Background
Healthcare-associated infections (HAIs) are a major threat to patient safety [
1] and a major cause of patient morbidity and mortality [
2]. HAIs are infections patients acquire when they are receiving care rather than those they had on admission [
3]. For the elderly, infection increases mortality, suffering, and hospital stays [
4]. Numbers from the Norwegian prevalence survey in November 2020 showed that, at any given time, 3.6% of all nursing home patients had an HAI, varying from 2.9 to 5.3% in different regions [
4]. The most effective preventive factor to avoid HAI is hand hygiene, which entails either washing them with soap and water or disinfecting them with alcohol-based hand rubs [
5].
The elderly population in Norway is increasing, and the age group of 76–79 years has increased by 47.5% over the last 10 years [
6]. With increasing age, the risk of frailty and chronic and multiple diseases rises, which influences physical function, quality of life, and psychological health. The elderly with the most complex health problems often reside in institutions [
7]. A review of the literature shows that the elderly have reduced function of their immune systems and are therefore more vulnerable to acute infections [
2,
8]. They are also more likely develop infections that need treatment with antibiotics than elderly people living at home [
9]. In Norway about 32,000 people live in long-term care nursing homes [
10], and are at risk of getting an HAI.
As outlined in a Cochrane review [
11], many HAIs can be prevented with good hand hygiene [
5]. Nevertheless, studies from nursing homes have shown that hand hygiene adherence varies widely, from 3.6% to 61% [
2,
12,
13]. These findings can be explained by differences in healthcare systems between different countries, as well as different healthcare facilities and hospital wards. Results are also influenced by the use of different measurement tools and methods, and it is therefore difficult to compare different studies [
14] due to their high heterogeneity [
15]. The only study that observed hand hygiene adherence in Norwegian nursing homes using the World Health Organization’s (WHO’s) validated tool for observation [
1], found a total adherence of 57% [
16]. WHO recommends that the use of observations with a validated observation tool as a method is considered the “gold standard” for assessing hand hygiene adherence [
17]. Thus far, few studies have used this method and emphasized hand hygiene adherence in Norwegian nursing homes.
Research on infection control has mainly focused on hospitals and specialist healthcare services [
2,
18]. The Norwegian government recently published an action plan with the main goals of reducing the rates of HAI and improving infection control in Norway [
19]. This plan includes a focus on hand hygiene, but mainly for hospitals. In nursing homes, surveillance of hand hygiene is only recommended [
19], and is justified by the municipality’s right to self-determination. However, the increased number of sick and vulnerable residents with advanced care needs shows that intensifying the focus on infection control is just as important in nursing homes as in hospitals.
In September 2021 in Norway, 814 people had died from the COVID-19 pandemic, and 81% of these were over the age of 70 [
20]. In 2020, nearly 57% of deaths occurred in nursing homes [
21]. Even though COVID-19 poses a lower threat after vaccination, the statistics show that we need better infection control in nursing homes. The coronavirus is mainly transmitted through droplets from a sick person’s nose or mouth. Droplets can land on surfaces with which people have contact; therefore, frequent, and thorough hand hygiene is one of the most important protective measures against COVID-19 [
22]. Focusing on infection control in nursing homes is crucial. Since good hand hygiene is the most effective preventive measure against infections [
11], the elderly population is increasing, and the elderly living in nursing homes have reduced immune systems and an increased risk of mortality, a focus on hand hygiene in nursing homes should be a priority.
The aim of this study is to investigate adherence to hand hygiene in nursing homes with the use of observation and a validated observation tool to assess adherence. In addition, this study aims to examine when healthcare workers perform hand hygiene and when they do not.
Results
Overall hand hygiene adherence
A total of 7316 indications were observed, and healthcare workers conducted hand hygiene according to recommendations in 4266 of the occasions, for a total adherence of 58.3%. A total of 3513 indications were observed in the February group and 3,803 in the March group. There was a significant (p < 0.001) decrease in adherence to hand hygiene between the February group (65.8%) and the March group (51.4%). In 42.2% of the situations, the healthcare workers used hand alcohol based antiseptic, and in 16.1%, they washed their hands. The median for how many indications one student observed was 61, with a range of 13 to 170 indications. In the February group, the median observed indications per student were 52, ranging from 13 to 170, and in March, it was 67, ranging from 15 to 147. From one session the median of observed indications was 30, ranging from 7 to 92. For each ward the median was 359, ranging from 106 to 809. The proportion of adherence was significantly different between the 20 wards (χ2 = 277.88, p < 0.001, phi = 0.20), with the lowest adherence of 26.4% and the highest of 83.1%. There was no significant difference between the adherence to hand hygiene between the different observation times (morning, afternoon, or evening) (χ2 = 3.40, p = 0.183, phi = 0.02).
