Healthcare-associated infections (HCAIs) can be extremely detrimental in health and social care settings where patients highly susceptible to disease. These are infections that the patient acquires during or after healthcare has been received which can be dangerous as contracting an infection whilst receiving healthcare from an unrelated problem could have a deteriorating effect on the patient in comparison to a healthy individual’s reaction.
Patients in hospitals and other healthcare settings have increased vulnerability so consequently are easily receptive to pathogens due to examples such as reduced immunity or open wounds. Therefore the appropriate precautions and procedures must be set in place to ensure cross-infection cannot occur. It is crucial for health professionals to understand how the infection spread so that they can consider and act upon the significant implications which are risked when improper measures are not followed hence why the knowledge of the chain of infection should be learned.
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Infection control is high on the agenda for healthcare providers because of its significance as it safeguards staff, patients, and the public, promotes safe environments and practice but also indicates the quality of healthcare given. It is imperative to focus on legislation that applies to the National Health Service like the NHS Constitution and the Nursing and Midwifery Council code of conduct. Communication, competence, and care of the six C’s can all be factored into how infection control is dealt with in the NHS.
One of the most common practices to lessen the risk of cross-infection is hand hygiene which has reduced overall infection rates in hospitals. (Bennett, Jarvis and Brachman 2007) Identify your new learning, giving the rationale for your choice of this topic The chain of infection should be learned in order to apply the appropriate infection prevention methods at each point.
The process simplifies how microorganisms spread and infection occurs. Microorganisms are named the “infectious agent” as they are able to produce infection in the body, they are always present but may be concentrated in some areas which are called “reservoirs”.
Reservoirs for possible infectious agents can be environments or people that can be transferred from one area to the next. The transmission of microorganisms from a person through exhaling or other bodily functions is labeled the “portal of exit”; the microorganisms are then able to be transmitted into a patient via contact, air, blood, meals, or liquids. The “portal of entry” describes the susceptible area to which microorganisms can be introduced into the patient, such as by mouth, urinary tract, or an aperture in the skin. (Brooker and Nicol, 2011)
Between the portal of exit and the portal of entry, there is potential for cross-contamination and this is where the need for hand hygiene arises. Adequate hand hygiene by nurses lessen this risk of healthcare-acquired infections as evidence shows that developing and bettering the technique that healthcare workers use to clean their hands contributes to the reduction of HCAIs that occur (Pratt et al, 2007). Damani (1997) suggested that the most prevalent cause of cross-infection was the transmission pathogens from one patient to another by pathogens occupying the hands of healthcare workers.
Contaminated hands easily transmit these microorganisms but so by cleaning hands appropriately hospitals can prevent (to an extent) harm to patients which is a fundamental concept in healthcare. (Pittel et al, 2000) This raises the importance for nurses to learn a technique that will clean the hands physically and of invisible microorganisms as nurse’s interactions towards patients account for roughly 80 percent of direct care patients receive. (Storr and Clayton-kent, 2004)
There are many documents on the different techniques of handwashing and when to do such techniques like the World Health Organisation’s five moments for hand hygiene (2006). WHO recommends that hands should be washed before coming into contact with the patient and before aseptic tasks to protect the patient against germs occupying the healthcare worker’s hands as well as immediately after an exposure risk to body fluids, after contact with the patient and their surroundings to protect yourself from pathogens exposed whilst carrying out these tasks.
This applies to the NMC’s code of professional conduct (2004) which states that a nurse must “act to identify and minimize risk to patients and clients”. This values the results of hand hygiene by identifying when to clean hands from the WHO’s five moments of hand hygiene and to use the endorsed hand hygiene technique of the trust to minimize risk to the patient. The handwashing procedure originally outlined by Ayliffe et al (1978) has been adopted by many organizations to provide various routines.
Hands were wet by a running tap and antiseptic detergents or liquid soap (5ml was poured onto the hands, the technique consisted of five backward and forwards strokes in the motion of; palm to palm, each palm over the other hand’s back, interlocking palm to palm, each palm over the other hand’s back interlocked and then the rotational scrubbing of the fingers into each palm finalized by the rubbing of the wrists during a 30-second time p. Then the hands were rinsed with water for 15-seconds and dried with two paper towels for 15-seconds. (Ayliffe et al, 1978)
Whilst this technique has strict timescales the WHO elects the timescale of roughly the time taken to sing “Happy Birthday” twice. This raises concerns over the approximates as this will differ from person to person. The procedure itself remains nearly exact except the addition of turning the tap off with a towel to avoid recontamination and the exact timings are lost. This technique only stated to use running water, however, no temperature was specified.
Hand Washing for Life (200-) advises that water should not be above 110? F as this temperature would cause hands to become damaged by losing delicate tissues on the skin. This can cause bacteria to become trapped and more difficult to remove, as well as cause pain to the worker. It is a legal requirement for health professions to take the necessary measures to ensure that they protect themselves, which includes their hands and others around them by taking care of their hands. (Health and Safety at Work Act 1974)
Dougherty and Lister (2010) give a comprehensive guide to effective hand washing, stating the minimum time to rub slathered hand together is 10-15 seconds. The guide recommended that attention should be given to areas that are missed most frequently like between fingers, tips of fingers, and thumbs. Single-use towels to dry hands were used in all techniques. Damani (2011) suggests that paper towels should be used and also used to turn off taps if hands-free control is not available.
An experiment carried out by Redway and Fawdar of the University of Westminster backed up Damani’s (2011) suggestion as drying hands with a paper towel decreased the number of bacteria compared to jet-air dryers and warm-air dryers which caused an increase. Given that the WHO technique has been used throughout the NHS by National Patient Safety Agency for hand cleaning techniques this would be a reliable technique to follow whilst also taking into consideration the detail given by Dougherty and Lister.
How has this learning made a difference to you Being aware of how many infectious opportunistic pathogens can be exposed to patients, which may lay dormant on healthcare workers hands, gives healthcare workers a better understanding of how to assess the risks of when passing infection can occur by referring to the chain of infection. The chain of infection makes nurses more aware of patients as susceptible hosts.
It is everyone’s responsibility to take appropriate considerations to the prevention and control of infection; this would include all healthcare professionals, the patients themselves, and the visitors. (Randle, Coffey, and Bradbury. 2009) The Francis report states that visitors and staff should adhere to hygiene requirements as well as reminding anyone who is seen to not adhere to these requirements so that the high standard of hygiene is achieved and promoted. (2013)
The knowledge when to wash by the WHO’s five moments enables nurses to make knowing when to wash their hand’s second nature. It also makes the nurse more aware of how serious it is to have clean hands as “clean hands save lives” as said by the National Patient Safety Alert from 2008 which states that the individual risks to patients are dramatically reduced if healthcare workers washed or disinfected their patients every time they needed to perform patient contact.
