstetric healthcare workers seem to adapt their hand hygiene behaviour to prevent infections facing the global COVID‐19 pandemic. To further improve interventions, social‐cognitive determinants should be considered, especially intention and (coping) self‐efficacy.

[Discussion groups as an approach to assess knowledge, attitudes and practices of hand hygiene among the adult intensive care unit professionals from a referral hospital]

OBJECTIVES

The adherence to hand hygiene practices among the adult Intensive Care Unit (ICU) professionals in this hospital has not improved substantially in the last years, regardless of the theoretical training sessions conducted. A study was made of the knowledge, attitudes, and practices of the ICU personnel in this field.

METHODS

Several small discussion groups with ICU staff organised by preventive medicine professionals were scheduled in March 2018. Semi-structured questions on hand hygiene and use of gloves were included. The points discussed were listed into strengths and weaknesses. Knowledge was then assessed using an anonymous questionnaire, after the sessions.

RESULTS

Thirteen 60-minute sessions were carried out with 157 participants from all professional categories (82% from ICU, median=11 participants / session). The majority perceived hand hygiene as a priority issue of personal responsibility for patient safety. They identified factors that limit their ability to improve their adherence. Certain habits have more to do with personal preferences than with theoretical knowledge or technical indications.

CONCLUSIONS

The discussion groups have helped to make a diagnosis of the situation that will be useful to strengthen those areas of improvement that have been identified. If we aim for a cultural change, and eliminate incorrect habits, it seems more useful to carry out adequate continuing education as part of the daily routine of professionals.

Adoption of electronic hand hygiene monitoring systems in New York state hospitals and the associated impact on hospital-acquired C. difficile infection rates

BACKGROUND

Approximately 721,800 hospital acquired infections occur annually, generating an estimated $10 billion in provider costs. Proper hand hygiene (HH) prevents hospital acquired infections, yet compliance is low. Electronic hand hygiene monitoring systems (EHHMS) are a potential solution, tracking and signaling HH events.

METHODS

We explored adoption of EHHMS in New York State acute care hospitals through a survey and interviews. Trend analysis was used to evaluate the impact of EHHMS on hospital-acquired Clostridium difficile infection (HA-CDI) rates.

RESULTS

Survey respondents represented approximately 30% (N = 56) of the total population of hospitals (N = 184) and EHHMS adoption was low (N = 2). The primary reason for nonadoption was cost (79.6%). HH compliance increased 20%-30% and HA-CDI decreased 70% for one hospital after an EHHMS, though not sustained; robust HH culture was mentioned as a necessary accompaniment. The trend analysis showed negligible impact on HA-CDI post-EHHMS for the second hospital. A critical access hospital without an EHHMS reported HH compliance of 90% attributed to strong HH culture.

CONCLUSIONS

Proliferation of EHHMS is low in New York State acute care hospitals and its impact on HH compliance and infection rates is questionable. Putting technology aside, strong HH culture seems essential for high compliance.

Use of non-sterile gloves in the ward environment: an evaluation of healthcare workers' perception of risk and decision making

Background

Studies have found that inappropriate use of non-sterile gloves (NSG) can affect hand hygiene compliance; the main risks are missing opportunities for hand hygiene and gloves being a vector for microbial transmission.

Aim

The aims of this study were to explore the accuracy of healthcare worker (HCW) risk assessment and decision making regarding the use of NSG.

Methods

The study was conducted in two acute NHS Trusts and a community social enterprise. A cross-sectional survey was carried out, followed by qualitative semi-structured interviews.

Findings

There were highly significant differences at the 95% probability level between staff groups, unqualified staff being significantly more likely than qualified staff to report NSG use when not indicated (P < 0.0001). The primary motivating factor for staff to wear NSG was for personal protection; the secondary factor being the protection of patients. Staff were also motivated by a desire to create an image of professionalism. Respondents were more likely to follow the lead of seniors in their own profession.

Discussion

The results suggest a necessity for change interventions aimed at unqualified staff such as healthcare assistants (HCAs). It would be beneficial to review the indications for glove use and amend organisational policies accordingly. Leaders in each professional staff group would be required to influence practice across organisations, taking into account motivating factors, and in association with multi-modal interventions to improve practice.

