Hand hygiene refers to removal of microorganisms which are transient or killing them and avoiding of visible dirty from hands without causing any harm to skin by using different techniques and hand washing agents [
Hands of healthcare workers act as vehicle for the transmission of healthcare-associated pathogens [
Healthcare-associated infection (HCAI) places a serious disease burden and has a significant economic impact on patients and healthcare systems throughout the world [
It is estimated that approximately 30% of healthcare providers report symptoms or signs of dermatitis involving their hands, and as many as 85% give a history of having skin problems after performing healthcare activities [
Different studies identified different factors that hinder practice of hand hygiene effectively such as using glove, unavailability and inaccessibility of alcohol-based hand rub, inadequate water supply, absence of detergent/soap, unavailability and inaccessibility of wash basins/sinks, lack of clean towels, poor quality of soap, and lack of hand lotion/lubricants [
Nurses, who are the majority, can contaminate their hands with 100–1,000 colony-forming units (CFUs) of
Hospital based observational cross-sectional study was conducted from July 3 to July 28, 2017, at the inpatient department of HFSUH in Harari Region, Harar town, Eastern Ethiopia, from July 3 to July 28, 2017. Harari Regional State is located 515 km away from A.A with estimated area of 334 square kilometers.
The observation was conducted on all nurses (116) who were working in inpatient department (Medical, Surgical, Pediatrics, Maternity, and ICU) of HFSUH.
Consecutive sampling technique was applied to obtain hand hygiene opportunities.
Observational checklist and self-administered questionnaires were tools used for data collection. Observational checklist which was adapted from WHO observational tool was used to assess hand hygiene practice [
Instructions on how to conduct observation were provided to data collectors and supervisors in a written protocol and in form of training before actual field work. Data were collected for 3 weeks in working hours of three shifts (morning, afternoon, and night shift) each day except weekends. The data collectors obtained informed voluntary verbal and signed consent from each respondent prior to data collection. In order to minimize the Hawthorne effect, observers did not provide details of the study procedures for nurses. The observer found a place where he/she could watch both the contacts and patient care activities and hand hygiene. Finally self-administered questionnaire was administered to identify factors that hinder hand hygiene practice of the nurses.
The data were first coded, entered, and cleaned using EpiData statistical software version 3.1 and then exported into SPSS statistical software version 22 for analysis.
Descriptive statistics (frequency, percent, mean, standard deviation, and tables) were used to present result on hand hygiene practice and factors that hinder the practice of hand hygiene.
The study protocol was approved by the Haramaya University, College of Health and Medical Sciences, Institutional Health Research Ethics Review Committee. Official letters of cooperation was written to Hiwot Fana Specialized University Hospital and concerned bodies to obtain their cooperation in facilitating the study. Information on the study was explained to the participants, including the procedures, potential risks, and benefits of the study. Informed voluntary written and signed consent were obtained from all respondents prior to the study.
A total of 110 study participants were observed that gave a response rate of 94.8%. The mean age (±SD) of respondents was
Sociodemographic characteristic of nurses in Hiwot Fana Specialized University Hospital [HFSUH], Harar, Eastern Ethiopia, 2017.
Variables | Frequency | Percentage |
---|---|---|
Age | ||
18–25 | 35 | 31.8 |
26–35 | 63 | 57.3 |
≥36 | 12 | 10.9 |
Sex | ||
Male | 49 | 44.5 |
Female | 61 | 55.5 |
Educational level | ||
Diploma | 19 | 17.3 |
BSc and above | 91 | 82.7 |
Year of experience | ||
≤1 | 26 | 23.6 |
2–4 | 50 | 45.5 |
>4 | 34 | 30.9 |
Ward currently working | ||
Medical | 31 | 28.2 |
Surgical | 22 | 20 |
Pediatrics | 32 | 29.1 |
Maternity | 15 | 13.6 |
ICU | 10 | 9.1 |
A total of 3902 opportunities and 732 hand hygiene actions were observed. The overall compliance was 18.7%. The compliance based on indication for hand hygiene indicated that the highest 22.9% hand hygiene practice was observed “before clean∖aseptic procedure.” Regarding the compliance in the working shift the highest 19.6% compliance was recorded at night shift and the observational data specific to the inpatient department indicates that the highest compliance 22.7% was observed in ICU ward of the hospital. Regarding opportunities observed, the highest numbers were recorded before touching patient (981), at night shift (1427), and emergency ward (781) compared to their counterparts. For each opportunity the hand hygiene action was performed by either washing with soap and water (HW) or hand rub by alcohol (HR); the highest action (179) was observed after touching a patient, in night working shift the highest (280) hand hygiene action was observed, and ICU had the highest (163) hand hygiene action compared to other wards (Table
Observational hand hygiene practice of Nurses in Hiwot Fana Specialized University Hospital [HFSUH], Harari, Eastern Ethiopia, 2017.
