Impact of Multimodal Intervention Strategies on Compliance to Hand Hygiene Practices among Staff Nurses in Obstetric and Gynaecological Wards
Mary VJ1, Salomi Thomas2, Suman Rao3
1Tutor, Department of Child Health Nursing, St. Johns College of Nursing, Bangalore.
2Associate Professor, Department of Child Health Nursing, St. Johns College of Nursing, Bangalore.
3Professor and Head of NICU, St. Johns Medical College Hospital, Bangalore.
*Corresponding Author Email: maryvj22@gmail.com
ABSTRACT:
Background: Hand hygiene is the most measure in the prevention of health care – associated infection (HCAI). Adherence to hand hygiene protocols in hospital by nurses enables in prevention and control the HCAI. Objective and Design: This Quasi experimental one group pre-intervention and post intervention study compares the compliance to hand hygiene practices before and after a multimodal interventional strategy Settings: Obstetrics and gynecology ward and private wards of a tertiary care hospital in Bangalore. Subject and Intervantion: Nurses working in the postnatal wards were enrolled in the study by purposive sampling. The staff nurses were observed for their hand hygiene compliance before and after a multimodal intervention strategy. The intervention consisted of educational initiatives, reinforcement of HICC protocol by demonstration and lectures, visual and verbal reminders, ensuring availability of hang hygiene solutions and individual and group teachings. The hand hygiene technique was scored on a validated tool. Statistical Analysis: A sample size of 64 nurses was needed for the study to have a power of 80% and a error of 5%. Mean pretest and post test scores were compared by t test. Associations with baseline variables were done by ANOVA. Outcome Measures: Hand hygiene compliance among staff nurses has improved significantly following multimodal intervention strategies from 45.31% to 65.78%. (P<0.001). There was also significant improvement in the techniques of hand hygiene (hand wash technique mean score improved from 5.97 + 1.284 to 8.16 + 1.158 (p < 0.05) and hand rub technique score from 4.52 + 0.992 to 6.69 + 1.489(p < 0.05)). Hand hygiene in the private wards was significantly better than the common wards. Conclusion: The multimodal intervention strategy including constant reinforcement, training sessions and motivation improved compliance to hand hygiene practices among staff nurses.
KEYWORDS: Hand hygiene, compliance, multimodal intervention, Staff Nurses.
INTRODUCTION:
The World Health organization [WHO] estimates that 10-30 percent of all hospital admissions result in Healthcare acquired infections [HCAI] An estimated 1.4 million people suffer from HCAI at any given time.1 In the wake of the growing burden of health care associated infections, the increasing severity of illness and complexity of treatment, superimposed by multi-drug resistant pathogen infections.2 Health care practitioners are reversing back to the basics of infection preventions by simple measures like hand hygiene.3 With “Clean Care is Safer Care” as a prime agenda of the global initiative of WHO on patient safety programmers, it is time for developing countries to formulate the much-needed policies for implementation of basic infection prevention practices in health care set-up.4
Nurses -the “nucleus of the health care system- spend more time with patients than any other HCW, their compliance with hand washing guidelines seems to be more vital in preventing the disease transmission among patients. Optimal hand hygiene behavior is considered the cornerstone for the prevention of healthcare associated infection (HAI). Multifaceted approaches to improve hand hygiene have been shown to increase compliance among healthcare workers and subsequently reduce infections. One of such efforts is the introduction of an evidence-based concept of “My five moments for hand hygiene” by World Health Organization.5
The investigator seeks to study the compliance to hand hygiene practices among staff nurses, working in the obstetrical and gynaecological wards. The research is an endeavor to increase the awareness and educate nurses about the need for compliance to hand hygiene practices.
METHODOLOGY:
All nurses working in the obstetric and gynecological wards that cater to postnatal mother- baby dyads were included in the study. Nurses newly recruited who had not completed their induction program were excluded.
OPERATIONAL DEFINITIONS:
Impact:
In this study, it refers to the extent to which the multimodal intervention strategies have achieved the desired effect in terms of compliance to the practice of hand hygiene.