The six C’s devised by Cummins and Bennett in 2012 state that one of a nurse’s prime responsibilities is to care, this means giving the care of controlling infection as it is extremely important to keep clear of potentially avoidable HCAIs which can have a significant impact to the patient’s physical and psychological state. This could worsen their condition, increase the length of stay, increase pain and suffering, and increase worry and stress. This all causes a massive impact on the economy as HCAIs cost the NHS over the estimated? 1 billion. (NAO, 2009)
The knowledge of appropriate hand hygiene also shows competence, another of the six C’s, as nurses can use what they have learned confidently to ensure they have controlled spreading infection. Hand hygiene is also a commitment, as a nurse may wash their hands but a commitment must be made to wash them to the standard that is appropriate. Communication is also vital in infection control as infection control is everyone’s responsibility. (Randle, Coffey and Bradbury, 2009)
In all aspects of infection control communication must be at the heart of the process so that the right precautions are taken. Staff and researchers must communicate with each other in order to maintain the same level of knowledge on hand hygiene so that the most up to date method is used. It is important for staff to communicate with patients to teach and improve their own hygiene to ensure the safety of themselves and others around them.
It is also key for staff to communicate to patient relatives in order for them to carry out routine hygiene which imperative for hospitals or other healthcare settings infection control. Information given would be useful for the public to know to reduce general sickness therefore reducing the burden on local NHS services. The actual technique should be addressed to all everyone as if it is not done adequately harmful microbes would still be on the hands and therefore infection can still occur. How will this learning influence your clinical practice
Applying the knowledge of hand hygiene learned to clinical practice would mean to risk assess the situation at hand in the environment by asking the assessment questions as described by Randle, Coffey, and Bradbury (2009), then use the five moments given by WHO (2006) to demonstrate competence in when to wash or disinfect hands. Nurses will be influenced by which situation they are placed in, for example when moving from one patient to other hands must be washed by water and liquid soap method (WHO, 2006).
The six C’s would also influence a nurse in hand hygiene as a nurse would think about caring for the patient, giving a commitment to safe care as well as being competent in this task. Electing the most effective handwashing technique must be done to successfully remove pathogens so that not to transmitted from one patient to another or one area to another. The techniques discussed vaguely circle around the same routine with differences in times, in clinical practice, these would all influence the nurse whilst performing hand hygiene but the standard practice would be used as it is the technique enforced by the NPSA adapted from the WHO.
The most recently updated hand hygiene method by the NPSA includes the use of alcohol gels, these should not be used as a constant alternative as they would lead to building up and therefore not effective for removing harmful microbes and are not suitable in some cases as they would not remove dirt or organic materials, cause a risk of ignition when handling medical gas cylinders and would not be effective against Clostridium difficile and Norovirus. (Brekle and Macqueen 2012) Therefore this would influence workers in clinical practice as alcohol gels should only be used out of these circumstances.
Describe how you will continue to develop this learning after this module The research into all hand hygiene methods should be regularly looked over as there will always be improvements to how the NHS handles infection control. One example of this would be the use of non-touch taps, a favorable option by many healthcare providers, but although creating minimal contact with a potentially easily contaminated area to control the outbreak of MRSA it has also led to the potential link between infrared taps and the outbreak of pseudomonas bacteria due to increased surface area in the plumbing of these taps.
(Department of Health, 2012) This example demonstrates that there will always be constant reviews into infection control so it is important to keep up to date on the latest information on practice available and to comply with the NMC code of conduct. A nurse must take part in additional learning or training to develop competence in hand hygiene practice and to constantly review themselves on their development in order to assess what they could do to improve.
Randle, Coffey, and Bradbury (2009) suggest that ongoing training will always be required in this area of practice. How does this personal and professional development relate to the NMC Code Developing and understanding the appropriate hand hygiene procedures for personal and professional practice is important to comprehend so that the nurse can continue to care for the patient their first concern. Caring for a patient means to not worsen their health by transmitting infection which could be preventable as by washing hands.
It is immensely important for nurses to act within their competencies which includes being able to competently hand wash appropriately to control infection as it is vital in performing any act of physical care to patients. (Dougherty and Lister 2011). Another section of the NMC code specifies that a nurse should administer care “based on the best available evidence or best practice”. All nurses must strive and aspire to remain on top of the developing and constantly modifying information and research on infection control.
This also relates significantly to the NMC code which represents that all nurses must maintain and improve their knowledge and skills based on the most up to date information throughout their working lives. Providing high-quality infection control at all times applies to the NMC code because it means that the nurse is complying with providing a high standard of practice and care at all times. How does your topic relate to the NHS Constitution states the rights and commitments to patients, the public, and the staff? (Department of Health, 2013)
The topic of handwashing relates to this document because the NHS constitution is the integral laws to which the NHS strives to stand by and infection control is high on constantly on the agenda for the NHS to improve upon. The constitution expresses that the NHS aims to provide the “highest standards of excellence and professionalism” and providing a high caliber of care that is “safe, effective and focused on the patient”. The terms safe and effective relationships to hand hygiene as nurses must follow hand hygiene procedures so that the care is given is not hindered by the possibility of passing infection.
The constitution also gives the values of the NHS, which includes the value to improve lives. The NHS commits to improve lives and not to decrease the health of the patient due to HCAIs and so it is paramount that infection control procedures are followed to lessen the risk of infections occurring whilst receiving healthcare. Patient rights are issued in the document, one particular is the right for the patient to be treated with a professional standard of care which has been administered by qualified professionals.
Service users of the NHS have the right to expect the quality of healthcare to be monitored and improved continuously, which includes safety, so hand hygiene of workers should be continuously reviewed to make sure it is up to the standard that will ensure safety.
The NHS Constitution commits to establishing a safe and hygienic setting that is fit for purpose which directly involves the matter of hand hygiene because of the importance of it in infection control which promotes a safe and clean environment. (Department of Health, 2013)
It is clear that transmitting infectious diseases can reduce if staff, patients, and visitors washed their hands before and after tasks, a routine hand hygiene technique cannot be stressed enough as it is paramount for all staff to adhere to so that the spread of infection at bay. It is now valued that hand washing is not only important when hands are visibly contaminated but is also vital that they are washed when it is not visible that they are contaminated due to the microscopic pathogens hidden on the skin.
This knowledge is essential to be passed on to all those who flow through a healthcare setting so that education can be continued on infection control. With this given, it is key that communication skills are overly efficient at voicing and helping in infection control with caring for the patients at the heart of the education.
With continued education and observations in this area, more people would be able to show acceptable handwashing and therefore reduce the risk of infection. Hand hygiene techniques influence all nurses because of the strong link to many of the six C’s and the vast importance to the health of all patients.
The prevalence of Healthcare-Associated Infections (HCAI) has increased and this triggers different organizations and governments to set policies, guidelines, and programs to minimize its occurrence. However, these activities to be effective and fulfill the objectives needs management, organizational, and components factors (NAO, 2000).
In this essay, I will describe the principles of infection control service, its structure and liaising with the different agencies involved to prevent the transmission of (HCAI).
