Clinical Question: In patients in acute care settings (P) will a hand hygiene program (I) compared to the current poor hand hygiene protocol amongst the health workers (C) reduce the rate of hospitals acquired infections (O) in a period of three months (T)?
Justification of the Question
Poor hand hygiene practices amongst the health workers have been linked to increased rates of healthcare-associated illnesses. While evidence shows appropriate hand hygiene programs can reduce the rates of transmission, non-compliance among the health care workers remains high. Advocating for interventions that promote adherence to hand hygiene practices will have immense benefits in regards to reducing the rates of hospital-acquired infections in a short period of time.
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Literature Review Summary
Hospital-acquired infections are a serious problem in today’s health care setting as they increase morbidity and mortality among patients and inhibit the effective delivery of health care services. According to Han et al. (2017), there are more than 1 million cases at any time. Furthermore, these rates can be reduced by the implementation of a proper hand hygiene program, such as washing the hands with soap and water or using alcohol-based rubs (Han et al., 2017). These interventions are targeted at the health care workers because growing evidence points to their fundamental roles in transmitting the pathogens that cause infections from one patient to another in both the inpatient and outpatient setting. Suppose health care workers were to comply with the hand hygiene protocols, Han et al. (2017) claim that the rate of hospital-acquired infections would drop by 14 – 31%. While the rate is variable, depending on the protocol used and the health care setting, its impact would be clinically significant, if not statistically.
The problem, however, is that compliance with the hand hygiene protocols, regardless of its effectiveness derived from evidence-based practice, is very low. According to Compton et al. (2018), compliance with the hand hygiene protocols is at 48%, which is lower than half of the times they contribute to increased rates of infection transmission. Another study by Ott et al. (2015) is consistent with Compton et al. (2018), where compliance with hand hygiene practices among physicians in acute health care settings was as low as 42%. Manresa et al. (2020) noted that some of the physicians and personnel who failed to observe hand hygiene protocols would proceed to put on gloves and perform invasive procedures. This pattern of behaviour creates a breeding ground for pathogens that results in infections to be passed to the community through health care workers. Note that patients who require the services of health care workers are most likely sick, thus susceptible to outside infections. Furthermore, health care workers will come into contact with different patients, thus increasing the number of infections they spread.
The previously discussed studies, while valuable in establishing evidence about hand hygiene protocols and the compliance rates, do not consider the reasons for non-compliance. Korniewicz & El-Masri (2016) observed that the majority of the health care workers pay attention to hand hygiene protocols when their wellbeing is under threat. Furthermore, other reasons for non-compliance were observed to be lack of education and training on the protocols, forgetfulness and distraction, large workloads, insufficient time, inconvenient mechanisms for dispensing the soap or alcohol-based hand rubs, and a perception that wearing gloves contradicts the need to observe hand hygiene protocols, among others (Jamali-Blasi et al., 2016; Korniewicz & El-Masri , 2016).
Intervention Plan
The problem identified earlier is not the lack of hand hygiene protocols that attempt to address the significant spread of hospital-acquired infections by the health care workers. Instead, it is about compliance with the protocols among the health care workers. Therefore, implementing any hand hygiene protocol, such as the five moments of hygiene recommended by the World Health Organization (Manresa et al., 2020), would require a change model that maximize the implementation of the protocols and sustains the practice, cultural, and behavioural changes in the long-term. Lewin’s change management model, therefore, is best suited to implementing the intervention plan. Lewin’s model is a three-step change management plan that involved unfreezing, changing, and refreezing.
Unfreezing
The purpose of the first step is to prepare the organization to accept the necessity of the change. Therefore, the status quo will be challenged. The aim of this step will be to create uncertainty among health care workers. As a result, they are more likely to accept new interventions and recommendations to solve the identified problems. When implementing this step, health care workers should be informed and educated about the current rates of hospital-acquired infections. Furthermore, they should be challenged to accept the change by informing them of their contributions to the rates of infections and their impact on the patients, in terms of morbidity and mortality.
