ABSTRACT
Objective
Nurses are in frequent hand contact with patients in intensive care units. With effective hand hygiene, health care-associated infections can be prevented and death rates from infections can be reduced. This research was conducted to determine the hand hygiene belief status and hand hygiene practice levels of intensive care nurses.
Methods
The research is of descriptive type. In this study, the snowball sampling method was adopted, and the research sample consisted of 228 intensive care nurses in Türkiye. Data were collected with the “Nurse Descriptive Information Form”, “Hand Hygiene Belief Scale (HHBS)” and “Hand Hygiene Practice Inventory (HHPI)”.
Results
As a result of the study, it was determined that the hand hygiene beliefs and hand hygiene practices of the intensive care nurses were high, and there was a moderate positive correlation between HHBS and HHPI.
Conclusion
It is recommended to make plans to improve hand hygiene culture in institutions in order to increase nurses’ hand hygiene beliefs and to develop appropriate hand hygiene behavior.
INTRODUCTION
Infections that are not in the incubation period when patients apply to the institution and develop during the provision of health care services in health institutions are called health care associated infections (HAI) (1). HAI causes an increase in the mortality and morbidity of patients and a prolongation of their hospital stay. In order to protect against HAI, both standard precautions and isolation precautions for infection should be followed within the framework of standard precautions. Hand hygiene practices are the first among the standard precautions taken to protect against contagious and infectious diseases (2). Health care workers can try two ways to ensure hand hygiene (3). The first of these is to wash hands with soap and water, and the second is to rub hands using alcohol-based hand sanitizers (4). The basic criterion for the application of both correct methods to ensure effective hand hygiene is to comply with the 5 indication rules determined by the World Health Organization (WHO) (5). Accordingly, hand hygiene should be provided “1. Before contact with the patient, 2. Before aseptic procedures, 3. After contact with body fluids, 4. After contact with the patient, and 5. After contact with the patient’s environment”. According to the WHO, a systematic organization should be established in the provision of health services to improve hand hygiene behavior in health workers (6). This system should be organized with the contributions of institution managers, infection control committees, relevant unit authorities, patients and their relatives. In our country, hand hygiene practices have been standardized in the Health Quality Standards Implementation Guide (7). These standards aim to establish similar hand hygiene policies in all health institutions. In terms of scope, regular training for employees, planning to encourage hand hygiene, supplying the necessary materials to ensure hand hygiene, and evaluating employees’ hand hygiene compliance with informed observations have been accepted as quality criteria. However, nurses’ beliefs about hand hygiene directly affect compliance. Intensive care units are the heart of critical patient care. Intensive care patients are vulnerable to HAI due to impaired consciousness, immunosuppression and multiple diseases (8). HAI cause patients’ quality of life to decrease, prolonged hospitalization and increased mortality. The simplest method to prevent this is to provide hand hygiene. Inadequate hand hygiene compliance threatens patient and staff safety. Intensive care nurses are health care workers who come into contact with patients the most. Effective hand hygiene practices of nurses depend on the accessibility of hygiene areas, the absence of missing materials, their belief in the practice and their personal values. Therefore, their belief in hand hygiene practices is an important component in providing effective hand hygiene (9). In this context, this study was conducted to evaluate the beliefs of nurses working in intensive care units about hand hygiene and their compliance with hand hygiene practices.
MATERIAL AND METHOD
Study Design and Sample
Type, Population and Sample of the Research
The population of this cross-sectional is composed of intensive care nurses in Türkiye. Snowball sampling method, which is one of the non-probabilistic sampling methods, was used as the sampling method. Since the net number of critical care nurses in Türkiye could not be reached, the research was carried out using the snowball sampling method. In this method, after determining the reference persons, it was tried to reach other relevant persons through these persons. The research was completed with 228 critical care nurses who agreed to participate in the research. It was thought that there would be less difficulty in reaching nurses.
Data Collection
Research data were collected through an online survey conducted with the voluntary participation of intensive care nurses working in Türkiye between October and November 2022. “Nurse Descriptive Information Form”, “Hand Hygiene Belief Scale (HHBS)” and “Hand Hygiene Practice Inventory (HHPI)” were used as data collection tools. The research was completed with a total of 228 intensive care nurses who volunteered to participate in the research.
