Hand hygiene and healthcare-associated infections: A critical analysis of literature

This paper critically analyses the literature on hand hygiene and healthcare-associated infections (HAIs). It reviews a systematic review, a quantitative study, and a qualitative study to understand the strategies that have been found effective in maintaining compliance of hand hygiene among nursing professionals. The paper also highlights the importance of follow-up evaluations and the need to address the combination of different determinants to increase compliance.

Running head: NURSING
Nursing
Name of the Student
Name of the University
Author Note

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Introduction
According to Hor et al. (2016) Healthcare-associated infections (HAIs) are one of the
frequently occurring adverse events that affect hundreds of millions hospital in-patients
annually. The HAIs increase the overall cost of care along with an increase in the length of
stay in the hospital. Brewster, Tarrant and Dixon-Woods (2016) highlighted under the under
the growing prevalence of the antimicrobial resistance, HAIs is serious concern and might
impose fatal threats. Under acute care settings in hospitals hand-hygiene is highlighted as the
principal concern in preventing HAIs. Pan et al. (2014) argued that the hands of the
healthcare workers are regarded as the primary vectors of the microbes’ transmission between
patients and the surrounding healthcare environment. Observing the "Five Moments" of hand
hygiene as proposed by WHO helps to follow the standardised protocol of hand hygiene
under healthcare settings (Al Kadi & Salati, 2012). However, National Safety and Quality
Health Service Standards of Government of South Africa highlighted that healthcare
professionals play an important role in preventing and managing HAIs. The standards also
highlight that healthcare professionals must communicate the patients and the care givers
about the important of the hand hygiene HH, disinfection and sterilization in preventing
HAIs. the following assignment mainly aims to analyse how HH is effective in preventing
HAIs and what are the approaches is important in uplifting the overall sterilization practice
among the healthcare professionals. The paper will mainly initiative with the critical analysis
of three papers (qualitative, quantitative and systematic review) published in relation to HH
and HAIs. Following the critique, the assignment will provide a summative overview of the
main findings of the selected research.

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Critiquing the literature
In the domain of HAIs and importance of hand hygiene, Huis et al. (2012) conducted
a systematic review in order to analyse the strategies which have been found to be effective in
maintaining the compliance of the hand hygiene among the nursing professionals towards the
prevention of the HAIs. Thus, the aim of this systematic review is focus and justified under
the context of novel research framework. Huis et al. (2012) utilized systematic searchers of
experimental and the quasi-experimental research on hand hygiene (HH) which were
published on Medline, Embase, CINHAL and Crochrane databases from January 2000 to
November 2009. Thus they authors review articles, which are during the tenure of 9-year gap.
This approach of the authors helped them to include important and relevant studies, which
fall under the scope of the research. The review of the 41 articles highlighted that addressing
only the important determinants of the observance of the HH like knowledge, action control,
awareness and facilitation is not comprehensive to change the HH compliance behaviour
among the nursing professionals. Addressing the combination of different determinants is
found to provide better results. Thus, the review highlighted that application of the alternative
improvement strategies like social influence, self-efficacy, attitude and intention will help to
increase the compliance of the nursing professionals in observance of hand hygiene.
However, one of the main limitations of the study is, authors failed to review adequate
resources during the tenure of 9 years and this might lead to the generation of biased
response. However, the result of the review is combined and was reasonable.
Monistrol et al. (2012) conducted a quantitative study in order to assess the impact of
HH educational program on HAIs in the medical wards. The authors mainly aimed to
evaluate the impact of multimodal intervention in the hospital wards on the compliance of
HH, alcohol-based hand rub (AHR) and its association with the rate of occurrence of HAIs
and hospital-acquired methicillin-resistant Staphylococcus aureus (HA-MRSA). Monistrol et