Infection control is a collection of different actions aiming to prevent the spread of communicable infections e.g. (HCAI), and the scope not just the medical professionals, but also patient safety, occupational safety etc (WHO, 2010).
Healthcare Associated Infection (HCAI) refers to the infection that developed in patients or healthcare workers in hospitals (POST, 2005). Worldwide there are 1.4 million patients with (HCAI) (Weinestein, 1998 cited by Pittet e.t.al, 2008); in the UK there are 9% infections of (HCAI) at any time, and 100,000 per a year (NAO, 2000). Usually, these are urinary tract infections, surgical wounds, and lower respiratory infections (WHO, 2002).
The importance of infection control service can be recognized from the impact of these infections on public health and governments. They cause stress, disability, and affect the quality of life (WHO, 2002). In UK there is an estimate that it causes 5000 deaths and contributes to 15,000 deaths yearly (NAO, 2004). The cost for treating these cases is 1 billion, and by implementing infection control activity 150 million can be saved (NAO, 2000). From this background, infection control becomes priority for WHO which creates World Alliance for Patient Safety (Pittet e.t.al, 2008) and in UK the priority is raised through different initiatives by the Department of Health (NAO, 2004).
Aims and objectives of hospital infection control service
There should be a program in every hospital for infection control having the aim of preventing and controlling the (HCAI) among health service consumers and providers (ICS, 2007a). This program has effective components which reflect the objectives and the functions of the service and these are recommended by the department of health (DH, 95 cited by NAO, 2000);
Surveillance of infection; this is aiming to detect outbreaks early, assessing the rate of infection, and evaluating the preventive and control measures in the hospital.
There are some methods of surveillance;
Alert organism; e.g. MRSA, if the microbiology report is positive, the patient is isolated or discharged, and other carriers are searched (ICS, 2007b).
Alert condition; e.g. chicken box, is an indication of high infection risk, measures of source isolation can be implemented (ICS, 2007b).
Targeted surveillance; refers to specific areas surveillance e.g. urinary tract infection surveillance (ISC, 2007b).
Education and training of the stuff; this is to increase their awareness of the importance of infection control measures, and to keep them updated about these measures.
Evaluating, and formulating of existing policies and guidelines.
Hospital hygiene monitoring; this includes sterilizing, cleaning, kitchen hygiene, disposal of clinical waste, etc.
Setting the auditing system; for standards and procedures within the service and other services to ensure they are in line with the infection control guidelines.
Participation in decisions; e.g. building extension plans, buying equipment.
Controlling and management of outbreak; if more than expected cases of infection developed, then the ward nurse should collect data about the cases, e.g. time of onset and date of admission, infection control team should be informed, source isolation measures applied, and specimen for microbiology should be taken (ICS, 2007c).
When an outbreak confirmed, actions will be taken, e.g. restricted movement of both staff and patients in the ward, no visiting, and stuff and patient screening by a microbiologist. These all depend on the nature of the outbreak and require cooperation between different members and organizations of infection control service (ICS, 2007c).
Antibiotic prescription; there should be monitoring the policy of antibiotic use to reduce antibiotic resistance (WHO, 2006).
Structure and organizations of hospital infection control service
Because these components represent different areas than to be effective it requires an organizational structure to deliver it and not just the responsibility of an expert or a team (Brannigan e.t.al, 2009). Thereby, there is a management framework of different organizations through which roles, responsibilities, and leadership styles are described to manage the infection and fit the program in the management structure of the hospital (NAO, 2000), and these are;
Chief executive officer/ Head of Hospital; responsible for setting different organizations, effective arrangements are practiced, and availability of resources for the program, e.g. technical (e.g. IT) and human resources for surveillance system (WHO, 2006).
Infection Control Officer (ICO); usually a microbiologist, work as a member of (ICC) and head of (ICT), involved in surveillance, analyzing and providing data of antibiotic resistance, involved in the management of outbreaks ( WHO, 2006).
Infection Control Committee (ICC); formed by representatives of different departments, e.g. infection control team, occupational health and infectious disease physicians and nurses, consultant of communicable diseases, it is responsible for using and applying policies, procedures, and guidelines in the hospital, cooperating with infection control team of developing annual program (NAO, 2000).
Infection Control Team (ICT); this includes infection control nurse and doctor. Responsible for day to day availability and applications of infection principles, updating program manuals, education training to all staff (NAO, 2000).
Clinical governance; is a system through which infection control service is linked to the management structure of the hospital to improve its effectiveness (QH, 2008). It is a framework of accountabilities; policies, performance, and standards to improve the quality of services delivered by hospitals and this includes infection control service, done for example by auditing, and evidence-based approach of the different procedures of the infection control program (Mastertone and Teare, 2001).
Liaising with other services and agencies
To minimize the transmission of the infection control service has to liaise with other services within and outside the hospital. These include for example the occupational health service to implement measures that keep staff safe and avoid spreading the infection, catering services to fulfill the legislation of food safety (NAO, 2000).
The service has to report about outbreaks to agencies like Health and Safety Agency in the UK (NAO, 2000), and to local public health and the public through media (WHO, 2002).
Example #3 – Cross Infection Control In Dentistry
Cross infection involves the spreading of disease from one source to another and hence increasing the number of people suffering that specific disease. In dentistry, infection control is of particular importance as bacterial infections of the oral cavity, like infection anywhere else in the body, can be potentially life-threatening.
The mouth carries a large number of potentially infectious micro-organisms; saliva and blood are known vectors in infection. It must be emphasized that cross-infection related to dental procedures is not specifically limited to the oral cavity. Fortunately, antibiotics and effective dental care delivery have drastically reduced the frequency of orofacial infections.
Cross infection in dentistry is such a wide subject and includes: the different ways in which infections can be spread in the dental surgery the different diseases of varying severity that are most commonly spread the ways in which the chances of cross-infection can be minimized action on complaints the legal and social implications on the dental practice should cross-infection occur due to neglect Health and Safety Laws British Dental Association and General Dental Council guidelines Case studies where cross-infection between dentist and patient (and vice versa) has occurred.
However, in this essay, I shall only be discussing the practical methods of reducing the risk of cross-infection. It is the responsibility of every dentist to treat patients with the required skill and to be cautious enough in order to minimize the harm caused to the patient which could lead to an allegation of negligence.
It must also be remembered that diseases can pass from patient to dentist, which could prove devastating to the dentist’s health and career in an age of diseases such as Hepatitis B and AIDS. A dentist always has a duty of care to prevent the transference of any infection associated with a number of micro-organisms whilst performing the dental treatment.
Other micro-organisms that may be transmitted if hygiene and cross infection control procedures are not strictly followed include Tuberculosis and Herpes Simplex. The current standards by which cross infection control is measured are those recommended by the British Dental Association and the Department of Health (in 1991).