Clinical experiences with a new system for automated hand hygiene monitoring: A prospective observational study

BACKGROUND

Hand hygiene compliance (HHC) among health care workers remains suboptimal, and good monitoring systems are lacking. We aimed to evaluate HHC using an automated monitoring system.

METHODS

A prospective, observational study was conducted at 2 Danish university hospitals employing a new monitoring system (Sani nudge). Sensors were located on alcohol-based sanitizers, health care worker name tags, and patient beds measuring hand hygiene opportunities and sanitations.

RESULTS

In total, 42 nurses were included with an average HHC of 52% and 36% in hospitals A and B, respectively. HHC was lowest in patient rooms (hospital A: 45%; hospital B: 29%) and highest in staff toilets (hospital A: 72%; hospital B: 91%). Nurses sanitized after patient contact more often than before, and sanitizers located closest to room exits and in hallways were used most frequently. There was no association found between HHC level and the number of beds in patient rooms. The HHC level of each nurse was consistent over time, and showed a positive correlation between the number of sanitations and HHC levels (hospital A: r = 0.69; hospital B: r = 0.58).

CONCLUSIONS

The Sani nudge system can be used to monitor HHC at individual and group levels, which increases the understanding of compliance behavior.

Understanding hand hygiene behaviour in the intensive care unit to inform interventions: an interview study

BACKGROUND

Improving hand hygiene (HH) compliance is one of the most important, but elusive, goals of infection control. The purpose of this study was to use the capability (C), opportunity (O), motivation (M), and behaviour (B; COM-B) model and the theoretical domains framework (TDF) to gain an understanding of the barriers and enablers of HH behaviours in an intensive care unit (ICU) in order to identify specific interventions to improve HH compliance.

METHODS

A semi-structured interview schedule was developed based upon the COM-B model. This schedule was used to interview a total of 26 ICU staff: 12 ICU nurses, 11 anaesthetic specialist registrars, and three anaesthetic senior house officers.

RESULTS

Participants were confident in their capabilities to carry out appropriate HH behaviours. The vast majority of participants reported having the necessary knowledge and skills, and believed they were capable of carrying out appropriate HH behaviours. Social influence was regarded as being important in encouraging HH compliance by the interviewees- particularly by nurses. The participants were motivated to carry out HH behaviours, and it was recognised that HH was an important part of their job and is important in preventing infection. It is recommended that staff are provided with targeted HH training, in which individuals receive direct and individualised feedback on actual performance and are provided guidance on how to address deficiencies in HH compliance at the bedside at the time at which the HH behaviour is performed. Modelling of appropriate HH behaviours by senior leaders is also suggested, particularly by senior doctors. Finally, appropriate levels of staffing are a factor that must be considered if HH compliance is to be improved.

CONCLUSIONS

This study has demonstrated that short interviews with ICU staff, founded on appropriate behavioural change frameworks, can provide an understanding of HH behaviour. This understanding can then be applied to design interventions appropriately tailored to the needs of a specific unit, which will have an increased likelihood of improving HH compliance.

Status of water, sanitation and hygiene services for childbirth and newborn care in eight countries in East Asia and the Pacific

Background

Water, sanitation and hygiene (WASH) services are critical to providing quality maternal and neonatal care in health facilities. This study aimed to investigate availability of WASH policies, standards, and services for childbirth and newborn care in hospitals in East Asia and the Pacific.

Methods

Descriptive analysis of survey data and observations of water, sanitation and hygiene services in maternity and neonatal care rooms and of deliveries in 147 hospitals in Cambodia, Lao People’s Democratic Republic, Mongolia, Papua New Guinea, Philippines, Solomon Islands, and Viet Nam. The main outcome measures were availability of national policies and standards; availability of water, sanitation, and hygiene services in maternity rooms and neonatal care units; and practice of hygiene at childbirth.

