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This essay will focus on hand washing and infection control within the clinical settings and their environment. My inspiration to explore infection prevention and control started during my six weeks placement in a Parkinson's unit within a National Health Service (NHS) hospital. This unit provides care for patients suffering from Parkinson disease for adults between the ages of 18 to the elderly.
There have been frequent incidents when bays within units have undergone closure due to the out break of infections such as Meticillin Resistant Staphylococcus Aureus (MRSA). I observed that the spread of infections has great implication as an out break causes sickness among healthcare staffs, as well as patients in care. The Health Act (2006) imposed legally binding duties on trust including provision of adequate hand washing facilities and hand rubs and mandated a rolling audit programme on hand hygiene that was embedded in local clinical governance frame works.
I have decided to explore the causes, effects and the difficulties in the management of infection prevention as a means to enhance my personal and professional development. In addition further knowledge of infection prevention and control, gained through this research will be applied in my future practice.
In this research confidentiality is going to be ensured in accordance to NMC( 2008) which emphasizes that nurses have a duty to respect people 's rights to confidentiality and data must be processed for limited purposes.
The research articles were selected from academic databases recommended by my lectures which were all found in the university library. I found some of the information from databases such as BNI (British National Index), CINAHL (the Cumulative Index to Nursing and Allied Health Literature), Medline (Medical Literature Analysis Retrieval System Online), and Cochrane. Articles accessed from these databases have been peer reviewed making the evidence more reliable as they have undergone a rigorous process to reduce bias.
Aveyard (2007) suggested that journals accessed from the university library are highly recommended when carrying out research based topics. When searching for articles to use, I typed in key words such as infection control, or infection prevention of qualitative and quantitative research into the search engine and lots of articles came up. I realised that this topic has been written by so many authors, I did not have difficulties searching for the articles. In order to narrow it, the search was further narrowed to display articles between the year 2000 to year 2012 written with England. I downloaded the research that was available via links to Full texts and Full text PDF's. I then carried out a hand search of the academic journals available at the University . To avoid accessing abstracts on the full text setting was applied. Combinations of search words were used, such as infection prevention and control, hand hygiene, isolation, wound care and cleaning. Several results showed on infection prevention and control. One article outside the United Kingdom was considered due to its relevance's on the topic.
Every year, a lot of people die due to the spread of infection in hospital. Healthcare professionals can take measures to prevent the spread of infectious diseases which is part of infection control.
Good hand washing is the most effective way to prevent the out break of infection with the hospital. It is estimated that it costs the NHS almost £1 billion pounds per year for the treatment of infection related diseases (DH, 2008). Currie and Maynard (1986) conducted a study which estimated the cost of HCAI in the UK to be £ 111 million. It is a fundamental role for hospitals, to be aware and understand as well as identify risks of infection and work towards eliminating or reducing risk of infection. According to Hospital Infection Society (2007) reported that the UK prevalence rate of HCAI of around 9%. The results of the first survey legitimised infection control as an emergency discipline. The introduction of the clinical governance (DH 1999) and control assurance (NHS, 1999) provided a framework for clinical quality improvement. One of the complements in the control assurance was that organisations fulfil their statutory and mandatory responsibilities for infection control (Cole, 2010). The Clean your hands campaign was rolled out in 2004 in England and Wales to healthcare workers in all acute National Health Service (NHS) hospital trusts. The setting of a national target for MRSA bacteraemia was set up in the publication of the Health Act 2006 (department of Health). Wilson (2006) argues that good infection prevention and control reduces morbidity and mortality thereby reducing costs to the health care community. Nurses have a responsibility to make sure that patients receive safe and effective care and that risks to them are minimised NMC(2008),therefore better infection control is a priority for all healthcare professionals in primary care Lawrence and May(2003) Judge and Hill (2004)Jenkinson et al (2006)NMC (2006).In addition NMC (2008a)states that all nurses must work within the limits of their competences meaning having the knowledge and having confidence thereby reducing risks through lack of knowledge.
Infection prevention and control can be defined as the clinical application of microbiology in practice (Royal College of Nursing, RCN 2010). According to Denic (2008, cited in Kirch, 2008) stated that infection control refers to the policies and procedures used to minimize the occurrence of hospital infections such as hand hygiene, cleaning/disinfection, sterilization, vaccination etc.
Furthermore Infection prevention and control can be defined as a series of strategies and practices that aim to reduce the risk of infection to the staff, patients and others where care is delivered (Endacott, 2009).
