In this research essay the essayist will discuss the principles of evidence- based nursing research and its importance in healthcare. Therefore a brief introduction in infection and infection prevention and control will also be made followed by the main focus of this research essay which will be hand hygiene by making use of five research terms, which are qualitative, quantitative, ethical consolidation, data collection and sample. In addition to this, the issue of the most common Healthcare – Associated Infections (HAIs) acquired in hospitals will also be explored and by referring to relevant research the essayist will investigate why then HAI still a major problem in the UK healthcare settings, as a number of studies and reports suggests that adequate hand hygiene practice is the key to reduce infection across the field of care (British Medical Journal, 2005; Lancet, 2007).
The method used to collect the primary source of information was gathered through the use of the University library digital search, Cinahl Plus (a comprehensive source of evidence-based full-text for nursing & allied health journals, which provide concise overviews of diseases and conditions and outline the most effective treatment options based on peer-reviewed medical research. Cinahl plus is available via EBSCO host), medical journal articles, books, publications and Department of Health (DH) database, and clinical guidelines if they indicate hand hygiene as a key to control and prevent HAI. A number of keywords were used, including quantitative, qualitative and research within the title ‘infection control’, ‘hand hygiene’ and ‘HAI’ so only records containing all the keywords were saved.
The resulting list of articles was then reduced to English language, adult population, and systematic reviews published between 2000 to present. Of the 26 randomized controlled trials (RCT), twelve were discarded, as some were not relevant and some were unavailable. Furthermore the remaining ten literature review was divided into subtopics: hand washing technique and decontamination, alcohol-based hand rub, MRSA, and patient infection prevention information. Evidence- based nursing practice is the term used to describe the process the nurses use to make clinical decisions and answer clinical questions based on scientifically proved evidence rather than on assumption, intuition or tradition (Bishop and Freshwater, 2003)
In order for nurses to make the correct decision, they have to be based in four approaches which include; reviewing the best available evidence from peer-reviewed researches; using their clinical expertise; determining the values and cultural needs of the individual, and determining the preferences of the individual, family and community. Therefore such could only be achieved if the nurse’s know how to access the latest research and correctly interpret and apply the findings to their clinical practice (STTI, 2005). Fact that is also supported by the Nursing & Midwifery Council (NMC), 2008, which states ‘nurses must deliver care based on the best available evidence or best practice’.
The fear of infection has been and will always be present in the human minds, rightly so as infections are the most common causes of death worldwide. From time to time we hear of methicillin- resistant Staphylococcus aureus (MRSA), C- Difficile, Norovirus, and any other organisms causing infection and threatening the health of the population (Ryan et al. 2001). Although in the developed countries the cardiovascular diseases and cancer are now the major causes, it is always an infection that tips morbidity into mortality (Meers, McPerson & Sedgwick, 2007). Infection prevention and control policies are a contentious issue in the healthcare settings. According to NICE (2012) new clinical guideline, everyone in involved in providing care must comply with the standard principles and regulations in infection control. Standard precautions should be applied at all times by the healthcare workers when caring for patients.
Such can be accomplished by practising simple skills including; good hygiene in clinical environment, appropriate decontamination of hands and equipment, correct use of personal protective equipment, correct use and disposal of sharps, aseptic technique and waste disposal (DH, 2007, Pratt et al. 2007). The purpose of this is to reduce the risk of infectious diseases to staff, patients and others where care is delivered. Additionally, is the healthcare professional duty and responsibility to provide and deliver safe care to patients (NMC, 2008). According to World Health Organization (WHO) 2005, there are around 5000 death in healthcare setting due to HAI though the actual number of infections developed in the community is unknown (NHS QIS, 2005).
Moreover, with many HAIs manifesting post-hospital discharge (National Audit Office (NAO), 2000), the prevalence of HAI in the UK is likely to be greater than that reported in current official statistics, although 15-30% of these can be prevented with good infection control practices such as adequate hand hygiene practice (Damani 2003). Wilson (2006) states that hand washing are a simple procedure and the rates of procedure should be high. However the evidence points to the contrary as it written in the Centers for Disease Control and Prevention (CDC) report, suggesting that healthcare professional’s compliance to hand hygiene standards averages at 40% (CDC, 2002). Furthermore, Rumbau et al (2001) suggests that poor hand hygiene practice is the major area in contention in healthcare settings and healthcare professionals fail to comply with appropriate hand hygiene technique due to workload, understaff, and skin conditions, i.e. dermatitis (WHO,2009).
