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Intensive and Critical Care Nursing 42 (2017) 17–21

Contents lists available at ScienceDirect

Intensive and Critical Care Nursing


journal homepage: www.elsevier.com/iccn

Clinical research article

Nurses’ perceptions of reasons for persistent low rates in hand


hygiene compliance
Nohemi Sadule-Rios ∗ , Graciela Aguilera
Baptist Health South Florida (BHSF), United States

a r t i c l e i n f o a b s t r a c t

Article history: Aim: The purpose of this study was to explore nurses’ perceptions of reasons for persistent low rates in
Accepted 17 February 2017 hand hygiene compliance in the Critical Care Unit and their recommendations for improvement.
Design and methods: This study used an exploratory, descriptive survey design to identify critical care
Keywords: nurses’ perceptions of barriers to hand hygiene compliance in the unit and their recommendations for
Barriers improvement.
Critical care unit
Results: Nurses selected high workload, understaffing and suggested lack of time as the main problems
Hand hygiene
with hand hygiene compliance in the critical care unit. Second to that, they identified difficulty accessing
Noncompliance
sinks and lack of appropriately located hand sanitisers at the point of care complemented by suggestions of
not enough sinks and inconveniently located hand sanitiser as major barriers to hand hygiene compliance.
Conclusion: Results of this study indicate that high workload and understaffing added to difficulty access-
ing hand hygiene resources contribute to low rates of hand hygiene compliance in the critical care unit.
Addressing nursing understaffing and workload and making some environmental modifications to allow
easy access to sinks and hand sanitisers may facilitate nurses hand hygiene compliance in this setting.
Further studies on the relationship between nurses’ workload, unit staffing, and hand hygiene compliance
rates are needed.
© 2017 Elsevier Ltd. All rights reserved.

Implications for clinical practice

• This article contributes to the literature about barriers to hand hygiene compliance, as it focuses on the challenges and recommen-
dations identified by critical care nurses.
• This study emphasises the importance of listening and valuing healthcare workers specific needs and suggestions for improvements
to get them engaged in the process of improving hand hygiene compliance.
• The results of this study suggest implications for nursing work assignments and patient safety.

devastating health care-associated infections and consequently,


Introduction prolonged patients’ hospital stay, disability, increased resistance
to antibiotic, increased mortality and high health care cost (WHO,
According to recent reports from the Centre for Disease Con- 2009). The World Health Organisation (WHO), the Centre for Dis-
trol and Prevention, healthcare workers do not clean their hands ease Control and Prevention (CDC), and The Joint Commission are
as often as they should (CDC, 2016). Poor hand hygiene com- some of the most influential organisations in healthcare campaign-
pliance among healthcare workers contributes to the spread of ing and promoting efforts to improve hand hygiene compliance in
healthcare settings. The problem of healthcare workers low hand
hygiene compliance has been studied numerous times; however,
∗ Corresponding author at: Baptist Health South Florida, 6200 SW 72 ST, Miami, suggested interventions to increase hand hygiene compliance vary
FL 33143, United States. and compliance continues to be low in hospitals around the United
E-mail address: nohemis@baptisthealth.net (N. Sadule-Rios). States and the other world nations.

http://dx.doi.org/10.1016/j.iccn.2017.02.005
0964-3397/© 2017 Elsevier Ltd. All rights reserved.
18 N. Sadule-Rios, G. Aguilera / Intensive and Critical Care Nursing 42 (2017) 17–21