Hand hygiene adherence by location, occupation, and indication
As seen in Table
1, there were significant (
p < 0.001) differences in location, occupation, and indication, as shown in the chi-square tests. The healthcare workers had the highest adherence in the disinfection room (81.7%) and the lowest adherence in the toilet or bathroom (46.2%). The nursing students had the highest adherence (80.5%), and the lowest was found in the unknown occupation group (31.7%). There were differences noted in whether the indication was before contact or after. For all three after-contact indications, adherence was over 65%; for the two before-contact indications, adherence was 46.7% before patient contact and 54.5% before an aseptic task.
Table 1
Descriptive table of total observed indications and hand hygiene adherence
Location |
Disinfection room | 619 | 81.7 (506) |
Shared space | 778 | 60.4 (470) |
Eating area | 1726 | 58.6 (1011) |
Patient room | 3585 | 55.7 (1998) |
Toilet or bathroom | 608 | 46.2 (281) |
Occupation |
Nursing students | 1019 | 80.5 (820) |
Occupational therapists, physical therapists, and bioengineers | 80 | 71.3 (57) |
Nurses | 2030 | 67.1 (1362) |
Medical doctors | 42 | 59.5 (25) |
Nursing assistant | 3107 | 49.5 (1539) |
Assistant and High school students | 839 | 47.7 (400) |
Unknown | 199 | 31.7 (63) |
Indication |
After body fluid exposure risk | 958 | 66.8 (640) |
After contact with patient surroundings | 1398 | 65.5 (915) |
After patient contact | 1848 | 65.3 (1206) |
Before aseptic task | 661 | 54.5 (360) |
Before patient contact | 2451 | 46.7 (1145) |
Total | 7316 | 58.3% (4266) |
There was a significant (χ2 = 409.97, p < 0.001, phi = − 0.237) association between wearing gloves and the use of hand hygiene. Of the workers who used gloves, 64.7% did not conduct hand hygiene according to the WHO recommendations. When not using gloves, only 34.7% did not use hand hygiene as recommended. Gloves were only used in less than 10% of the observations in the dining area, shared space, or disinfection room, in 28% of the observations in the patient room, and in 50% in the toilet or bathroom.
Regression analyses
Results from the bivariate linear regression analyses supported the findings from the chi-square tests. The only non-significant variables in the regression analysis were status as occupational therapist, physical therapist or bioengineer (
p = 0.45), or medical doctor (
p = 0.31; Table
2). In the multivariate model, these results changed when including the interaction terms of place and glove use. In the disinfection room, healthcare workers had a 19% higher probability of conducting hand hygiene than in other rooms. Occupation was significantly associated with hand hygiene adherence. Nursing students had the highest adherence rate, followed by nurses. The “nursing assistants” and “assistants and high school students” groups had a decreased and relatively similar result, while the group of unknown occupations had the lowest adherence.
Table 2
A linear probability model using hand hygiene as a dependent variable
Constant | – | – | – | 0.69 | 0.63–0.75 | < 0.001 |
Location |
Toilet or bathroom (ref.) | | | | | | |
Patient room | − 0.26 | − 0.30 to − 0.22 | < 0.001 | − 0.01 | − 0.07–0.04 | 0.686 |
Eating area | − 0.23 | − 0.28 to − 0.19 | < 0.001 | − 0.01 | − 0.06–0.05 | 0.806 |
Shared space | − 0.21 | − 0.27 to − 0.16 | < 0.001 | − 0.02 | − 0.0 to –0.04 | 0.456 |
Disinfection room | 0.26 | − 0.22–0.30 | < 0.001 | 0.19 | 0.13–0.25 | < 0.001 |
Occupation |
Nurses (ref.) | | | | | | |
Medical doctors | − 0.08 | − 0.22–0.07 | 0.309 | − 0.05 | − 0.19–0.09 | 0.49 |
Occupational therapists, physical therapists, and bioengineers | 0.04 | − 0.07–0.15 | 0.445 | 0.08 | − 0.02–0.18 | 0.13 |
Nursing students | 0.13 | 0.10–0.17 | < 0.001 | 0.13 | 0.09–0.16 | < 0.001 |
Nursing assistant | − 0.18 | − 0.20 to− 0,15 | < 0.001 | − 0.17 | − 0.19 to − 0.14 | < 0.001 |
Assistant and High school students | − 0.19 | − 0.23 to − 0.16 | < 0.001 | − 0.16 | − 0.19 to − 0.12 | < 0.001 |
Unknown | − 0.35 | − 0.42 to − 0.29 | < 0.001 | − 0.34 | − 0.41 to − 0.28 | < 0.001 |
Indication |
Before patient contact (ref.) | | | | | | |
Before clean procedure | 0.08 | 0.04–0.12 | < 0.001 | 0.08 | 0.04–0.12 | < 0.001 |
After contact with patient, surroundings or body fluids | 0.12 | 0.17–0.21 | < 0.001 | 0.12 | 0.01–0.14 | < 0.001 |
Time-period |
February (ref.) | | | | | | |
March | − 0.14 | − 0.17 to − 0.12 | < 0.001 | − 0.12 | − 0.14 to − 0.10 | < 0.001 |
