Free Hand Washing Education And Hospital Acquired Infections Literature Review Example

Type of paper: Literature Review

Topic: Nursing, Medicine, Viruses, Vaccination, Hygiene, Disease, Infection, Study

Pages: 7

Words: 1925

Published: 2020/12/23


Hospital-acquired infections have always been a major impediment to high-quality health care especially in regards to fast patient recovery. These infections occur when the patient is exposed to bacteria and viruses possibly acquired from another patient in the same hospital. Most of the hospital-acquired infections are however preventable. Some simple strategies can be introduced in these health settings, and these can have a significant impact in terms of reducing the number of infections that are transmitted to patients around the hospital. It is from this aspect that this paper draws its premise. This paper aims to look at one of the intervention techniques that is used to curb hospital acquired infections. This is hand hygiene compliance. It has been suggested that compliance to hand hygiene specifically hand washing can have a significant impact when it comes to hospital acquired infections and thus, medical personnel should be subjected to an education program teaching on the same. This paper will conduct an exhaustive review of various research that has been conducted on the issue to show whether a hand education washing education program is indeed an effective infection control mechanism on acute care patients.


This paper aims to answer a specific PICOT question using the information from the acquired sources. This question is; What is the effectiveness of a handwashing education program among health care workers in reducing hospital-acquired infections on acute care patients during hospitalization? The topic will be answered using information obtained from the various research articles that report on the issue. There has in fact been a lot of research conducted on this issue, and it emerges that the effectiveness of handwashing as an infection control mechanism is quite a contentious issue.
Hospital acquired infections have been increasing in the modern medical world, and this has drawn the attention of various stakeholders including the government, regulatory bodies, and medical insurers.
DiDiodato (2013) conducted a study at an Ontario clinic to establish if hand hygiene compliance had in any way reduced the risk of hospital acquired infections among a group of patients. The research combined prospective, ecological, cross section, times series, and ecological approaches to studying this relationship. A total of 166 hospitals were subjected to the study. The entire data for the study was extracted from the official patient safety indicator database for Ontario from October 1, 2008 to December 31, 2011.The main types of infection considered included Clostridium difficile infection (CDI) and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Regression analysis was then used to analyze the trend and associations for each of the indicators. Some of the dependent variables utilized in the study included the heath care region, the type of hospital, and the year. The results indicated that HHC rates improved between these periods. The rates for the MRSA infection did not indicate any change while there was a minor decrease in the rates of CDI. The authors found and concluded that there was no association between improved hand-hygiene compliance and the two infections.
Nair et al. (2014) also conducted a correlational study in India using a sample of 46 nursing and 98 medical students at a tertiary medical college. The authors wanted to study if nurse’s compliance to hand washing would have any effect on the rates of disease transmission among patients. A WHO hand hygiene questionnaire was used to collect data while another self-structured questionnaire was used to compare practices and attitude. Using Z test to compare the proportion of correct responses between the nursing and medical students, it was found that the nursing students had more knowledge and better attitude towards hand washing and also practiced it more often than their medical counterparts. However, from the entire group, only 9% were well knowledgeable about the whole concept of hand washing. The authors concluded that current training programs on hand hygiene practices need to be improved for both nursing and medical students. These training programs also need to be conducted more frequently and should also be accompanied by efficient monitoring and feedback techniques so as to encourage medical and nursing students to comply with hand hygiene guidelines and practices.
Erasmus et al. (2009) conducted a qualitative study to examine the determinants of hand hygiene compliance in healthcare workers such as nurses and doctors in any given hospital setting. The researchers used a structured interview design to collect data from a sample of 65 medical personnel including nurses, medical students, medical residents and attending physicians. This was done across surgical departments and intensive care units in a total of 5 hospitals in Netherlands. The primary result of the study was that most of the medical personnel who comply with hand hygiene actually do it for personal protection purposes rather than for patient safety. The participants also indicated that norms and examples from senior medical personnel or supervisors significantly influenced their compliance or non-compliance to hand washing guidelines. Some of the personnel also questioned the truth in the assertion that hand washing is an effective measure to curb cross-infections in hospitals. The main conclusion drawn by the authors was that hand hygiene is mainly influenced by personal beliefs about self-protection and that compliance to hand washing guidelines is hindered by the lack of effective role models or social norms that support the practice.
Lloyd-Smith (2014) conducted a study to describe an infection control champion program that could be effective in reducing cases of infection. In this study, the author used semi semis structured focus groups to describe the feasibility as well as the factors that were either critical or that acted as an impediment to the sustainability of a distributed model of infection control placed in 3 Canadian hospitals for a total of 3 months. The researchers also calculated an economic estimate of the infection control champion program in comparison with the cost incurred in hiring a brand new infection control practitioner. From the results, the focus group indicated that the program could be feasible. Some of the mentioned barriers included staff turnover and lack of time. Factors seen as critical to the implementation of the program included adequate resources and support, well-defined goals and roles, active engagement from all staff levels, flexible structure, and constant program evaluation. It was also found that the ICC program’s cost per bed was significantly less than that of hiring a new infection control practitioner. The authors, therefore, concluded that this model of infection prevention and control can be very beneficial when infection control teams in hospitals are under sourced. However, for the program to succeed, several factors must be present.
