Hand hygiene of medical students and resident physicians: predictors of attitudes and behaviour

Health care workers' knowledge and perceptions on WHO hand hygiene guidelines, and the perceived barriers to compliance with hand hygiene in Cyprus

BACKGROUND

Hand hygiene (HH) is recognized as an important measure to avoid the transmission of harmful germs, and assists significantly in preventing healthcare-associated infections. HH compliance among health care workers (HCWs) is a result of their knowledge and perceptions.

AIM

To investigate the knowledge and perceptions of WHO hand hygiene guidelines among HCWs, and the perceived barriers to compliance with hand hygiene in a major public hospital in Cyprus.

METHODS

A descriptive correlational study was conducted in September of 2019. The target population was all of the HCWs in Nicosia General Hospital (N = 1,386). The final sample consisted of 820 participants (119 physicians, 613 nurses, 27 physiotherapists, 59 ward assistants, 2 unidentified). This study used the HH knowledge and perception questionnaire that was developed by the WHO.

RESULTS

The results revealed that the average percentage score for knowledge among our sample was 61%, and statistically significant differences were observed among HCWs with regard to certain questions. It was found that HCWs, in most of their responses, presented high percentages of correct answers regarding their perceptions on hand hygiene guidelines but several perceived barriers to compliance on HH guidelines were identified as well.

CONCLUSIONS

Knowledge and perceptions of HH guidelines among HCWs were moderate and good respectively. In addition, several perceived barriers to compliance on HH recommendations were identified. HH education is recognized as an important tool for removing these barriers but the recommended HH strategy should be multi-modal and consider local resources, administrative support and barriers to compliance with HH.

Determinants of compliance with infection prevention measures by physicians: a scoping review

Despite evidence that application of infection prevention measures can reduce healthcare-associated infections, compliance with these measures is low, especially among physicians. Intervention effects often do not sustain. An overview of determinants for physicians' infection prevention behaviour and successful behaviour change strategies is lacking. The aim of this review was to identify what determinants influence physicians' infection prevention behaviour, what strategies to improve compliance have been explored, and whether theories, models, and frameworks from implementation science have been used in these studies. A literature search was performed in PubMed, Embase, APA PsycInfo and Web of Science up to June 2nd, 2023, in collaboration with a medical information specialist. All study types focusing on infection prevention behaviour of physicians in high-income countries were included. Data on determinants and strategies was extracted; determinants were categorized into the Theoretical Domains Framework (TDF). Fifty-six articles were included. The TDF domains 'environmental context and resources', 'social influences', 'beliefs about consequences', 'memory, attention and decision-making', 'knowledge', and 'skills' were found most relevant. The prevailing determinant covers a theme outside the TDF: socio-demographic factors. Sustainable interventions are multimodal approaches that at least include feedback, education, and a champion. Theories, models, and frameworks have rarely been used to guide implementation strategy development. In conclusion, it was found that intervention studies rarely specify the determinants that they aim to address and they lack theoretical underpinning. Future initiatives should combine knowledge about determinants with implementation science to develop theory-based interventions tailored to determinants.

Quality Improvement Project to Improve Hand Hygiene Compliance in a Level III Neonatal Intensive Care Unit

This quality improvement project aimed to improve hand hygiene (HH) compliance in a Level III Neonatal Intensive Care Unit. The project was conducted over three Plan-Do-Study-Act (PDSA) cycles, with each cycle lasting two months. The interventions included healthcare worker (HCW) education on HH, repetition of education, and immediate feedback to HCWs. Compliance data were collected through covert observations of HCWs in the NICU. The overall compliance rate increased from 31.56% at baseline to 46.64% after the third PDSA cycle. The HH compliance was noted to be relatively low after touching patient care surroundings, at entry and exit from the NICU main unit, before wearing gloves and after removing gloves, at baseline and throughout the three PDSA cycles. HCW education alone did not result in significant improvements, highlighting the need for additional interventions. The study underscores the importance of involving NICU leadership and providing immediate feedback to promote HH compliance. Further efforts should focus on addressing the false sense of security associated with glove usage among HCWs, individual rewards and involving the healthcare staff in the shared goal of increasing HH compliance. Consideration of workload metrics and their impact on compliance could steer future interventions.