The perception of health care workers, including primary care physicians, should be changed in two ways. First, they should be discouraged from thinking that observing the hand hygiene protocols protects them, especially when their wellbeing is under threat (Korniewicz & El-Masri , 2016). Secondly, physicians should be educated on the need to practice the hand hygiene protocols before performing invasive procedures by challenging the perception that gloves protect them and their patients (Manresa et al., 2020). Hospital administrators should also be challenged to implement the changes, by explaining to them that ensuring full compliance with the hand hygiene protocols significantly reduces the costs for the hospitals and facilities in the long-term. This phase should be completed in 2 – 3 weeks.
Change
Once the health care workers, hospital administrators, and other stakeholders are ready, the change process can start. This is the part of the model that the intervention proposed will be implemented and evaluated primarily. Change, however, will not occur overnight but will require patience and persistence regardless of the resistance. Throughout the change phase, the health care workers and stakeholders will continuously be educated and reminded about the necessity of the intervention and how they will benefit. After all, not everyone will fall in line if they are told the change is necessary.
For instance, this step would involve removing the barriers that inhibit compliance with the hand hygiene protocols. For instance, if the health care workers do not comply with the hand hygiene protocols due to a large workload or insufficient time, then the disinfecting rubs should be placed at convenient positions where the workers can access them without interrupting their duties. Stewardson et al. (2016) noted that the changes should be implemented not only in practical settings but also in basic training. Health care practitioners taught about the intervention and its necessity during basic training (behaviour learned) are more likely to carry on the beliefs and behaviours into practice later. Therefore, the hand hygiene protocols should be integrated into the basic training programs to create routine behaviour for the health care professionals. This phase should be completed in 2 – 2.5 months.
Refreezing
The last step of the change model and intervention plan happens when the health care practitioners have embraced the interventions and compliance with the hand hygiene protocols is maximum. The refreeze step requires creating a status quo with the new behavioural and practice changes, achieved by internalization and institutionalization of the changes. This ensures that the hand hygiene practices are incorporated into normal operating procedures and the worker’s duties. The other purpose of the refreeze step is to keep the health care practitioners from slipping back to their old behavioural patterns. The refreeze step of the intervention plan, therefore, has two objectives.
First, it provides support and training for all health care practitioners. The purpose is to keep everyone informed about the necessity of the changes (leading to internalization) and support. The support can be in the form of adopting to the needs and preferences of the workers. For instance, if the busy practitioners find handwashing with soap and water to be wasting time, they can be supported by the use of alcohol-based hand rubs. Secondly, the refreezing step needs to develop strategies to sustain the change. Three things are essential for success. First, the interventions must gain support from the hospital’s leadership. Secondly, the interventions need to be institutionalized by incorporating them into the normal procedures by the health care practitioners. Lastly, there must be feedback systems to deal with upcoming problems and challenges. There is no time limit on this last phase as compliance with hand hygiene protocols need to be sustained for as long as the health care practitioners deliver their services.
Responsibilities for Implementation and Feedback
The first step of the intervention plan will be the responsibility of health care practitioners. There is a hierarchy in the hospitals, and there are influencers among peers. Therefore, these influencers and authoritative figures will be the first targets to challenge and educate on the need for a change in the facilities. Nurses (RNs and CNAs), for instance, interact with most of the patients and are the first group to target. RNs are most influential and should be given the responsibility of educating their subordinates and peers on the importance of complying with the hand hygiene protocols.
Part of the intervention plan to promote compliance with hand hygiene protocols involves creating educational material and documentation. The hospital administration will have the responsibility of providing financial and other support required. However, the creation of the materials will be left to the different groups. For instance, primary care physicians on board with the intervention plan will have the responsibility of creating the documentation to convince their peers. The same responsibilities are assigned to the nurses. Note that the responsibility for education and creating documentation for the intervention plan is left to the health care practitioners because they can express the changes in a language that they can understand easily.
