Quality improvement project to analyze Assistant in Nursing (AINs’) knowledge level on the importance of handwashing to improve the quality of care provided to the residents in the facility.
Abstract
Hand hygiene includes either washing hands with plain soap and water when the hand is visibly soiled or rubbing alcohol-based hand-rub when the hand is not visibly soiled. Hand hygiene is the single most effective strategy to prevent healthcare-associated infections in the aged care facility. These healthcare-associated infections increased the morbidity and mortality rate in the nursing homes, infecting the residents as the residents are more immune suppressed and vulnerable to the infections. Therefore, an Assistant in Nursings’ knowledge regarding the importance of hand hygiene is important as they are with the residents most when compared with other health care staff.
Aim
This study focused on improving the Assistant in Nurings’ knowledge level on the importance of hand hygiene by conducting education and training session in the nursing home they worked.
Methodology
One group pre-test post-test design was used. A modified version of the question issued by the World Health Organization was administered to Assistant in Nursings’ to answer before and after the intervention. The pre-test post-test answers were recorded and analyzed using IBM SPSS Statistics Subscription version.
Main findings
The overall finding suggested that education and training session is effective in improving the Assistant in Nursings’ knowledge level with the mean score of (0.96 ± 0.048) compared to before the training (0.77 ± 0.104), (t= 8.721, p < 0.05). The result also suggested that most of the Assistant in Nursings’ were aware that healthcare-associated infections impacted the clinical outcome of the residents. Other findings included the role of self-awareness and organizational support in improving the compliance of hand hygiene.
Conclusion
The study was able to improve the Assistant in Nursings’ knowledge level with the help of education and training session. Although the study achieved its aim, the observational method of studies is recommended to further do the study with objectivity.
Introduction
In Australia, the older generation is growing rapidly, and they are expected to grow more in number in the coming year thus seeking more shelter in nursing homes. The residents in the nursing home are mostly malnourished, immunosuppressed, mentally disabled and have various illness which makes them more susceptible to the infections present in the surrounding. These infections have a high chance of getting transmitted from one resident to another if the caregiver does not wash their hand regularly. Therefore, this project is conducted with the aim of improving the Assistant in Nursings’(AINs’) level of knowledge regarding the importance of hand hygiene in a nursing home. The study is one group pre-test post-test design where the AINs’ knowledge level is analyzed by administering the modified questionnaire of World Health Organization (WHO) before and after the intervention. It is conducted in an aged care facility with 80 residents and nearly 50 AINs. After the intervention, the data are collected and analyzed. The results and findings are discussed in the result and discussion section. The findings from this study suggest that educating and training the AINs’ on hand washing techniques and its importance may reduce the rate of HCAIs’ in the nursing home thus, promoting the quality of care provided to the residents residing in that facility.
Background and literature
The World Health Organization (WHO) has estimated that there are more than 1.4 million cases of healthcare-acquired infection (HCAI) occurring at any given time in the world because of the lack of proper hand hygiene (World Health Organization, 2009). The prevalence of HCAI ranges from 6-10 per 100 residents in a year in an aged care facility. Also, in the study conducted by Stone et al. (2015), between 1.6 to 3.8 million infections occurred in a nursing home in a year. As, the elderly residents are immunosuppressed, malnourished and poorly mobilized, they are more vulnerable to HCAI resulting in 26% -50% of hospital admission, long term disability, additional financial burden for both nursing home and residents and even death (World Health Organization, 2019b) which is more intensified when the AINs do not perform hand hygiene as per the recommendation. Therefore, the WHO launched a core program called ‘Clean care is safer care’ in 2005 to reduce the health care-associated infection by performing proper hand hygiene (World Health Organization, 2019d).
In Australia, the Australian Commission on Safety and Quality in Health Care (ACSQHC) collaborated with Hand Hygiene Australia (HHA) to implement the National Hand Hygiene Initiative (NHHI) in 2008. The purpose of this initiative was to develop an effective strategy to improve hand hygiene nationwide in all the health care facilities and to monitor its effectiveness (Hand Hygiene Australia, 2019d). The National Hand Hygiene Benchmark in Australia is 80% since 2017. The NHHI audit 2019 shows that the overall compliance is 85.3% and that of the acute-aged care setting is 86.6% (Hand Hygiene Australia, 2019b). Although numerous initiatives are planned and implemented, compliance always remains low. WHO recommended the hand hygiene multimodal improvement strategy consisting of five key components to improve the compliance of hand hygiene in any health care setting. Watson (2016) conducted a study where they analyzed this multimodal strategy, in their study, the overall hand hygiene compliance rate increased from 51.3% to 98.6% after the administration of those strategies. But they also suggested that this multimodal approach will only be successful if all the five key components are used along with the recommended My 5 moments of hand hygiene. Therefore, this study will focus on whether the education and training component of the hand hygiene multimodal strategy will help to improve the AINs’ knowledge level thus improving the compliance rate.