Dental Students’ Knowledge, Attitude, and Confidence toward Evidence-based Dentistry: A 5-year Retrospective Study

AIM

The purpose was to assess dental students' knowledge, attitude, and confidence toward evidence-based dentistry in five graduating Doctor of Dental Surgery (DDS) classes.

MATERIALS AND METHODS

All dental students (class of 2019, 2020, 2021, 2022, and 2023) enrolled in the D3 research design course were required to take a pre-Knowledge, Attitude, and Confidence in Evidence-based Dentistry (KACE) survey. On completion of the 11-week course, a post-KACE survey was distributed to compare the differences in the three domains of evidence-based dentistry (EBD). For the knowledge domain, the responses from the 10 questions were converted to either correct (1) or wrong (0) so that the compiled scores could range from 0 to 10. The attitudes and confidence domains used a five-point Likert scale. The compiled attitude score was a sum of the responses from 10 questions yielding a range from 10 to 50. For confidence, the compiled score ranged from 6 to 30.

RESULTS

The mean knowledge scores of all classes together before and after training were 2.7 and 4.4, respectively. Overall, there was a statistically significant difference between pre- and post-knowledge indicating an improvement in knowledge associated with the training (p < 0.001). The mean attitudes of all classes together before and after the training were 35.3 and 37.2, respectively. Overall, there was a statistically significant improvement in attitude (p < 0.001). The values of mean confidence of all classes together before and after the training were 15.3 and 19.5, respectively. Overall, there was a statistically significant improvement in confidence (p < 0.001).

CONCLUSIONS

A dental curriculum emphasizing Evidence-based practice (EBD) resulted in increased knowledge acquisition, improved attitude, and confidence toward EBD of dental students.

CLINICAL SIGNIFICANCE

Educational initiatives emphasizing evidence-based dentistry increase students' knowledge acquisition, improved attitude, and confidence toward EBD that may also translate to active implementation of EBD in their future practices.

A survey of hand hygiene practices among Indian medical undergraduates

Background

Hand hygiene is the simplest and most effective method to prevent hospital acquired infections (HAI). Compliance with hand hygiene among health providers is, however, widely variable due to significant knowledge gaps and behavioral issues. The knowledge and practices of hand hygiene among medical undergraduate students, the future health workforce in the current COVID-19 pandemic will enable a reality check and ensure course correction at an early stage of their learning.

Methods

An online questionnaire-based survey based on a standard, validated WHO 25-point (multiple-choice question and Yes/No answers) hand hygiene survey was undertaken among medical undergraduate students in an urban city from April to June 2020. Each correct response was awarded 1 point, and an incorrect response was awarded 0 points. The maximum achievable score was 25, and the minimum score was 0.

Results

A total of 457 students with a mean age 20.24 ± 1.27 years completed the survey. A total of 415 (90.8%) students received hand hygiene training in the past three years. Overall 27.6% (n = 126) students had good knowledge, 65.4% (n = 299) had moderate and 7% (n = 32) had poor knowledge of hand hygiene practices.

Conclusions

There were significant knowledge gaps regarding hand hygiene among medical undergraduate students in the midst of the COVID-19 pandemic. There is a need to strengthen existing teaching methods to positively impact behavioral change and potentially translate into better hand hygiene compliance among the future health workforce of the country.

Deterioration in hygiene behavior among fifth-year medical students during the placement of intravenous catheters: a prospective cohort comparison of practical skills

BACKGROUND

The American Association of Medical Colleges has defined peripheral intravenous cannulation as one of the eight practical skills that a medical student should possess upon graduation. Since following a standard hygiene protocol can reduce the rate of complications such as bloodstream infections, the medical student's compliance to hygienic standards is highly relevant.

METHODS

This unicentric longitudinal cohort study included 177 medical students undergoing OSCE 1 in the winter semesters 2016/2017 and 2017/2018 as well as OSCE 2 during the winter semesters 2018/2019 and 2019/2020 at the University of Cologne. Their performance in peripheral intravenous cannulation was rated by trained student supervisors using a scaled 13-item questionnaire and compared between OSCE 1 and OSCE 2.