Jang et al. (2010) conducted a qualitative study among 153 healthcare workers from almost all job categories. The objective of this study was to comprehend some of the hand hygiene behavioral determinants. The setting for this study was Mount Sinai Hospital, a tertiary hospital for acute care that has an affiliation with the University of Toronto. The method involved verbatim transcription of forum group discussions. In addition, three investigators independently conducted a thematic analysis. One of the findings of this research is that workload realities that include interruptions and urgent care usually make adherence or compliance to hand hygiene quite impossible. In addition, most of the health workers trust their own judgment when it comes to assessing the situation that requires or that does not require the washing of hands. In addition, it was shown that many of the health workers lacked sufficient knowledge on the concept of health hygiene although many were willing to learn. The finding also indicated that those who observed hand hygiene mainly did it for self-protection purposes. Workers also reported lack of hand hygiene products as a factor influencing their compliance to hand hygiene guidelines and some claimed that the practices of their peers also influenced them. Therefore, the authors conclude that most of the hand hygiene in hospitals is conducted for personal protection purposes and that limited access to hand hygiene supplies and products act as a barrier. In addition, team effort and the presence of role models are important in encouraging a hand washing culture among hospital workers.
Stevenson et al. (2014) conducted a quantitative study on a set of rural hospitals in Utah and Idaho. A total of 10 hospitals in the two states were recruited to take part in a cluster-customized trial involving multidimensional infection control interventions to determine the feasibility of these interventions in a setting characterized by limited resources. Out of the ten hospitals, individualized campaigns were initiated to promote hand hygiene compliance, as well as outbreak control in five. The other five were randomized to continue with the already existing infection control strategies. The primary outcome measure was hand hygiene compliance observations across all hospitals. In terms of infection, the colonization of patients with resistant and pathogens was assessed using periodic prevalence studies. Among the findings, it emerged that hand hygiene compliance increased by 20.1% in five hospitals where new infection control strategies were initiated while in the control group, the change was -3.1%. Therefore, the authors indicate that interventions to reduce intervention control through hand hygiene compliance campaigns are feasible even in rural hospitals where there are limited resources.
It is clear that hand washing compliance significantly reduces the risk of infection control. Some of the studies discussed above paint a clear picture of this argument.
While these studies indicate that infections can be significantly reduced by hand hygiene, many do not go into explicit details about what exactly hand hygiene entails, and there is some sense of ambiguity about the issue. This is perhaps one area that studies could perhaps improve on by being more specific.
Other authors have conducted similar studies and found similar results, that hand washing compliance reduces the rate of hospital acquired infections.
Rabie and Curtis (2006) conducted a systematic review of eight research articles that reported an impact of handwashing intervention on respiratory infections and found that hand washing generally lowered the risk of respiratory infection by a value ranging 6% to 44%.
Mathur (2011) is very emphatic on this issue even going as far as claiming that “There is now undisputed evidence that strict adherence to hand hygiene reduces the risk of cross-transmission of infections."
Some studies have suggested that education and training should be provided to medical personnel to promote hand compliance. Helder et al. (2010) conducted a study on the effect of an education program concerning hand hygiene and its relation to nosocomial bloodstream infections incidence. It emerged that the education program led to improved hand hygiene practices among medical personnel and hence a reduction in nosocomial infections.
An almost similar result was found by Lee and Greig (2012) who established that hand washing as one of the infection control interventions significantly led to the reduction of nosocomial virus outbreaks in hospitals.
The current statistics on hand hygiene as observed by the review of the six primary articles are not so good. Most of the articles showed low levels of handwashing compliance among both nurses and doctors. Erasmus et al. (2010) conducted a systematic study of articles on the same issue and found in all the studies analyzed, the median compliance rate was 40% with compliance being even lower in intensive care units which is a very worrying statistic.
Huis et al. (2012) also conducted a similar systematic review of quasi-experimental and experimental research on hand hygiene strategies from articles gotten from a variety of medical databases such as CINAHL, Medline, and Cochrane. Out of the 41 articles assessed, most of them showed positive changes which is further proof that hand hygiene does indeed reduce hospital acquired infection. However, it was shown that HH compliance is determined by several factors including social influence, self-efficacy and attitude and these should all be considered when designing strategies to promote compliance and not just education.
Some researchers suggest that the patients should be included in the hand hygiene campaigns as they can also encourage the health care personnel (Lander s et al., 2012)
More research clearly needs to done to establish exactly how to improve hand hygiene. Some studies have already attempted to do this. Boyce (2011) suggests the use of electronic monitoring systems claiming “Preliminary studies suggest that use of electronic monitoring systems is associated with increased hand hygiene compliance rates. This is further supported by Marra et al (2013) who says that direct observation is not enough to assess hand hygiene adherence and that other techniques such as electronic devices or even the measurement of hand hygiene product usage should be used.
As shown by Nichol et al 2011, methicillin-resistant Staphylococcus aureus (MRSA) is the most common bacterial and in fact the most prevalent in Canada and as research has shown, its prevalence can be reduced through hand washing. Another bacteria as shown by Lowe et al (2013) is New Delhi metallo-β-lactamase-l-producing Klebsiella pneumoniae (NDMl-Kp) and this once also be significantly minimized through hand hygiene.
Some of the studies explored have not been able to prove that interventions such as hand control can explicitly reduce hospital acquired infections. Gould et al. (2010) comments on this by saying that just because there is no explicit evidence that shows the effect of hand washing interventions, this does not mean that hand washing should not be promoted. Gould et al., (2010) states that “Much HAI is spread by direct contact, and it is logical to suppose that hand hygiene can interrupt the chain of infection"