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al. (2012) mainly employed before-after intervention study approach and post 1-year
assessment was conducted in three medicines wards. They mainly used WHO HH
observation method for monitoring HH compliance and the infection. The analysis of the
results highlighted that proper observance of the multimodal interventions like compliance of
the HH through AHR helped to decrease the spread to HA-MRSA. However, Monistrol et al.
(2012) highlighted that it is the duty of the healthcare professionals to maintain a proper
follow-up during pre and post interventions periods. The main limitation of the study is
follow-up evaluation after one year. According to Lewis (2015) the follow-up studies cause
decrease in the overall sample size during the course of the year and this decrease in the
sample size might lead to biased outcome. One of the strength of the study is, the compliance
of HH was measured via the use of direct observation during the daily work-routine. In order
to reduce the inter-observer error, the observers were standardized against each other through
10% of monitoring sessions. The recording to the observation was done based on the WHO 5
step framework of the HH. This help in uniform tabulation of data. The study followed all the
ethical regulations.
Hor et al. (2016) conducted a qualitative study; the aim of the study was to elucidate a
better understanding about the infection prevention and control (IPC) under routine clinical
practice. The authors mainly highlighted over the prevention of the cross-contamination
under the application of effective HH and personal protective equipment (PPE). The
qualitative study mainly reported on an interventionist video reflexive ethnography study that
explored how the healthcare professionals utilized IPC in New South Wales, Australia. They
conducted 46 semi-structured interviews, 24 weeks long field-work (observation and
videoing) and 22 reflexive sessions. 177-participants from different health care profession
like nursing, clerical, cleaning staffs and the medical professionals were included in the case
study. The large sample size is the main strength of the study. According to Malterud,

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Siersma and Guassora (2016), large sample size helps in the reduction of the biased response.
However, the selection of the focus groups was not uniform as it included healthcare
professionals from diverse domains and this might hamper the reliability and validity of the
elucidated results. The post-intervention analysis with grounded theory approach highlighted
that the healthcare professionals go beyond the hand hygiene and PPE. The extra initiatives
include cleaning of the vulnerable spaces in order to restrict the movement of the
microorganism and doing proper buffers ad trajectory planning. Though there was clear
statement of findings, the results are not applicable under the global context. The limitations
highlighted by the author stated that their findings are only applicable to the sites where they
conducted their research.
Findings and conclusion
The analysis of the literary articles published online in the domain of HH and HAIs
upheld the principle of National Safety and Quality Health Service Standards by the
Government of South Australia. According to safety standards, in preventing and controlling
the HAIs, it is the duty of the healthcare professionals, especially the nursing professionals to
take active efforts. For compliance of the infection prevention by HH, proper knowledge,
action control, awareness and facilitation is not comprehensive. Combination of different
determinants like self-efficacy, attitude and intention are helpful in proper compliance of HH.
Analysis of the literary article further highlighted that HH with alcohol helps to provide better
infection control for HA-MRSA. However, proper follow-up during post and pre-intervention
are also important. Apart from hand hygiene, hygienic of the surrounding environment is also
important in the prevention of HAIs. Thus all these aspects must be included under trajectory
planning.

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References
Al Kadi, A., & Salati, S. A. (2012). Hand hygiene practices among medical
students. Interdisciplinary perspectives on infectious diseases, 2012.
Brewster, L., Tarrant, C., & Dixon-Woods, M. (2016). Qualitative study of views and
experiences of performance management for healthcare-associated infections. Journal
of Hospital Infection, 94(1), 41-47.
Government of South Africa. (2018). National Safety and Quality Health Service Standards.
Access date: 3rd October. Retrieved from:
https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/
clinical+resources/safety+and+quality/
standards+and+accreditation+on+safety+and+quality/
national+safety+and+quality+health+service+standards#Standard%203%20-
%20Preventing%20and%20Controlling%20Healthcare%20Associated%20Infections
%20(PDF%202000KB)
Hor, S. Y., Hooker, C., Iedema, R., Wyer, M., Gilbert, G. L., Jorm, C., & O'sullivan, M. V.
N. (2016). Beyond hand hygiene: a qualitative study of the everyday work of
preventing cross-contamination on hospital wards. BMJ Qual Saf, bmjqs-2016.
Huis, A., van Achterberg, T., de Bruin, M., Grol, R., Schoonhoven, L., & Hulscher, M.
(2012). A systematic review of hand hygiene improvement strategies: a behavioural
approach. Implementation Science, 7(1), 92.
Lewis, S. (2015). Qualitative inquiry and research design: Choosing among five
approaches. Health promotion practice, 16(4), 473-475.

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Malterud, K., Siersma, V. D., & Guassora, A. D. (2016). Sample size in qualitative interview
studies: guided by information power. Qualitative health research, 26(13), 1753-
1760.
Monistrol, O., Calbo, E., Riera, M., Nicolás, C., Font, R., Freixas, N., & Garau, J. (2012).
Impact of a hand hygiene educational programme on hospital‐acquired infections in
medical wards. Clinical Microbiology and Infection, 18(12), 1212-1218.
Pan, S. C., Lai, T. S., Tien, K. L., Hung, I. C., Chie, W. C., Chen, Y. C., & Chang, S. C.
(2014). Medical students' perceptions of their role as covert observers of hand
hygiene. American journal of infection control, 42(3), 231-234.