Use of gloves |
Not wearing gloves (ref.) | | | | | | |
Wearing gloves | − 0.29 | − 0.31 to − 0.26 | < 0.001 | − 0.31 | − 0.38 to − 0.24 | < 0.001 |
Interaction term: Gloves*Patient room | – | – | – | 0.11 | 0.03–0.19 | 0.008 |
In the first bivariate analyses, there was no significant difference between the three different after-indications, so they were combined into one variable. The indication “before contact with patients” had significantly lower adherence to hand hygiene then “before cleaning procedures” and “after contact with patients, patient surroundings, or contact with body fluids.” The time period (February or March) and the use of gloves were also negative and significant. The probability of correct hand hygiene adherence was reduced by 30.8% with the use of gloves. However, in the patient room, there was an 11% increase in adherence to glove use compared to the toilet and bathroom. The interaction terms for the other locations were not significant. The variables that influenced adherence the most were use of gloves, occupation as a nursing assistant, and whether the observations were conducted in February or March (Standardized β: − 0.25, − 0.17, − 0.12).
Discussion
To our knowledge, this is the first study to investigate hand hygiene adherence in 20 nursing home wards in Norway.
The overall adherence found in the present study (58.3%) was similar to two other studies. One Norwegian study of nursing homes revealed a 57.2% adherence rate [
16], and one French study of different settings for the elderly found an overall adherence rate of 61.5% [
12]. It is surprising that the observations conducted during an ongoing pandemic, with an increased focus on infection control and hand hygiene, are similar to observations conducted in 2009 and 2018. All healthcare workers had the opportunity to watch an educational video of how and when to conduct proper hand hygiene, and they knew that they were being observed. Other studies have shown increased hand hygiene adherence when participants know they are being watched, as described by the Hawthorne effect [
24].
An adherence of 58% may not be sufficient to prevent all HAIs in nursing homes, so the question is: What is high enough adherence? WHO has suggested that role models in hand hygiene need to have at least 80% adherence [
26], but there is little evidence to support this recommendation [
15]. Having a too-low acceptable adherence level can cause false safety, but a too-high level can be an unrealistic goal for many and decrease motivation for change. Further research is needed on what an acceptable level of hand hygiene adherence is.
A surprising finding in this study is that the results from the two groups of students showed a significant decrease in hand hygiene adherence, from 65.8% in February to 51.4% in March. There are no other differences between the two groups regarding occupation, glove use, indications, and locations of observations conducted that are of clinal relevance, and these findings are therefore difficult to explain. One explanation may be the COVID-19 pandemic. There was an increasing number of persons infected with COVID-19 in January [
20], and there was a pronounced focus on vaccination in nursing homes during January and February [
27]. The focus on this disease increases the focus on proper hand hygiene, and may serve as an explanation for the February group’s higher adherence. In March, most residents were vaccinated [
28], and the possible pressure to hinder an infection outbreak of COVID-19 may have been lower.
Another possible explanation relates to the different ways in which the two student groups were recruited. The March students may have had higher motivation and knowledge about hand hygiene because they volunteered to participate, whereas the February students were asked to join. The March students may, therefore, have more easily captured the moments where hand hygiene was not conducted according to recommendations.
Another finding that may indicate a greater motivation to conduct observations among the March students is that the March students gathered significantly more (67 indications per student) observations than the February students (52 indications per student). One final explanation may be that hand hygiene adherence is difficult to keep up with over time [
29], and increased focus on hand hygiene in January increased adherence in February before it decreased in March.