Subsequently, the heavy workload may have a negative impact on compliance (O’Boyle et al, 2001, Pittet et al 1999), resulting in infecting patients with avoidable HAIs such as staphylococcus aureus bacteraemia (MRSA) and Clostridium difficile infection (C-difficile), among others types of infection (DH, 2003). Eventually, the distress and suffering it causes to the patient who acquires the above mentioned infection whilst in hospital, leads to loss of confidence and credibility and reputation of healthcare professionals and the NHS Trusts. As a result, it brings an increase to the costs of the already under funded hospitals from increased stays, increased medical expenses and damage to the patients and their relatives who may decide taking lawsuit demands (WHO report, 2006). NAO (2000) states that the cost of HAIs is approximately £ 1 billion per year, also around 9% of patients in hospitals in England at one time have an HAI.
The Journal of Hospital Infection (JHI), (2008) own researchers A. Mears et al, carried out a quantitative and qualitative research study following the death of 180 patients infected with stomach infection in one of the worst outbreaks ever seen in the NHS Trust. The outbreak was blamed on poor measures, to manage, control and prevent infection, despite the Trust having high rates of HAI over several years (JHI, 2009). The study was aimed to investigate the potential factors linked to HAIs rates in acute NHS hospitals and which interventions may be effective to tackle this issue.
The mixed methodological research terms used in the research was purposely chosen as it has been proved that integrate both research terms (qualitative and quantitative) in a study are essential to answer different sort of questions, collect different types of data and produce different type of answer (Burnang and Hannigan, 2000, Bourgeois, 2002). In addition, multiple data sources are useful in researches or studies as they are part of within method triangulation to make the study more trustworthy and credible, also to enhance its depth by meeting different needs at different stages of a project, as well as compensates for shortcomings in any one method (Bourgeois, 2002; Kelly and Long, 2005), as it has been proved by the findings.
Qualitative method is an organized, descriptive, systematic, and intensive process to collect data by using computer software programs i.e.ATLAS.ti, to efficiently examine, analyse, and organise data, also to synthesize large volumes of data (Rebar et al, 2011). This method focuses on individual perceptions and how these are described, as well as recognise that the way people behave is determined by many factors including; what is expected of them, how they interpret the behaviour of other people, and how they feel about what is happening (Rebar, Gersch, Macnee & McCabe, 2011). It is essential that the research is carried out with an open mind, as preconceptions could distort the interpretation of what is going on (Rapport, 2008). .
The method used for data collection in the study was semi-structure interview and a self- completion questionnaire with textual analysis of response to open questions, sent to 900 NHS Trust nurses. Interviews and questionnaires are the most common methods used for data collection. A questionnaire is an instrument used to collect specific written data in order to specifically target objective factors or interest (Rebar et al, 2011). Whereas interviews are better for collecting sensitive personal information as the interviewer can establish a rapport with the subject (Crombie and Davies, 2002). Out of 900 nurses interviewed 700 acknowledged that inadequate hand washing by healthcare staff was the major cause of HAI. When questioned why healthcare professionals fail to comply with appropriate hand hygiene technique, more than 70% answered that lack of time, workload and high activity levels was the reason, and 66% answered low staff level and insufficient and inconveniently located sinks makes it difficult to comply.
These findings are supported by evidence from infection control literature. However, it is clearly specified in the literature that the consequences of high activity levels experience among healthcare workers can have a negative impact on compliance (DH 2003, McCall & Tankersley, 2007). Besides The self- completion questionnaires were returned with 100% response rate. The results demonstrated that more than 95% of nurses assume that the inclusion of infection prevention and control in the staff (including medical students) training programmes may address the causes of the outbreak, therefore help to promote good infection prevention and control in the NHS Trusts hospital.
Wilson (2006) argues in his literature that effective interventions in the management of HAIs, would involve a behaviour change on its own, feedback on behaviour, ownership of the problem and personal growth from healthcare staff. As such training alone would not be enough. The research terms and choice of methods used by the researcher were appropriate as it provided the reader with a detailed understanding of the issues discussed in the study also can be used as a basis for future work.
The Health Protection Agency (2006) reports that MRSA tops the list of HAI acquired in the NHS hospitals by 40% and in average 4000 patients develop this condition every year. The situation is so serious that the credibility and subsistence of NHS as an institution may be in jeopardy (Cooper et al, 2004, Marshall et al, 2004& Voss, 2004). In the UK the levels of MRSA in hospital has staggering arisen from 2% in 1990 to 42% in 2000, generating a major public health problem and a source of public and political concern (Hawker, et al., 2005).