Running head: NURSING
Appendix
Author/s
(year)
Country
Aims
or
Purpose
Sample/ setting
or
Key stake-holders
and their roles
Design/
methods
or
Type of paper
Main findings
or
Primary argument
Strengths and limitations
of the paper
Article
1
Huis et al.
(2012)
Australia
To analyse the
strategies which
have been found to
be effective in
maintaining the
compliance of the
hand hygiene
among the nursing
professionals
towards the
prevention of the
Systematic review
of experimental and
the quasi-
experimental
research on hand
hygiene (HH)
which were
published on
Medline, Embase,
CINHAL and
Crochrane
Systematic
review of the
research articles
The main findings of the study
highlighted that addressing only
the important determinants of
the observance of the HH like
knowledge, action control,
awareness and facilitation is not
comprehensive to change the
HH compliance behaviour
among the nursing
professionals. Addressing the
combination of different
The main limitations of the
study is, authors failed to
review adequate resources
during the tenure of 9 years
and this might lead to the
generation of biased
response. However, the
result of the review is
combined and was
reasonable and this helped to
provide a collated overview

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HAIs databases from
January 2000 to
November 2009.
Total studies
reviewed: 41
determinants is found to
provide better results. Thus, the
review highlighted that
application of the alternative
improvement strategies like
social influence, self-efficacy,
attitude and intention will help
to increase the compliance of
the nursing professionals in
observance of hand hygiene.
and thus can be regarded as
strength of the study
Article
2
Monistrol et
al. (2012)
Spain
The aim of the
study was to
evaluate the impact
of multimodal
intervention in the
hospital wards on
A prospective
before-after
interventional study
was undertaken in a
hospital in Spain
with 500 beds in
A prospective
before-after
interventional
study with
quantitative
approach
The analysis of the results
highlighted that proper
observance of the multimodal
interventions like compliance of
the HH through AHR helped to
decrease the spread to HA-
The limitation of the study is
follow-up evaluation after
one year. According to
Lewis (2015) the follow-up
studies cause decrease in the
overall sample size during

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the compliance of
HH, alcohol-based
hand rub (AHR)
and its association
with the rate of
occurrence of HAIs
and hospital-
acquired
methicillin-resistant
Staphylococcus
aureus (HA-
MRSA).
tertiary care
settings. The
authors mainly used
four phase study
with base phase,
intervention period
and post
intervention periods
and follow-up
phase for
evaluation.
mainly
employed
before-after
intervention
study approach
and post 1-year
assessment was
conducted in
three medicines
wards. The
authors used
WHO HH
observation
method for
monitoring HH
compliance and
MRSA. However, Monistrol et
al. (2012) highlighted that it is
the duty of the healthcare
professionals to maintain a
proper follow-up during pre and
post interventions periods.
the course of the year and
this decrease in the sample
size might lead to biased
outcome. One of the strength
of the study is, the
compliance of HH was
measured via the use of
direct observation during the
daily work-routine. In order
to reduce the inter-observer
error, the observers were
standardized against each
other through 10% of
monitoring sessions. The
recording to the observation
was done based on the WHO

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the infection. 5 step framework of the HH.
This help in uniform
tabulation of data. The study
followed all the ethical
regulations.
Article
3
Hor et al.
(2016)
Australia
The aim of the
study was to
elucidate a better
understanding
about the infection
prevention and
control (IPC) under
routine clinical
practice. The
authors mainly
highlighted over the
They conducted 46
semi-structured
interviews, 24
weeks long field-
work (observation
and videoing) and
22 reflexive
sessions. 177-
participants from
different health care
profession like
Qualitative
research
method based
on grounded
theory
The healthcare professionals go
beyond the hand hygiene and
PPE. The extra initiatives
include cleaning of the
vulnerable spaces in order to
restrict the movement of the
microorganism and doing
proper buffers ad trajectory
planning.
The large sample size is the
main strength of the study.
Though there was clear
statement of findings, the
results are not applicable
under the global context and
this is the main limitation of
the study.

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prevention of the
cross-
contamination
under the
application of
effective HH and
personal protective
equipment (PPE).
nursing, clerical,
cleaning staffs and
the medical
professionals were
included in the case
study.

Running head: NURSING