Need for study:
WHO estimated in the report ‘Report on the Burden of Endemic Health Care-Associated Infection Worldwide’, that an elderly adults residing in a nursing home are 20 times more vulnerable to the HCAIs caused by lack of hand hygiene compared to younger adults and can develop at least three infections in a year (World Health Organization, 2012) and these infections can be limited if proper hand hygiene is performed by the care staff (Felemban, St John, & Shaban, 2015).
Significance of the study
The findings of this project contribute to the benefit of the health-care staff, facilities and the residents residing in the facility considering that hand hygiene plays an important role in reducing the transmission of the HCAIs. The increasing number of old people suggests that the nursing home will be more crowded and thus more attention towards quality and safe care (hand hygiene) is needed in the coming years. Thus, those AINs’ who apply the recommended approach that is explained in this project will be able to provide quality care to the residents. With the help of this study, the facility managers will have insight on how to improve AINs’ knowledge on hand hygiene, and also on how to promote hand hygiene in the facility. Thus, this study will be significant to those who are working as a health care worker and want to improve the quality of life of residents and themselves.
Aim
To improve AINs’ knowledge of handwashing practices in a residential aged care facility.
Objective
The objective of this quality improvement project is to adequately analyze the impact of an educational intervention on AINs’ knowledge about the importance of handwashing while caring the residents residing in the nursing home by conducting one group pre-test and post-test project.
Project methodology
Project Design:
A one group pre-test post-test design using a standardized perception survey questionnaire of the WHO was performed (questionnaire provided in Appendix B). A one group pre-test and post-test design is a design where the effect of the intervention is determined in one given sample either in individual or in the group (Mike Allen, 2017). The main focus of the project was to analyze the AINs’ perception and knowledge regarding the importance of handwashing, so all the samples were given the same treatments and assessments to determine the effectiveness of the intervention. One group pre-test and post-test design are simple and easy to follow and as the total time duration allocated for the project was short, this design was the approachable option (Knapp, 2016). A total number of correct answers given by the samples after the administration of both pre-test and a post-test questionnaire was recorded. The Gannt Chart (Appendix A) has detailed the total timeframe of the project.
Project Setting:
The project was conducted in a well-established nursing home located in Sydney’s southwest. There were approximately 80 beds with 80 residents who were being cared for by 50 AINs’ including those with the permanent shift, part-time shift or casual shifts. The nursing home has been providing personalized care to elderly people for more than 30 years. Approval was taken from the care manager before the commencement of the project.
Population and Sampling:
All the AINs’ working in those nursing homes were encouraged to participate in the quality improvement project through verbal communications during handover and memorandum. The sample included all the AINs’ who showed interest in volunteering for the project. Although there were as many as 50 AINs’ working, only 30 AINs’ participated voluntarily in the project. Participation of all the AINs’ in the education session was recorded in the participation sheet for future references.
Intervention:
The hand hygiene multimodal improvement strategy was recommended by WHO, consisting of five key components: system change including availability of alcohol-based hand rub in an accessible places and continuous availability of adequate soap and water and hand towel, education and training, adequate evaluation and feedback, reminders and institutional safety climate (World Health Organization, 2019e). WHO has also claimed that this model focuses on improving the compliance of handwashing by all the care staff who are working in any health care settings (World Health Organization, 2019c). Among these five key components, the education and training component was used in the project. Karaoglu and Akin (2018) stated that educational interventions and training on proper hand washing increases the compliance rate of hand washing and the level of knowledge of those who participated in the education and training session. Therefore, this project focussed on the education and training component of the hand washing multimodal improvement strategy.
