Hand hygiene remains the single most important intervention in the prevention of cross-infection in health care settings (ICN 1998). Hospital – acquired infections are a major threat to patients and place a great burden on national health services. According to Lusardi (2007), each occurrence of healthcare associated infection in the United Kingdom costs on average about £3,000 (Department of Health 2000).
Nursing accounts for about 80 per cent of the direct care patients receive and it often involves personal and intimate care activities (Wade 1995). Healthcare associated infections (HCAI) are a potentially avoidable outcome of this care, affecting about one in ten patients, and are described as common and, in some cases, life-threatening (DoH 2003). Some of the infections acquired by patients will be caused by microbes spread on the hands of those providing care, including student nurses.
The hand hygiene practices of nursing students are an important area to examine because nursing students are the future work force and pre-registration training provides the opportunity to address any factors leading to non-compliance with hand hygiene practices (Henson & Hayes 1998). Lymer et al. (2004) have suggested that nursing students are in an ideal position to promote effective hand hygiene as they can act as agents of change in practice by sharing good hand hygiene knowledge and practices with qualified staff. It is from this background that I want to explore more and find out if student nurses comply with hand hygiene practice whilst in clinical areas.
In order to have the answers to the above inquiry, I am going to examine various academic research studies that have been carried out on hand hygiene among nursing students in clinical areas. I intend to outline the main themes identifiable in the literature reviewed as well as give a short summary of the main issues and identify the gaps in current academic knowledge. At the end of this literature review, I will then come up with a clear statement of a research question. Finally, I will try and identify an appropriate methodological approach to the stated research question.
The literature examined was gained by searching electronic, academic and professional journal databases. The databases accessed were CINAHL, the British Nursing Index, Embase, Ovid Journals and Medline. The databases were first searched using the key terms ‘hand hygiene’, ‘barriers’ and ‘compliance’. Then the results from each term were looked at individually and then as a combination of terms. To gain a wider understanding of the topic, the key terms ‘hand washing’, ‘alcohol gel’, ‘infection control precautions’ were used and as the study was related to a specific group, i.e.
nursing students, ‘students’ and ‘nursing students’ were combined with search terms. The search parameters were limited to dates between 2007-2009 to ensure the collection of recent work. Further literature was sought by hand searching recent journals and texts. Internet and library resources were used to gain access to international and national guidelines.
The search strategy was to include articles published in English. The following four qualitative research articles were then selected: Erasmus et al (2009), Barrett & Randle (2008), Cole (2008) and Lusardi (2007). Please see appendix for the articles used in this literature review.
From these chosen articles, various common findings and similarities, different and contradictory findings as well as debates and conflicting ideas were identified which the author will outline in the following passage.
Lack of positive role models
In all the four articles examined it would appear that influences of other staff on hand washing practice was a major subject pertinent to hand hygiene among nursing students. From the findings presented by Lusardi (2007), students were aware of other’s practice and gave more examples of bad practice than good when asked.
One student described how a doctor saw patients on one ward then went to another ward without hand washing or using alcohol gel, while another described how a doctor, having entered and exited a ward that was closed due to an outbreak of diarrhoea and vomiting, passing all of the warning signs on its doors, curtains and main desk as he did so, subsequently failed to wash his hands before attending to his patients (Lusardi 2007). Erasmus et al (2009)’s findings concurred with Lusardi (2007)s’ research in which students mentioned the presence of negative role models that is, experienced nurses and doctors who were noncompliant with hand hygiene guidelines as reasons for their non-compliance.
Erasmus et al (2007) insisted that students appear to copy the hand hygiene behaviour of the physicians they see at work, often resulting in poor hygiene habits that will, in turn, be copied by future students. Barrett and Randle (2008)’s research findings suggest that student complied with the hand hygiene practices witnessed in the clinical area to fit into the nursing team and not rock the boat (Barrett and Randle 2008). This was apparent in that students in this study identified that they followed the hand hygiene practices of their mentors to maintain a positive relationship and to be accepted as part of the nursing team. This meant that at times they did not perform hand hygiene or performed it inadequately as they perceived that they had to show their busyness and had to get jobs done quickly. Cole (2008) found out that when discussing the factors that influence their compliance, students discussed the impact of cues to action in clinical practice and the behaviour of role models.
In her study Lusardi (2007) found out that student participants thought that they were responsible for their own practice and went on to say that it indicates that they understand their duty of care to patients.
The results appears to confirm that students’ own responsibility for hand hygiene was the main influence on their practice. One said: ‘It was up to you to do it and take responsibility for yourself.’ They qualified this statement however by linking their responsibility with their conscience to prevent the spread of infection to patients, saying: ‘I don’t particularly want to feel responsible for passing somebody’s infection onto somebody else.’
