Utilising Evidence Based Care- Hand Hygiene
The author chose hand hygiene due to its frequency of use and importance in nursing practice. An intensive care nurse can wash their hands up to 40 times an hour. The aim of hand hygiene is to decrease the transient flora, and ideally the technique should be quick to perform, reduce skin contamination effectively and does not cause skin irritation (Hugonnet and Pittet, 2000). Hand hygiene can be conducted by either the use of hand washing with un-medicated detergent and water or hand disinfecting using an alcohol solution (Rotter, 1999). I have chosen hand hygiene and student compliance as the basis of my search and this essay because I feel this is relevant to my experience as a student as well as to my practice as a qualified nurse. Researching articles on this subject interests the author because it provides up to date and relevant evidence to support current and future practice as well as influence the behaviour of my colleagues. This subsequently affects the quality of care that service users receive, whatever clinical setting the author is working in. Health care professionals acquire pathogens on their hands from patient contact, and may transmit them to other patients if hand hygiene guidelines and recommendations are not followed. Studies have shown that compliance with hand hygiene rarely exceeds fifty percent (Pittet, 2000). Hand hygiene is considered the most important measure for preventing nosocomial infections (Picheansathian, 2004). A nosocomial infection is defined as an infection that is evident but previous to admission was not present or incubating (Mayone-Ziomek, 1998).
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The Nursing and Midwifery Council’s code of professional conduct clearly states that care and patient advice must be “based on the best available evidence” (NMC, p. 4). Keeping the skills and knowledge base up to date will require utilising the most current and relevant research. As a registered professional under the code of professional conduct by the NMC a nurse has the responsibility to deliver care based on current evidence. The United Kingdom National Health Service has experienced various policy changes highlighting the need and encouraging the use of relevant evidence into the practice of all registered health care professionals. This move towards evidence-based practice is a move away from care or treatment based on a knowledge base. Evidence based practice is considered the combination of evidence from research, with clinical expertise and patient values to provide effective care (Sackett et al., 1997). The Department of Health argues that it is no longer acceptable for healthcare professionals to base care on tradition. They must be able to justify the decisions they have made using professional expertise which clearly includes using relevant and up to date evidence to inform practice.
A Nursing Times supplement that gives further insight into what is expected and recognises that there may not always be a current and/or relevant piece of literature available and instead alternative sources may need to be utilised (Kirkland, et al., 2008). Not all evidence is judged to be of equal value. A number of hierarchies of evidence have been developed to enable different research methods to be ranked according to the validity of their findings. The hierarchies only provide a guide to the strength of the evidence and other issues such as the quality of research also have an important influence. Evans (2006) proposed a hierarchy that is specific to healthcare, particularly because when the evaluation process of healthcare studies considers the appropriateness or relevance; existing hierarchies are inadequate (Evans, 2006).
During my searches I accessed several electronic sources. I used the search engine google as well as directly searching appropriate web sites such as the National Institute of Clinical Excellence, British Medical Journal and Royal College of Nurses.
The primary research I found was a quantitative study titled ‘Efficacy of hand rubbing with alcohol based solution versus standard hand washing with antiseptic soap: randomised clinical trial’ and it was conducted by Girou et al (2002). The aim of the study was to compare the efficacy of hand rubbing with an alcohol based solution with hand washing with antiseptic soap in reducing contamination of hands during patient contact. The trial was based in three French intensive care units and 23 health care workers volunteered to take part. The randomised participants performed 114 patient care activities. All participants were previously educated in the use of the alcohol based solution. When the need for hand hygiene arose, an imprint of finger tips and the palm of the dominant hand were taken, before and one minute after. Each finger tip and palm was imprinted on a commercial contact agar plate. In both groups the counts of bacteria were significantly reduced after hand hygiene, but the hand rubbing with the alcohol solution was more effective than hand washing.
The motivation of the quantitative study can be question due to the trial being funded by the company that provided the alcohol solution, Bode SA, Hamburg Germany. As to whether this had any implications to the results we can only question. The company who produce the alcohol solution have obvious financial incentives. The sample size is not particularly large, but also the findings are not externally valid. The findings apply particularly to an intensive care setting. Care in intensive care units is very different to that of various other wards as it is one to one whereas nurses on other wards may have contact with a number of other patients. This limits the extent to which the findings can be generalised to other clinical settings; but also the study is culturally bound. How French and British nursing practices vary must be considered if I was to attempt to apply the evidence into practice. In studies such as this when the participants are educated and are aware of the investigators intention the Hawthorne Effect may be present. The Hawthorne effect relates to an increase in worker productivity produced by the psychological stimulus of being singled out and made to feel important (Holden, 2001). In relation to Girou et al’s (2002) research it was not possible to blind nursing staff to the conduction of the study so the Hawthorn effect may contribute to outcomes of the study.
