What is going on with hand hygiene compliance and healthcare-associated infections?

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hand washing Real Stories from the Streets of Healthcare!

With Martine Ehrenclou, MA and Beth Boynton, RN, MS

With patients and healthcare professionals all too often on opposite sides of the table, our goal is to bridge that gap. As a patient/patient advocate and registered nurse, Real Stories From the Streets of Healthcare is our way of discussing real stories and issues that involve patients and families, nurses, other healthcare professionals, and the healthcare environment itself.  We plan to look behind the closed door, break down walls of silence, and tackle thorny issues to increase understanding of the complex healthcare problems we all face.  See our welcome page for  more information about our blog duets here.

Blog Duet # 3:  What is going on with hand hygiene compliance and healthcare-acquired infections? 

Beth

Hand hygiene seems like a simple thing.  It is well documented that following protocols decreases

Beth

Beth

the incidence of healthcare-associated infections (which can be debilitating or life-threatening) and the spread of bacteria that are resistant to antibiotics. In preparing for this duet I did a little research looking for the latest statistics and recommendations about hand hygiene.  There is a lot available online and much of it requires sifting through sophisticated scientific data.  The CDC progress report  indicates significan reductions in many infections with an increase in catheter associated urinary tract infections. There’s even a ~200 page document by the Joint Commission called, “Measuring Hand Hygiene Adherence:  Overcoming the Challenges”!   I even found conflicting or at least confusing  information on CDC recommendations re: alcohol-based handrub versus soap and water handscrub.

Now, I’m not against science or data, please know this.  But as a busy nurse I only want to know what I need to know and I want the infection control people to distill out the essential information and make it available.  In my opinion, we have what we need to know:

  • Research supports association between nurse staffing and healthcare-associated infections (HAIs).  http://bit.ly/1A0AiAW
  • Hand Hygiene in hospitals is less than 50 %  (OUCH!) http://1.usa.gov/1A0ALTB

Let’s make sure there is enough staff (try putting a catheter in an obese patient without help or when you are rushing) and focus on behavior and the underlying communication and interpersonal skills that contribute to positive relationships and cultures.  Ironically, even solving the staffing dilemma requires effective communication that ensures nurses (and others) are able to set limits, delegate, and exchange constructive feedback as an ongoing dynamic that is going on all the time.   This is the kind of work that will ensure practitioners remind each other to wash hands and create the psychological safety that will help patients feel comfortable doing the same.

Martine

Martine

Martine

When I first read your post, I started doing some research with your thoughts in mind. I foundstudies and articles that support what you wrote. A Medscape article gave this example: a nurse is taking care of a sick patient in the NICU and the baby has an infection. Another emergency arises with another baby and the nurse has to rush to care for that baby and in the process doesn’t have time to wash her/his hands or because of the demands of the emergency.

I also understand about understaffing and time pressures. Ever since I interviewed over a couple hundred nurses for my books, I gained a lot of empathy for nurses and their struggles.  I heard first-hand what they are up against. Which is why in both of my books I tried to instill empathy for nurses and appreciation for the jobs they do. Patients need loved ones to act as their advocates when hospitalized because of the patient safety risks. It’s unfortunate that we have to enlist loved ones in the first place. Some nurses and physicians I interviewed said, “Never be a patient in the hospital alone. Always have a family member with you.”

Hospital administrations need to do something.

But I keep bumping up against the commitment to the patient. The safety of the patient is the most important right? People are terrified of hospitals and for good reason. I’ve written about hand washing quite a bit because of the 1.7 million hospital-acquired infections a year in hospitals (AHRQ FAQ) and the 99,000 people who die from those infections annually. Hand washing is such a simple act to prevent the spread of infections and it is the most effective. Washing one’s hands for 20 seconds in warm, soapy water does the job.

If we undergo a major surgery or life threatening event, we are treated in hospitals by clinicians who are supposed to help not harm us. The number of preventable HAIs and resulting patient deaths is just unacceptable. Those kind of odds would not work in any other business. But in healthcare it’s tolerated. Patients go to hospitals anyway because we have to. And if loved ones are available, we enlist them to act as our advocates during our hospital stays to help prevent HAIs, to prevent medication mistakes and other medical errors. We have no choice but to count on nurses and physicians to help us recover and heal. If patients truly are the #1 priority in hospitals, then something needs to be done to reduce the number of HAIs and deaths because of them.

As patients we are the customers. Through our health insurance, we pay the bills. In what other service industry would this kind of hazard be tolerated regardless of the internal pressures employees suffer with? Not to minimize what you describe as those pressures  are real, reported in studies, and they affect the morale of clinicians and then translate to patient care. But the argument that hand washing simply takes too much time (patient emergencies aside) is like saying we are too tired and stressed from a bad marriage to take care of our kids properly.

