Hand Hygiene Skills Development

4KNIP418 – Knowledge and Skills for Adult Nursing Assignment 1- Hand Washing

When providing healthcare, hands are the key pathway of germ transmission (WHO 2009)[1], effective hand hygiene will decrease the amount of preventable Healthcare/Hospital Associated Infections (HCAI) and consequently an overall reduction in patient mortality. This demonstrates that hand hygiene is vital within a healthcare setting and thus this assignment will discuss my application of this important skill in clinical practice. The National Institute for Health and Care Excellence states that one in 16 people being treated in an NHS hospital picks up a hospital acquired infection such as meticillin-resistant staphylococcus (MRSA). [2]In this essay I will aim to highlight the process and steps taken when performing hand hygiene, why I performed this skill, when and where and why this skill should be applied. Finally, I will reflect upon how this skill has informed my future practice.

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The trust that I have been working in has created a hand hygiene policy which was strictly followed by all healthcare professionals. Within this policy is a ‘five moments for hand hygiene at the point of care’, adapted from the World Health Organisation (WHO) World Alliance for Patient Safety (2006) brochure, which provides information on when hand hygiene should take place. For the duration of my placement, the five moments that I carried out hand hygiene, as advised by the policy, mainly included but was not limited to the following instances: prior to patient contact, prior to carrying out an aseptic task, regardless of whether or not gloves have been worn, after body fluid exposure, mucous membrane and non-intact skin, after patient contact and lastly, after having contact with patient surroundings. [3]Furthermore, the five moments for decontaminating the hands through the use of alcohol hand rub included: prior to or after leaving the ward, moving from a contaminated body site to a clean body site during patient care, after removing gloves, prior to handling food and finally, prior to handling medicine.[4]

In the case that hands were not visibly soiled, I decontaminated my hands by rubbing them with an alcohol-based gel, as this is the preferred method for performing routine hygienic hand antisepsis.[5] To begin with, I applied a palm full of the alcohol-based gel, covering the entire palm, I then rubbed my hands together with my palms facing each other. After that I placed my right palm over the left dorsum of my hand whilst interlacing the fingers and repeated this on the left hand. I then went on to rubbing the gel on the back of my fingers facing opposing palms whilst interlocking my fingers. The next step was rotationally rubbing the left thumb grasped in the right palm and vice versa. The final step was rotationally rubbing with clasped fingers on the right hand in the left palm, and vice versa. This process should last for 20-30 seconds. Once my hands were completely dry and the alcohol gel evaporated I was able to carry out tasks safely. 

However, if my hands were not visibly dirty, I washed my hands with soap and water. The first step I took was wetting my hands with water, after that I applied soap ensuring that there was enough soap that covered the entire surface of my hand. I then used the same process that I carried out when using the alcohol rub. However, the final steps involved in washing hands with soap included rotationally rubbing the left thumb whilst clasping the right palm, and then repeating this on the right thumb. I then rinsed my hands with water and dried them thoroughly using a single use towel. Finally, to ensure that I do not contaminate my hands I used the towel to turn off the faucet. *490

In this section I will discuss evidence that supports the approach I used when undertaking hand hygiene during clinical practice, why the skill is fundamental to patient care, and finally a discussion of professional values and the way in which they impacted the way that I carried out the skill in practice.

To begin with, the National Institute for Clinical Excellence (NICE) undertook research to explore various means that will prevent health care associated infections (HCAI) in NHS hospitals in England, this including hand hygiene. Regarding the choice of agent for decontaminating my hands, research suggests that handwashing using liquid soap and water, or the use of ABHR will remove transient microorganisms and meet acceptable hand hygiene standards. [6] [7] Furthermore, M. Lindsay Grayson et al (2009) laboratory study proved that hand hygiene through the use of soap and water or ABHR is highly effective in reducing influenza. [8] Furthermore, A Gupta, P Della-Latta, B Todd, et al (2004) studies found that ABHR was preferred over handwashing due to its efficacy, availability and acceptability of healthcare workers. Although, hand washing is required due to evidence portraying that ABHR is ineffective in removing organic matter and some microorganisms. [9]

Laboratory studies conducted by NICE supports the technique that I used when decontaminating my hands, they proved that paper towels efficiently dry hands whilst successfully removing bacteria.[10] [11]As well as this, the hands and wrists must be fully exposed to the hand hygiene agents and not just the palms, which overall decreased carriage of microorganisms. [12]