Nurses may have had their own beliefs or perceptions as to how they should be performing the clinical task of hand hygiene. The technique to record the growth of bacteria by only sampled the palm and finger tips will not provide information about contamination of the other parts to the hand. Ayliffe et al (1992) suggests that between the fingers and the finger nail area are the most frequently missed during hand washing and these areas were not monitored using the technique employed in this study. The more accurate technique was recognised in the studies report but claimed that this technique was more time consuming and it could not be implemented without an unethical breach on delivery of care. This study has vast amounts of current and relevant evidence to support the findings it has produced. Evidence produced using randomised controlled trial is considered the second most valuable evidence according to the hierarchy of evidence.
The secondary research piece chosen is titled ‘A systematic review on the effectiveness of alcohol based solutions for hand hygiene’ and was conducted by Picheansathian (2004). Articles and studies published from January 1992 till April 2002, in English and Thai, which related to the use of alcohol solution, were assessed. There were 41 articles selected that all explored various usages of alcohol solutions. The study results were pooled in statistical Meta analysis. This systematic review supported the use of alcohol solutions for a number of reasons; Alcohol solutions removed more micro organisms more effectively required less time and irritated the hands less than hand washing with other various solutions. Also studies showed that increased availability of alcohol solutions improved compliance by health care professionals, it is easier to increase the number of alcohol solutions availably than increase the number of sinks.
The studies were divided into groups as some of the research aims varied. Nearly all studies favoured the use of alcohol solutions. This review recognises that there are a number of factors that may indicate the use of alcohol solutions. Of the 58 studies retrieved from the search process on 41 were considered appropriate for the review. It is suggested that the 17 excluded articles, were so because they were either an expert opinions or they lacked sufficient details surrounding the findings. This would be an opportunity for the investigator to dismiss articles that go against the hypothesis of the review. The quantity of studies is sufficient enough to contribute to the validity of the findings. However, as to what kind of care setting the 41 articles refer to is unknown. This can bring into question whether the findings can be appropriately generalised to all nursing contexts from community nursing to intensive care and ward nursing.
The articles reviewed were from both English and Thai nursing settings; and these two cultures vary greatly and if nursing staff were to apply these findings to practice, consideration must be made as to ways the two cultures differ in a nursing context. So application of the findings can be questions. But I am confident these findings are applicable to my future practice settings. All the articles under review by Picheansathian (2004) are quite recently published, 1992-2002. However some are over ten years old, but all are of a satisfactory quality. This article is a systematic review, this brings with it increased value according to the hierarchy of evidence.
There are a number of factors that influence non compliance with evidence based practice, particularly surrounding hand hygiene. For example, culture, values, beliefs, tradition. Doctors tend to be worst at compliance with hand hygiene policy (Suchitra and Lakshmidevi, 2006). This tends to be due to tradition. Doctor’s practice has previously not been questioned by anyone other than between Doctors themselves. Still it remains that they are rarely instructed by fellow staff of their poor practice. This may be due to their medical expertise deterring staff of a perceived lower hierarchal status confronting them.
Despite the call from the Department of Health and the Nursing and Midwifery Council for nurses to utilise evidence based practice it is not uncommon for the findings of latest research not to be implemented. Barrett and Randle identifies that even though students can receive and be armed with the latest evidence “professional socialisation” (Barrett & Randle, 2008, p. 1855) leads them to adopt the culture of their placement and to emulate their mentors. Hannes et al identified several themes but amongst them was “fear the negative comments of others” (Hannes et al, 2007, p. 166). A further study identified a feeling of time constraints as a barrier to implementing new practices and utilising the latest evidence, additionally this also made the nurses feel they didnt have time to keep up to date with current developments (Retsas & Nolan, 1999). Also when nurses did have the time to investigate the latest ideas and developments the quantity of new research is seen as overwhelming with many nurses feeling inadequately capable of evaluating, critiquing and identifying relevant evidence and research (Retsas & Nolan, 1999).