Such rise has been attributed to the appearance of new strains with epidemic potential, hospital patients who are vulnerable to infections and failure to sustain good hospital hygiene, including hand hygiene. Several studies of health professionals in hospitals fault the spread of antibiotic resistant infections to poor hand hygiene and decontamination among healthcare professionals (Sharek et al.2002, Ariello et al 2004). In the document ‘Wining Ways’ released by the DH (2003), it is clearly stated that hand hygiene is essential to reducing the exposure of patients to HAIs, therefore the responsibility remains with staff to demonstrate high levels of compliance in hand disinfection protocols. However, improving compliance with hand hygiene remains a pressing patient safety concern (Lautenbach, 2001).
The WHO (2009), developed a strategy known as “Five Moments for Hand Hygiene” to improve hand hygiene compliance among healthcare workers and to add value to any hand hygiene improvement strategy, also to educate healthcare workers about the benefits of effective hand washing correlated with the correct techniques and timing of hand hygiene. The strategy indicates that cleaning hands at the right time and in the correct way should be an indispensable element of care, and form an integral part of the culture of all health service, and any failure to address this issue in a satisfactory manner could be seen as a breach of the Code of Professional Conduct. As a result it may put in question the healthcare professional fitness to practice and endanger his/ hers registration (CDC, 2002; NMC, 2006).
The CDC first released formal written guidelines on handwashing in hospitals in 1975, aiming to reducing the risk of infection in hospitals, though it is believed that the idea has been around long before that (JHI, 2006). The NICE (2004) and HPA(2004) guidelines proposes that effective hand washing techniques should involve preparation, washing, rinsing, drying and the sequence should take roughly 40 to 60 seconds. The preparation, involves wetting the hands under tepid water (hot water should be avoided as it increases skin irritation) before applying liquid soap to all surfaces of the hand. Then the hands must be rubbed together, paying particular attention to the tips of the fingers, the thumbs and areas between the fingers for at least 15 seconds.
Finally, the hands should be rinsed thoroughly and the taps turned off by using the elbows to avoid recontamination. The hands should be pat dry with good quality paper towels which are therefore disposed of in a foot-operated bin (NICE, 2003). The above mentioned technique should be performed immediately, before direct patient contact or care (including aseptic procedures), after direct patient contact or care, after exposure to body fluid, after any contact with patient’s surrounding i.e. bed making, after touching wound dressings, handling medication, etc. Hand rubs or alcohol gel is part of the modern hand wash procedure. They are frequently used in between hand washing, as an alternative agent to water and soap or when hands are physically clean (i.e. not contaminated with organic matter or soil), (Endacott, Jevon and Cooper, 2009).
Alcohol gel/ rub should be applied in sufficient quantity to cover hands and wrists, as any surface that is not covered may leave contamination on the hands. The hands should be rubbed together briskly for approximately 10-15 seconds, until the hands feel dry. Hands should be washed with water and soap after every five applications of alcohol hand gel. Many campaigns’ and studies in hand hygiene clearly state the responsibility of healthcare professionals in the fight of infection prevention in hospitals, however sparse studies mention the involvement of patients in the combat of same. A study revealed that 70% of patients did not receive any information in hand hygiene or other information regarding infection control and prevention when admitted to hospital (British Journal of Nursing, 2007).
Several literature highlight the fact that infection may be caused by the patient’s own microbial flora or acquired from other infected patient via the contaminated hands of those delivering care (A. Mears et al, 2008). A government document originally initiated in the NHS Plan (DH, 2002) to encourage the empowerment of patients through patient information, are correlated with the clinical governance strategy of engaging patients in partnership to improve care. This new concept will empower patients by allowing them to be involved in the management of their care (Duncason and Pearson, 2005), also in decision making powers between the patient and the healthcare professional (Henderson, 2003). Moreover, this newly acquired power by the patients will also empower them to be involved in monitoring and reporting on standard of cleanliness in hospital wards (DH, 2004).
Additionally, Christopher Paul Duncan and Carol Dealey (2006) did a qualitative piece of research with the purpose to explore patient opinions about asking healthcare workers to wash their hands before a clinical procedure and assess if patients knowledge and awareness about infection risks they are exposed while in hospital would influence the patients’ anxiety about asking. The method used in the study to collect data was a semi-structure questionnaire designed to be used in a descriptive survey. Data collection involves the gathering of information for qualitative and quantitative research through a variety of data sources, for instance, questionnaires, observations, interviews, conversations telephone interviews, books, past researches or studies, books and documents including, public and private documents i.e. official reports or historical documents to specifically target objective factors or interest (Mason, 2002; Rebar et al, 2011).
