Study of hand hygiene behavior among nurses in Critical Care Units

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Iranian Journal of Critical Care Nursing Summer 2011, Volume 4, Issue 2; 95 - 98
Study of hand hygiene behavior among nurses in Critical Care Units
Roghieh Nazari* Msc, Mahmood Haji Ahmadi1 Msc, Marziye Dadashzade2 BSc, Parvane Asgari2 BSc
*. Amol Faculty of Nursing and Midwifery, Babol Medical Sciences University, Babol, Iran
1. Children’s non Ommunicable Diseases Research Center, Babol Medical Science University, Babol, Iran
2. Hefdah Shahrivar Hospital, Amol, Iran
Abstract
Introduction: The role of hands is well known as a leading cause of infection transmission in hospitals, and hands
hygiene is the first step recommended for infection control. This study was conducted to evaluate hand hygiene
behavior among critical care nurses.
Methods: In this study, hands hygiene behavior was unobviously monitored in 159 hand-sanitizing situations among
critical care units nurses, and their behavioral status as well as the patients profile and the performed procedure were
recorded in a checklist designed based on national guidelines of disease control and protection. Data were analyzed by
SPSS17 statistical software using descriptive analytical tests.
Results: The observed nurses wore glove in 150 situations (94.3 percent); whereas, they attempted to sanitize their
hands only in 27 positions (16.98 percent), from which alcohol was used in 20 cases (74 percent), and soap and water
and plain water in other situations. Most cases of hand hygiene were following the contact with patients. There was a
significant relationship between the glove types used by nurses and infection risk of the observed procedure with hands
hygiene (P <0.05).
Conclusion: The results of the present study indicate poor performance of hand hygiene among nurses in critical units.
Considering that risk of nosocomial infection transmission is potentially higher in these wards, it behooves officials and
practitioners to pay more attention to revise supervisory and educational planning.
Key words: Hands hygiene; Critical Care Units; Nurses; Nosocomial infection
Introduction
Nosocomial infection is one of the main
problems of critical care units affecting 20
percent of patients hospitalized in these
wards, and increases mortality rate to more
than 30 percent [1]. In addition to enhanced
mortality, such infections lead to longer
hospitalization duration and more treatment
expenses [2]. Due to risk-making factors such
as numerous injuries, low level of
consciousness and poor preventive
mechanisms, patients of critical care units are
more subjected to hospital infections than
other patients. These infections include those
cases being developed following 48 hours of
hospitalization [1]. The role of hands has been
well recognized by researchers as a major
cause of infection transmission in hospitals
[3], and health providers' hands have been
enumerated as one of the main sources of
transmission; hence, hand washing is
recommended to all healthcare providers as a
first step in the control and prevention of
hospital infection [4], and it has been
emphasized to be done in a sanitary way
using soap and water, chlorhexidine
gluconate, alcohol gel or other permitted
materials before and after any contact with
patients or equipment [5-6]. Owing to
destroying colonized microorganisms on
hands skin, this method is considered as one
of the most effective approach in the
prevention of nosocomial infections [7]. The
importance of hands hygiene has urged many
researchers to study in this field and, as a
major concern of developed countries, led to
numerous studies in most communities,
especially Europeans and Americans
countries. These investigations indicate that
despite simplicity, cheapness and easiness of
hands sanitization, it is attempted less than
expected by care providers [5, 8-9], and
although most health centers are
implementing extensive programs to train this
behavior, it is less accepted among the staff
[10]; as an instance, the related rate has been
accounted only 21% in a study in the United
States [5]. Various reasons have been
declared by nurses for not adequately washing
their hands, such as not being habituated, lack
of knowledge, negligence, routine work, lack
of washing and drying equipment, crowded
wards, inappropriate washing materials, and,
ultimately, defect in management system [11-
12]. In recent years, many positive steps have
been taken toward reducing hospital infection

96 Study of hand hygiene behavior among nurses in critical care units
in our country. Nurses and committees of
infection control have put great emphasis on
hands hygiene while providing training and
managing guidelines. Therefore, according to
these recommendations and practices on the
one hand, and the importance of hands
sanitization especially in critical care units on
the other hand, it seems necessary to
investigate hands hygiene behavior among
nurses in critical care units.