Results

Three of seven countries had national WASH policies and three had standards for health facilities. Seventy-seven percent of hospitals had a sink with water and soap or alcohol hand rub in delivery rooms, 78% in neonatal care rooms and 42% in postnatal care rooms. Only 44% of hospitals had clean sinks with water, soap and hand drying methods in the delivery room, 40% in neonatal care units and 10% in postnatal care rooms. Flush toilets were available in or next to delivery rooms in 60% and neonatal care units in 50% of 10 hospitals with data. Countries with WASH standards had a higher proportion of hospitals with water and hand hygiene services. Appropriate hygiene was practiced by health workers in 65% of 371 deliveries observed, and more likely in delivery rooms with a sink, water and soap.

Conclusions

Coverage of WASH services for maternal and newborn care must be improved to reduce risks of maternal and newborn morbidity and mortality.

Multimodal intervention program to improve hand hygiene compliance: effectiveness and challenges

BACKGROUND

Hand hygiene (HH) is considered the most important measure to tackle the transmission of healthcare-associated pathogens. However, compliance with recommendations is usually low and effective improvement strategies are needed. We aimed to assess the effectiveness of an intervention targeting hand hygiene promotion among healthcare workers (HCWs).

METHODS

We conducted a pre-post interventional study design in the university hospital Sahloul, Sousse, Tunisia, from January 2015 to December 2016. The intervention program consisted of training sessions and distribution of posters of hand hygiene guidelines. To assess the evolution of HH observance at pre- and post-intervention, the same observation form was distributed and collected at healthcare workers' workplace.

RESULTS

Of the 1201 and 1057 opportunities for hand hygiene observed among all categories of HCWs, overall compliance enhanced significantly from 32.1 to 39.4% (p < 0.001) respectively at pre- and post-intervention. Nurses were the most compliant with a significant improvement from 34.1 to 45.7% (p < 0.001) respectively at pre- and post-intervention. Furthermore, analysis by department showed significant improvement of compliance in orthopedic department (p < 0.001), maxillofacial-surgery department (p < 0.001), pediatrics department (p = 0.013), and emergencies (p = 0.038).

CONCLUSION

This study showed the feasibility and effectiveness of a health-setting-based intervention to enhance hand hygiene observance in the context of a developing country.

Implementation interventions in preventing surgical site infections in abdominal surgery: a systematic review

Background

Surgical site infections (SSIs) are highly prevalent in abdominal surgery despite evidence-based prevention measures. Since guidelines are not self-implementing and SSI-preventive compliance is often insufficient, implementation interventions have been developed to promote compliance. This systematic review aims to identify implementation interventions used in abdominal surgery to prevent SSIs and determine associations with SSI reductions.

Methods

Literature was searched in April 2018 (Medline/PubMed and Web of Science Core Collection). Implementation interventions were classified using the implementation subcategories of the EPOC Taxonomy (Cochrane Review Group Effective Practice and Organisation of Care, EPOC). Additionally, an effectiveness analysis was conducted on the association between the number of implementation interventions, specific compositions thereof, and absolute and relative SSI risk reductions.

Results

Forty studies were included. Implementation interventions used most frequently (“top five”) were audit and feedback (80% of studies), organizational culture (70%), monitoring the performance of healthcare delivery (65%), reminders (53%), and educational meetings (45%). Twenty-nine studies (72.5%) used a multimodal strategy (≥3 interventions). An effectiveness analysis revealed significant absolute and relative SSI risk reductions. E.g., numerically, the largest absolute risk reduction of 10.8% pertained to thirteen studies using 3–5 interventions (p < .001); however, this was from a higher baseline rate than those with fewer or more interventions. The largest relative risk reduction was 52.4% for studies employing the top five interventions, compared to 43.1% for those not including these. Furthermore, neither the differences in risk reduction between studies with different numbers of implementation interventions (bundle size) nor between studies including the top five interventions (vs. not) were significant.

Conclusion

In SSI prevention in abdominal surgery, mostly standard bundles of implementation interventions are applied. While an effectiveness analysis of differences in SSI risk reduction by number and type of interventions did not render conclusive results, use of standard interventions such as audit and feedback, organizational culture, monitoring, reminders, and education at least does not seem to represent preventive malpractice. Further research should determine implementation interventions, or bundles thereof, which are most effective in promoting compliance with SSI-preventive measures in abdominal surgery.