This study has revealed several things regarding the effectiveness of hand washing education and hospital acquire infections. A majority of the studies and research conducted on the issue suggests that high compliance to hand hygiene or handwashing by medical personnel such as doctors and nurses’ leads to a decrease in the number of hospital acquired infections. However, this assertion or finding is contentious as there are several studies that have been conducted on the same issue and that have not shown an explicit relationship between the two. Another major finding that is that levels of hand hygiene or hand washing are actually very low in modern hospitals , especially in Canada and new strategies and education programs need to be initiated to encourage medical personnel to be more compliant to hand hygiene. The implication of this topic and indeed these findings to nursing practice is enormous. First of all, these finding reveals a massive deficiency in nursing that could be affecting the quality of care. As a profession, nursing strives to avail the highest quality of care to patients. However, aspects such as hand washing non-compliance act as an impediment to the advancement of the discipline and therefore as a barrier to the achievement of high quality and effective care. The findings from this study should act as an impetus for nursing leaders to spring into action. An aspect of hand washing should be introduced in the nursing curriculum for those who are still pursuing nursing studies, and for those already in the field, they should be subjected to regular training programs that emphasize on the aspect of hand washing or hand hygiene compliance and its role and contribution towards the ultimate goal of nursing practice; high quality care that facilitates faster patient recovery.