The foundation of nursing is to provide safe and effective care; hand hygiene is a fundamental skill to patient care and not carrying out hand hygiene would be violating our duty of care. This is because hand hygiene enhances patient safety, as well as minimising the risk of patients acquiring an infection during episodes of health care. Pittet, Allegranzi and Joyce (2009), state that ineffective hand hygiene from nurses has the potential to infect not only their patients, but also their family members. [13] Furthermore, this skill is fundamental to patient care as evidence suggests tat it is the most effective way to prevent pneumonia and diarrheal diseases, which amounts to 3.5 million deaths per year worldwide (Institute of Medicine 2000). [14]

Professional values from the Nursing and Midwifery council (NMC) as well as St George’s trust values influenced the way in which that I carried out this skill during practice.  The NMC code outlines professional standards that nurses are required to uphold, one example is to “always practice in line with the best available evidence”.[15] This impacted the way that I carried out hand hygiene because I ensured that the technique, decontaminating agent and moments for hand decontamination was carried out in accordance with evidence-based guidelines in St George’s hospital policies and hand washing posters. Another example within the code is to “Be aware of, and reduce as far as possible, any potential for harm associated with your practice”. In order to achieve this, I stuck to the recommended hand hygiene practices regarding the control and prevention of infection. In addition to this, the moments that I carried out hand hygiene acted in accordance with this value as I took “all reasonable personal precautions necessary to avoid any potential health risk to ~ people receiving care”.[16]

St. George’s Healthcare NHS Trust has set out values in their ‘living our values’ policy which states that all staff members are required to “adhere to the hand hygiene policy”.[17] Furthermore, the hand hygiene policy states that all staff must “ensure effective prevention and control procedures are incorporated into their daily practice”[18]

In this section, I will be acknowledging the way in which this experience has impacted my own practice, determine whether or not I will use the same approach and my professional approach of the skill. To begin with, I have come to the realisation that I was more confident to care for patients after I decontaminated my hands properly, this is because I felt more comfortable as I was not worried about cross contamination. Furthermore, from my experience I noticed that patients were more willing and comfortable to allow me to carry out care episodes if I decontaminated my hands in front of them.

From my experience, I believe that I will use the same approach in my next placement including, the same technique, when to use certain decontaminating agents and the moments for hand hygiene.  However, I will take into consideration additional aspects when carrying out this skill. For example, I will perform hand hygiene in front of patients. Another difference that I will make is to shorten the duration of washing my hands, this is based off of NICE Journal of Hospital Infection (2014) research suggested that different durations of hand washing did not significantly affect the reduction of bacterial presence.[19] Despite this, I will follow the World Alliance for Patient Safety – (2009) which states that decontamination through the use of ABHR should take 20-30 seconds and 40-60 seconds for handwashing.[20]

Coming from a Muslim background, I believe hand hygiene to be significant as my religion reiterates cleanliness and hygiene. Having this religious belief allows me to be more open and willing to carry out hand hygiene accurately, whereas Leventhal and Cameron (1987), Seto (1995) and Naikoba and Hayward (2001) study demonstrated that healthcare workers handwashing compliance rates equated to 12%.[21]

To conclude, it is imperative that nurses maintain hand hygiene in order to prevent and control infection amongst patients, their families and healthcare workers. As discussed before, effective hand hygiene will decrease the amount of preventable Healthcare/Hospital Associated Infections (HCAI) and consequently an overall reduction in patient mortality, reiterating the importance of this skill. This assignment outlined the skill of hand hygiene, discussed the process of performing hand hygiene, why I performed this skill, the five points of hand hygiene, why this skill should be applied and my reflection upon the way in which this skill has informed my future practice.

