Much research has been conducted on how to increase hand hygiene compliance. However, ICT® decided to go to the source and ask healthcare workers themselves why they don’t always practice hand hygiene.
Every healthcare professional knows the importance of hand hygiene (HH). It is the first and most critical defense against the chain of infections. So why is it so difficult to maintain HH adherence in healthcare settings? A myriad of methods have been devised to encourage and enforce adherence: mobile phone apps, video cameras, computer programs, stickers and other small symbols of positive feedback, and most often infection preventionists (IPs) among healthcare workers (HCWs) noting who followed the necessary HH guidelines and who did not.
But why do healthcare workers, knowing the importance, not perform the proper HH procedures every time it is approved or required by their facilities? Infection control today® (ICT®) went to IPs and asked, “What prevents you from performing HH and what do you think prevents other HCWs from consistently adhering to HH requirements?”
Why hand hygiene is important
Leslie Bozigian Curtin, RN, CMIP, former assistant director of nursing and infection prevention specialist at Sumter East Rehab, has been in the healthcare field for 40 years. “To break the chain of infection, you have to have an infectious agent, a method of transmission and a susceptible host. Then you must have [a] method of delivering the agent to the susceptible host. So any time you can break one of those links in the chain, you will break the infection process. The easiest way to do that is HH,” she said.
Why is hand hygiene not consistently performed?
Tracy M. Field, RN, corporate infection prevention specialist for Ecumen, a long-term care organization, said ICT® she sees HH not being done, especially in long-term care (LTC) facilities, despite technological advances. “Things have come a long, long way. In the 30 years I’ve been in health care, one of the biggest things that has evolved is hand sanitizer. They have these wall units right in the patient rooms, right in the living rooms. They have these strategic solution locations all over the place. But even though they are there, I can still see [HCWs] walk past them,” she said.
The first barrier to HH adherence is knowing the patient, Field said ICT®. “We live and work with them [patients] whom we love very much. We are their family and they are our family. When you feel like you love it [patient], you take care of them every day; you don’t see them as contagious. You might miss out [HH] because it’s not like the hospital…and that [patient] in front of you is not super sick. This is a different situation. In elderly care, HH is just as important: everything we can do to prevent infections. But there is this sweetness in the care we take [due to familiarity]. I see that as a big barrier,” she said.
Field also explained the second barrier: complacency. In a long-term care facility, a health care professional might think, “I took care of this person every day [in the past] a week; I know they are not sick. HCW returns 2 days later, [and the patient has] COVID-19 or norovirus. And HCW was already exposed. There is this kind of complacency when the HCW thinks, “Oh, I take care of these [patients] The whole time. They are not sick. I see that thought as a barrier to elder care,” she said.
Other reasons for incorrect HH that emerged in discussions with IPs were staffing challenges and lack of time. In these situations, the HCW tries to do everything and the HH is the easiest and first guideline to be ignored. “The understaffing is so overwhelming that you’re exhausted and frustrated,” Field said.
However, Field explained that those feelings are no excuse. “[HCWs] they complain that they don’t have time. [However,] I do not think [HCWs] they can argue that they don’t have time to wash their hands or… use hand sanitizer… It’s not that we don’t have time. Our mind is so busy with wearing a mask, wearing safety glasses, putting on a dress and so on for these rooms. It is an overload of intense situations that overwhelms medical professionals. We lose that laser focus and you fall back and miss some steps,” she said.
Curtin tells his health workers to perform HH in the following situations:
1. When you put your bag away
2. When you put your coat away
3. Before entering another room on the device
4. If you walk into someone’s room and pass a tray
5. Meanwhile, providing patient care
6. Before providing any patient care
7. When you go to the toilet
8. Before and after a meal or snack
9. After performing care that requires gloves, you should remove your gloves and wash your hands again
ICT® also asked Laura Miller, MD, MPH, FAAFP, the main reason she sometimes finds herself not following HH procedures. Miller is an assistant professor in the Department of Family Medicine and Public Health at the University of Minnesota in Minneapolis. “I think No. 1 is time and so many different things in our cognitive spaces. We go in and out of different locations with patients and care teams. There’s a lot going on [and] there are a lot of moving parts going on,” Miller said.
Miller said another reason for poor HH adherence is lack of access to hand sanitizer. It might not be recharged or not in the right place. “That’s a big gap that I’ve noticed, and it’s certainly something that can be addressed. We’ve come a long way now that we’re in the age of readily available hand sanitizers. We moved on to owning [hand sanitizer] along with hand washing stations. It is more convenient and more beneficial to have hand sanitizer available instead of hand washing [stations] because it takes much more time and space [wash].”
Also, according to Miller, simply remembering to do HH can be difficult “especially in more urgent and emergency situations.
situations when trying to get into the emergency room [because] Your patient is not feeling well in the hospital. She went on to say, “When you’re in midwifery and you’re pressed for time, it’s hard to stop when you have something more urgent at hand.”
Miller echoed other health care workers he spoke with ICT® for sticky and/or smelly hand sanitizer or soap. “There have been times when a refill pack or something else is different … so I’ll avoid that.” She also mentioned allergies or dermatological effects from hand sanitizer. Because it is alcohol-based, it is a drying agent that can cause serious and chronic skin problems.
However, Curtin said there was no excuse for the lack of adherence to HH; even children know to wash their hands well and often.
No matter the cause of improper HH, her advice to healthcare workers is always the same: “You can’t wash your hands or use hand sanitizer too many times.”