Hand hygiene adherence has been found to vary significantly between studies, countries, and health facilities [
1,
15]. However, evidence also indicates that hand hygiene compliance varies within the same type of healthcare facility and the same region [
12]. It is therefore important to assess the representativeness of the included nursing home wards. Conducting observations in 20 nursing home wards, as in this study, should give a representative picture of the nursing homes in that area. Most nursing homes have the same owner, are run in the same way, and all have a quality manager, so it is surprising that hand hygiene adherence varied to the extent found in this study, from 26.4% to 83.1%. These findings indicate that the quality of care can vary greatly between nursing home wards. Occupation may explain some of this variety. In the ward with the lowest adherence, nursing assistants were mostly observed, and in the ward with the highest adherence, nursing students, who were found to have the highest adherence, were mostly observed.
This study found that hand hygiene adherence is largely dependent on the staff’s occupation, and these findings are supported in the literature from nursing homes. One study observing nursing assistants found very low hand hygiene adherence [
13], while three other studies comparing nursing assistants with nurses found that nurses had higher adherence than nursing assistants [
2,
14,
16,
30]. These findings are supported in this study. Additionally, nurses often have higher adherence than medical doctors [
14‐
16]. This was not significant in the linear regression, but was noted in the chi-square analyses. One reason for this methodological difference may be the small number of observations of medical doctors and occupational therapists, physical therapists, and bioengineers, especially when divided by the other independent variables.
Of our significant results, lower education also resulted in a decrease in adherence. This may indicate that there is an association between the length of education of the staff’s occupation and hand hygiene adherence. Low education may indicate that those with such status are not learning enough about hand hygiene at school or do not have the skills to practice them. To ensure good hand hygiene adherence, a good knowledge base for healthcare workers must be ensured, with a special focus on employees with occupations that have a shorter period of education.
Of the occupations with permanent positions, nurses were found to have the highest adherence. Even so, they were underrepresented as employees in this study. For each nurse position, there were almost three assistants or nursing assistants. An increase in nurse positions may positively influence hand hygiene adherence in nursing homes. On the other hand, it was the nursing students who had the overall highest adherence, which has also been found in another Norwegian study [
16]. In a systematic review, nursing students reported greater knowledge and adherence than nurses [
31]. Two possible explanations for these findings are the new intensified education in infection control during their education, and the recency of their education. The fact that nursing students have greater adherence than nurses may indicate that infection control is forgotten if the topic is not revisited. This is supported by the literature, which emphasizes the difficulty of creating long-lasting effects of interventions to improve hand hygiene [
5,
32,
33]. Staff in nursing homes have often different education and training, and their skills and understanding about the importance of hand hygiene and infection prevention varied greatly [
16]. Therefore, reminders of the importance of hand hygiene adherence must be an ongoing activity to all the nursing homes` employees.
One study found an association between location and hand hygiene adherence [
16], but they did not conduct a regression analysis. They found that location was only significant for the toilet and bathroom and disinfection room when controlling for the interaction terms of glove use and location. Patient room, dining area, and shared space lost their significance. These results indicate that it is more likely the use of gloves, and not location, affects the probability of hand hygiene adherence.
We found that the probability of using hand hygiene correctly dropped by 30.8% on average when using gloves, and that hand hygiene was not performed in 64.7% of instances. The literature supports the idea that glove use reduces hand hygiene adherence [
34‐
36]. Studies have revealed the misuse of gloves by healthcare workers, in that they wear gloves when they are not recommended, the gloves are not changed as often as they should be [
35,
36], two pairs of gloves are worn, or gloves are sanitized [
16]. These findings may indicate a lack of knowledge among healthcare workers. To improve hand hygiene adherence, healthcare workers need to increase their knowledge, especially regarding proper glove use.
Previous literature suggests that healthcare workers often use gloves to protect themselves [
35] and conduct hand hygiene after contact with patients more often than before [
2,
14‐
16,
37]. The same pattern was found in this study. There was a gap between the “before” and “after” indications, where the three “after” indications had at least 65% hand hygiene adherence, while before patient contact had almost 20% lower (46.7%), and before aseptic tasks had 10% (54.5%) lower adherence. Several studies support these findings, with before-patient contact showing 18.4% to 26.0% lower adherence to hand hygiene than after-patient contact [
14,
15,
34]. It seems that healthcare workers perform hand hygiene to protect themselves and not the patients in nursing homes, and that this can be a contributing factor to why nursing home residents get HAIs. These findings indicate that healthcare workers need to improve their knowledge to increase hand hygiene adherence in nursing homes.
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