The same precautions should be implemented when treating every patient and every practitioner has a general obligation to treat patients known to be the carriers of infectious diseases. Confidentiality must be preserved and a careful medical history taking is vital. Ideally, the same precautions should be adopted for every patient during treatment (universal precautions).
The meaning of taking universal precautions is that the dentist should treat all patients as though they are infected with an incurable disease which is easily spread. It is imperative that all dental staff are vaccinated against Hepatitis B, Diphtheria, Pertussis, Poliomyelitis, Rubella, Tetanus, and Tuberculosis and must undergo thorough training in cross infection control including how to use an autoclave. All new staff must be appropriately trained in infection control procedures prior to working in the surgery. Dentistry should be practiced in a sterile environment that constitutes dental surgery. Surfaces should be clean and disinfected and dental laboratory items should be disinfected also. Great care should be taken to avoid the contamination of these surgery surfaces.
The orientation of equipment in surgery is an important but overlooked aspect of infection control – ideally, it should be simple and uncluttered with, if possible, two distinct areas: one for the dental surgeon and one for the dental nurse. All instruments must first be cleaned, then sterilized using an autoclave (with a minimum temperature of 115 C for a duration of 30 minutes: the higher the temperature of the autoclave, the shorter the corresponding time period)before reuse. Also, special precautions are to be taken if certain items of equipment are to be reused e.g. hand-pieces must be sterilized by autoclaving after each patient. The storage of instruments after sterilization is equally as important as the sterilization itself.
They should be stored in a clean, covered, and sterile environment and should not be handle without wearing protective clothing e.g. gloves (which should be well fitted and not powdered). In certain circumstances, disposable items and instruments must be used e.g. impression trays and beakers. However, disposable local anesthetic needles must always be used and never reused on another patient.
As well as gloves, sterile masks, and eye protection should be worn – these reduce the risk of spreading of air-borne diseases and the risk of contaminating or being contaminated through touch or via the eyes (it is possible for the disease to spread by the dissolution of micro-organisms into the watery surface of the eye).
Also, thorough hand-washing with anti-bacterial soap is advisable as it reduces the risk of cross-infection further. Lacerated, abraded and cracked skin can offer a portal to micro-organisms. Jewelry and watches should not be worn during clinical procedures. Sharps injuries are a major factor by which cross-infection may occur, especially of the more serious diseases. Therefore, the utmost care must be taken to avoid injuries that actually pierce the skin.
Also, careful disposal of clinical waste is fundamental as these usually include items that have come into contact with a bodily fluid such as blood (especially applicable to syringes and swabs). Rubber dam isolation offers substantial advantages and hence should be used whenever possible and practical. It increases the quality of the operative environment and virtually eliminates saliva/blood splatter and aerosols – when working without a rubber dam, the use of high-velocity aspiration is essential. Each practice must have an infection control policy which describes the practice policy for all aspects of infection control and provides a useful guide to the training necessary for each member of staff to be competent in its implementation.
Carrying out infection control procedures requires co-operation from the dental team as a whole, whether it be in a practice or in a hospital environment. The responsibility of care that dentists have is, although not as widely recognized, extremely high and any slight lack of concentration could result in neglect and ultimately lead to serious illness or even death of the patient or practitioner.
Therefore, infection control is a very important area of dentistry and should not be ignored as it can have serious implications on the reputation of dentistry as a profession.
The aim of this essay is to discuss the importance of infection control. The essay will begin by looking at the prevalence of infection. This will be followed by a discussion of the infection control measures in place to break the chain of infection whilst evaluating the problems of implementing the various techniques in practice. Reference will be made to a wide range of literature which will support arguments and demonstrate evidence-based practice. The essay will then conclude and offer recommendations for future practice.
With the outbreak of antibiotic-resistant infections, infection control is becoming a major concern for health organizations all over the world (Department of Health (DH), 2003). Generally between 4 and 10 % of patients hospitalized in a more economically developed country, such as the United Kingdom (UK), the United States of America (USA), or Australia, develop a hospital-associated infection during their time in hospital (DH, 2003). Currently, the DH (2003) estimates that one in ten NHS patients will contract a healthcare association infection whilst staying in an NHS hospital thus giving the UK one of the highest rates of healthcare-associated infections in the western world.
As well as significantly raising healthcare costs and lengthening hospital stays, it is estimated that hospital-associated infections cause 25,000 patient deaths every year (Borton and McCleave, 2000). Although these facts and figures may seem daunting, the situation can be improved by implementing a number of simple measures to break the chain of infection and prevent hospital-associated infections occurring.
Huband and Trigg (2000) explain that for a nosocomial (healthcare-associated) infection (HAI) to occur there must be a susceptible host, an infectious agent, and a means of transmission from the source of the infectious agent to the susceptible host. If any of these components are not present the chain of infection is broken and infection cannot occur (Mallik et al, 1997).
The susceptible host is perhaps the hardest part of the chain to control since patients are generally admitted to the hospital as a result of an illness or injury which often leaves them more vulnerable to infection. As well as patients who are immunologically compromised because of illness or injury, there are also patients who are more vulnerable just because of their circumstances.
The elderly and the very young (children of the gestational age of fewer than 32 weeks) are at high risk because their immune system is not yet fully developed (Huband and Trigg, 2000) and patients undergoing immunosuppressive treatment, or who have an immunosuppressive illness such as human immunodeficiency virus (HIV), may struggle to fight off infections (Hockenberry et al, 2003).
Although this means that there will almost always be a susceptible host present, there are still a lot of healthcare professionals can do to protect vulnerable patients. Measures are in place to assess each patient individually to uncover their needs and equip nurses with the correct information to produce a protective care plan.
One of the areas in contention, especially in the media is the hygiene practices in hospitals and by staff and how they contribute to the problem of HAI’s (REF). Nurses’ actions account for roughly 80 percent of the direct care patients receive and usually involve personal and intimate care activities (REF).
As such, the chance of infecting a patient with an avoidable HAI is as high as ten percent and some of the infections will be caused by microbes present on the hands of those providing care (REF). Evidence from a review conducted by Pratt et al (2000) concludes that in outbreak situations contaminated hands are responsible for transmitting infections. This is supported by the evidence presented in the NICE (2003) infection control guideline.
The act of hand hygiene, however, is simple but effective against the possibility of cross-contamination between patient-patient or indeed from nurse to patient and vice versa. In a non-randomized controlled trial (NRCT) a handwashing program was introduced and in the post-intervention period, respiratory illness fell by 45% (Ryan et al, 2001) A further NRCT, introducing the use of alcohol hand gel to a long term elderly care facility, demonstrated a reduction of 30% in HAI over a period of 34 months when compared to the control unit (Fendler et al, 2002).
One descriptive study demonstrated the risk of cross-infection resulting from inadequate hand decontamination in patient’s homes (Gould et al, 2000). Despite these findings and hand hygiene being a simple procedure and the rates of compliance should be high; the evidence points to the contrary (REF). A study conducted by Jenkins (2004) found that even when staff did perform hand hygiene 89% missed some part of their hands. In another study, Parini (2004) reported that work pressure reduces opportunities for effective hand hygiene in between procedures or patient handing.