Beth

I hear you, Martine.  I really do.  And as a consumer or patient I agree that washing hands is a simple procedure that makes a big difference and should be done.  I know HAIs are a big problem and am a strong proponent of the work you are doing to encourage patients to remind healthcare professionals to wash hands and have an advocate with them as much as possible.   Staying as healthy as possible and avoiding hospitals is also wise, although I understand most people who are in the hospital are there because they have to be.

As a nurse, I want to scream, “Give me the resources and I’ll provide safer care.  Make sure that soap, towels, gloves, and alcohol-based sanititizers are easily and consistently accessible, make sure I have enough help to do ALL of the tasks I have to do according to the protocols of my organization, and create products that protect my skin.”  Proper handwashing, rinsing, and drying takes  closer to 1 min (the washing part is 20 sec).  I only pick at this issue because in a chronically understaffed hospital, I guarantee that if I do it right for one patient, I will have to cut corners someplace else.  (In the CDC slide-show they note 56 min out of an 8 hour shift for one nurse based on 1 min/wash and 7 times/hour [I’m sure it is more in some situation e.g. long-term care] ).  I can’t tell you how many times I had to go get paper towel or soap or that someone had hung a cloth towel on the back of the bathroom door in my last job.  It didn’t matter that I practically begged for more nurse assistant staff.  I also guarantee that if I have to go looking for soap or towels that this 1 minute can easily become 5 or more.  This is eternally frustrating in an environment that relentlessly calling upon us to do more than humanly possible.

A friend of mine told me once that she would want a nurse to be a martyr because she felt that nurse would turn over every stone to help her spouse.  She challenged me to consider the same if it were my son in the hospital.  As a mother, yes I want every stone unturned, but as a nurse, I want every stone unturned for all my patients and be healthy and have a long rewarding career and I can’t do that in many places in the current system.  So, when you ask whether patient safety is most important, I answer with ‘Yes, of course it is and making that a reality requires attention to staffing.’

A nurse researcher whom I admire,  Patricia Ebright, PhD, CNS, RN, FAAN shared this quote for the youtube:  Interruption Awareness:  A Nursing Minute for Patient Safety, “A commitment to understanding and appreciating the complexity of RN work is needed to guide the more substantive and sustained improvements required to achieve patient safety and quality”.

Having said all of that, I want to add that my text book which is due out late this summer, “Successful Nurse Communication: Safe Care, Healthy Workplaces, & Rewarding Careers” will contribute to a stronger voice within the nursing profession.   As such, I believe it will help with HAIs and many other issues.  I am passionate about patient safety and I so respect your work in that direction.

So what else can we do now?  Maybe we could start a campaign where consumers could get an inside glimpse of the work of nurses called ‘Walk a mile (or 10) in my shoes’.   We’d have to make it safe for HIPAA and make sure the nurse and hospital want to give an honest view, but maybe worth talking about.  What are your thoughts?

Martine

I’m not convinced it is our place as patients to get in between you and your employers. We do our best to be our own advocates, to enlist loved ones to help us, but the bottom line is that patients need to be taken care of. We pay the bills to those who treat us for very serious and often life-threatening conditions if we are hospitalized. We need those hospitals. It might feel threatening to patients to speak up on your behalf, just as it is scary for patients to even ask physicians questions because of the fear that care will be compromised. I don’t believe that patients will take that risk. This is really an issue between hospital staff and administration.

It is not a big part of my work to educate patients and families on how to speak up to nurses and doctors to request hand washing. I wrote one post on that because a study was published that reported that most nurses and physicians do not welcome requests from patients/families to wash their hands. It’s uncomfortable for us to make requests for hand washing. We don’t want to have to do it. I certainly don’t.

Patient safety has to come first. From what you describe, hospitals and their employees are on opposite sides of the fence about this issue. I hear your frustration about not having what you need to implement patient safety standards. It’s a sorry situation and the hospital administration should be paying attention and giving their employees what they need to do the job they aspire to. I hear that and agree that something must be done. However, it feels like a boundary violation to ask the patients who are in dire need or might be at some point, to protest or intervene in this conflict.

Maybe there is another way to approach your superiors since past approaches have not worked. I don’t believe it is the patient’s place to get an inside view of what you go through to help you solve what is a work/insider problem. Perhaps your administrators should be enlisted to walk in nurses’ shoes. Maybe that should be a requirement before they take on the job. Maybe you and your colleagues could join together and present the problems and offer solutions. Maybe nurses’ unions could play a more important part in this problem.