RESULTS

Overall, a decline in the correct placement of peripheral intravenous catheters was observed among advanced medical students during OSCE 2 (mean total score: 6.27 ± 1.84) in comparison to their results in OSCE 1 (mean total score: 7.67 ± 1.7). During OSCE 2, the students were more negligent in regard to hygienic behavior, such as disinfection of the puncture site as well as hand disinfection before and after venipuncture. Their patients were also less likely to be informed about the procedure as compared to OSCE 1.

CONCLUSIONS

An unsatisfying performance in regard to peripheral intravenous cannulation was observed in medical students with hygiene compliance deteriorating between the third and fifth year of their study. Thus, we promote an extension of practical hygiene and stress management training in medical school to reduce complications associated with intravenous catheters, such as bloodstream infections.

Medical interns' reflections on their training in use of personal protective equipment

BACKGROUND

The current COVID-19 pandemic has demonstrated that personal protective equipment (PPE) is essential, to prevent the acquisition and transmission of infectious diseases, yet its use is often sub-optimal in the clinical setting. Training and education are important to ensure and sustain the safe and effective use of PPE by medical interns, but current methods are often inadequate in providing the relevant knowledge and skills. The purpose of this study was to explore medical graduates' experiences of the use of PPE and identify opportunities for improvement in education and training programmes, to improve occupational and patient safety.

METHODS

This study was undertaken in 2018 in a large tertiary-care teaching hospital in Sydney, Australia, to explore medical interns' self-reported experiences of PPE use, at the beginning of their internship. Reflexive groups were conducted immediately after theoretical and practical PPE training, during hospital orientation. Transcripts of recorded discussions were analysed, using a thematic approach that drew on the COM-B (capability, opportunity, motivation - behaviour) framework for behaviour.

RESULTS

80% of 90 eligible graduates participated. Many interns had not previously received formal training in the specific skills required for optimal PPE use and had developed potentially unsafe habits. Their experiences as medical students in clinical areas contrasted sharply with recommended practice taught at hospital orientation and impacted on their ability to cultivate correct PPE use.

CONCLUSIONS

Undergraduate teaching should be consistent with best practice PPE use, and include practical training that embeds correct and safe practices.

Hygiene practices during clinical training: knowledge, attitudes and practice among a cohort of South Asian Medical students

BACKGROUND

Proper hygienic practices are important in preventing nosocomial infection. This study aimed to determine knowledge, attitudes and practices (KAP) on hand, attire and equipment hygiene during clinical training among medical students at a State Medical Institution in Sri Lanka.

METHODS

This cross-sectional study was conducted among 3rd, 4th and final (5th) year medical students of the Faculty of Medicine, University of Colombo, who had undergone at least 6 months of clinical training. KAP on hand hygiene (HH), attire hygiene (AH) and equipment hygiene (EH) were assessed using a pre-tested, self-administered questionnaire with a Likert-type scale. KAP scores were graded as follows: good ≥75; moderate:74.9-50; unsatisfactory:49.9-25; poor:< 25%. KAP based on duration of training and gender were compared using independent samples t-tests.

RESULTS

Three hundred thirty-three students participated (mean age 24 ± 1.1 years, male: female = 1: 1.2). Combined KAP scores on hand and attire hygiene were moderate (HH:73%, AH:65%) while equipment hygiene was unsatisfactory (EH:47%). Senior students (5th year) had higher combined KAP and knowledge (K) on hand hygiene (HH KAP 75% vs. 72%, p = 0.01; K:72% vs. 67%, p = 0.001) and equipment hygiene (EH KAP 50% vs. 44%, p = 0.001; K:47% vs. 35%, p = 0.001) compared to junior students (3rd/ 4th years). However, they had lower KAP and P scores on attire hygiene (AH KAP 63% vs. 67%, p = 0.006; P:60% vs. 67%, p = 0.004). Female students had better AH compared to male students (KAP:67% vs. 64% p = 0.01; K 71% vs. 66%, p = 0.048; P:66% vs. 62%, p = 0.05).

CONCLUSIONS

Overall, hand hygiene was moderate among medical students and improved with progression of training. Attire hygiene was also graded as moderate but to a lesser extent compared to hand hygiene, lower in males, and declined over time, indicating need for better reinforcement of attire hygiene practices with progression of clinical training. Equipment hygiene was unsatisfactory among most medical students and thus needs to be highlighted as a potential area to be improved during clinical training. This study suggests that knowledge, attitudes and practices on equipment and attire hygiene among medical students was less satisfactory and needs to receive greater emphasis during medical clinical training.