Expert opinion, however, is consistent in its assertion that effective hand decontamination which refers to the process for the physical removal of blood, body fluids, and transient microorganisms from the hands, i.e., handwashing, and/or the destruction of microorganisms, i.e., hand antisepsis (Boyce and Pittet, 2002), results in significant reductions in the carriage of potential pathogens on the hands and logically decreases the incidence of preventable HAI leading to a reduction in patient morbidity and mortality (Boyce & Pittet, 2002; Infection Control Nurses Association (ICNA), 2002).
Therefore, as an infection control measure hands should be washed before and after each patient contact and before every episode of care that involves direct contact with patients’ skin, their food, invasive devices, following removal of gloves or dressings (iCNA, 2002; NICE, 2003; Jamieson et al, 2002). This may be a full hand wash, using liquid antibacterial soap and water or alcohol rubs (Nicol et al, 2003).
A full hand wash should be carried out before placing gloves on the hands; when the hands are visibly soiled; after contact with contaminated materials, e.g. linen; when performing an aseptic technique; before handling food; after using the toilet and before leaving the ward (Parker, 2002). The NHS Quality Improvement Scotland (2003) and NICE (2003) contend for hand washing, to be reliable, it should take about 20 seconds and should follow the standardized hand washing techniques. Both surfaces of the hands should be washed thoroughly, taking particular care of areas that are usually missed, for example, nail beds, back of thumbs, and in-between fingers.
The hands should be wetted first, the soap applied and used to wash the hands, then with the hands bring rinsed in clean water and thoroughly dried with disposable paper towels (Stewart, 2002). Hot air dryers or re-usable towels should not be used in the clinical setting as studies have shown the increased contamination after drying, or with the hand dryers, the lack of drying (Parker, 2002). The taps should be turned off with an elbow or wrist or in the case of normal taps, a paper towel (Clark, 2004).
Part of modern-day hand hygiene procedures now includes alcohol rubs which are in widespread use as they are easily used and are effective in destroying the transient microbes found on the hands. They are usually used between hand washes and require no water or paper towels as the alcohol evaporates very quickly. Myers & Parini (2003) explains most contain an emollient to ensure that constant use of alcohol does not cause skin problems. Alcohol gel rubs however are not a substitute for handwashing as they are ineffective if used on hands contaminated with body fluids or excreta (Nicol et al, 2003).
It also has been shown that without washing the hands regularly when using alcohol rubs causes a build-up of emollient on the hands, which means that the alcohol becomes less effective at killing the transient bacteria (Girou et al, 2002). Kampf and Loffler (2003) showed the use of antimicrobial soap and water along with an alcohol gel sanitizer was the most effective at reducing the number of transient microbes, over 99.99 percent, compared with just fewer than 99.0 percent for antimicrobial soap and water alone, and 99.46 percent for just alcohol gel sanitizer. This highlights the fact that the use of only alcohol gel or handwashing alone still leaves a risk of contamination, albeit a negligible one.
As part of any infection control measure NICE (2003) recommendations the use of personal protective equipment (PPE) by healthcare personnel in primary and community care settings which includes the use of aprons, gowns, gloves, eye protection and facemasks. Under the Control of Substances Hazardous to Health Regulations (Health and Safety Executive, 2002), all healthcare professionals caring for patients are required to make proper use of PPE provided. Correct use of PPE is a key measure in preventing the spread of infection. ICNA (2002) states disposable aprons and gloves reduce the number of micro-organisms on uniforms, clothing and hands, but do not eliminate them.
Gould (2010) contends that disposable gloves and aprons should be worn for all contacts with patients with MRSA, but this according to Bissett (2007) is not an excuse for the ineffective washing of hands, as hands should be washed even when gloves have been worn. Gloves cannot be guaranteed 100% impervious (Clark et al 2002). Gloves sometimes leak or may tear, especially with prolonged use, and the hands may become contaminated as they are removed (DH 2008). In addition, safe removal of aprons is very important: Aprons must be removed by breaking the ties and rolling the apron inwards to prevent scattering of skin flakes and organisms.
Infection control also relates to the clinical environment. Studies have confirmed that large numbers of bacteria are present in the surrounding environment and that symptomatic carrier contribute to the spread of infection (Mutters et al 2009). The isolation of patients with suspected or confirmed infections such as particularly methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C. difficile) in a side room is strongly recommended (DH, 2007; Health Protection Agency (HPA), 2009). Masterton et al (2003) in a joint UK working group reviewing hospital isolation facilities recognized that although isolation may be requested regularly, it is not always possible.
Similarly in a prospective study conducted in a large UK hospital over 12 months, approximately one in five requests for patient isolation was not met for a number of reasons, including lack of facilities (Wigglesworth and Wilcox 2006). Hence where isolation facilities are not available, patients should be cohorted (DH and HPA 2009). Isolating patients conversely has some element of psychological risks, for example, anxiety, depression, and feeling of loss of choice (Gammon 1998) and is something that the nursing staffs need to be aware of and assess regularly.
Specific local infection control guidelines should also be readily available to help support nurses and other healthcare professionals carry out effective environmental decontamination. Bacteria can survive on surfaces, so common sense indicates that, if the environment is kept clean, the bacterial load will be reduced (Bissett, 2006). Gould et al (2007) points out that transmission of infections such as MRSA can also take place from environmental reservoirs of the bacteria, including bedpans and urinals contaminated with spores. Hence, patient equipment hygiene is another important aspect of infection control in preventing the risk of spread infection.
Although this list is not exhaustive, nurses caring for patients should ensure clean hoists, slings, baths, cot sides, toilet seats, commodes, and bedpan holders after each use. Lockers, bed tables, and chairs also need regular cleaning. According to WHO (2009) all care equipment must be treated in the same way.
NICE (2003) states widely available approved detergent wipes are useful for cleaning and MRSA prevention. Disinfectants are not cleansers, so equipment needs to be cleaned with a detergent first, unless a sanitizer that combines both cleaning and disinfectant properties is available. Local guidelines on clearing up spillages of blood and body fluids should also be followed, remembering to wear aprons, gloves and eye protection (if required) to ensure safety and reduce the risk of infection for the person cleaning up the spillage.
Nurses working in both hospitals and community settings should be aware of the growing threat of HCAI such as MRSA and acknowledge the need for universal precautions when nursing patients with this form of infection. Moreover, infection control departments have a clear responsibility to provide staff in clinical areas with information on infection control policies and procedures. It is imperative that all nurses and other healthcare professionals are made aware of the existence of such policies and procedures (NICE, 2003).