Multi Modal Intervention Strategies:
Multimodal interventions strategies used in this study included:
1. Educational Initiatives-Demonstration and lecture based on WHO’s Your Five Moments of Hand Hygiene: Before patient contact, before aseptic task, after body fluid exposure risk, after patient contact, after contact with patient surroundings.
2. Reinforcement of HICC protocol
· Visual reminders, in the form of posters in the nurses’ station and in different parts of each ward.
· Verbal remainders to use hand hygiene solution.
· Availability of hand hygiene solutions and facilities.
3. Individual teaching and group discussion.
Fig 1
Compliance:
In this study, it refers to the extent to which staff nurses adhere to hand hygiene before and after handling newborns, before and after caring post-natal mothers and laboring mother as measured by compliance check list.
Formal permission was obtained from St. John’s Medical College Hospital. Purposive sampling technique was used to select 64staffnurses fulfilling the inclusion and exclusion criteria and their privacy was ensured. The purpose of the study was explained to the staff and a written consent was obtained. Baseline information was collected from samples using questionnaire. Data collection technique used for the study is participatory observation checklist. Staff nurses were observed on their practices of hand hygiene while taking care of mothers and neonates using observation checklist. Ten opportunities for each staff nurses were observed in the pre-intervention period to find out existing compliance to hand hygiene practices. Hand hygiene techniques (hand wash and hand rub) were observed separately, using WHO 7 steps of hand hygiene technique.
After the completion of pre observation, multimodal interventional strategies were administered. Educational initiatives, demonstration and lecture based on WHO your five moments of hand hygiene. Power point presentation was used for lecture and demonstration was done on hand hygiene technique (hand wash and hand rub). The group discussion was conducted in each ward after the lecture in order to find out the causes of non compliance and suggestions to improve the compliance of hand hygiene in the wards Visual reminders, in the form of posters in the nurses’ station and in different parts of each ward Verbal reminders to use hand hygiene solution, easy and liberal availability of hand hygiene solutions. Individual teaching is done at the bed side when staff nurses were taking care of the patient according to the necessity. After a gap of two weeks, staff nurses were again observed for ten opportunities in order to find out the compliance to hand hygiene practice and hand hygiene technique (hand wash and hand rub) were observed separately, using observational check lists.
|
Accessibe popluation |
staff nurses working in obstertrics and gynecology ward and private rooms in selected hospitals, Bangalore |
|
Sample and sampling technique |
64 staff nurses who met the eligibility criteria were purpostive sampling |
|
Reserach design |
quasi experimental one gruop pre-intervention and post - intervention design. |
|
Instrument |
Interview schedule for demographic data observation check list for compliance of hand hygiene practies. check list for hand hygiene technique |
|
Data collection method |
particitary observation on compliance to HH &HH practices |
|
Data analysis |
descriptive and inferential statistics |
|
Outcome |
Difference in the compliance hand hygine practice and hand hygine techniques as evidened by differnce in the compliance score and hand hygiene technique. |
Tool: The tool of data collection consist of three sections
Section A:
Interview schedule for demographic data includes age, years of experience, education and area of work.
Section B:
Observation check list Hand hygiene basic compliance observation form (WHO).
Section C:
Checklist for Hand hygiene technique (WHO).
RESULTS:
SECTION 1 Distribution of Staff nurses according to selected baseline Variables
Table I: Frequency and percentage distribution of staff nurses according to age, education, area of work and years of experience n=64
|
Sl No |
Basic Line variables |
Frequency |
Percentage(%) |
|
1 |
Age in Years |
|
|
|
21-24 |
34 |
53.1 |
|
|
25-29 |
24 |
7.5 |
|
|
>=30 |
6 |
9.4 |
|
|
2 |
Educational Qualification |
|
|
|
Diploma |
16 |
25 |
|
|
Degree |
48 |
75 |
|
|
3 |
Area of Work |
|
|
|
Common Ward |
37 |
57.8 |
|
|
Private Ward |
27 |
42.2 |
|
|
4 |
Years of Work |
|
|
|
0-2 |
44 |
68.8 |
|
|
2-4 |
12 |
18.8 |
|
|
>4 |
8 |
12.5 |
Table 1 depicts that majority of the staff nurses (53:1) belongs to the age group of 21-24 years. In relation to the educational status majority (75%) had Degree Qualification. Regarding area of the work 57.8% staff nurses were working in common ward. Majority of the subjects (68.8%) had 0-2 years of experience.