Hand hygiene knowledge and attitude of medical students in western Saudi Arabia

Background

The practice of hand hygiene (HH) has prime importance among Health Care Professionals (HCPs) and non-compliance could cause adverse consequences. By keeping the importance of HH in mind, this study aims at investigating the knowledge and attitudes towards HH among medical students and interns at King Abdulaziz University (KAU), Jeddah, Saudi Arabia (SA).

Methods

The study includes 453 medical students and interns (189 males & 264 females). This study was completed in three months; from September to November 2017. The World Health Organization (WHO) HH questionnaire was used and data were analyzed on SPSS-21.

Results

Two-third of the participants 292 (64.2%) had formal training in HH in the last three years. Almost half of the participants 254 (56.1%) had correct knowledge regarding the major course of transmission of potentially detrimental microbes among patients in the healthcare premises. Just 124 (27.4%) of the respondents had the correct knowledge about the most common basis of germs accountable for healthcare-related infections. Females had significantly better knowledge than males regarding the type of HH technique needed before palpation of the abdomen (177(54%) Vs. 151(46%); P < 0.002), before an injection (175(54.5%) Vs. 146(45.5%); P < 0.007), after emptying a bedpan (207(64.7%) Vs. 113(35.3%); P < 0.001), following discarding examination gloves (256(60.4% Vs. 168(39.6%); P < 0.001] and after exposure to blood (200(64.1%) Vs. 112(35.%); P < 0.001). Female participants had better knowledge than males regarding the type of HH actions. Females also had a significantly better attitude towards the importance of HH than males (240(62.5%) Vs. 144(37.5%); P < 0.001).

Conclusion

The majority of the participants' knowledge regarding HH was not up to the mark; however, female students had better knowledge compared to male students. The medical students and interns' knowledge and positive attitude towards HH can play a pivotal role in preventing HCPs associated infections and it would overall decrease the infection-related burden on the hospital and governmental budgets. It is suggested that multi-dimensional plans are required to change this low compliance to a higher rate.

Visibility and transmission: complexities around promoting hand hygiene in young children - a qualitative study

Background

Effective hand hygiene practice can reduce transmission of diseases such as respiratory tract infections (RTIs) and gastrointestinal infections, especially in young children. While hand hygiene has been widely promoted within Australia, primary care providers’ (PCPs) and parents’ understanding of hand hygiene importance, and their views on hand hygiene in reducing transmission of diseases in the community are unclear. Therefore, the aim of this study was to explore the views of PCPs and parents of young children on their knowledge and practice of hand hygiene in disease transmission.

Methods

Using a cross-sectional qualitative research design, we conducted 30 in-depth interviews with PCPs and five focus groups with parents (n = 50) between June 2014 and July 2015 in Melbourne, Australia. Data were thematically analysed.

Results

Participants agreed that hand hygiene practice was important in reducing disease transmissions. However, barriers such as variations of hand hygiene habits, relating visibility to transmission; concerns around young children being obsessed with washing hands; children already being ‘too clean’ and the need to build their immunity through exposure to dirt; and scepticism that hand hygiene practice was achievable in young children, all hindered participants’ motivation to develop good hand hygiene behaviour in young children.

Conclusion

Despite the established benefits of hand hygiene, sustained efforts are needed to ensure its uptake in routine care. To overcome the barriers identified in this study a multifaceted intervention is needed that includes teaching young children good hand hygiene habits, PCPs prompting parents and young children to practice hand hygiene when coming for an RTI consultation, reassuring parents that effective hand hygiene practice will not lead to abnormal psychological behaviour in their children, and community health promotion education campaigns.

Guiding hand hygiene interventions among future healthcare workers: implications of knowledge, attitudes, and social influences

BACKGROUND

Medical students in their clinical years play an important role in healthcare delivery, yet poor levels of hand hygiene (HH) compliance in this population raise the risk for propagating nosocomial infections. To date, there has been a lack of dedicated interventions showing sustainable improvements in HH in this population.

METHODS

A multicenter, cross-sectional study was conducted among 450 medical students in their clinical years (third to fifth years). A self-administered, pre-validated questionnaire based on the World Health Organization's "Knowledge" and "Perception" questionnaires was used to explore HH knowledge, attitudes, practices, and desired interventions.