This research will discuss articles on the practice of infection control by firstly considering the rational, literature search, evidence and analyses of five chosen research articles. In addition a range of research methods used in the articles will be discussed by considering qualitative, quantitative, sampling, ethical consideration and data collection. Furthmore the author a student, working within a Parkinson's unit will consider recommendations for best practice. Since infection control is a broad topic this research will be focusing on hand washing and Health Care Associated Infections (HCAI). Hand washing is considered as one of the most vital infection prevention measure. Gould and Drey (2008) reported that hand hygiene is the most essential aspect of infection prevention and control for healthcare workers. Furthermore Gould and Grey (2008) stated that hand hygiene is an important procedure for preventing the spread of HCAIs and is considered fundamental to good infection control practice. Failure to comply with hand hygiene in a satisfactory manner could be seen as a breach of the Code of Professional Conduct NMC (2002). This research will also tackle on the importance and ways of reducing healthcare associated infections.
The research was based on semi-structured interviews. Parahoo (2006) support the use of semi-structured interviews because they allow the topic and perspectives to emerge.
In a research conducted by (Erkan, Findik and Tokuc 2011) to evaluate the nurse's hand washing behaviour and knowledge before and after a training programme. In the study were 350 nurses sampled, however 200 nurses agreed take part. The participants received training on hand washing techniques and they completed pre and post test surveys.
The study received an ethical approval from the Ethics Committee of Trakya University Medical Faculty. Informed consent was obtained verbally from the nurses who participated voluntarily. The participants were given oral information about how the study was going to be carried out.
The nurses were given survey forms before the hand washing training to determine the nurses' knowledge on hand hygiene. The survey consisted of 44 questions about hand washing. The questions included preferred ways of hand washing, the quality of their hand washing and also the behaviour of nurses on hand washing. The questions that were unclear were clarified during the first session .The training lasted 1 month with two sessions per week. In completion of their training nurses were given booklets on hand washing prepared by the researchers to enhance the effectiveness of their training and badges to raise the awareness of hand washing to the public. The booklet covered topics like the history of hand washing, types of hand washing and their purposes and also hospital infections.
The participants had 8 years experience in nursing 192 of the nurses were females and 8 males. The nurses were all from different departments of health including surgical clinics, intensive care, managing nurses, service nurses and internal clinics.
The results of the study highlighted that training programmes have some positive effects on the quality of hand washing and hand washing behaviour of nurses. Hand-washing training programmes are vital in terms of teaching, renewing the knowledge and also creating understanding. In addition training is the best way to learn and this can transforms knowledge into behaviour thereby allowing trained participants to maintain the information in practice. Finally the study recommended the implementation of hand -washing training programmes in order to improve the behaviour and the knowledge of nurses with respect to hand washing (Erkan, Findik and Tokuc 2011).
A qualitative research was carried out by Randle and Clarke (2011) to understand senior infection and prevention and control nurses experience and perceptions of implementing the day to day aspects of the Code of Hygiene. In the research, Randle and Clarke (2011) elaborate that the code of hygiene is legislative and sets out compliance standards in order to reduce infection rate as well as emphasises how failing healthcare providers can improve upon standards.
A qualitative research is an umbrella term encompassing a wide range of methods such as interviews, case studies, ethnographic research and discourse analysis (Parahoo, 2006). In the research 5 senior infection prevention and control nurses participated in the taped semi-structured interviews and a systematic analysis was applied to analyse the findings.
The study found that managerial intervention in infection control achieves significant control (Randle and Clarke, 2011). This is due to the fact that managers are in the position to champion a course because they understand more about infection control and its implication to healthcare practice and can also acts as role models; hence they can encourage other junior staff to adhere to the good practice of preventing infections.
Parahoo (2006) stated that in a semi-structured interview the researcher is very much in control of the interview process and the prearranged questions provide the structure to the interview. The advantage of using a semi-structured is that they can provide quantitative and qualitative type as the degree of control and structure on the part of the interviewer is minimal to allow the topic and perspectives to emerge (Parahoo, 2006). Furthermore Parahoo (2006) however stated that in semi-structured interviews, the researcher is very much in control of the interview. This exposed the use of semi-structured interview to biased as an element of probes has to be applied to enable valid and reliable data to be collected. Reliability and validity are ways of demonstrating and communicating the rigour of research processes and the trustworthiness of research findings (Lacey, 2006).
Randle and Clarke (2011) requested ethical approval and gained consent from the participants before carrying out semi-structured interviews. The author acknowledges that permission from the local research ethics committee reported that the study fulfilled the criteria of service evaluation. Bell (2010) note that ethical committees play an important part by ensuring that no badly designed or harmful research is permitted. Furthermore Darlington and Scott (2002) refer to ethics committees as having a gate keeping responsibility in all research which involves human subjects as they are extra vigilant when considering research proposals. Randle and Clarke (2011) noted that participants were given an opportunity to withdraw from the study. This process of providing a withdrawal choice follows the ethical procedures required for a research. Credibility to the research was placed by the researcher by covering a different geographical area over England. Credibility has been defined as the extent to which the findings of a study reflect the experience and perceptions of those who provided the data (Parahoo, 2006).