The education and training component consist of many strategies which are used to educate health care workers, among those strategies few suitable strategies were considered for this project. Handing the posters showing My 5 moments for hand hygiene and demonstrating them the steps shown in the poster was the first strategy (Appendix D). World Health Organization (2019a) stated that My 5 moments for Hand Hygiene helps the care staff to understand when to perform the hand hygiene. This approach recommends health-care workers to wash their hands before touching a patient, before performing any aseptic procedure, after touching body fluids, after touching a patient and finally after touching the patients’ surroundings (World Health Organization, 2019a). This is an evidence-based, field-tested and user-centered approach and is very easy to understand and can be used in various health care settings including aged care homes. As this strategy was approachable for our project the participating AINs’ were educated with the help of posters and through demonstration of 5 moments of hand hygiene.
Another strategy included distributing the AINs’ with posters showing steps on how to handwash (Appendix F) and steps on how to hand-rub with alcohol-based solution (Appendix E) (World Health Organization, 2019a). Hand Hygiene Australia (2019a) stated that alcohol hand-rub is the gold standard of care for proper hand hygiene practice in any health care settings. Similarly, hand washing is done when hands are visibly soiled. The steps to handwash when it becomes visibly soiled are: wet hand properly with water and apply adequate soap, rub palm to palm then rub the right palm over the left dorsum with interlaced fingers and repeat the same for other hand, do the same for the front side of the hand, interlock the fingers and rub back of the fingers of opposing palms, then rub the thumb of the opposite hand and do the same on other, clean the fingernails by rotational, backward and forward rubbing of both hands, then rinse the hands with running water and finally dry the hands with single-use towel (Hand Hygiene Australia, 2019c). Similar steps are followed for an alcohol-based hand-rub method where water and soap are replaced by alcohol-based hand-rub. Alcohol-based hand-rub are very effective against most of the bacteria and viruses that may be present in the facility. It has been the most recommended since 2002 for proper hand hygiene routine as it has the advantages like significantly reducing bacterial count on hands, consumes less time, more accessible, self- drying and causes less skin irritation compared to soap and water (Hand Hygiene Australia, 2019a). Therefore, education was given, and the demonstration was done to help the AINs’ to understand the steps of hand washing and the use of alcohol-based hand rub.
The final strategy used for the education and training was showing AINs’ video about the importance of hand washing in YouTube issued by Centre for Disease Control (Centre for Disease Control and Prevention (CDC), 2017) (Appendix G). Karaoglu and Akin (2018) stated that today YouTube has become one of the leading audio-visual information centre with medically relevant videos. It can be used to promote educational videos that show the importance of hand hygiene to bring change in the way the healthcare worker normally thinks or perceives hand hygiene. Madathil, Rivera-Rodriguez, Greenstein, and Gramopadhye (2015) stated that understanding the audio-visuals information is easier and they often help the viewer to relate the information gained from the video with real life and make decisions. Therefore, AINs’ was shown the video during education session as the last intervention so that they could understand the importance of handwashing and bring change in their practice of handwashing.
Data Collection Methods and instruments:
For this project, we used the ‘Perception Survey for Health-Care Workers’ questionnaire which was formulated and approved by WHO. The questionnaire consists of 21 questions that help to analyze the knowledge and perception of healthcare workers regarding the association between healthcare-associated infections and handwashing (World Health Organization, 2009). The questionnaire has been validated by WHO and is also reliable. The questions in the questionnaire were modified including removing the questions that were not related to the project reducing total questions to 13 questions, converting some complex terms into simple terms. The answers choices in the original questionnaire were different including yes or no opinions from very low to very high and not effective to very effective. But for the better understanding and simplicity, the questions were modeled to be answered with yes or no answers. The modified questions are provided in Appendix C. The pre-test questionnaire was administered to participating AINs’ before giving them education and training and the same questionnaire was administered to them after the intervention. The answers were collected and recorded in a file for future data analysis.
Project Period:
The total time duration taken to complete this quality improvement project was 8 weeks (the project commenced from the 3rd week, so the starting week is Week 3). The overall duration for problem identification was 2 weeks where the problem was identified on 25th March. Week 5 was the duration to seek approval from the manager, so the approval was received from the care manager on 4th April. After seeking approval from the care manager, proposal writing was started and lasted till 11th April of Week 6. Pre-test questionnaire was administered in Week 6 from April 8 to April 14 and the answers were collected on the same day of administration. The education session included an explanation of 5 moments of hand hygiene and 9 steps of handwashing and a video showing the importance of handwashing which was done right after handover for about 8-10 minutes in Week 7 from April 15 to 21. The post-test questionnaire was administered on Week 8 from April 29- May 5 and the answers were collected on the same day of administration. Data analysis was done in Week 9 and Week 10 from May 6 to May 19 and the report was presented on 16th May of Week 10. The final report of the project will be submitted on 6th June.
