Hand hygiene among health professionals: a question of perception

When healthcare professionals think that the place where they work actively promotes prevention of hospital-acquired infections, they do more to help reduce their occurrence, particularly by washing their hands often.

That's what Laurence Bernard, an assistant nursing professor at Université de Montréal, and a team of researchers found when they assessed the impact that prevention-focused hospitals have on hand-hygiene compliance by their personnel.

Their study was published in the April edition of the Journal of Advanced Nursing.

Three types of organizational cultures

Medical literature identifies three types of organizational cultures that approach hospital-acquired (or nosocomial) infections in different ways: individually, hierarchically and collaboratively.

In an individual culture, health professionals perceive patient safety from their own perspective, deciding what practices they can personally employ to prevent the transmission of nosocomial infections.

In a hierarchical culture, healthcare professionals have the view that risks arise from a failure to comply with infection control and prevention standards. This is also referred to as a “blaming” culture.

Lastly, in a collaborative culture, hospitals promote patient safety by having everyone – healthcare personnel, patients, housekeeping staff and visitors – play a role in prevention, a role that has been explained and understood by all as a collective endeavour.

A more accurate perception of risk

To gauge the impact of these three approaches on hand-hygiene compliance rates, Bernard and her colleagues surveyed 4,430 health professionals in three hospitals on how they the view their institution's prevention culture. They also went to each hospital to observe how often personnel washed their hands. A Belgian hospital was studied for its individual-style culture, a Quebec hospital for its hierarchical culture, and another Quebec hospital for its collaborative culture.

The researchers found that the hand-hygiene compliance rate was 35 per cent when the institution's prevention culture was perceived as individual, 53 percent when it was hierarchical, and 77 per cent when it was collaborative, close to what is considered to be the ideal compliance threshold in the United States: 80 per cent.

“Generally, in Canadian hospitals this (ideal) rate varies from 50 to 80 per cent; it’s rare to get 100 per cent,” said Bernard. In general, she added, “our data indicates that when there’s a sense of team spirit with respect to patient safety and nosocomial infection prevention, risk management becomes more collective and people act more responsibly."

This sense of mutual responsibility has a positive impact on the hospital's various units and within the overall organization, she added, in terms of risk management, the supervision and control of prevention operations, learning and knowledge transfer, leadership and, lastly, patient safety.

An issue of global concern

While the study’s findings are not necessarily representative of hand-hygiene compliance rates in all hospitals, the issue is of great concern around the globe, said Bernard.

Hand hygiene remains the most effective (and least costly) infection control measure: 80 per cent of common infections can be transmitted by contaminated hands, according to the World Health Organization. "Of every 100 hospitalized patients, at least seven in high-income and 10 in low- or middle-income countries will acquire a healthcare associated infection,” WHO says.

In Canada, some 8,000 Canadians die every year from hospital-acquired infections and 220,000 others are infected. In Quebec, between 80,000 and 90,000 people get infected during their stay in hospital – about 10 per cent of all admissions.

For Bernard, establishing a collaborative culture of infection prevention requires, above all, the leadership and active involvement of hospital management.

“In settings where patient safety is considered a priority, means are made available to establish prevention programs and interventions, but this is often what’s lacking,” she noted. “The main problem is insufficient resources and time: there are so many needs to be met in the health sector that infection prevention becomes an enormous challenge.”

Training is also key – and needs to be strengthened, she added.

 “Professionals are not always well trained in risk prevention and management. These concepts are not sufficiently transferred and adapted to health professionals. They really need to be addressed to a fuller extent, particularly at the bachelor’s degree level, not only to ensure that hand hygiene is promoted, but more broadly to encourage a more organizational and collaborative spirit.”