Beth

I’d like to be clear that I’m not suggesting that patients, who I agree are dependent and vulnerable, should walk in our shoes.  I distinguish patients from consumers and perhaps there is or should be a better term.   Change agents need to understand the systems they are trying to change.  I wonder if Patient Advocacy programs educate about the complexity of the work.  Do you know?

Also, I  have ‘screamed’ many times with rare success (once) and more often messages to be quiet e.g.  “If you don’t like it here, there’s the door” or  “You need to manage your time better”.

I think your idea would work for administrators/leaders who are willing to listen and learn. Many are not and that is part of the underlying problem.

This is a frustrating place to end a blog duet.  A place of tension and conflict.  And yet, we put it out there to invite input from others, consider each other’s perspective,  and generate more topics to discuss.

Martine

Having completed and graduated from a patient advocacy program at UCLA, I did not hear much about nurses’ struggles. Perhaps that should be part of the curriculum since professional patient advocates who work in hospitals will be working with the nursing staff. But how that would manifest, I don’t know. Patient advocates who work in hospitals work for the hospital and their allegiance is to their employer. Independent patient advocates work for the patient. It sounds like nurses who work in hospitals need their own advocates or a team of advocates.

I did not understand that administrators/leaders don’t listen and simply blame nurses. Now I think I understand better why you are looking elsewhere for intervention. I still don’t believe that patients should be a part of it, but maybe there is another way to go. It would seem that the people with more power could be helpful. Perhaps hospital board members and investors could be informed about this pressing and ever-present problem and the reasons behind it. Perhaps if they were approached with detailed information about what you have described, how those internal problems affect the success and reputation of the hospital, how they affect patient safety and ultimately patient satisfaction (scores.) Perhaps then they would be amenable to your solutions and be willing to get involved.

Maybe you and other nurses are in unions. I don’t know if they are effective with a problem like this or not.

Beth

I think that we are uncovering some of the real dysfunction in our system and although it is frustrating to not have clear solutions for the seemingly simple problem of hand hygiene, I am inspired by your willingness to get closer to the truth of core issues.

I would be very grateful if we can hold on to discussion of unions and consumers’ role or patients’ role (and terminology) in evolving our healthcare system for future duets.   You raise a key point about power and yet even that is complicated because it raises questions in my mind about the power that consumers have and what happens when people in power refuse to listen?

I do think we could take an action step regarding your idea about patient advocacy programs and awareness of the struggles of (your term) or the complexity of (my term)  nurses’ work.  I propose that we draft a letter that WE can send to program leaders using hand hygiene as a persistent problem, asking for feedback about what is and isn’t in the program and maybe offering to develop a seminar or course.  I don’t know exactly what this would look like, but suspect it would be a valuable process for us.  If you agree, let’s work on that while waiting to see what other thoughts readers have about the hand hygiene issue!

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3 Responses to What is going on with hand hygiene compliance and healthcare-associated infections?

  1. Colette McGuire, RN says:

    I an an RN that has worked in academic and community hospital settings and have been a patient and the lack of handwashing is criminal. I understand that it takes a minute to complete times the number of patients times the number of unique tasks but if that’s what it takes so be it. As a profession we need to take ownership of the fact that we spend the most time with the patients and as a profession make handwashing our #1 public health priority in our practice. I agree with Martine that it’s uncomfortable as a patient to need to request that someone wash their hands. So nurses need to own it and then change the culture surrounding it. Sadly, I have found that nursing administration gives verbal credence to evidence based practice but when push comes to shove they’re not willing to enforce the practice with increased staff, better unit leaders, management presence, and needed equipment/technologies etc. To prevent HAI’s.

    • Thanks for your insights, Colette. You are tapping into very complex dynamics that involve individual assertiveness on the part of nurses and supportive cultures on the part of organizations. I think it is a shared responsibility and when nursing administration is supported by senior leadership and empowers the support of staff nurses, we’ll see more change.

  2. Garlic7girl says:

    Semmelweis would turn over in his grave to see our so ADVANCED society can’t accomplish a simple task. Tsk, tsk, tsk…it is even more a shame we are having difficulty talking with our hospital administrators about time to do this simple task (among other things like extra staff) and I am presuming you have talked with the administrators at said hospitals. I am also surprised Martine that nurses and their plight were not discussed at all in your education. I say this because apart of my education as a nurse was to be a firm patient advocate. I am truly saddened and outraged how hospitals have solely become a business and not a business with the center being ”having the optimum outcome for our patients”. YES! I encourage you all to work as a team and not through to the side this very important issue: the nurse, patient advocate, doctor if you can get one and the patient! I say yes because folks have no problem demanding good service elsewhere patients need to make their expectations known too. Hey maybe not all are shy but someone will speak.

What are your thoughts?