RESULTS

Self-reported HH compliance was found to be low (56.8%), and moderate HH knowledge (61.8%) was observed among all study respondents. Public university students expressed greater knowledge than students in private and semi-private universities. Superior HH practices were associated with better individual HH attitudes, positive perceived HH attitudes in other healthcare workers (HCWs), and higher HH knowledge scores. The highest-rated interventions for improving HH compliance included role-modeling by HCWs, display of "clear HH instructions," and "ensuring availability of hand sanitizers."

CONCLUSION

Our results call for a multifaceted approach to improve HH compliance among medical students, by ensuring adequate HH supplies/hand sanitizers, providing HH training in curricula, and effecting a cultural change mediated by professional modeling and open communication.

'And you'll suddenly realise 'I've not washed my hands': medical students', junior doctors' and medical educators' narratives of hygiene behaviours

OBJECTIVE

Compliance to hygiene behaviours has long been recognised as important in the prevention and control of healthcare associated infections, but medical doctors still display some of the lowest rates of compliance of all healthcare workers. We aim to understand compliance to hygiene behaviours by analysing medical students', junior doctors' and medical educators' narratives of these behaviours to identify their respective attitudes and beliefs around compliance and how these are learnt during training. Such an understanding can inform future interventions to improve compliance targeted to areas of greatest need.

DESIGN

A qualitative study, using narrative interviews (nine focus groups and one individual interview). Data were analysed thematically using inductive framework analysis.

SETTING

Teaching hospitals in the UK.

PARTICIPANTS

Convenience sample of 25 participants: third-year medical students in their first clinical year (n=13), junior doctors (n=6) and medical educators (n=6).

RESULTS

We identified four main themes: (1) knowledge, (2) constraints, (3) role models/culture and (4) hygiene as an added extra. Knowledge varied across participant groups and appeared to influence behaviours; medical students relied on what they have been told by seniors, while medical educators relied on their own knowledge and experience. There was a strong belief that evidence for the effectiveness of good hygiene behaviours is lacking. Furthermore, medical educators' behaviour appears to strongly influence others. Finally, hygiene was predominately viewed as an added extra rather than an integral part of the process.

CONCLUSIONS

Awareness of the evidence around good hygiene needs to be improved at all levels. Medical students and junior doctors should be encouraged to consider why they are asked to perform certain hygiene behaviours in order to improve ownership of those behaviours. Medical educators need to recognise their responsibilities as role models for their junior counterparts, thereby understanding their role in developing the culture of hygiene practices within their clinical domains.

Attitudes and practices of Irish hospital-based physicians towards hand hygiene and hand rubbing using alcohol-based hand rub: a comparison between 2007 and 2015

BACKGROUND

Hand hygiene is the cornerstone of infection prevention and control practices, and reduces healthcare-associated infections significantly. However, international evidence suggests that medical doctors demonstrate poor compliance.

AIM

To explore and compare practices and attitudes towards hand hygiene, particularly hand rubbing using alcohol-based hand rub (ABHR), among hospital-based physicians in Ireland between 2007 and 2015.

METHODS

In 2007, a random sample of doctors in a large teaching hospital was invited to complete a postal survey using a validated questionnaire. In 2015, the study was replicated among all doctors employed in a university hospital group, including the setting of the original study, using an online survey. Data were analysed using SPSS and Survey Monkey.

FINDINGS

Predominately positive and improving attitudes and practices were found, with 86% of doctors compliant with hand hygiene before patient contact in 2015, compared with 58% in 2007. Ninety-one percent of doctors were compliant after patient contact in 2015, compared with 76% in 2007. In 2015, only 39% of respondents reported that they 'almost always' used ABHR for hand hygiene. However, this represents 13.5% more than in 2007. Stated barriers to use of ABHR included dermatological issues, poor acceptance, tolerance and poor availability of ABHR products.

CONCLUSION

Greater awareness of hand hygiene guidelines and greater governance appear to have had a positive impact on practice. However, despite this, practice remains suboptimal and there is scope for substantial improvement. Continued and sustained efforts are required in order to build on progress achieved since the World Health Organization hand hygiene guidelines were published in 2009.