SECTION II: Comparison of hand hygiene practice before and after multimodal interventional strategies.
Table II a: Comparison of hand hygiene compliance before and after multi modal interventional strategies n=64
|
SL NO |
Items Score (%) |
Max (%) |
Range (%) |
Mean |
SD |
Test of significance |
P Value |
|
Paired t test |
|||||||
|
1 |
Pre test |
100 |
30-70 |
45.31 |
10.23 |
22.014 |
<0.001* |
|
2 |
Post test |
40-80 |
65.78 |
9.225 |
* Significant
Table II b: comparison of hand hygiene techniques (hand wash) before and after multimodal intervention strategy n=64
|
SL NO |
Items Score (%) |
Max (%) |
Range (%) |
Mean |
SD |
Test of significance |
P Value |
|
Paired t test |
|||||||
|
1 |
Pre test |
10 |
4-8 |
5.97 |
1.284 |
17.13 |
<0.001* |
|
2 |
Post test |
5-10 |
8.16 |
1.158 |
* Significant
The data in the above table shows means score of hand hygiene compliance before the intervention was 45.31. That mean score after the intervention increased to 65:78. The obtained t test value is22.014 significant at 0.05 level. Thus there is a significant difference in the hand hygiene compliance before and after multimodal intervention strategies.
Table II c: comparison of hand hygiene techniques (hand rub) before and after intervention. n=64
|
SL NO |
Items Score (%) |
Max (%) |
Range (%) |
Mean |
SD |
Test of significance |
P Value |
|
Paired t test |
|||||||
|
1 |
Pre test |
10 |
3-6 |
4.52 |
0.992 |
17.36 |
<0.001* |
|
2 |
Post test |
4-10 |
6.69 |
1.489 |
* significant
Table II b depicts that there is a significant difference in the pretest and post test score of hand wash techniques. The mean pretest score before intervention was 5.97 is increased to 8.16 after intervention. The obtained t value is significant at 0.05 level.
Data presented in Table II c depicts that there is a significant difference in the hand hygiene technique (hand rub) before and after intervention with obtained t value at 0.05 level. Thus the Hypothesis 1 there is a significant difference in compliance to hand hygiene practice before and after multimodal interventional strategies among staff nurses at 0.05 level is accepted.
SECTION III: Association between compliance to the practice of hand hygiene with base line variables.
Table- III- Association between compliance to the practice of hand hygiene with baseline variables.
|
SL No |
Baseline variables |
Frequency |
HH Comp Pre score |
Test of sig. |
P Value |
|
|
|
Mean |
Standard Deviation |
|
|||
|
1 |
Age |
|
|
|
|
|
|
21-24 |
34 |
46.47 |
10.115 |
|
|
|
|
25-29 |
24 |
45 |
10.632 |
0.973A |
0.384 |
|
|
>=30 |
6 |
40 |
8.944 |
|
|
|
|
2 |
Years of Experience |
|
|
|
|
|
|
0-2 |
44 |
47.05 |
10.692 |
|
|
|
|
4-Feb |
12 |
40.83 |
7.93 |
2.160A |
0.124 |
|
|
>4 |
8 |
42.5 |
8.864 |
|
|
|
|
|
|
|
|
|
|
|
|
3 |
Education |
|
|
|
|
|
|
Diploma |
16 |
42.5 |
10.646 |
1.238t |
0.228 |
|
|
Degree |
48 |
46.25 |
10.027 |
|
|
|
|
4 |
Area of work |
|
|
|
|
|
|
Common ward |
37 |
4.81 |
7.593 |
4.783t |
<0.001* |
|
|
Private Room |
27 |
51.48 |
10.267 |
|
|
|
A - ANOVA, t- independent t test:
Table III Shows that there is a significant association between compliance to practice of hand hygiene with area of work (private room). The obtained t value is significant at 0.05 level. There is no significant Association between other baseline variables (Age, Years of Experience and Education). Hypothesis 2 is accepted for area of work at 0.05 level.