Hand hygiene non-compliance is an international problem, evi- There is a fatal association between hand hygiene noncompli-
denced by the variety of approaches devised worldwide to improve ance and hospital infections leading to the loss of millions of human
hand hygiene compliance. A team of researchers conducted a lives worldwide and a consequent increased financial burden on an
cluster randomised trial study to evaluate the effectiveness of already struggling healthcare system (WHO, 2009). Unfortunately,
an intervention involving the hospital leadership in increasing despite the variety of initiatives, campaigns, and efforts to increase
hand hygiene compliance among nurses in the Netherlands (Huis hand hygiene compliance among healthcare workers worldwide,
et al., 2013). The study was conducted from September 2008 to 61% of healthcare workers still do not comply with best practice
November 2009 in 67 nursing wards of three hospitals. Results recommendations for hand hygiene (WHO, 2016).
indicated that having leaders involved and invested in promoting
and modeling hand hygiene compliance increases hand hygiene Methods
compliance among nurses (Huis et al., 2013). Moreover, in Saudi
Arabia, researchers reported that previous emphasis on educating Aim
healthcare worker has yielded some results (Tan and Olivo, 2015).
They explored perceptions about hand hygiene among health- The purpose of this study was to explore nurses’ perceptions
care workers using the questionnaire developed by the WHO to of reasons for persistent low rates in hand hygiene compliance in
87 healthcare professionals. Findings of this study revealed that the Critical Care Unit and their recommendations for improvement.
healthcare workers understand the importance of hand hygiene The results of this study may provide new insights into what has
in preventing infections in the hospital (Tan and Olivo, 2015). In become a persistent issue in healthcare, hand hygiene noncompli-
Canada, the public were surveyed to examine their level of com- ance. This study will also give critical care nurses an opportunity
fort asking healthcare providers to perform hand hygiene at the to contribute to making improvements through their recommen-
point of care (Flannigan, 2015). As part of this study, researchers dations for increased hand hygiene compliance.
also surveyed healthcare workers to explore how comfortable they
would be with the public approaching them about hand hygiene
Design
at the point of care. Interestingly, the majority of participants felt
that they would be at an increased risk for infection if health-
This study used an exploratory, descriptive survey design to
care providers did not comply with hand hygiene; however, many
identify critical care nurses’ perceptions of barriers to hand hygiene
Canadians did not feel comfortable asking healthcare workers to
compliance in the unit and their recommendations for improve-
perform hand hygiene prior to providing care for them. Most of
ment.
the healthcare providers did not mind if patients were to ask
them to perform hand hygiene at the point of care. Researchers
Research questions
recommended that healthcare providers should implement hand
hygiene in front of patients as a method of standard practice
(1) What are nurses’ perceptions of the reasons for the persistent
(Flannigan, 2015). In a more recent study in North Carolina, United
low rating in hand hygiene compliance in the critical care unit?
States, a programme was implemented involving observations of
(2) What are nurses’ suggestions to improve hand hygiene compli-
hand hygiene and immediate feedback among healthcare work-
ance in the critical care unit?
ers. The study was conducted during 2013–2015 in an 853-bed
hospital. This programme was useful in decreasing healthcare asso-
ciated infections and increasing healthcare workers participation in Ethical considerations
improving their own hand hygiene compliance (Sickbert-Bennett
et al., 2016). Researchers received approval from the institutional review
Hand hygiene compliance rates are not optimal in many hospi- board (IRB 16-029) to conduct this study. This included an initial
tals across the United States and other nations in the world (Borg assessment by peer facilitated review process and a final review
et al., 2014; CDC, 2016). Most recently, a team of experts from The and approval by IRB. In order to minimise risk of confidential-
Joint Commission Centre for Transforming Healthcare reported that ity breaches for participants, questionnaires were completed and
hand hygiene compliance averaged 45.5% in eight hospitals in the submitted anonymously and no demographics or identifying infor-
United States (Chassin et al., 2015). In the United Kingdom, Ireland, mation was requested to allow nurses to freely express themselves.
and Central/Eastern European countries, hospitals have established
disciplinary measures and obligatory hand hygiene training for Sample and setting
persistent hand hygiene non-compliance among healthcare work-
ers (Borg et al., 2014). In Saudi Arabia, researchers observed 242 A convenience sample of critical care nurses was selected. Crit-
healthcare workers including physicians, nurses, and therapists, ical care nurses who worked twelve hours, day or night shift were
performing hand hygiene in five intensive care units (Alsubaie invited to participate in the research for a period of one month. The
et al., 2013). They reported a noncompliance rate of 58% associated inclusion criteria consisted of nurses working full time in the criti-
with the type of intensive care unit (ICU), with the higher rates of cal care unit who agreed to participate in the study. Forty-seven
noncompliance in the medical ICU and paediatric ICU. Moreover, critical care nurses answered the questionnaire. This study was
there was a significant increased noncompliance among physi- conducted in a 452 beds Magnet hospital. All nursing and allied
cians (64.4%) and other healthcare staff (65.1%), followed by nurses health staff follow the same infection control policies and proce-
(55.4%), working during day shift and when taking care of patients dures in this facility. They have received hand hygiene education
(Alsubaie et al., 2013). According to investigators, recommenda- including demonstrations, followed by evaluations and site obser-
tions for studies to investigate the demands of the unit environment vations.
might be helpful in identifying factors affecting noncompliance
(Alsubaie et al., 2013). Lack of compliance with hand hygiene prac- Instrument
tices is still a serious and persistent problem causes of which are
not well understood. More studies should be done examining spe- The questionnaire content was derived from a literature review
cific barriers to hand hygiene compliance across different hospitals identifying the most common barriers related to lack of compliance
(Chassin et al., 2015). in hand hygiene in healthcare settings including environmental
N. Sadule-Rios, G. Aguilera / Intensive and Critical Care Nursing 42 (2017) 17–21 19