Data Analysis Methods:
IBM SPSS Statistics Subscription version was used for the statistical analysis of the pre-test and post-test collected data. Descriptive statistical method (Mean, Standard Deviation, frequencies) and T-value was calculated using the mentioned software. A p-value of less than 0.05 was considered statistically significant.
Results
Thirty AINs’ voluntarily agreed to participate in the project, 15 of them working their morning shift, 10 of them doing their afternoon shift and 5 of them doing their night shift. All the participating AINs’ were provided with posters of hand washing technique, my 5 moments of hand hygiene and how to hand rub with alcohol-based hand-rub to give them to increase their knowledge and demonstration was shown to them. YouTube video showing the importance of hand washing was also shown to them during the education and training session. The modified version of the questionnaire developed for this project which
was derived from WHO was administered to them to answer before and after the education and training session.
| SN | Pre-Test Post-Test Questions | Pre-Test Answers | Post-Test Answers | ||
| YES | NO | YES | NO | ||
| 1 | Did you receive education in hand hygiene in the last year? | 30 | 0 | 30 | 0 |
| 2 | Do you routinely use an alcohol-based hand rub for hand hygiene? | 8 | 22 | 30 | 0 |
| 3 | An effort is required for you to perform good hand hygiene. | 9 | 21 | 30 | 0 |
| 4 | Healthcare-associated infections impact on the patient’s clinical outcome? | 30 | 0 | 30 | 0 |
| 5 | Hand hygiene is important in preventing healthcare-associated infections? | 30 | 0 | 30 | 0 |
| 6 | Hand hygiene is in priority list at your institution as patient safety issues. | 10 | 20 | 28 | 2 |
| 7 | Leaders and senior managers at your institution support and openly promote hand hygiene | 11 | 19 | 28 | 2 |
| 8 | The health care facility makes alcohol-based hand rub always available at each point of care. | 13 | 17 | 28 | 2 |
| 9 | Hand hygiene posters are displayed at point of care as reminders. | 12 | 18 | 28 | 2 |
| 10 | Each health care worker receives education on hand hygiene. | 30 | 0 | 30 | 0 |
| 11 | Clear and simple instructions for hand hygiene are made visible for every health care workers. | 30 | 0 | 28 | 2 |
| 12 | You always perform hand hygiene as recommended (being a good example for your colleague) | 10 | 20 | 30 | 0 |
| 13 | Hand hygiene is automatic and do not need to be reminded. | 30 | 0 | 30 | 0 |
Table 1: Pre-test Post-test questionnaire used to analyze AINs’ knowledge level and their pre-intervention and post-intervention answers.
Table 1 gives clear information about the correct and incorrect answers given by the participating AINs’ both before and after the intervention. It can be clearly seen that most of the AINs’ (30 AINs’) received an education about hand hygiene in the previous year. Only a few (8 AINs’) were confident to answer the questions related to the routine use of alcohol-based hand-rub before the intervention but almost all of them (30 AINs’) were using alcohol-based hand rub for hand hygiene after the intervention. Similarly, most of the participating AINs’ (30 AINs’) were aware that healthcare-associated infections impacted the patients’ clinical outcome and hand washing played a crucial role in reducing HCAIs.