Registered nurses must be aware that they may be in breach of the NMC’s Code of Professional Conduct (2004) specifically clause 1.4: “You have a duty of care to your patients and clients, who are entitled to receive safe and competent care.” Meaning should a nurse fail to take appropriate precautions when dealing with a patient, for instance, disregard for hand hygiene procedures the nurse may be liable for disciplinary procedures by the NMC.
This may make nurses more aware of their responsibility with regards to HCAI such as MRSA and infection control. DH (2008) argues staff must take a pro-active rather than a reactive approach to the barriers that they face with implementing infection control procedures such as hand hygiene. Nurses must ensure that the materials needed are readily available and others can be sourced if the need arises and that their training on infection control is up-to-date (RCN, 2000).
In conclusion, MRSA with its antibiotic resistance has become one of the major challenges to scientists and researchers in the health and medicine sector since the 1990s due to the increased rate of the number of inpatients who have caught infection due to cross-infection.
It is integral for nurses, other healthcare professionals, and visitors to follow the various precaution measures set out according to the hospital policies, procedures, and guidelines as this will assist in the prevention of the transmission of MRSA. The high numbers of HCAI’s are putting patients’ lives and well-being at risk and it also has significant implications on the NHS finance and resources.
For this reason, there is a clear need for nurses and other healthcare professionals to work collaboratively to tackle infection such as MRSA if infection rates are to fall. Improving nurses’ knowledge of the cycle of infection in MRSA is one step in helping to prevent and control this infection. This may be in the form of education and training on the aspects of infection control, with constant updates on the current issues that are supported through evidence-based practice (NMC, 2008). This will not only improve practice and assist in the appropriate use of resources but will also contribute towards ensuring HCAI’s do not reach epidemic proportions.
The barriers to adequate hand hygiene are apparent, these must be overcome to ensure that Hospital Acquired Infections do not reach epidemic proportions, and as a result, there are implications to nursing practice that must be met (Simpson, 1997). This may be in the form of education and training on the aspects of infection control, with constant updates on the current issues that are supported through evidence-based practice (RCN, 2004).
This will not only improve practice and assist in the appropriate use of resources but will also contribute towards nurses’ professional profiles for PREP requirements (NMC, 2004). Infection control departments have a clear responsibility to provide staff in clinical areas with information on infection control policies and procedures. It is imperative that clinical staff are made aware of the existence of such policies and procedures (NHS Quality Improvement Scotland, 2004).
Registered nurses must be aware that they may be in breach of the NMC’s Code of Professional Conduct (2004) specifically clause 1.4: “You have a duty of care to your patients and clients, who are entitled to receive safe and competent care.” Meaning should they fail to take appropriate precautions when dealing with a patient, for instance, disregard for hand hygiene procedures they may be liable for disciplinary procedures by the NMC.
This may make nurses more aware of their responsibility with regards to infection control. Staff must take a pro-active rather than a reactive approach to the barriers that they face with hand hygiene. They must ensure that the materials needed are readily available and others can be sourced if the need arises and that their training on infection control is up-to-date. (Scottish Executive, 1998).
In this research study essay, the author will go over the principles of evidence-based nursing research and its importance in health care. For that reason, a short introduction in infection and infection avoidance and control will likewise be made followed by the primary focus of this research essay which will be hand health by utilizing 5 research study terms, which are qualitative, quantitative, ethical debt consolidation, information collection, and sample.
In addition to this, the concern of the most common Health care– Associated Infections (HAIs) acquired in medical facilities will also be checked out and by referring to relevant research study the essayist will investigate why then HAI still a significant issue in the UK healthcare settings, as a number of research studies and reports recommends that sufficient hand health practice is the crucial to reduce infection throughout the field of care (British Medical Journal, 2005; Lancet, 2007).
The approach utilized to gather the primary source of details was collected through the use of the University library digital search, Cinahl Plus (an extensive source of evidence-based full-text for nursing & & allied health journals, which offer concise summaries of illness and conditions and describe the most effective treatment options based upon peer-reviewed medical research study.
Cinahl plus is readily available by means of EBSCO host), medical journal short articles, books, publications and Department of Health (DH) database, and clinical guidelines if they show hand health as a crucial to control and avoid HAI. A variety of keywords were used, including quantitative, qualitative and research study within the title ‘infection control’, ‘hand hygiene’ and ‘HAI’ so only records containing all the keywords were conserved.
The resulting list of articles was then reduced to the English language, adult population, and systematic reviews published between 2000 to present. Of the 26 randomized controlled trials (RCT), twelve were discarded, as some were not relevant and some were unavailable. Furthermore, the remaining ten literature review was divided into subtopics: handwashing technique and decontamination, alcohol-based hand rub, MRSA, and patient infection prevention information.
Evidence-based nursing practice is the term used to describe the process the nurses use to make clinical decisions and answer clinical questions based on scientifically proved evidence rather than on assumption, intuition or tradition (Bishop and Freshwater, 2003)
In order for nurses to make the correct decision, they have to be based in four approaches which include; reviewing the best available evidence from peer-reviewed researches; using their clinical expertise; determining the values and cultural needs of the individual, and determining the preferences of the individual, family and community. Therefore such could only be achieved if the nurse’s know how to access the latest research and correctly interpret and apply the findings to their clinical practice (STTI, 2005). Fact that is also supported by the Nursing & Midwifery Council (NMC), 2008, which states ‘nurses must deliver care based on the best available evidence or best practice’.
The fear of infection has been and will always be present in the human mind, rightly so as infections are the most common causes of death worldwide. From time to time we hear of methicillin-resistant Staphylococcus aureus (MRSA), C- Difficile, Norovirus, and any other organisms causing infection and threatening the health of the population (Ryan et al. 2001).
Although in the developed countries the cardiovascular diseases and cancer are now the major causes, it is always an infection that tips morbidity into mortality (Meers, McPerson & Sedgwick, 2007). Infection prevention and control policies are a contentious issue in healthcare settings. According to NICE (2012) new clinical guidelines, everyone in involved in providing care must comply with the standard principles and regulations in infection control. Standard precautions should be applied at all times by healthcare workers when caring for patients.
Such can be accomplished by practicing simple skills including; good hygiene in the clinical environment, appropriate decontamination of hands and equipment, correct use of personal protective equipment, correct use and disposal of sharps, aseptic technique and waste disposal (DH, 2007, Pratt et al. 2007). The purpose of this is to reduce the risk of infectious diseases to staff, patients, and others where care is delivered.
Additionally, is the healthcare professional duty and responsibility to provide and deliver safe care to patients (NMC, 2008). According to World Health Organization (WHO) 2005, there is around 5000 death in healthcare settings due to HAI though the actual number of infections developed in the community is unknown (NHS QIS, 2005).
Moreover, with many HAIs manifesting post-hospital discharge (National Audit Office (NAO), 2000), the prevalence of HAI in the UK is likely to be greater than that reported in current official statistics, although 15-30% of these can be prevented with good infection control practices such as adequate hand hygiene practice (Damani 2003). Wilson (2006) states that hand washing is a simple procedure and the rates of procedure should be high.