Reference list

• Who.int. (2009). Hand hygiene: Why, How & When?. [online] Available at: http://www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and_When_Brochure.pdf[Accessed 21 Nov. 2018]
• Mehdi Lead Nurse in Infection Control, S. (2011). Hand Hygiene Policy. [ebook] London: St George’s Healthcare NHS Trust, pp.7-8. Available at: https://www.stgeorges.nhs.uk/wp-content/uploads/2013/09/Clin_2_0_AppD_Prot06.pdf [Accessed 27 Nov. 2018].
• STEERE, A. (1975). Handwashing Practices for the Prevention of Nosocomial Infections. Annals of Internal Medicine, [online journal] 83(5), p.1. Available at: http://annals.org/aim/fullarticle/689832 [Accessed 11 Dec. 2018].
• Loveday, H., Wilson, J., Pratt, R., Golsorkhi, M., Tingle, A., Bak, A., Browne, J., Prieto, J. and Wilcox, M. (2014). epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection, [online journal] 86, pp.S1-S70. Available at: http://H.P.LovedayaJ.A.WilsonaR.J.PrattaM.GolsorkhiaA.TingleaA.BakaJ.BrowneaJ.PrietobM.Wilcox
• [Accessed 14 Dec. 2018].
• Pratt, R., Pellowe, C., Wilson, J., Loveday, H., Harper, P., Jones, S., McDougall, C. and Wilcox, M. (2007). epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection, [online journal] 65, pp.S1-S59. Available at: https://www.sciencedirect.com/science/article/pii/S0195670113600122 [Accessed 20 Dec. 2018].
• Malliarou, M. (2013). Hand Hygiene of Nurses and Patient Safety. International Journal of Nursing & Clinical Practices, [online journal] 4(1), p.4. Available at: https://www.researchgate.net/publication/257200630_The_Importance_of_Nurses_Hand_Hygiene [Accessed 20 Dec. 2018].
• Nursing Times (2014). NICE highlights how hand washing can save lives. [online newspaper] p.1. Available at: https://www.nursingtimes.net/home/behind-the-headlines/nice-highlights-how-hand-washing-can-save-lives/5070301.article [Accessed 20 Dec. 2018].
• Nmc.org.uk. (2018). The Code. [online] Available at: https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf [Accessed 20 Dec. 2018].
• Stgeorges.nhs.uk. (2014). [online] Available at: https://www.stgeorges.nhs.uk/wp-content/uploads/2014/10/Living-Our-Values-Theatres-Standards.pdf  [Accessed 20 Dec. 2018].
• Stgeorges.nhs.uk. (2014). [online] Available at: https://www.stgeorges.nhs.uk/wp-content/uploads/2013/09/Clin_2_0_AppD_Prot06.pdf [Accessed 20 Dec. 2018].
• Science Direct ELSILVER. (2017). Exploring new approaches to improve hand hygiene monitoring in healthcare. [online] Available at: https://www.sciencedirect.com/science/article/pii/S2468045116302206 [Accessed 1 Jan. 2019].
• Anon, (2001). Handwashing Compliance by Health Care Workers. [online] Available at: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/485276 [Accessed 1 Jan. 2019].

[1] World Health Organisation (WHO) – Hand hygiene: Why, how and when? (06/2009)

[2] NICE (2014)

[3] H.P.LovedayaJ.A.WilsonaR.J.PrattaM.GolsorkhiaA.TingleaA.BakaJ.BrowneaJ.PrietobM.Wilcoxc – Journal of Hospital Infection, 2014

[4] Mehdi Lead Nurse in Infection Control, 2011

[5] Steere – Handwashing Practices for the Prevention of Nosocomial Infections 1975

[6] Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force – Infect Control Hosp Epidemiol, 23 (Suppl. 12) (2002)

[7] National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England – RJ Pratt, CM Pellowe, JA Wilson (2007)

[8] Efficacy of soap and water and alcohol-based hand-rub preparations against live H1N1 influenza virus on the hands of human volunteers – ML Grayson, S Melvani, J Druce, et al (2009)

[9] Outbreak of extended-spectrum beta-lactamase-producing Klebsiella pneumoniae in a neonatal intensive care unit linked to artificial nails – A Gupta, P Della-Latta, B Todd, et al (2004)

[10] Effects of 4 hand-drying methods for removing bacteria from washed hands: a randomized trial – Mayo Clin Proc (2000)

[11] Efficiency of hand drying for removing bacteria from washed hands: comparison of paper towel drying with warm air drying – Infect Control Hosp Epidemiol, (2005)

[12] National Clinical Guideline Centre

Infection: prevention and control of healthcare-associated infections in primary and community care: partial update of NICE Clinical Guideline 2. NICE Clinical Guidelines – Royal College of Physicians, London (2012)

[13] The importance of nurses hand hygiene Maria Malliarou,  RN, BSc, MSc, PhD, Pavlos Sarafis, RN, BSc, MSc, PhD , Sofia Zyga, RN, BSc, MSc, PhD, Theodoros C Constantinidis, MD, PhD – (2013)

[14] To Err Is Human – Institute of Medicine (2000)

[15] Nursing and Midwifery code – (10/18)

[16] Nursing and Midwifery code – (10/18)

[17] St George’s Healthcare NHS Trust – Living our Values: Theatre standards (14)

[18] ST George’s Healthcare NHS Trust – Hand Hygiene Policy (01/14)

[19] NICE – National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (2014)

[20] World Alliance for Patient Safety. WHO guidelines on hand hygiene in health care 2009

[21] Bischoff W., Reynolds T., Sessler C., Edmond M. & Wenzel R. (2000) Hand‐washing compliance by health care workers: impact of introducing an accessible, alcohol based hand antiseptic. Internal Medicine 160(7), 201–214.