Methods
In this descriptive-analytic study, hand
hygiene behavior was observed in 159
sanitizing situations among critical care
nurses in 2009-2010. Observation was
performed randomly and unobviously by a
trained observer. Hand hygiene behavior was
defined as any situation in which nurses were
required to sanitize their hands, such as
contact with patients, giving medication,
contact with equipment and so on [5]. The
study was implemented after hospitals
approval and coordination with the Infection
Control Unit, responsible for training and
supervision of hand hygiene behavior. The
study results including patients' profile, type
of the performed procedure, ways of hands
sanitization, types of sanitizing material,
hand-drying manner after washing, apparent
infectious secretion in patients and risk of
infection transmission were recorded in a
checklist, which was designed based on
national guidelines of hand hygiene.
It should be noted however that only hand
sanitizing behavior has been described in the
present paper, and no judgment has been
given in regard to the accuracy of the
behavior-performing mode.
All the study nurses had passed audiovisual
training course of hand hygiene, and
sanitizing facilities such as sink, liquid soap
and water were available in all parts of units;
glycerin alcohol solution was also accessible
on each patient's overhead. Hand-washing
instruction was hung beside the sinks, and
sanitizing method using alcoholic liquid was
put in each ward. Data were analyzed by
SPSS software using descriptive statistics, t-
test and chi-square.
Results
Situations were observed while taking care of
159 patients (with the mean age of 44.6 ±
20.67 years), from which 101 was related to
males and 58 to female patients. Gender of
the nurses was female in 143 cases (90
percent). The observed participants wore
glove in 150 situations (94.3%), but attempted
to sanitize their hands only in 27 cases (16.98
%), from which alcoholic liquid was used in
20 (74 %), soap and water in 5 (18.5 %), and
plain water in 2 situations (7.5 %). Washed
hands and those sanitized with alcoholic
liquid were respectively dried with disposable
paper tissues and with exposure to the air.
Table 1 represents number and percentage of
hand-sanitizing situations before, after, and
both before and after the contact with patients
in regard to risk of infection transmission,
infectious discharge, wearing gloves and
gender.
This table shows that hand hygiene behavior
have not been observed in 83 percent of
nurses; whereas, 5 percent before, 13 percent
after, and 9 percent both before and after
contacting patients have attempted to sanitize
their hands.
There was a significant relationship between
types of gloves used by nurses and infection
transmission risk of procedure with hand
hygiene (P <0.05), but no statistical difference
was found in other cases (P> 0.05).
Discussion
The study findings indicate that percentage of
situations in which nurses attempted to
sanitize their hands has been much less than
expected. Results of researches conducted in
general units, even in developed countries,
also suggests poor performance of nurses and
other medical staff in hand sanitization [5, 10
and 13]. Researchers have numerated
crowded wards, being accustomed to
traditional tasks, lack of knowledge,
negligence, unavailability of hand sanitizers
and eventually low administrative action as
the reasons behind such a low-performing
behavior [11-12]. Thus, in our study, factors
such as equipment unavailability and lack of
access to information were controlled through
providing hand-sanitizing materials and

Nazari R. et al. 97
extensive education to all nurses. Therefore,
other influential factors were needed to be
found and discussed.
Results have shown that study participants
have more used alcoholic liquid for hand
sanitization, while, Forester stated that 89.5 %
of staff prefer washing with soap and water to
alcoholic liquid [14].
Presumably, the availability of alcoholic
liquid over all the beds and its easier use
compared to soap and water and no need for
drying hands have contributed to such a result
in our study.