| Table 2: Difference between all the thirteen Pre-mean and thirteen Post-mean | |||||
| Mean | N | Std. Deviation | Std. Error Mean | ||
| Pair 1 | posttest1 | 1.00a | 30 | 0.000 | 0.000 |
| pretest1 | 1.00a | 30 | 0.000 | 0.000 | |
| Pair 2 | posttest2 | 1.00 | 30 | 0.000 | 0.000 |
| pretest2 | 0.40 | 30 | 0.498 | 0.091 | |
| Pair 3 | posttest3 | 1.00 | 30 | 0.000 | 0.000 |
| pretest3 | 0.63 | 30 | 0.490 | 0.089 | |
| Pair 4 | posttest4 | 1.00a | 30 | 0.000 | 0.000 |
| pretest4 | 1.00a | 30 | 0.000 | 0.000 | |
| Pair 5 | posttest5 | 1.00a | 30 | 0.000 | 0.000 |
| pretest5 | 1.00a | 30 | 0.000 | 0.000 | |
| Pair 6 | posttest6 | 0.90 | 30 | 0.305 | 0.056 |
| pretest6 | 0.47 | 30 | 0.507 | 0.093 | |
| Pair 7 | posttest7 | 0.93 | 30 | 0.254 | 0.046 |
| pretest7 | 0.60 | 30 | 0.498 | 0.091 | |
| Pair 8 | posttest8 | 0.90 | 30 | 0.305 | 0.056 |
| pretest8 | 0.73 | 30 | 0.450 | 0.082 | |
| Pair 9 | posttest9 | 0.93 | 30 | 0.254 | 0.046 |
| pretest9 | 0.70 | 30 | 0.466 | 0.085 | |
| Pair 10 | posttest10 | 1.00 | 30 | 0.000 | 0.000 |
| pretest10 | 0.93 | 30 | 0.254 | 0.046 | |
| Pair 11 | posttest11 | 0.90 | 30 | 0.305 | 0.056 |
| pretest11 | 0.60 | 30 | 0.498 | 0.091 | |
| Pair 12 | posttest12 | 1.00a | 30 | 0.000 | 0.000 |
| pretest12 | 1.00a | 30 | 0.000 | 0.000 | |
| Pair 13 | posttest13 | 1.00a | 30 | 0.000 | 0.000 |
| pretest13 | 1.00a | 30 | 0.000 | 0.000 | |
Furthermore, 19-20 AINs’ were not confident about the support they receive from the facility like appropriate posters and instructions before the intervention, but after the intervention, they (30 AINs’) were able to identify the support provided from the facility. Finally, all the AINs’ (30 AINs’) were confident that they performed hand hygiene without being reminded and as per the recommendation after the education and training session.
| Table 3: Difference between post-mean and pre-mean | |||||
| Mean | N | Std. Deviation | Std. Error Mean | ||
| Pair 1 | Post_mean | 0.9667 | 30 | 0.04816 | 0.00879 |
| Pre_mean | 0.7744 | 30 | 0.10484 | 0.01914 | |
After analyzing the difference between pre-mean and post-mean, there was a statistically significant improvement in AINs’ knowledge on the importance of handwashing after the education and training session with the mean score of (0.96 ± 0.048) compared to before the training (0.77 ± 0.104), (t= 8.721, p < 0.05). This finding indicates that the education and training session was effective in changing the perception and thinking of the AINs’ regarding hand washing ultimately improving the AINs’ knowledge level.
| Table 4: Difference between overall Post-mean and Pre-mean | |||||||||
| Paired Differences | t | df | Sig. (2-tailed) | ||||||
| Mean | Std. Deviation | Std. Error Mean | 95% Confidence Interval of the Difference | ||||||
| Lower | Upper | ||||||||
| Pair 1 | Post_mean – Pre_mean | 0.19231 | 0.12078 | 0.02205 | 0.14721 | 0.23741 | 8.721 | 29 | 0.000 |
Discussion
The findings from this study suggest that educating and training the AINs’ on hand washing techniques and its importance may reduce the rate of HCAIs’ in the nursing home thus, promoting the quality of care provided to the residents residing in that facility. There was evidence of statistically significant (P < 0.005) effect of the education and training on AINs’ knowledge level on the importance of handwashing. The result showed that most of the AINs’ started using alcohol-based hand rub for hand hygiene after participating in the education and training session where the mean score improved from (0.40 ±0.498) before intervention to (1.00 ± 0.000) after intervention. The previous study of Halm and Sandau (2018) also suggested that alcohol-based hand rub is more effective in reducing harmful bacteria compared to when washed with soap and water. The same study suggested that alcohol-based hand-rub causes less skin irritation compared to soap and water.