Randle and Clarke (2011) stated the sample size selected prior was seven subjects. The study used a purposive sample approach and five subjects participated in the study. Macnee and McCabe (2008) refer a purposive sampling as consisting of participants who are intentionally or purposefully selected because they have certain characteristics related to the purpose of the research. Parahoo (2006) defined a sample as a subset or proportion of the target population. In carefully selecting a sample which is representative of population, this enables recommendations to be drawn. Polit and Becks (2004) argued that due to the aims and nature of research in which perceptions and experiences are being studied, small sample sizes could be considered appropriate. Macnee and McCabe (2008) argued that the composition and richness of the setting and participants rather than the sample size have greater use in obtaining results of a qualitative study. A systematic approach was used to analyse the data collected. Waltz et al (2010) stated that use of a systematic analysis provides the simplification of recorded language to sets of categories that represent the presence, frequency or intensity of selected characteristics.
The results of the study highlighted interventions and barriers of compliance. The difficulties of implementation of infection and control procedures were clearly evidenced in the recommendations. Gould (2004) stated that infection control policies and procedures are based on key principles which, must be applied correctly to reduce risks for patients, staff and other visitors to the clinical environment these are cleaning, disinfection and sterilisation. The barriers to implementation and compliances infection control and prevention cannot be achieved if they is lack of resources specifically isolation facilities Randle and Clarke (2011). Creedon et al (2008) noted that organisational cultures and staff contribute in affects infection prevention and control practice. It is therefore important and crucial for healthcare workers to be aware inappropriate practice and to be driven into following bad practice.
In another study conducted by (Swanson and Jeanes 2011) aimed at summarising key infection and prevention issues. Swanson and Jeanes (2011) adopted key principles of hand hygiene, asepsis, appropriate use of personal protective equipment, hygiene and cleanliness, decontamination of equipment and sharps as crucial in infection and prevention. Nurses have a duty to ensure that patients receive safe and effective care and that risks to them are minimised (NMC 2008). Therefore better infection control is precedence for all healthcare professionals in primary care (Lawrence and May, 2003. Judge and Hill, 2004. Jenkinson et al, 2006. NMC, 2006).
Hand hygiene is the foundation for infection control conduct and hand washing forms part of hand hygiene practices. Sax et al (2007) suggested 5 moments of hand hygiene which encourages health-care workers to clean their hands firstly, before touching a patient, secondly, before clean/aseptic procedures, thirdly after body fluid exposure/risk, fourthly after touching a patient and fifthly after touching patient surroundings. Hand hygiene is conceded as a reasonably cheap and straightforward procedure than many other infection prevention and control procedures. Healthcare workers however fail to practice it when they as required. According to Beggs et al (2009) hand hygiene is widely regarded as the most effective way of preventing HCAI on the principle that cleansing of hands breaks the chain of infection. The Royal College of Nursing (2005) emphasised that all healthcare staff should undertake infection control training as part of their induction and on an annual basis. Poor hand hygiene plays a role in the transmission of microbes and eventually results in the increased rates of patient to patient and staff to patient infections in clinical and community settings.
In England and Wales, the National Patient Safety Agency (NPSA) has taken the lead for developing hand hygiene guidelines and audit. The CleanYourHands campaign which was launched in 2004 to help reduce the spread of HCAI as an initiative and response to public concerns (National Patient Safety Agency, 2004). The CleanYourHands campaign was started after the government and public concern reported high levels of meticillin resistant Staphylococcus aureus (MRSA) bacteraemia, meticillin sensitive aureus (MSSA) bacteraemia, and Clostridium difficile. The main components of the campaign comprised provision of alcohol hand rub at the bedside, distribution of posters reminding healthcare workers to clean their hands, regular audit and feedback of compliance, and provision of materials empowering patients to remind healthcare workers to clean their hands.
WHO(2006) noted that training, observation and feedback of performance in hand hygiene is important in making sure that staffs are aware of best practice Hand hygiene is often cited as the single most important measure to prevent HCAI; however, compliance is a problem to all health settings WHO (2009). Portsmouth (2007) considered the legal, ethical and professional dimensions to infection prevention and control compliance and posed a question around how health professionals may interpret their obligations and their duty of care. It is significant to not only consider infection control and prevention as a procedure to be followed. The issue of infection and control compliance has legal implication on the safety of patient in care and individual staff member to take responsibility to remain safe from infectious diseases.