Statistical Analysis
The data were evaluated using SPSS 26.0. Skewness and kurtosis values, Kruskal-Wallis test, Mann-Whitney U test, and Pearson correlation test were used in the analysis.
Ethical Considerations
Approval was obtained from the Human Research Ethics Committee of T.C Zonguldak Bület Ecevit University (approval number: 205760, dated: 29.08.2022). Before starting the survey, an information screen emphasizing the purpose of the research and an informed consent form were presented to all participants. After obtaining consent from the intensive care nurses who volunteered to participate in the study, the nurses were directed to the questionnaire items.
Data Collection Tools and Study Instruments
The data were collected using the “Nurse Introductory Information Form”, which includes information such as age, gender, marital status, education level, and length of work in the profession, and HHBS and HHPI. HHBS and HHPI were developed by Van de Mortel (10) in 2009 and their Turkish validity and reliability study was performed by Karadağ et al (11). The HHBS total score ranges from 22 to 110, and a high score is interpreted as having a positive belief about hand hygiene. The total score of the HHPI varies between 14 and 70, with a high score indicating that hand hygiene practices are always performed. In the Turkish validity and reliability study, the internal consistency reliability coefficient was determined as 0.76 for HHBS and 0.85 for HHPI (10). The test-retest reliability of the scale and inventory was determined as 0.66 and 0.60. In this study, Cronbach’s alpha value was found to be 0.70 for HHBS and 0.73 for HHPI.
RESULTS
The mean age of the nurses participating in the study was 31.39±8.08 years, and most of them were women (82%), married (56.6%) and undergraduate (50%). It was determined that 39% of the intensive care nurses participating in the study had five years or less professional experience and 41.2% of them worked in the mixed intensive care unit. 37.7% of the intensive care nurses had 3 years or less intensive care experience. Most of the participants (60.1%) worked in shifts, giving care to 1-3 patients (52.6%) per shift. In addition, 96.9% of them had received training on hand hygiene and practices in their institutions (Table 1).
The HHBS mean scores of the intensive care nurses participating in the study were 89.79±8.36, and the HHPI score averages were 66.71±4.45 (Table 2).
There was no significant difference between the HHBS mean scores of the intensive care nurses and socio-demographic data, gender, marital status, educational status, working type, unit of work, number of patients given daily care, and hand hygiene training. However, there was a significant difference between the nurses’ HHBS and the duration of working in the profession (p=0.004) and working in the intensive care unit (p=0.003). There was no significant difference between the HHPI score averages of the intensive care nurses and their socio-demographic and occupational characteristics (p>0.05) (Table 3).
When the relationship between HHBS mean scores and HHPI mean scores was evaluated, a moderately positive significant (r=0.398, p=0.000) relationship was found between the two scales (Table 4).
DISCUSSION
Patients who are provided with health services in intensive care units are followed up more frequently than outpatients or inpatients due to the presence of comorbid diseases in addition to their diagnosis and are exposed to more invasive interventions (12). In this context, hand contact with intensive care patients increases 5-10 times more than other patients in health care institutions (13). When the literature is examined, it is seen that there are many studies on the evaluation of hand hygiene knowledge levels and practices of nurses, student nurses and health workers (14-16). Although there are studies evaluating hand hygiene compliance for health care workers in intensive care units (17), no study has been found that examines hand hygiene beliefs and hand hygiene practices of intensive care nurses together. For this reason, it is thought that this study will contribute to the literature.
Considering the studies evaluating hand hygiene compliance in intensive care units, it is reported that the hand hygiene compliance of health care workers is high (18, 19). As a result of this research, hand hygiene belief and practice levels of nurses working in intensive care units were found to be high. When the studies evaluating hand hygiene compliance according to the intensive care units worked in were examined, it was found that the hand hygiene compliance rates of the health care workers, especially in the pediatric and neonatal intensive care units, were higher than those of the other intensive care unit workers (20, 21). Although there was no statistically significant difference in the current study, the high mean scores of HHBS and HHPI in neonatal intensive care and pediatric intensive care units are in line with the results of previous studies.