Similarly, the result showed that majority of the AINs’ agreed that the HCAIs’ impact the patients’ clinical outcome with the mean score of (1.00 ± 0.000) both before and after the intervention. Likewise, WHO has also supported that HCAI can impact the patients’ clinical output in various forms like prolonged hospitalization (transfer from aged care homes), long-term disability, high cost for the patients, their family and the health system and sometimes death (World Health Organization, 2019b). Another study conducted by Castle, Wagner, Ferguson, and Handler (2014) stated that HCAIs are the main reason for the 1.7 million morbidities and mortalities of the residents residing in the aged care home with 1.6-3.8 million infections and nearly 388,000 deaths. Similarly, the study conducted by Tan and Olivo (2015) also concluded that the HCAIs’ are the adverse events happening in health care setting including aged care homes that have a high impact (54%) and very high impact (21.8%) on patients’ clinical outcome and they also concluded that hand hygiene is the single and most effective technique to reduce the HCAIs rate in nursing homes.
In our project, almost all the participating AINs agreed that hand hygiene is important in preventing the healthcare-associated infections with the mean score of (1.00 ± 0.000) both before and after the intervention. They were aware that they should perform hand hygiene whenever needed. A similar study conducted by Sendall, McCosker, and Halton (2019) also stated that hand hygiene is the most important technique to limit the frequency of transmission of micro-organisms from AINs to residents or vice-versa and to prevent the occurrence of HCAIs. Since hand hygiene is one key method to reduce the HCAIs in nursing homes, the care staff working in the nursing home should adhere to the hand hygiene as per the recommendation of the My 5 Moments of Hand Hygiene. But the study of Castle et al. (2014) concluded that compliance rate of hand hygiene in the nursing homes are very low as the AINs’ are not washing their hand as per the recommended guidelines. They suggested the culture and attitude of the AINs’ plays a crucial role.
The result also showed that the AINs’ agreed that the facility was providing enough organizational support like making hand hygiene as a priority, support from leaders and managers, availability of alcohol-based hand-rub and posters displayed at the point of care. The mean score ranged from (0.47 ± 0.507) to (0.90 ± 0.305), (0.60 ± 0.498) to (0.93 ± 0.254), (0.73 ± 0.450) to (0.90 ± 0.305) and (0.70 ± 0.466) to (0.93 ± 0.254) respectively. After the intervention, they were able to identify that the facility was providing adequate resources like alcohol-based hand-rub, hand towel, soap and water, and support from Care Manager and General Manager by providing the posters, pamphlet as the reminders. In the study conducted by, they explained that if the AINs’ are given a nudge like posters, pamphlets, continuous supervision, and feedback, they are more likely to adhere to handwashing. Likewise, after understanding the importance of hand hygiene, the participating AINs’ were able to analyze that they should look at the posters available around the facility to promote their compliance of hand washing. They also suggested that although nudging helps to improve the hand hygiene compliance in any health care settings, it should not be considered as the most effective one and should be combined with other components of the hand hygiene multimodal strategy. Furthermore, the study conducted by McInnes, Phillips, Middleton, and Gould (2014) focused on Manager’s perception regarding current strategies to improve hand hygiene. They stated that if the managers of any health care settings including that of aged care homes show support and become a role model by tailoring the recommended hand hygiene techniques to their clinical and non-clinical staff, they can bring change in the way the staff thinks about the hand hygiene.
Another finding of our study shows that he AINs’ received the education on hand hygiene from time to time in the facility characterized by the mean score of (0.93 ± 0.254) before education and training session to (1.00 ± 0.000) after the intervention. It is found that after receiving the education and watching the video, they participated in the education session regarding hand washing conducted by their facility. The study of Gould, Moralejo, Drey, Chudleigh, and Taljaard (2017) concluded that educational interventions may help to improve hand hygiene compliance in the aged care facility. Therefore, our findings also showed that the education and training session was effective. Lastly, another finding of our study was that the AINs’ started to perform hand hygiene as recommended and they do not need to be reminded after participating in the education and training session. This is represented by the mean score of (1.00 ± 0.000) both before and after the intervention.
In general, the study supports the WHO hand hygiene campaign ‘Clean Care is Safer Care’. The findings suggest that the AINs’ have a high level of understanding about the HCAIs and importance of hand hygiene in a nursing home. This is a small project conducted in a short duration of time; therefore the findings are difficult to generalize. The limitation of this project is a single location and use of a very small sample. Since the study used self-reporting technique, the objectivity of the data can be restricted. Therefore, a study where the observation technique is used may provide more reliable data.