This sense of responsibility extended to the need to protect themselves and their families from infections: ‘I’m very aware of what I can pick up, and you do not want to take it home to your family’ ( Lusardi 2007). Cole (2008)’s results on responsibility are consistent with the findings of (Lusardi 2007) which indicate that students’ own responsibility for hand hygiene influence their practice. In his study Cole (2008), one student expressed that, “It’s a basic function; part and parcel of who you are. By not washing your hands, of course you are letting the patient down, but you are letting yourself down as well. It might be a clichу but it is important to know that you have done the right things before I go home.”
Examining the studies of Erasmus et al (2009) and Barrett & Randle (2008), nothing was mentioned specifically regarding the responsibility of students towards hand hygiene compliance. However, Erasmus et al (2009) findings indicate that if participants were asked to provide reasons for performing hand hygiene, the most frequently given were the protection of oneself from cross-infection.
Barriers to hand hygiene compliance.
Findings from all the articles suggest that dryness and soreness caused by regular hand wash; lack of time and a heavy workload, with there being fewer opportunities to complete hand hygiene during busy morning shifts as barriers to hand hygiene compliance.
In their study Erasmus et al (2009), found out that the participants specified dryness and soreness of hands after performance of hand hygiene, mainly as disadvantages associated with performance of hand hygiene. Barrett and Randle (2008) purports that frequent hand hygiene was seen as worsening pre-existing skin conditions such as eczema. They went on to say that these factors then stopped or made participants reluctant to clean their hands. However in Cole (2008)’s findings one student commented: ” My hands mighty be cracked and sore but it does not stop me from washing them. At the end of the day we are here for the patient, you make sacrifices.”
Findings by Barret and Randle, (2008) indicates that lack of time and a heavy workload were stated as barriers to hand hygiene compliance. It was perceived that less time was available to complete hand hygiene during busy morning shifts when there was a higher number of tasks to complete and patients to be washed and dressed (Barret and Randle 2008). Erasmus et al (2009), argues that barriers to hand hygiene compliance mentioned by participants were the occurrence of emergent situations, lack of availability of and easy access to hand hygiene materials, the lack of time, and forgetfulness.
In study Lusardi (2007), six students identified time and workload pressures as reasons for poor hand hygiene: ‘I think sometimes when you’re rushing round, if someone needs something urgent doing, it’s easy to forget.’ Students most often cited a lack of time as the reason for their failure to practice hand hygiene, although two students said that the actual reason was laziness: ‘I do think it is lack of education, but laziness as well.’ (Lusardi 2007). Three students acknowledged time pressures but said that staff should still decontaminate their hands. Only one student cited lack of staff as a reason for poor practice (Lusardi 2007). Other findings on this topic suggest that the type of clinical procedure being undertaken was a barrier to hand hygiene compliance ( Barrett and Randle 2008).
Social control was a common theme in three of the articles. In the study by Erasmus et al (2009), all participants mentioned a lack of social control with regard to compliance with hand hygiene guidelines, and all groups reported difficulties in addressing others about their hand hygiene behaviour.
Students stated that they complied with the hand hygiene practices witnessed in the clinical area to fit into the nursing team and not rock the boat. The ‘fitting in’ meant that students would not challenge staff as they felt this would result in a negative relationship and subsequently they would not be accepted as part of the team (Barret and Randle 2008).
Lusardi (2007) maintained that the effect of socialisation on the students was evident in their interviews. They described how they kept up good hand hygiene despite the poor practice around them, but would not challenge other staff (Lusardi 2007).
In her study Lusardi (2007), three students commented on how difficult it was to speak out when they were only there for a short time and did not want to get into trouble, especially with the auxiliary nurses. More than one student talked about trying to ‘fit in’ and related other skills to the problem of hand hygiene, particularly manual handling (Lusardi 2007).
Improving healthcare workers’ hand hygiene compliance remains a complex issue because of the wide number of factors that affect their compliance. The findings of the qualitative studies explore above indicate that lack of positive role models among and social norms established by senior health workers may hinder compliance. Barriers to hand hygiene compliance such as dryness and soreness caused by regular hand wash and the health worker’s responsibility also influences hand hygiene compliance.
The findings of these studies should inform methods for stimulating hand hygiene compliance in health care setting. It is essential therefore that educators and registered staff encourage nursing students to take responsibility for their practice in this way if they are to ensure that hand hygiene practice is and remains efficient, effective, evidence based and sustainable (Lusardi (2007). Further research into nursing students’ past and recent experiences is needed to influence their future hand hygiene practice. It is from this view that I would like to derive my research question for a future research proposal.
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