However, the evidence points to the contrary as it is written in the Centers for Disease Control and Prevention (CDC) report, suggesting that healthcare professional’s compliance to hand hygiene standards averages 40% (CDC, 2002). Furthermore, Rumbau et al (2001) suggest that poor hand hygiene practice is the major area in contention in healthcare settings and healthcare professionals fail to comply with appropriate hand hygiene technique due to workload, understaff, and skin conditions, i.e. dermatitis (WHO,2009).
Subsequently, the heavy workload may have a negative impact on compliance (O’Boyle et al, 2001, Pittet et al 1999), resulting in infecting patients with avoidable HAIs such as staphylococcus aureus bacteremia (MRSA) and Clostridium difficile infection (C-difficile), among others types of infection (DH, 2003). Eventually, the distress and suffering it causes to the patient who acquires the above-mentioned infection whilst in hospital, leads to loss of confidence and credibility and reputation of healthcare professionals and the NHS Trusts.
As a result, it brings an increase to the costs of the already underfunded hospitals from increased stays, increased medical expenses and damage to the patients and their relatives who may decide taking lawsuit demands (WHO report, 2006). NAO (2000) states that the cost of HAIs is approximately £ 1 billion per year, also around 9% of patients in hospitals in England at one time have an HAI.
The Journal of Hospital Infection (JHI), (2008) own researchers A. Mears et al, carried out a quantitative and qualitative research study following the death of 180 patients infected with stomach infection in one of the worst outbreaks ever seen in the NHS Trust. The outbreak was blamed on poor measures, to manage, control and prevent infection, despite the Trust having high rates of HAI over several years (JHI, 2009). The study was aimed to investigate the potential factors linked to HAIs rates in acute NHS hospitals and which interventions may be effective to tackle this issue.
The mixed methodological research terms used in the research was purposely chosen as it has been proved that integrate both research terms (qualitative and quantitative) in a study are essential to answer different sort of questions, collect different types of data and produce different type of answer (Burnang and Hannigan, 2000, Bourgeois, 2002). In addition, multiple data sources are useful in researches or studies as they are part of within method triangulation to make the study more trustworthy and credible, also to enhance its depth by meeting different needs at different stages of a project, as well as compensates for shortcomings in any one method (Bourgeois, 2002; Kelly and Long, 2005), as it has been proved by the findings.
Qualitative method is an organized, descriptive, systematic, and intensive process to collect data by using computer software programs i.e.ATLAS.ti, to efficiently examine, analyse, and organise data, also to synthesize large volumes of data (Rebar et al, 2011). This method focuses on individual perceptions and how these are described, as well as recognize that the way people behave is determined by many factors including; what is expected of them, how they interpret the behaviour of other people, and how they feel about what is happening (Rebar, Gersch, Macnee & McCabe, 2011). It is essential that the research is carried out with an open mind, as preconceptions could distort the interpretation of what is going on (Rapport, 2008). .
The method used for data collection in the study was semi-structured interviews and a self-completion questionnaire with textual analysis of responses to open questions, sent to 900 NHS Trust nurses. Interviews and questionnaires are the most common methods used for data collection. A questionnaire is an instrument used to collect specific written data in order to specifically target objective factors or interest (Rebar et al, 2011). Whereas interviews are better for collecting sensitive personal information as the interviewer can establish a rapport with the subject (Crombie and Davies, 2002).
Out of 900 nurses interviewed 700 acknowledged that inadequate handwashing by healthcare staff was the major cause of HAI. When questioned why healthcare professionals fail to comply with appropriate hand hygiene technique, more than 70% answered that lack of time, workload, and high activity levels were the reason, and 66% answered low staff level and insufficient and inconveniently located sinks make it difficult to comply.
These findings are supported by evidence from infection control literature. However, it is clearly specified in the literature that the consequences of high activity levels experience among healthcare workers can have a negative impact on compliance (DH 2003, McCall & Tankersley, 2007). The self-completion questionnaires were returned with a 100% response rate. The results demonstrated that more than 95% of nurses assume that the inclusion of infection prevention and control in the staff (including medical students) training programs may address the causes of the outbreak, therefore help to promote good infection prevention and control in the NHS Trusts hospital.
Wilson (2006) argues in his literature that effective interventions in the management of HAIs, would involve a behaviour change on its own, feedback on behaviour, ownership of the problem, and personal growth from healthcare staff. As such training alone would not be enough. The research terms and choice of methods used by the researcher were appropriate as it provided the reader with a detailed understanding of the issues discussed in the study also can be used as a basis for future work.
The Health Protection Agency (2006) reports that MRSA tops the list of HAI acquired in the NHS hospitals by 40% and in average 4000 patients develop this condition every year. The situation is so serious that the credibility and subsistence of NHS as an institution may be in jeopardy (Cooper et al, 2004, Marshall et al, 2004& Voss, 2004). In the UK the levels of MRSA in hospital has staggering arisen from 2% in 1990 to 42% in 2000, generating a major public health problem and a source of public and political concern (Hawker, et al., 2005).
Such rise has been attributed to the appearance of new strains with epidemic potential, hospital patients who are vulnerable to infections, and failure to sustain good hospital hygiene, including hand hygiene. Several studies of health professionals in hospitals fault the spread of antibiotic-resistant infections to poor hand hygiene and decontamination among healthcare professionals (Sharek et al.2002, Ariello et al 2004).
In the document ‘Winning Ways’ released by the DH (2003), it is clearly stated that hand hygiene is essential to reducing the exposure of patients to HAIs, therefore the responsibility remains with staff to demonstrate high levels of compliance in hand disinfection protocols. However, improving compliance with hand hygiene remains a pressing patient safety concern (Lautenbach, 2001).
The WHO (2009), developed a strategy known as “Five Moments for Hand Hygiene” to improve hand hygiene compliance among healthcare workers and to add value to any hand hygiene improvement strategy, also to educate healthcare workers about the benefits of effective hand washing correlated with the correct techniques and timing of hand hygiene.
The strategy indicates that cleaning hands at the right time and in the correct way should be an indispensable element of care, and form an integral part of the culture of all health service, and any failure to address this issue in a satisfactory manner could be seen as a breach of the Code of Professional Conduct. As a result, it may put into question the healthcare professional fitness to practice and endanger his/her registration (CDC, 2002; NMC, 2006).
The CDC first released formal written guidelines on handwashing in hospitals in 1975, aiming to reduce the risk of infection in hospitals, though it is believed that the idea has been around long before that (JHI, 2006). The NICE (2004) and HPA(2004) guidelines propose that effective hand washing techniques should involve preparation, washing, rinsing, drying and the sequence should take roughly 40 to 60 seconds.
The preparation involves wetting the hands under tepid water (hot water should be avoided as it increases skin irritation) before applying liquid soap to all surfaces of the hand. Then the hands must be rubbed together, paying particular attention to the tips of the fingers, the thumbs, and areas between the fingers for at least 15 seconds.