Boyce, J. M. (2011). Measuring Healthcare Worker Hand Hygiene Activity Current Practices and Emerging Technologies. Infection Control, 32(10), 1016-1028.
DiDiodato, G. (2013). Has improved hand hygiene compliance reduced the risk of hospital-acquired infections among hospitalized patients in Ontario? Analysis of publicly reported patient safety data from 2008 to 2011. Infection Control & Hospital Epidemiology, 34(6), 605-610. doi: 10.1086/670637
Erasmus, V., Brouwer, W., van Beeck, E. F., Oenema, A., Daha, T. J., Richardus, J. H., &Vos, M. C. et al (2009). A qualitative exploration of reasons for poor hand hygiene among hospital workers: lack of positive role models and of convincing evidence that hand hygiene prevents cross-infection. Journal of the Society of Hospital Epidemiologist of America, 30(5), 45-49. doi: 10.1086/596773
Erasmus, V., Daha, T. J., Brug, H., Richardus, J. H., Behrendt, M. D., Vos, M. C., & van Beeck, E. F. (2010). Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infection Control, 31(03), 283-294.
Gould, D. J., Moralejo, D., Drey, N., & Chudleigh, J. H. (2010). Interventions to improve hand hygiene compliance in patient care. The Cochrane Library.
Greig, J. D., & Lee, M. B. (2012). A review of nosocomial norovirus outbreaks: infection control interventions found effective. Epidemiology and Infection, 140(07), 1151-1160. doi:
Helder, O. K., Brug, J., Looman, C. W., van Goudoever, J. B., & Kornelisse, R. F. (2010). The impact of an education program on hand hygiene compliance and nosocomial infection incidence in an urban neonatal intensive care unit: an intervention study with before and after comparison. International Journal of Nursing Studies, 47(10), 1245-1252.
Huis, A., van Achterberg, T., de Bruin, M., Grol, R., Schoonhoven, L., & Hulscher, M. (2012). A systematic review of hand hygiene improvement strategies: A behavioral approach. Implement Sci, 7(1), 92.
Jang, T. H., Wu, S., Kirzner, D., Moore, C., Youssef, G., Tong, A., & McGeer, A. (2010). Focus group study of hand hygiene practice among healthcare workers in a teaching hospital in Toronto, Canada. Infection Control, 31(02), 144-150.
Landers, T., Abusalem, S., Coty, M. B., & Bingham, J. (2012). Patient-centered hand hygiene: The next step in infection prevention. American Journal of Infection Control, 40(4), 11-17.
Lloyd-Smith, E., Curtin, J., Gilbart, W., & Romney, M. G. (2014). Qualitative evaluation and economic estimates of an infection control champions program. American Journal of Infection Control, 42(12), 1319-1321. doi:10.1016/j.ajic.2014.08.017
Lowe, C. F., Kus, J. V., Salt, N., Callery, S., Louie, L., Khan, M. A., & Simor, A. E. (2013). Nosocomial transmission of New Delhi metallo-β-lactamase-1-producing Klebsiella pneumoniae in Toronto, Canada. Infection Control, 34(01), 49-55.
Marra, A. R., Moura, D. F., Paes, Â. T., Dos Santos, O. F. P., & Edmond, M. B. (2010). Measuring Rates of Hand Hygiene Adherence in the Intensive Care Setting a Comparative Study of Direct Observation, Product Usage, and Electronic Counting Devices. Infection Control, 31(08), 796-801.
Mathur, P. (2011). Hand hygiene: back to the basics of infection control. The Indian Journal of Medical Research, 134(5), 611.
Nair, S. S., Hanumantappa, R., Hiremath, S. G., Siraj, M. A., & Raghunath, P. (2014). Knowledge, attitude, and practice of hand hygiene among medical and nursing students at a tertiary health care centre in Raichur, India. ISRN Preventive Medicine, 2014(4). doi:10.1155/2014/608927
Nichol, K. A., Adam, H. J., Hussain, Z., Mulvey, M. R., McCracken, M., Mataseje, L. F& Canadian Antimicrobial Resistance Alliance (CARA). (2011). Comparison of community-associated and health care-associated methicillin-resistant Staphylococcus aureus in Canada: results of the CANWARD 2007–2009 study. Diagnostic Microbiology and Infectious Disease, 69(3), 320-325.
Rabie, T., & Curtis, V. (2006). Handwashing and risk of respiratory infections: a quantitative systematic review. Tropical Medicine & International Health, 11(3), 258-267.
Stevenson, K. B., Searle, K., Curry, G., Boyce, J. M., Harbarth, S., Stoddard, G. J., & Samore, M. H. (2014). Infection control interventions in small rural hospitals with limited resources: results of a cluster-randomized feasibility trial. Antimicrobial Resistance and Infection Control, 3(1), 1-7.

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