Opportunities | HH action | Compliance (%) | |
---|---|---|---|
Indication | |||
Before touching a patient | 981 | 153 | 15.6 |
Before clean/aseptic procedure | 576 | 132 | 22.9 |
After body fluid exposure risk | 463 | 100 | 21.6 |
After touching a patient | 943 | 179 | 19 |
After touching patient surroundings | 939 | 168 | 17.9 |
| | | |
Shift | |||
Morning | 1354 | 253 | 18.7 |
Afternoon | 1121 | 199 | 17.8 |
Night | 1427 | 280 | 19.6 |
Ward | |||
Medical | 638 | 105 | 16.5 |
Surgical | 750 | 134 | 17.9 |
Pediatrics | 505 | 105 | 20.8 |
Maternity | 511 | 104 | 20.4 |
ICU | 717 | 163 | 22.7 |
Emergency | 781 | 121 | 15.5 |
Concerning the method used for hand hygiene action, the majority, 111 (11.3%) among 153 actions “before touching patient,” 109 (18.9%) among 132 actions “before clean/aseptic procedure,” 136 (14.4%) among 179 actions “after touching a patient,” and 128 (13.6%) among 168 actions “after touching patient surroundings,” were performed by hand rubbing with alcohol based hand rub. Hand washing with soap and water was performed highly, 57 (12.3%) among 100 actions “after body fluid exposure” compared to any other indications of hand hygiene (Figure
Method of hand hygiene of nurses in governmental hospitals of Harari Regional State, Eastern Ethiopia, 2017.
Reason for not practicing hand hygiene [HH] was shown by self-administered questionnaire after observation for each nurse with response rate of 100%; the majority (93 (84.5%)) of the respondents’ reason was lack of training, 84 (76.4) respondents’ reason was lack of conveniently located sink, and 87 (79.1) said lack of time to perform hand hygiene (Table
Respondents’ reasons for not practicing hand hygiene in Hiwot Fana Specialized University Hospital [HFSUH], Harari, Eastern Ethiopia, 2017.
Reasons for not practicing hand hygiene | Frequency | Percentage |
---|---|---|
Lack of training | ||
Yes | 93 | 84.5 |
No | 17 | 15.5 |
Fear of irritation and dryness to hand washing agents | ||
Yes | 54 | 49.1 |
No | 56 | 50.9 |
Lack of conveniently located sink | ||
Yes | 84 | 76.4 |
No | 26 | 23.6 |
Lack of hand washing agents | ||
Yes | 79 | 71.8 |
no | 31 | 28.2 |
Wearing glove | ||
Yes | 67 | 60.9 |
No | 43 | 39.1 |
Lack of time | ||
Yes | 87 | 79.1 |
No | 23 | 20.9 |
The results of this study in observed hand hygiene practice of nurses based on WHO indication were as follows: before touching a patient, 15.6%; before clean/aseptic procedure, 22.9%; after body fluid exposure risk, 21.6%; after touching a patient, 19%; and after touching patient surroundings, 17.9%. The overall observed hand hygiene practice was 18.7%.