It is very important to inform health care professionals about correct hand hygiene practices in increasing compliance with hand hygiene (22). In a study conducted in seven intensive care units in Europe, it was reported that individual and team compliance increased in the prevention of health care relationships through education and observation (23). In five intensive care units in China, the initial period of 3 (three) months and a follow-up period were planned, and it was determined that the compliance rate increased within 2 (two) periods with administrative support, material accessibility, education and training, reminders, process monitoring and feedback. Hand hygiene strategies were emphasized (24). Again, in a systematic review examining hand hygiene compliance in intensive care units, it was reported that education, effectiveness, environmental regulation, and hand hygiene belief had an effect on increasing hand hygiene compliance (22). In addition, it has been reported that practices such as planning reminder techniques for hand hygiene and continuing trainings increase the awareness of employees about hand hygiene practices (25). In our country, hand hygiene trainings are compulsory in the centers where health services are provided within the scope of quality standards in health, and it is seen that most of the participants in the research receive training on hand hygiene practices and its importance (7).
It can be thought that creating a positive organizational culture in institutions and providing appropriate working conditions will contribute to increasing compliance and belief in hand hygiene. The presence of hand hygiene reminders in the working environment of the employees (sink, soap dispenser, hand antiseptics, etc.), workload, working conditions such as the department / unit they work in, as well as their individual characteristics such as cognitive perceptions, beliefs, health professional competencies have an important place in increasing hand hygiene compliance (26, 27). When the results of the research were examined, it was found that the levels of belief and practice in hand hygiene were found to be significantly higher in nurses with more professional working years and in nurses with professional qualifications who worked in the intensive care unit for more than 7 (seven) years. It is a thought-provoking finding that the average score of nurses who have only 10 years or more intensive care experience is lower than those who work for 7-9 years.
In a study Karahan et al. (28) conducted, it was determined that there is a weak relationship between the hand hygiene beliefs of health care professionals and their hand hygiene practices. As a result of this research, it was determined that there was a moderate positive relationship between two similar scales. Although this finding is an important finding in terms of strengthening hand hygiene practices, which is the most effective method in the prevention of HAI it does not embody the behaviors of nurses. Price et al. (29) argues that the level of evidence for practices / statements other than observing hand hygiene practices is low. Similarly, in a study conducted in a mixed intensive care unit, HAI rates were found to be high, although the hand hygiene compliance of health care workers was high (30).
Studies on nurses’ hand hygiene beliefs are very limited in the literature. However, the belief of intensive care nurses in hand hygiene practices and their complete implementation play a key role in the prevention of HAI. In this context, nurses’ perceptions of health-related attitudes and behaviors, beliefs and attitudes about hand hygiene practices, problems preventing compliance should be determined, and plans should be made to develop positive attitudes and behaviors. Planning multidisciplinary practices, including patients and employees, together with managers in health care institutions, will contribute to increasing the awareness of nurses (31).
Study Limitations
In this study, the number of intensive care nurses in Türkiye could not be reached and the sample size could not be determined. For this reason, the study was carried out with nurses who accepted to answer the questions by clicking on the survey link sent from social media applications and WhatsApp applications. Since the HHBS and the HHPI are mostly based on the statements of people, the data on hand hygiene practices could not be based on evidence. For this reason, it is thought that observing hand hygiene practices in future studies will lead to a more qualified result. In addition, it is thought that intensive care nurses with a high workload are insufficient in allocating time due to the large number of scale items.
CONCLUSION
As a result, hand hygiene belief and hand hygiene practice levels of intensive care nurses were found to be high. It was determined that there was a significant relationship between the two scales, which had a moderately positive effect on each other. As the seniority of the nurses in the profession increased, there was a significant difference in hand hygiene beliefs and practices. However, it was determined that the belief and compliance with hand hygiene practices in nurses working in intensive care units for more than 10 years were lower than those of nurses working between 7 and 9 years. The decrease in the belief of nurses in hand hygiene practices may have been caused by working under the same workload and with intensive patient circulation for many years. In this context, a similar study by increasing the number of samples can make a meaningful contribution to the literature. Determining new targets and strategies for hand hygiene practices in order to improve the attitudes and behaviors of intensive care nurses may decrease HAI rates by increasing hand hygiene compliance. For this purpose, it is thought that practices and measures such as increasing in-house training, forming hand hygiene compliance teams, determining intensive care representatives, observing hand hygiene practices, including nurses working in the unit as observers, being a role model for managers in hand hygiene, organizing hand hygiene events and campaigns in institutions, establishing a reward system for units with high hand hygiene compliance and a good workload planning will increase compliance with hand hygiene beliefs and practices.