The feeling of being overwhelmed by the amount of research and evidence available is seen by Glasziou & Haynes (2005) as expected when there is so much information at hand. Identifying what is made even more difficult by advertising and biased research. Davis et al (2003) instead present continuing medical education, continuing professional development and knowledge translation as pathways for utilising evidence based practice. Continuing medical education and continuing or professional development are argued to have limited effects on changing practice (Davis, et al., 2003). Knowledge translation builds on these increasing the knowledge and skill base, once this is done then the practice environment is made conducive to the new skill base and the new changes are reinforced and reviewed (Davis, et al., 2003). The changing of the practive environment to encourage the development of evidence based practice could be useful in reducing the effects of Barrett & Randle’s (2008) professional socialisation and also support those who feel they lack the authority to implement change as seen in the Retsas & Nolan (1999) study. This encouragement to implement would also appear to be supported by Glasziou & Haynes who identify that even when there is recognition, awareness and willingness to change, “habits do not change easily, despite our best intentions” (Glasziou & Haynes, 2005, p. 38)
The NHS work force is diverse and is made up of many nationalities and cultures. The validity of research must be questioned in its application to other cultures to the culture the research was conducted. Ahmed (2002) highlighted this in his article which explained that some, not all, Muslims could not use the alcohol based solutions as the Islamic Doctrine describes alcohol as ‘Haram’ Forbidden in the Koran. Some Muslims fear the potential inhalation of fumes and systemic dermal diffusion of the alcohol solution (Ahmed, 2002). There has been no definitive research in to the likelihood of this, Muslims concerned by this may be exempt from new policy surrounding the implementation of alcohol solution; but suitable alternatives must be considered.
According to the NMC a registered nurse it is your duty to facilitate students and help them develop and your responsibility to deliver care based on up to date evidence and when possible to ‘validate research’. Once a qualified nurse, it will be my duty to wash my hands using the most up to date evidence at the time. This can be done by consulting infection control guidelines, it will also be my duty to ensure that other member of staff and students abide by most recent policy and guidelines, if not, then actions must be taken to educate them. In practice I have recognised the importance of alcohol solutions and most obviously the reduction in time spent decontaminating hands. It is unrealistic to expect busy professional to spend 17% of the valuable time at a sink (Voss & Widmer, 1997).
The importance of hand hygiene cannot be ignored. There is much evidence to support the need to decontaminate hands before and after patient contact; and as a result reducing the rate of nosocomial infections. The evidence obtained from the research articles I discussed would both support the use of an alcohol solution to decontaminate hands. Even traditionally nurses understand the implications of not washing their hands but they need to be aware of the use of more effective means of maintaining hand hygiene in nursing practice. The National Patient Safety Agency’s ‘clean your hands’ campaign has been implemented in the North Bristol Trust. This action seems to be addressing the issue surrounding availability. Alcohol solution dispensers are now available at every bedside, entrance to all wards and clinical areas, on all notes and drugs trolley and in clinical rooms. These interventions are vital in the reduction of nosocomial infections.
It is important for healthcare professionals to be aware that evidence is not ‘proof’ (Van Zelm, 2006). Much thought must take place to implement research. Duffin (2004) explains that solely placing alcohol dispensers at patient bedsides will not improve hand hygiene. Health care professionals need to be educated in their use and the importance of their use. Evidence based practice is a form of decision making. If a healthcare professional was to implement evidence without critically considering the validity of the research, it would be considered dangerous practice and not truly evidence based (Van Zelm, 2006). Evidence generally seems to support the use of alcohol solutions. The use of alcohol rub reduces time spent undertaking performance of hand washing. Previous to the use of waterless alcohol solutions nurses that would comply 100% to hand washing with soap would spend up to 17% of their time doing the task; whereas with the use of alcohol solution, this is reduced to less than 3% (Voss & Widmer, 1997).
In conclusion there is a vast amount of research and new ideas available at the moment. Evidence is being produced regulalry and it can be difficult to stay up to date (Hannes et al, 2007). Additionally we are expected to obtain informed consent and where this is not possible act in the best interests of the patient (Nursing and Midwifery Council). Informed consent means providing the patient with all the information they need to make a decision, as practices and treatments change we need to stay informed so that the information we give to patients is correct and current. Additionally we are called upon to share information with colleagues as well as to work effectively within the team (Nursing and Midwifery Council). A willingness to share current evidence based practice helps to keep colleagues informed and up to date and ensure te increased effectiveness of the nursing teams. Staying informed and up to date with current evidence and research not only ensures patients receive the best possible care but make the role of a nurse easier at a time when the NHS is under going many changes and the lines between different professions become more and more blurred.
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