barriers and attitudinal beliefs (Chagpar et al., 2010). The question- Table 1
Responses by 47 critical care nurses’ perceived barriers to hand hygiene compliance.
naire included 18 items assessing nurses’ barriers to hand hygiene
compliance in the critical care unit and two open-ended questions Questions N %
giving nurses the opportunity to explain the main problem they 1. Lack of appropriate hand hygiene products 17 36.2
perceived as a barrier to hand hygiene compliance and their sug- available at the point of care
gestions for improvement. Prior to the study, the questionnaire was 2. Difficulty accessing sink locations 22 46.8
reviewed by six individuals who exhibited characteristics similar to 3. Difficulty donning gloves when hands are 22 46.8
damp
those comprised in the study population. The purpose of reviewing
4. Products placed in inconvenient locations 20 42.6
the questionnaire was to seek the opinions of professional content 5. Products identified by brand names instead 3 6.4
experts to assess the questionnaire for clarity, readability, com- of by product making it difficult to
pleteness, and acceptability of questions and response alternatives differentiate between hand soap and
alcohol-based product
(Waltz et al., 2010). Revisions to the content of the questionnaire
6. Product refilling process is time consuming 9 19.1
were not needed on the basis of input received. 7. Inconsistent mounting height of the 3 6.4
alcohol-based hand sanitisers
Procedures 8. Skin irritation 18 38.3
9. Lack of skin care promotion and lotions at 17 36.2
the point of care
Nurses, who were currently working on the unit, were
10. Patients’ needs are a priority to hand 13 27.7
approached about their participation interest. Those who hygiene
expressed desire to participate, were given a copy of the cover 11. Wearing gloves is enough to prevent health 4 8.5
letter and questionnaire. Nurses, who agreed to participate in the care associated infections.
12. I forget to do it sometimes 16 34
study, were instructed to answer the questionnaire identifying
13. Insufficient time 12 25.5
the most common barriers related to lack of compliance in hand 14. High workload and understaffing 24 51.1
hygiene and to return the completed questionnaire to a secure box 15. Insufficient number of sinks 11 23.4
in the unit. No further contact between researchers and potential 16. Hand washing is not essential to prevent 1 2.1
participants was made. Researchers collected the completed health care associated infection.
17. Interference with worker-patient relation 3 6.4
questionnaire from the locked box at the end of every work day.
18. Other: (please specify) 4 8.5

Data analysis
Table 2
Comments written by critical care nurses on the questionnaire.
Descriptive statistics were used to summarise the responses
from the questionnaire items with SPSS, version 23.0. Content from Examples of other reasons given by critical care nurses to perceived barriers to
the open-ended questions was summarised and analysed based on hand hygiene compliance (4 nurses)
word repetition and the frequency of the responses. (a) No sinks outside of the rooms
(b) Lack of sinks
The main problem with hand hygiene compliance perceived by critical care
Results nurses (25 nurses)
(a) Inconveniently located hand sanitisers
Forty-seven nurses completed the questionnaire during the (b) Not enough sinks
(c) Lack of time
one-moth period of the study. Of the 47 participants, 25 (53%)
Specific suggestions to improve hand hygiene compliance in the critical care
responded giving examples of the main problem they encountered unit (32 nurses)
with hand hygiene in the critical care unit. Thirty-two (68%) offered (a) Place hand sanitisers in conveniently and easy to access locations such
specific suggestions on how to improve hand hygiene compliance as next to gloves, close to patients’ rooms, upon entering and inside the
room, inside and outside the room, in two places in the room, and in the
in the critical care unit. Results are reported based on the number
same location in every room.
and percentage of nurses who selected the specific item (Table 1). (b) Place more sinks by nurse station and in more convenient locations.
The top seven main reasons selected by nurses for the low rank- (c) Provide lotions and better moisturising cleanser products.
ing in hand hygiene compliance in the critical care unit were the (d) Provide education for families, patients, and physicians.
following: Twenty-four nurses chose high workload and under- (e) Have more Clinical Partners working on the floor to allow staff to have
more time.
staffing (item # 14) as the main reason for scoring low-ranking
(f) Place reminders in bathrooms, small signs on the charts, computers,
in hand hygiene compliance, which was the highest percentage of and patients’ rooms, and reinforce hurdles.
answers (51%), indicating that item # 14 was the most important
reason. Items # 2 and # 3, difficulty donning gloves when hands
are damp and difficulty accessing sink locations, were selected hand hygiene compliance and their suggestions for improvement.
by 22 (47%) nurses as the second main reasons for low compli- Responses to the open-ended questions were grouped based on
ance. Twenty nurses (43%) chose products placed in inconvenient word repetition and the frequency of the responses. Twenty five
locations (item # 4) as the third main reason for low-ranking in nurses reported that the main problem with hand hygiene in the
hand hygiene compliance among critical care nurses. Skin irritation critical care unit was inconveniently located hand sanitisers, not
(item # 8) was selected by eighteen nurses (38%). Finally, seventeen enough sinks and lack of time. Lastly, thirty-two nurses provided
nurses (36%) selected lack of appropriate hand hygiene products specific suggestions for hand hygiene compliance. Findings are
available at the point of care (item # 1) and lack of skin care pro- recorded in Table 2.
motion and lotions at the point of care (item # 9) as major reasons
for low ranking in hand hygiene compliance in the critical care unit. Discussion
Only four nurses gave other specific reasons (item # 18) as the main
problem they encounter with hand hygiene in the critical care unit. The most important barriers to hand hygiene compliance iden-
The most common reasons given were no sinks outside the rooms tified by critical care nurses were high workload and understaffing.
and lack of sinks. This was corroborated by nurses indicating that lack of time was
The questionnaire also included two open-ended questions giv- one of the main problems with hand hygiene compliance in the
ing nurses the opportunity to explain the main problem with critical care unit in their responses to the open-ended questions.
20 N. Sadule-Rios, G. Aguilera / Intensive and Critical Care Nursing 42 (2017) 17–21

