How to Obtain Better Hand Hygiene Adherence: Ideas From Health Care Workers on the Floor

Many studies have been done on how to increase hand hygiene adherence. However, ICT® decided to go to the source and ask the health care workers themselves why they do not always follow hand hygiene.

Every medical professional knows the importance of hand hygiene (HH). It is the first and most critical defense against the chain of infection. So why is HH adherence so difficult to maintain in health care facilities? Countless meth­ods have been devised to encourage and require adherence: apps on cell phones, video cameras, computer programs, stick­ers, and other small tokens of positive feedback, and most often, infection pre­ventionists (IPs) among health care work­ers (HCWs) noting who followed required HH guidance and who did not.

But why do HCWs, knowing how important it is, not perform the appro­priate HH procedures every single time it is endorsed or required by their facilities? Infection Control Today® (ICT®) went to IPs and asked, “What keeps you from per­forming HH, and what do you think keeps other HCWs from consistently adhering to HH requirements?”

Why Hand Hygiene Is Important

Leslie Bozigian Curtin, RN, CMIP, former assistant director of nursing and infection preventionist at Sumter East Rehab, has been in the health care field for 40 years. “To break the chain of infection, you have to have an infective agent, a method of transmission, and a susceptible host. Then you must have [a] method of getting the agent to the susceptible host. So anytime you can break any one of those links in the chain, you will break the infection process. The easiest way to do that is HH,” she said.

Why Isn’t Hand Hygiene Consistently Performed?

Tracy M. Field, RN, corporate infection preventionist for Ecumen, a long-term care organization, told ICT® she sees HH not per­formed, especially in long-term care (LTC) facilities, despite technological advances. “Things have come a long, long way. In the 30 years I’ve been in health care, one of the biggest things that has developed is the placement of hand sanitizer. They have those wall units right at the patient rooms, right at the resident rooms. They have these strategic placings of solution everywhere. But even though those are there, I still see [HCWs] walk by them,” she said.

The first barrier to HH adherence is familiarity with the patient, Field told ICT®. “We live and work with these [patients] whom we love very much. We’re their family, and they’re our family. When you feel like you love this [patient], you take care of them every day; you don’t look at them as infectious. You might skip [HH] because it’s not like the hospital…and this [patient] in front of you is not super sick. It’s a different situation. In senior care, HH is just as important: all we can do for infection prevention. But there is this sweetness about the care we give [due to familiarity]. I see that as a big barrier,” she said.

Field also explained the second barrier: complacency. In an LTC facility, an HCW may think, “‘I took care of this person every single day [in the past] week; I know they’re not sick.’ The HCW comes back 2 days later, [and the patient has] COVID-19 or norovirus. And the HCW was already exposed. There’s this kind of complacency where the HCW thinks, ‘Oh, I take care of these [patients] all the time. They’re not sick.’ I see that thought as a barrier for senior care,” she said.

Other reasons for improper HH that came up in the discussions with IPs were staffing challenges and lack of time. In these situations, the HCW tries to get everything done, and HH is the easiest and first guideline to be overlooked. “Staff shortages are so overwhelming that you’re frazzled and frustrated,” Field said.

However, Field explained these feelings are no excuse. “[HCWs] complain they don’t have time. [However,] I don’t think [HCWs] can argue they don’t have time to wash their hands or…use hand sanitizer…It is not that we don’t have time. Our mind has gotten so loaded with wearing the mask, wearing eye protection, putting on a gown, and so on for these rooms. It’s an overload of intense situations that is bogging HCWs down. We lose that laser focus, and you fall back and miss some steps,” she said.

Curtin tells her HCWs to perform HH in the following situations:

1. When you put your purse away

2. When you put your coat away

3. Before you go into any other room on the unit

4. If you go into someone’s room and deliver a tray

5. In between providing care for patients

6. Before providing any patient care

7. When you go to the restroom

8. Before and after you eat a meal or snack

9. After providing care requiring gloves, you must take your gloves off and wash your hands again

ICT® also asked Laura Miller, MD, MPH, FAAFP, the main reason she sometimes finds herself not following HH procedures. Miller is an assistant professor in the Department of Family Medicine and Community Health at the University of Minnesota in Minneapolis. “I think number 1 is time and so many different things in our cognitive spaces. We’re in and out of different locations with patients and care teams. There’s a lot of things going on [and] a lot moving parts happening,” Miller said.

Miller said another reason for poor HH adherence is lack of access to hand sanitizer. It may not be refilled or in the right place. “That’s a big gap I have noticed, and it is certainly something that could be actionable. We have come a long way now that we are in the era of hand sanitizer solutions readily available. We’ve transitioned to having [hand sanitizer] alongside hand washing stations. It is handier and more useful to have hand sanitizer solution available instead of hand washing [stations] because it takes so much more time and space to [wash].”

Additionally, according to Miller, simply remembering to do HH may be difficult “especially in more emergent and urgent

situations, when you’re trying to get in the emergency department [because] your patient is not doing well in the hospital.” She went on to say, “When you’re in obstetrics, and you’re having a crunch in your time, it’s hard in the moment to stop when you have something more urgent in front of you.”

Miller echoed other HCWs who spoke to ICT® about sticky and/or smelly hand sanitizer or soap. “There have been times when a refill pack or something is different…so I’m going to avoid that one.” She also mentioned allergies or dermatologic effects from hand sanitizer solution. Being alcohol based, it is a drying agent that may cause severe and chronic skin issues.

However, Curtin said there is no excuse for lack of HH adherence; even children know to wash their hands well and often.

No matter their reason for improper HH, her admonition to HCWs is always the same: “You can’t wash your hands or use hand sanitizer too many times.”