Note that part of implementing the intervention plan is to institutionalize the changes through organizational policy and to update normal operating procedures. However, some of the barriers to compliance with the hand hygiene protocols identified earlier will prevent success with this objective. Feedback, therefore, will be used to address some of these challenges. The nature of the feedback is such that any modification to operating procedures will impact a health care worker’s job. If the new procedure inconveniences a practitioner or keeps them from doing their duties, they will provide feedback on the exact issue and propose a solution. If the solution is acceptable, it will be implemented throughout the facility.
There are two things that need to be noted when using feedback, however. First, not all feedback is constructive or will be aimed at promoting compliance with the hand hygiene protocols. Some of the practitioners might take advantage of the opportunity to shirk their responsibilities or pass them off to others. Therefore, the incorporation of feedback in the hospitals and facilities should be handled carefully. Secondly, creating a feedback culture in a hospital that did not have one is a prerequisite to the success of the intervention plan. Feedback, as noted in the last step of the intervention plan, was key to sustaining compliance with the protocols.
Therefore, if the hospital of the facility did not have existing mechanisms for handling and incorporating feedback, they should start by addressing it through the existing organizational structure. For instance, if a CNA identifies an issue with the hand hygiene protocol, they can discuss it with their peers, create solutions then bring the matter to the attention of their supervising RNs. The issue and solution will be passed up the organization’s chain till it reaches an individual with the power to implement the change. Therefore, addressing feedback in the hospital will require communication, vertical and horizontal, among the health care practitioners and other stakeholders.
Conclusion
In summary, the study identified hand hygiene as cleaning an individual’s hand in a manner that lessens the injurious pathogens on the hands, thus decreasing the danger of infection transmission among healthcare personnel and among patients. It revealed that hand hygiene is effective in the inhibition of hospital-acquired infections. It showed that the majority of the health workers do not adhere to the hand hygiene routines, which increases the rates of transmission. It also showed that approximately 48% of the healthcare workforce comply with the hand hygiene protocol, which is less than half of the times they should. A three-step intervention plan using Lewin’s change management model was proposed to help improve compliance with hand hygiene protocols.
References
Compton, D., & Davenport, T. E. (2018). Compliance with hand-washing guidelines among visitors from the community to acute care settings: a scoping review. Journal of Acute Care Physical Therapy , 9 (1), 19-34.
Han, A., Conway, L. J., Moore, C., McCreight, L., Ragan, K., So, J., ... & McGeer, A. (2017). Unit-specific rates of hand hygiene opportunities in an acute-care hospital. infection control & hospital epidemiology , 38 (4), 411-416.
Jammali-Blasi, A., McInnes, E., & Middleton, S. (2016). A survey of acute care clinicians' views on factors influencing hand hygiene practice and actions to improve hand hygiene compliance. Infection, Disease & Health , 21 (1), 16-25.
Korniewicz, D. M., & El-Masri, M. (2016). Exploring the factors associated with hand hygiene compliance of nurses during routine clinical practice. Applied Nursing Research , 23 (2), 86-90.
Manresa, Y., Abbo, L., Sposato, K., de Pascale, D., & Jimenez, A. (2020). Improving patients’ hand hygiene in the acute care setting: Is staff education enough?. American Journal of Infection Control .
Ott, M., & French, R. (2015). Hand hygiene compliance among health care staff and student nurses in a mental health setting. Issues in mental health nursing , 30 (11), 702-704.
Stewardson, A. J., Sax, H., Gayet-Ageron, A., Touveneau, S., Longtin, Y., Zingg, W., & Pittet, D. (2016). Enhanced performance feedback and patient participation to improve hand hygiene compliance of health-care workers in the setting of established multimodal promotion: a single-centre, cluster randomised controlled trial. The Lancet Infectious Diseases , 16 (12), 1345-1355.