The present study was conducted among 64 staff nurses, in the age group of 21-24 years old. Majority of them (53.1%) have the qualification of degree in nursing.48 of them (75%) have clinical experience of up to 2years (68.8%) and 37 (57.8%) staff nurses were working in obstetrics and gyne common wards. The study revealed that the more compliance of hand hygiene was observed between the age group of 21-24. Baseline characteristics were similar to a previous descriptive cross – sectional study was, conducted in the intensive care units of a hospital in Kuala Lumpur on nurses compliance to hand hygiene practice and knowledge. Total no of staff nurses were 84. It showed that majority of (53.6%) the staff nurses were in the age of 21 to 30 years. The respondents’ years of working experience was 1 to 5 years (34.5%) and majority of them had the education qualification of Diploma. 6
The present study revealed that there is a significant difference in the pre test and post test scores in hand hygiene compliance and hand hygiene practices after multimodal interventional strategies. Compliance increased from 45.31±10.23 to 65.78±9.225 (p<0.001) Techniques of hand rub increased from 4.52±0.992 to 6.99±1.489 (p<0.001) and hand wash increased from 5.97±1.284 to 8.16±1.158(p<0.001) A similar prospective study was conducted in the adult ICU of a tertiary care hospital in northern India. Initially hand hygiene compliance was observed over a period of 6 weeks, The hand hygiene compliance of staff nurses pre intervention was 21.48% and post intervention was 61.59% (p<0.0000).7
In the present study the hand hygiene compliance before and after implementation of a multimodal interventional strategies was 40 to 55% before patient contact and 42 to 62% after patient contact. In a study by Lam at all, the hand hygiene compliance before the implementation of a multimodal implementation program in a neonatal ICU improved from 40 to 53% before patient contact and from 39 to 59% after patient contact. They concluded that an effective education program could improve hand hygiene compliance.8
Reasons for non – compliance as expressed by the study group after group discussion pre and post intervention were, Hand washing agents cause irritations and dryness, sinks are inconveniently located, shortage of sinks, often too busy, insufficient time, patient needs take priority, wearing of gloves, beliefs that glove use obviates the need for hand hygiene, low risk of acquiring infection from healthy mothers and neonates, not thinking about it, forgetfulness, non availability of hand hygiene solutions and facilities. According to other studies the reasons for non – compliance were lack of knowledge of guidelines/ protocols, lack of rewards/ encouragement, lack of role model from colleagues or superiors, lack of scientific information of definitive impact of improved hand hygiene on HCA.9
There is significant association between compliance to the practice of hand hygiene with area of work (private ward) with mean and standard deviation of 51.48± 10.267 which is significant at p<0.05 level. It is also evident that there is no significant association between compliance to the of hand hygiene with other selected base line variables of staff nurses.
A similar study was done in Klang Valley Hospital on nurses compliance to hand hygiene practice and knowledge. The findings showed the total mean and standard deviation of knowledge (60.65±4.213) and compliance (84.65±7.024) to be high among the respondents. There were significant differences between respondents' years of service with the knowledge and compliance with p values <0.05. The results showed significant differences between respondents with post basic course with compliance to hand hygiene with a p value <0.05 actual p value added (p = 0.001) 10
IMPLICATIONS FOR NURSING:
· The adherence to compliance of hand hygiene practices in the respective areas can reduce mortality and morbidity rate related to HCAI.