Coincidentally, our study was conducted during the time when and February 2014 on the topic of hand hygiene compliance among
the study facility was going through system wide changes and an healthcare workers revealed that implementing a variety of inter-
increase in critical care nurses’ turnover rate. These circumstances ventions to address hand hygiene compliance barriers works best
might have contributed to the high nurse-to-patient ratios and in improving hand hygiene compliance among healthcare work-
understaffing reported by the participants. Nursing understaffing ers (Kingston et al., 2016). Results indicate that there is a need to
has been associated with increased patient mortality rate compli- implement interventions that target the specific barriers to hand
cations, and failure to rescue (Cho et al., 2015; Friese et al., 2008). hygiene compliance in the unit in addition to education and surveil-
Nurses have also reported that the quality of patient care, as defined lance. Therefore, special attention should be given to the reasons
by the Institute of Medicine, is affected by high workload or inad- expressed by the participants for low compliance and their sugges-
equate number of licensed registered nurses to provide care to tions for improvement should be considered.
patients as needed (Buerhaus et al., 2005). Inadequate staffing is
perceived by nurses as unsafe care for patients which can lead to Clinical implications
missed or delayed care and recognition of signs of patients’ deteri-
oration (Wolf et al., 2016). Furthermore, researchers have reported Our results indicate that having the adequate nurse-patient
that high nursing workload has an adverse effect on patient safety ratios and consequently, more time, cleanser products available at
(Lang et al., 2004). From the available evidence, it appears that hav- the point of care, and easy accessible sink locations for hand hygiene
ing an appropriate licensed registered nurse to patient ratio and may facilitate nurses’ compliance with hand hygiene. Hence, the
other personnel to care for patients in the unit should be considered researchers suggest implementing critical care nurses’ recommen-
among the most suitable interventions to improve hand hygiene dations for improvement.
compliance and therefore, reduce healthcare associated infection
rates.
1. Frequent staff meetings should be held to assess and discuss ade-
Hand hygiene noncompliance among healthcare workers con-
quate nurse-patient ratios and responsibilities in the critical care
tinues to be the focus of research studies and worldwide initiatives.
unit.
Low hand hygiene compliance has been linked to high hospital-
2. Hand hygiene should be made easy and convenient by
wide infection rates and increase patient mortality worldwide • Placing alcohol-based hand rub dispensers near the point of
(Allegranzi and Pittet, 2009). This study has identified that hav-
care, such as:
ing the inadequate amount of licensed nurses to care for patients • Next to each patient’s bed.
in the critical care unit might hinder hand hygiene compliance. • Attached to the frame of patient beds.
Overall, it appears that noncompliance is linked to high workload • Near the door to each patient’s room (either adjacent to the
and understaffing. This was made evident by nurses perceptions
door in the hallway or just inside the door).
reflected on the responses to this survey. Hand hygiene compli- • At nursing stations or on medication carts.
ance continues to be a challenge worldwide. The results of this • Supplied as portable (pocket or belt) individual dispensers for
study suggest that nursing high workload and understaffing can
personal use.
have negative implications for hand hygiene compliance, and until
3. Responsibility for checking alcohol-based hand rub dispensers
this issue is addressed, education and other interventions will not
and glove boxes should be assigned on a regular basis to assure
be completely successful.
that:
Nurses selected difficulty accessing sink location and lack of
a. Dispensers and glove boxes are not empty.
appropriately located hand sanitisers at the point of care comple-
b. Dispensers are operational.
mented by suggestions of not enough sinks and inconveniently
c. Dispensers provide the correct amount of the product.
located hand sanitiser as major barriers to hand hygiene compli-
4. Assign a team to evaluate the accessibility and location of the
ance. These results are not unique to this study since inconvenient
sinks since difficult to access sinks may adversely affect hand
location of sinks and busy work setting have been identified in
hygiene compliance rates and come up with suggestions for
past studies as reasons for low hand hygiene compliance among
improvements.
healthcare workers (Ellingson et al., 2014). Moreover, low hand
5. Initiate a multi-component publicity campaign (e.g. posters,
hygiene compliance was associated to poor access to sinks in a
labels with messages, posters, and reminders).
hospital in Canada (Deyneko et al., 2016). Our findings were also
6. Create a culture where reminding each other about hand hygiene
confirmed by the specific suggestions for improvement nurses
is encouraged and makes compliance a social norm.
reported including, place hand sanitisers in conveniently and easy
7. Celebrate hand hygiene efforts and improvements made in com-
to access locations, place more sinks by nurse station and con-
pliance rate at the end of every quarter.
venient locations, and have more nursing assistants working on
8. Engage patients and families in hand hygiene efforts by pro-
the floor to allow staff to have more time. In a similar study to
viding patient safety brochures outlining appropriate hand
identify and describe predictors and determinants of critical care
hygiene and encourage and empower them to remind healthcare
nurses noncompliance with hand hygiene, researchers found that
providers to comply with these standards.
nurses’ negative attitudes towards time-related barriers are predic-
tors of poor compliance (De Wandel et al., 2010). On the other hand,
making hand hygiene resources easily available to nurses increases Most of the above recommendations were specific suggestions
healthcare providers’ compliance (Suresh and Cahill, 2007). made by the research participants. Some of the above recommenda-
A promising finding of this study is that 47 out of 48 nurses tions were adapted from the Institute for Healthcare Improvement
identified hand hygiene compliance as an essential method to pre- recommendations How-to Guide (IHI, 2006).
vent health care associated infection. Most participants in this study
viewed hand hygiene as key to prevent infections in the unit. Pre- Limitations
vious efforts to educate and train critical care nurses about the
importance of hand hygiene in preventing infections have been This study surveyed critical care nurses from only one hospi-
successful as evidenced by the responses by the majority of the tal. Another limitation of the study is that only critical care nurses
nurses in this study. However, knowledge is not enough. A litera- met the inclusion criteria. Results may be different if this study
ture review that included 57 clinical trials between December 2009 is done including a variety of healthcare providers and more than
N. Sadule-Rios, G. Aguilera / Intensive and Critical Care Nursing 42 (2017) 17–21 21