There are two ways of collecting data: primary or/ and secondary sources. Primary sources are collected directly by the researchers themselves, whereas secondary sources are gathered through researches or studies published by others researchers. In this particularly study the initial semi-structured questions allows the researcher to gain an insight of the participant’s feelings about asking healthcare workers to wash their hands. Asking patients to ask staff to wash their hands might be challenging as there are ethical issues attached to it. Ethical issues are mainly concerned with a balance between protecting the right of participant’s privacy, safety, confidentiality and protection from deceit, whilst at same time pursuing scientific endeavour (I. Holloway, 2008). As it is outlined in the Nuremberg Code, some basic principles are to be reviewed for ethical appropriateness (Burnard, 2006). These principles include autonomy, beneficence and non-maleficence. Autonomy refers to recognition that participants have the right to decide on a course of action or follow it.
Meaning, the participant must have reasonable awareness of the nature of the research and its possible consequences, based on that they whether give or withhold consent. The patients must feel free from coercion. In the context of research, the researcher must maximise the benefit of the patients whilst minimizing harm (Gillon, 2003), in the sense of , it may cause distress to the patients to ask staff to wash their hands as this may affect the care they get, reason why the chance of benefit should always outweigh the chance of harm (beneficence). Gillon (2003) defines non- maleficence as the avoidance of doing harm or the risk of doing harm. However in the Nuremberg Code, is outlined that a minor harm may sometimes offset a greater good, i.e. patients ask staff to wash their hands might affect the relationship with staff, but staff will be aware that patients have a voice in their care and therefore wash hands prior to start caring for them, then benefit all others patients.
Researchers are required to ensure that all participants have an equal chance of be included from a study or benefit from it results. It is unfair and unjust to excluded participants from the study because their race, colour, gender, age or so on (National Research Ethics Service (NRES), 2006). The questionnaire was dispersed to a randomized convenience sample of 224 inpatients to all department of an acute NHS Trust hospital. Sample in qualitative research seek to identify participants who have experience with the phenomenon of the interest to the researcher and who will bring as much depth, detail and complexity to the study (Rebar et al, 2011).
In this study the researchers chose to use a convenience sampling. Conveniences sampling the participants are readily available; though members of the sample may not be best respondents in the illumination of the research question (Newell and Burnard, 2011). The returned sample was 185 since some patients were too sick to answer and further 34 patients refused to participate. The study showed that 73 (71.6%) patients felt less anxious to ask staff to wash their hands before a clinical procedure if they were using a badge saying ‘It’s OK to ask’. Patients well-informed about infection risks to themselves while in hospital were more anxious to ask, although an explanation could not be found. Out of 184 patients involved in the study only 25 (25.2%) were given information about hand hygiene and infection prevention when admitted in hospital, as opposed to 74 (74.7%) of patients who were given no information.
The findings go against the DH (2003), plan to involve patients in their care management, also inform the patients about health issues they may face while in hospital (NPSA, 2004; Duncanson and Person, 2005). Whilst the kind of sampling and data collection strategies used by the researchers were detailed and descriptions of personal accounts were given, a purposive sampling would have been more appropriated as participants would have been intentionally selected as they would have more characteristics related to the purpose of the research, hence would have more relevant things to say (Newell and Burnard, 2011) Additionally, interviews would have been better choice for collecting data and would fill the existing gap in the study.
In conclusion, several studies links poor hand hygiene to the high rates of hospital acquired infections in NHS hospitals, yet insufficient evidence was supplied to enable a view to be taken on its potential contribution to reducing infection (A. Mears et al, 2009). More work needs to be done on hand hygiene, standards monitoring and education of healthcare professionals in the management and improvement of infection prevention and control in primary care practice (Wilson, 2006). Undoubtedly, adequate hand hygiene is the foundation for infection control activities, however there are still several actions which NHS Trust hospitals can put in place to prevent and reduce the risks of infection, including the environment, infecting microbes and antimicrobial stewardship, patterns of healthcare and the patient treatment and diagnostic interventions (Patient Environment Action Team, 2005). Thus, the literature appraisal has highlighted the lack of the research in these areas.