So hand hygiene cases can be augmented by
providing a qualified alcoholic liquid
acceptable to nurses, beside all the beds and
required areas, especially in pocket form.
In regard to hand-drying manner, findings
display that in cases in which hands
sanitization were performed by soap and
water (although the number of cases was
low), participants dried their hands with
disposable paper tissues.
In spite of the fact that no significant
difference has been reported between drying
hands with cloth towels, paper towels and
electric dryers in some investigations,
credible sources and other researchers have
introduced disposable tissue as the best and
safest means of drying hands [11]; this is
required to prevent re-contamination of hands
after washing. Another important point in the
mentioned table is related to washing hands
based on types of gloves. Even though nurses
were wearing gloves in most situations, they
sanitized their hands only in few cases,
especially more after contact with patients.
This means that instead of trying to prevent
and control infection transmission to patients,
they were most thinking of protecting
themselves. However, researches have
declared that even if they do not pursue this
goal, glove is not still enough and cannot
Table1. The number and percentage of hand-
hygiene situations before, after, and both before and after contact with the
patients in regard to risk of infection transmission, infectious discharge, wearing gloves and gender
Variable
Number
of
observed
healthcare
situations
Hands
sanitization
only before
patients
care
n (%)
Hands
sanitization
only after
patients
care
n (%)
Hands
sanitization
both before
and after
patients
care n
(%)
Hands
sanitization
neither
before nor
after
patients
care n (%)
X2
P
value
All the observed
situations 159 5 (3.1) 13 (8.2) 9 (5.7) 132 (83)
Risk of
infection
transmission
Low 8 0 (0) 1 (12.5) 1 (12.5) 6 (75)
Moderate 119 4 (3.4) 7 (5.9) 3 (2.5) 105 (88.2) 14.17 0.028
High 32 1 (3.1) 5 (15.6) 5 (15.6) 21 (65.7)
Infectious
discharge
Yes 17 1 (5.9) 2 (11.8) 1 (5.9) 13 (76.4)
2.25
0.52
No 142 4 (2.8) 8 (7.7) 8 (5.6) 119 (83.9)
Wearing
glove
Without
glove 9 0 (0) 4 (44.4) 1 (11.2) 4 (44.4)
Plastic
glove 15 2 (13) 3 (20) 3 (20) 7 (47)
Latex
glove 84 2 (2.4) 2 (2.4) 2 (2.3) 78 (92.8) 41.79 0.00
Sterile
glove 7 1 (1.4) 0 (0) 0 (0) 6 (98.6)
Plastic +
latex 44 0 (0) 8 (18) 3 (6.8) 33 (75.2)
Patients
gender Male 101 3 (2.9) 8 (7.9) 5 (4.9) 85 (84.3)
0.267
0.959
Female 58 2 (3.4) 5 (8.6) 4 96.9) 47 (81.1)

98 Study of hand hygiene behavior among nurses in critical care units
protect them against the patient's flora. Other
studies have also expressed the effect of
gloves on hand hygiene, from which some are
in accordance with our study and consider
wearing glove as a cause of reduced washing,
and some others as a reason to increase
washing performance [11].
Another look at the table demonstrates that
with increasing risk of infection transmission
and infectious discharge, hand sanitizing
cases enhances, especially after contact with
patients, which is not unexpected or far from
the purpose of self-protection.
Conclusion
Taken together, the present study showed
poor performance of hand hygiene among
nurses in critical care units. Considering that
risk of nosocomial infection is potentially
higher for patients of these wards, it
necessitates officials and practitioners to take
a positive step toward improving this
behavior through revision and alteration of
training and supervisory programs in
particular. It is also recommended to
researchers and those who are interested to
design studies in order to stem causes as well
as solutions for the improvement of hand
hygiene behavior.
Acknowledgements
The authors would like to thank Research
Deputy of Babol University of Medical
Sciences and reverent authorities of Infection
Control Unit of selected hospitals.
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