Also observed practice was low compared to the finding from different studies that ranged between 21.48 and 53% in Northern India, Kuwait, South Florida, Istanbul, Saudi Arabia, and Nigeria [
Different studies indicated that hand hygiene practice among nurses before touching a patient was 41.7%, 38.6%, 43.8%, and 10% in study conducted in South Florida, Taiwan, Istanbul, and Northern India, respectively [
Practice after touching patient was 74.6%, 72.1%, 42.0%, and 16% in studies conducted in Istanbul, South Florida, and Taiwan, respectively [
Practice after exposure to body fluids among nurses was too 5.5%, 16.8%, and 43.5% in study conducted in Taiwan, Istanbul, and Northern India, respectively [
Practice before aseptic and clean procedure among nurses showed 6.8%, 7%, and 23.8% and hygiene practice after touching patient surroundings was 16.1%, 42.86%, and 60.1% in study conducted in Taiwan, Istanbul, and Northern India [
Generally when compared to this study the observed practice of hand hygiene was lower than this study; the difference might be due to lack of knowledge, training, and awareness about the WHO indications on hand hygiene. Even though there is socioeconomic difference between these countries the measurement tool we used was similar.
Most of the hand hygiene opportunities 781 in this study occurred in the emergency wards reflecting a high demand for hand hygiene. The highest compliance was observed in ICU, 22.7%, and the lowest in the emergency wards, 15.5%; in other wards the result indicates 16.5% in medical wards, 17.9% in surgical wards, 20.8% in pediatrics, and 20.4% in maternity.
There was a significant difference of hand hygiene practice in the observed compliance between different ward categories (
This study was consistent with the study conducted in Southern Nigeria in which nurses who believed that facilities for hand washing were inadequate were less likely to have good handwashing practice [
Generally, the study tried to assess the magnitude of hand hygiene practice of nurses and it can be an input for infection prevention program together with other pocket studies from different corners of the country (Ethiopia). But the study might have faced Hawthorne effect; hence observation will be used as data collection tool; the observer may have potential influence on behaviors of nurses (since this method implies that the nurses are aware of being observed) and the impact of the observer’s interpretation of the definitions and the actual situation on the reliability of the data.
Observed practice of hand hygiene among nurses in Hiwot Fana specialized University Hospital was too poor. High practice was observed in ICU ward and low practice was observed in emergency ward even though the most of the hand hygiene opportunities occurred in the emergency wards reflecting a high demand for hand hygiene. Lack of training, conveniently located sink, hand washing agents, and lack of time were major reasons for not practicing hand hygiene. Successful promotion of hand hygiene through multiple strategies, which includes senior and middle management support and commitment to make hand hygiene an organizational priority and instituting system change (e.g., making hand hygiene products available at the point of care), should be considered.
Alcohol based hand rub
Healthcare-associated infections
Healthcare workers
Hiwot Fana Specialized University Hospital
Hand hygiene
Hand hygiene action
Hand washing
Intensive Care Unit.
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
The study protocol was approved by the Haramaya University, College of Health and Medical Sciences, Institutional Health Research Ethics Review Committee. Official letters of cooperation were written to Hiwot Fana Specialized University Hospital and concerned bodies to obtain their cooperation in facilitating the study. Information on the study was explained to the participants, including the procedures, potential risks, and benefits of the study.
Informed voluntary written and signed consent were obtained from all respondents prior to the study.
The authors declare that they have no conflicts of interest.
Nefsu Awoke conceived the original idea and was involved in proposal development, design, and data collection and analysis and in all stages of the research project. Biftu Geda, Aseb Arba, Tiwabwork Tekalign, and Kebreab Paulos participated in design, data analysis, and all stages of the research project. Finally, all authors revised the manuscript and approved the final version.
The authors would like to thank Ministry of Education, Wolaita Sodo University, and Haramaya University for their technical support. Next they would like to acknowledge Hiwot Fana Specialized University Hospitals, data collectors, supervisors, study participants, and all who supported the study directly or indirectly, without whom the research would not be done. The source of funding for this research was covered by Ministry of Education in collaboration with Wolaita Sodo University for resources and data collection.