· Establish ongoing monitoring and feedback on infection rates, such as tracking endemic and emerging drug
· Ensure hand-hygiene resources are accessible throughout the organization, including patient care corridors and at the entrance and exit of patient rooms. Resistant pathogens.
· The study provides evidence-based practice for clinical research
· It is an evidence to create awareness among healthcare workers towards adherence to hand hygiene.
· Create a multidisciplinary design and response team led by a senior administrator to emphasize that the organization is committed to hand-hygiene compliance.
CONCLUSION:
The present study concludes that the compliance to hand hygiene practices improved after adopting multimodal interventional strategies. Formal communication and hand hygiene education, promotion and leadership support are essential in order to improve the hand hygiene practices among staff nurses in the hospital. Therefore, the investigator strongly believes that this would be an authentic piece of information for health care personnel that would help them to provide comprehensive patient care by ensuring improvement in the quality of nursing practice.
REFERENCES:
1. WHO Guidelines on Hand Hygiene in Health Care: A Summary World Health Organization; Patient Safety Challenge Clean Care is Safer Care.©. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18538700
2. Ashu S. Mathai, Smitha E. George, John Abraham. Efficacy of a multimodal intervention strategy in improving hand hygiene compliance in a tertiary level intensive care unit. Indian journal of critical care medicine. 2011 Jan-Mar; 15(1): 6–15. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21633540.
3. Ali O. Addalaziz, Mohammad N. EI- Gamal, Abdullah M.Assin. Changes in hand hygiene compliance after a multimodal intervention among health-care workers from intensive care units in Southwestern Saudi Arabia. Journal of Epidemiology and Global Health. December 2014; 4(4): 315–321.Available from: http://www.sciencedirect.com/science/article /pii/S2210600614000501.
4. R Kapil, HK Bhavsar, M Madan. Hand hygiene in reducing transient flora on the hands of healthcare workers: An educational intervention. Indian journal of microbiology.2015; 33 (1): 125-128. Available from: https://www.ncbi.nlm.nih .gov/pubmed/21633540.
5. Veena Maheshwari, Navin Chandra M kaore, Vijay Kumar Ramnani. A Study to Assess Knowledge and Attitude regarding Hand Hygiene amongst Residents and Nursing Staff in a Tertiary Health Care Setting of Bhopal City. Journal of clinical and diagnosis research. 2014; 8(8):04-07. Available from: europepmc.org/abstract/med/25302193
6. Purva Mathur. Hand hygiene: Back to the basics of infection control. Indian journal of medical research. 2011; 134(5): 611–620.Available from: m;https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3249
7. Bischoff WE, Reynolds TM, Sessile CN, Edmond etal Hand washing compliance by health care workers: The impact of Introducing an accessible, alcohol-based hand antiseptic. Arch Int Med. 2010; 160:1071-21.45. Available from:https://www.ncbi.nlm.nih.gov/books/NBK133371/
8. Bukhari SZ, Hussain WM, Banjar A, Almanimani WH, Karima TM, FantaniMI. Hand hygiene compliance rate among health care Professional. Saudimed.2011; 32(5): 515.Available from: https://www.ncbi.nlm.nih.gov/pubmed/21556474
9. Lam BC, Lee J, Lau YL. Hand hygiene practices in a neonatal intensive care unit: a multimodal intervention and impact on nosocomial infection. Pediatrics.2004; 114(5): 565-71. Available from:https://www.ncbi.nlm.nih.gov/pubmed/15492360
10. Jaafar MZ, Lim B. Nurses compliance to hand hygiene practice and knowledge at Klang Valley hospital. Clin Ter. 2013;164(5): 407-11. doi: 10.7417/CT.2013.1604. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24217826
Received on 02.04.2020 Modified on 06.06.2020
Accepted on 21.07.2020 ©A&V Publications All right reserved
Asian J. Nursing Education and Research. 2021; 11(1):123-128.
DOI: 10.5958/2349-2996.2021.00032.X