one institution. Another limitation to this study is that the ques- De Wandel, D., Maes, L., Labeau, S., Vereecken, C., Blot, S., 2010. Behavioral determi-
tionnaire was administered at a time when the study facility was nants of hand hygiene compliance in insensitive care units. Am. J. Crit. Care 19
(3), 230–239.
going through system wide changes and an increase in critical care Deyneko, A., Cordeiro, F., Berlin, L., Ben-David, D., Perna, S., Longtin, Y., 2016. Impact
nurses’ turnover rate. of sink location on hand hygiene compliance after care of patients with Clostrid-
ium difficile infection: a cross-sectional study. BMC Infect. Dis. 16, 203, http://
dx.doi.org/10.1186/s12879-016-1535-x.
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encevich, E., Polgreen, P.M., Schweizer, M.L., Trexler, P., VanAmringe, M., Yokoe,
Results of this study indicate that high workload and under- D.S., 2014. Strategies to prevent healthcare-associated infections through hand
hygiene. Infect. Control Hosp. Epidemiol. 35 (8), 937–960.
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Friese, C.R., Lake, E.T., Aiken, L.H., Silber, J.H., Sochalski, J., 2008. Hospital nurse prac-
tance of hand hygiene compliance to prevent health care associated
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Impact of a team and leaders-directed strategy to improve nurses’ adherence to
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