Finally, the hands should be rinsed thoroughly and the taps turned off by using the elbows to avoid recontamination. The hands should be pat dry with good quality paper towels which are therefore disposed of in a foot-operated bin (NICE, 2003). The above-mentioned technique should be performed immediately, before direct patient contact or care (including aseptic procedures), after direct patient contact or care, after exposure to body fluid, after any contact with the patient’s surroundings i.e. bed making, after touching wound dressings, handling medication, etc. Hand rubs or alcohol gel is part of the modern hand wash procedure. They are frequently used in-between hand washing, as an alternative agent to water and soap or when hands are physically clean (i.e. not contaminated with organic matter or soil), (Endacott, Jevon and Cooper, 2009).
Alcohol gel/ rub should be applied in sufficient quantity to cover hands and wrists, as any surface that is not covered may leave contamination on the hands. The hands should be rubbed together briskly for approximately 10-15 seconds until the hands feel dry. Hands should be washed with water and soap after every five applications of alcohol hand gel.
Many campaigns’ and studies in hand hygiene clearly state the responsibility of healthcare professionals in the fight of infection prevention in hospitals, however sparse studies mention the involvement of patients in the combat of the same. A study revealed that 70% of patients did not receive any information in hand hygiene or other information regarding infection control and prevention when admitted to the hospital (British Journal of Nursing, 2007).
Several literature highlight the fact that infection may be caused by the patient’s own microbial flora or acquired from another infected patient via the contaminated hands of those delivering care (A. Mears et al, 2008). A government document originally initiated in the NHS Plan (DH, 2002) to encourage the empowerment of patients through patient information, is correlated with the clinical governance strategy of engaging patients in partnership to improve care.
This new concept will empower patients by allowing them to be involved in the management of their care (Duncason and Pearson, 2005), also in decision making powers between the patient and the healthcare professional (Henderson, 2003). Moreover, this newly acquired power by the patients will also empower them to be involved in monitoring and reporting on the standard of cleanliness in hospital wards (DH, 2004).
Additionally, Christopher Paul Duncan and Carol Dealey (2006) did a qualitative piece of research with the purpose to explore patient opinions about asking healthcare workers to wash their hands before a clinical procedure and assess if patients knowledge and awareness about infection risks they are exposed while in the hospital would influence the patients’ anxiety about asking.
The method used in the study to collect data was a semi-structured questionnaire designed to be used in a descriptive survey. Data collection involves the gathering of information for qualitative and quantitative research through a variety of data sources, for instance, questionnaires, observations, interviews, conversations telephone interviews, books, past researches or studies, books and documents including, public and private documents i.e. official reports or historical documents to specifically target objective factors or interest (Mason, 2002; Rebar et al, 2011).
There are two ways of collecting data: primary or/ and secondary sources. Primary sources are collected directly by the researchers themselves, whereas secondary sources are gathered through researches or studies published by other researchers. In this particular study, the initial semi-structured questions allow the researcher to gain an insight into the participant’s feelings about asking healthcare workers to wash their hands.
Asking patients to ask staff to wash their hands might be challenging as there are ethical issues attached to it. Ethical issues are mainly concerned with a balance between protecting the right of participant’s privacy, safety, confidentiality, and protection from deceit, whilst at the same time pursuing scientific endeavor (I. Holloway, 2008).
As it is outlined in the Nuremberg Code, some basic principles are to be reviewed for ethical appropriateness (Burnard, 2006). These principles include autonomy, beneficence, and non-maleficence. Autonomy refers to the recognition that participants have the right to decide on a course of action or follow it.
Meaning, the participant must have a reasonable awareness of the nature of the research and its possible consequences, based on that they whether give or withhold consent. The patients must feel free from coercion. In the context of research, the researcher must maximize the benefit of the patients whilst minimizing harm (Gillon, 2003), in the sense of, it may cause distress to the patients to ask staff to wash their hands as this may affect the care they get, the reason why the chance of benefit should always outweigh the chance of harm (beneficence).
Gillon (2003) defines non- maleficence as the avoidance of doing harm or the risk of doing harm. However in the Nuremberg Code, is outlined that minor harm may sometimes offset a greater good, i.e. patients ask staff to wash their hands might affect the relationship with staff, but staff will be aware that patients have a voice in their care and therefore wash hands prior to start caring for them, then benefit all others patients.
Researchers are required to ensure that all participants have an equal chance to being included from a study or benefit from its results. It is unfair and unjust to excluded participants from the study because of their race, color, gender, age or so on (National Research Ethics Service (NRES), 2006).
The questionnaire was dispersed to a randomized convenience sample of 224 inpatients to all department of an acute NHS Trust hospital. Sample in qualitative research seeks to identify participants who have experience with the phenomenon of the interest to the researcher and who will bring as much depth, detail, and complexity to the study (Rebar et al, 2011).
In this study, the researchers chose to use convenience sampling. Conveniences sampling the participants are readily available; though members of the sample may not be the best respondents in the illumination of the research question (Newell and Burnard, 2011). The returned sample was 185 since some patients were too sick to answer and further 34 patients refused to participate. The study showed that 73 (71.6%) patients felt less anxious to ask staff to wash their hands before a clinical procedure if they were using a badge saying ‘It’s OK to ask’.
Patients well-informed about infection risks to themselves while in the hospital were more anxious to ask, although an explanation could not be found. Out of 184 patients involved in the study, only 25 (25.2%) were given information about hand hygiene and infection prevention when admitted in the hospital, as opposed to 74 (74.7%) of patients who were given no information.
The findings go against the DH (2003), plan to involve patients in their care management, also inform the patients about health issues they may face while in hospital (NPSA, 2004; Duncanson and Person, 2005). Whilst the kind of sampling and data collection strategies used by the researchers were detailed and descriptions of personal accounts were given, a purposive sampling would have been more appropriated as participants would have been intentionally selected as they would have more characteristics related to the purpose of the research, hence would have more relevant things to say (Newell and Burnard, 2011) Additionally, interviews would have been a better choice for collecting data and would fill the existing gap in the study.
In conclusion, several studies link poor hand hygiene to the high rates of hospital-acquired infections in NHS hospitals, yet insufficient evidence was supplied to enable a view to be taken on its potential contribution to reducing infection (A. Mears et al, 2009). More work needs to be done on hand hygiene, standards monitoring, and education of healthcare professionals in the management and improvement of infection prevention and control in primary care practice (Wilson, 2006).
Undoubtedly, adequate hand hygiene is the foundation for infection control activities, however, there are still several actions which NHS Trust hospitals can put in place to prevent and reduce the risks of infection, including the environment, infecting microbes and antimicrobial stewardship, patterns of healthcare and the patient treatment and diagnostic interventions (Patient Environment Action Team, 2005). Thus, the literature appraisal has highlighted the lack of research in these areas.