Conclusion
In conclusion, the participating AINs’ have a high level of awareness about the importance of hand hygiene. They were mindful that hand hygiene was the single most technique to reduce the occurrence of HCAIs. They were also known that HCAIs affected the clinical output of the residents. Organizational factors such as availability of adequate alcohol-based hand-rub, soap and water, and paper towel, adequate posters and feedback forms in the hand washing areas, education and training sessions and commitment from the organizational heads played important role in improving the compliance of hand hygiene. Moreover, the study improved the AINs’ knowledge level regarding the importance of hand hygiene in an aged care home. For future recommendation, since the study used self-reporting strategy, observational studies can be done to measure the data objectively.
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World Health Organization. (2019b). The burden of health care-associated infection worldwide. Retrieved from https://www.who.int/infection-prevention/publications/burden_hcai/en/
World Health Organization. (2019c). Clean Care is Safer Care: Summary of the multimodal strategy. Retrieved from https://www.who.int/gpsc/news/simple_guideline/en/
World Health Organization. (2019d). The first global patient safety challenge: “Clean Care is Safer Care”. Retrieved from https://www.who.int/gpsc/clean_care_is_safer_care/en/
World Health Organization. (2019e). Testing the WHO Guidelines on hand hygiene in health care in eight pilot sites worldwide. Retrieved from https://www.who.int/gpsc/country_work/pilot_sites/introduction/en/
Appendices
Appendix A: Perception Survey for Health care workers
- Did you receive education in hand hygiene in the last year?
Yes
No
- Do you routinely use an alcohol-based hand rub for hand hygiene?
Yes
No
- What effort is required for you to perform good hand hygiene?
No effort A big effort
- In general, what is the impact of a health care-associated infection on a patient’s clinical outcome?
Very low Very high
- What is the effectiveness of hand hygiene in preventing health care-associated infection?
Very low Very high
- Among all patient safety issues, how much of a priority is hand hygiene at your institution?
Very low Very high
-
- In your opinion, how effective would the following actions be to improve hand hygiene permanently in your institution? Please check one box on the scale, according to your opinion.
a-Leaders and senior managers at your institution support and openly promote hand hygiene.
Not effective Very effective
b-The health care facility makes alcohol-based hand rub always available at each point of care.
Not effective Very effective
c-Hand hygiene posters are displayed at point of care as reminders.
Not effective Very effective
d- Each health care worker receives education on hand hygiene.
Not effective Very effective
e-Clear and simple instructions for hand hygiene are made visible for every health care worker.
Not effective Very effective
f-You always perform hand hygiene as recommended (being a good example for your colleagues).
Not effective Very effective
g-Residents are invited to remind health care workers to perform hand hygiene.
Not effective Very effective
- What importance does the head of your department attach to the fact that you perform optimal hand hygiene?
Not effective Very effective
- What importance do your colleagues attach to the fact that you perform optimal hand hygiene?
No importance Very high importance
- What importance do patients attach to the fact that you perform optimal hand hygiene?
No importance Very high importance
- Is hand hygiene automatic or do you need to remember or be reminded to do it?
No importance Very high importance
Appendix B: Modified Pre-test Post-test questionnaire
| SN | Modified pre-test post-test questionnaire | Pre-test Answers | Post-test Answers | ||
| YES | NO | YES | NO | ||
| 1 | Did you receiver education in hand hygiene in the last year? | ||||
| 2 | Do you routinely use an alcohol-based hand rub for hand hygiene? | ||||
| 3 | An effort is required for you to perform good hand hygiene. | ||||
| 4 | Health care-associated infections impact on the patient’s clinical outcome? | ||||
| 5 | Hand hygiene is important in preventing health care-associated infections? | ||||
| 6 | Hand hygiene is in priority list at your institution as patient safety issues. | ||||
| 7 | Leaders and senior managers at your institution support and openly promote hand hygiene | ||||
| 8 | The health care facility makes alcohol-based hand rub always available at each point of care. | ||||
| 9 | Hand hygiene posters are displayed at point of care as reminders. | ||||
| 10 | Each health care worker receives education on hand hygiene. | ||||
| 11 | Clear and simple instructions for hand hygiene are made visible for every health care workers. | ||||
| 12 | You always perform hand hygiene as recommended (being a good example for your colleague) | ||||
| 13 | Hand hygiene is automatic and do not need to be reminded. | ||||