Cole (2010) carried out a quantitative research, to chart the rise of infection control in the NHS. The research was based on literature research which focused on the progress and implementation of government legislation on infection prevention and control. Marshall et al (2004) noted that MRSA became increasingly endemic throughout the UK healthcare system, and search and destroy approach was taken. The introduction of clinical governance in 1999 provided for a quality improvement and control assurance standards (Cole, 2010). This policy initiative was driven by the financial cost incurred in the treatment and control of HCAI. Cole (2010) reported that media headlines of superbugs, modern plagues, forgotten massacres and filthy hospitals received considerable support from the government who introduced policy initiatives to address the problem of hospital infections. According to National Audit Office (NAO, 2004) widespread non-compliance with infection control policies and procedure was noted due to lack of evidence based guidelines. Hay (2006) stated that surveillance importance was identified by the NAO report. Surveillance has been defined as routine collection and analysis of infection rates with feedback to staff (Hay, 2006). The introductions of mandatory surveillance in all NHS trust reducing patient acceptance of 1 in 10 chance of acquiring an infection. Cole (2010) failed to provide evidence of reduction of infection in NHS hospitals. The research provided recommendations to measuring progress of infection control or prevention by avoiding organisational self-determination. The introduction of more legislation would accelerate reduction in mortality rates and decrease expenditure (Cole, 2010).
Knoll et al (2010) carried out a quantitative data on factors influencing nursing staff compliance with hand hygiene. A quantitative research has been conceded as explaining phenomena by collecting data that is analysed using mathematically based methods such as particular statistics (Parahoo, 2006). The main purpose of a quantitative research is to measure concepts or variables for example attitudes objectively and to examine by numerical and statistical procedures the relationship between them Parahoo (2006). Knoll et al (2010) monitored 181 nursing staff for sanitary disinfections of the hands and statements were summarized. An analysis of the data collected was done into a numerical form and results were produced in percentages of correct procedures at 51.9% and not carried out or not done properly 48.1%. The study showed results of reduced hand disinfection performed due to shared increased in a stress factor (maximum ward capacity and severity of patients cases) and imbalance of work effort in the context of time available (Knoll et al ,2010). Furthermore relevance of training courses in infection control was found to have implications on compliance with hand hygiene. Gould et al (2007) argued that poor hand hygiene compliance is now widely recognised as a major healthcare issue related to heavy workload and poor staff morals. The introduction of government cuts urge implication of staff level reductions due to cost cutting measures. This further impacts on staff workload and as the Knoll et al (2010) highlights evidence of compliance in hand hygiene measures.
A study carried out by Ali et al (2005) was done on 120 patients without known MRSA from hospital and the community being admitted to a hospice. The focus of the research required ethical approval form a research ethics committee. The researcher clearly highlighted the method used in gaining informed consent from the participants in the study after written information was provided. Ali (2005) study considered investigating MRSA within a sample group of terminally ill patients. A total of 19.5% of potentially eligible participants were involved in the study. This research however noted that constrains of the sample size was mainly to the fact that other potential participants were to ill to provide consent. The findings of the study showed that from the total participants 2.5% only two participants were proven to developed symptomatic infection due to MRSA. The relevance and ethics around this study can be greatly questionable. Chaloners (2007, cited in Keele, 2011) defined ethics as a branch of philosophy concerned with determining right and wrong in relation to peoples decisions and actions. The responsibility of the local ethics committee is to ensure the ethics of a research a assessed and that the nature of research does not impacted or negatively affect participants. It can be argued that Ali et al (2005) research although ethically considered and approved, could have negative impacts on the wellbeing to the participants. It is also arguable that from the results of the research MRSA alone had little influence to the eventual death of the participants involved.
Stone et al (2012) had done a research on 187 acute trusts to evaluate the national Cleanyourhands campaign to reduce staphylococcus aureus bacteraemia and clostridium difficile infection in hospitals in England and Wales. The results were combined from the procurement of soap and alcohol hand rub per patient bed. The sample size used in the research has significant implication on the validity and reliability of the findings. The use of a national as well as vast geographical area enables research finding to provide a true reflection on the population. However Stone et al (2012) research could be criticised for excluding hospital trusts that 18 months of missing data. The research findings demonstrated that the implementation of the cleanyourhands campaign and procurement of alcohol hand rubs. The research illustrated a correlation of alcohol hand rub procurement was associated with a rise in C difficile infection and soap was independently associated with a reduction in C difficile.
In conclusion five research terms which include sample, qualitative, quantitative, ethical consideration and data collection have been discussed from a selection of five research articles. Hand washing and infection prevention and control have been discussed. a variety of recommendation have been drawn from the research studies such education and nursing student encouragement effective hand hygiene and acting as agents of change , good supervision from mentor learn effective correct practice procedures, staff stress and implication on non-compliance on hand hygiene. Correlation studies showed an association with the use of soaps and hand gels in the reduction of infections diseases. The responsibility and expectation for healthcare worker to take infection control procedure and own it has been over emphased. The emphasis on legislative as well as policy on the importance of infection control and prevention has been discussed by the implementation of the Health Act 2006, clinical governance, cleanyourhands campaign and Health and Social Care Act.